Crural Repair with or without Fundoplication During Sleeve Gastrectomy for Hiatal Hernia: Reflux Recurrence and Intrathoracic Migration at 18 Months.

INTRODUCTION: Crural repair is standard when a hiatal hernia is found during sleeve gastrectomy, yet reflux and transhiatal migration persist. Data on whether an antireflux wrap adds value to an adequate crural repair are limited, because most comparative series omit hiatal repair from controls. METHODS: Two-center non-randomized cohort of 66 consecutive patients with severe obesity and symptomatic hiatal hernia, operated by one surgical team. All underwent laparoscopic sleeve gastrectomy over a 38 Fr bougie with posterior crural repair; 31 also received a fundoplication from the preserved fundus (Nissen < 50 years, Toupet ≥ 50 years) and 35 did not. The primary outcome was reflux remission at 18 months (gastroesophageal reflux disease questionnaire score < 8 without erosive esophagitis). All had endoscopy at 18 months. RESULTS: The largest baseline standardized mean difference was 0.41. Reflux remission was 96.8% versus 65.7% (difference 31.1%, 95% confidence interval [CI] 12.4-47.8; p = 0.002). Intrathoracic migration affected 0 of 31 versus 8 of 35 patients (0% versus 22.9%; p = 0.005). After crural repair alone, recurrence was similar across hernia sizes (33.3% versus 34.6%). Excess weight loss (89.1% versus 87.2%; p = 0.073) and optimal weight response (87.1% versus 85.7%) did not differ. Persistent dysphagia was more frequent after fundoplication (16.1% versus 2.9%; p = 0.091) but mild in all cases, without dilation or reoperation. CONCLUSION: Adding a fundoplication was associated with better symptomatic, endoscopic and anatomic outcomes, without impairing weight loss. Hernia size did not identify patients in whom crural repair alone sufficed.