Concomitant hiatal hernia repair during laparoscopic sleeve gastrectomy and 5-year endoscopic esophagitis: a retrospective cohort study of 400 patients.

BACKGROUND: Reflux-related mucosal injury remains an important long-term concern after laparoscopic sleeve gastrectomy (LSG). Hiatal hernia (HH) is a potentially modifiable anatomical factor, but long-term endoscopic evidence on the effect of concomitant hiatal hernia repair (HHR) during LSG remains limited. METHODS: This single-center retrospective cohort study, reported in accordance with STROBE, included 400 consecutive patients who underwent primary LSG in 2019. Preoperative upper endoscopy was performed in all patients. HH was defined intraoperatively and selectively repaired by concomitant posterior cruroplasty. Five-year endoscopy was available in 356 patients (89.0%). The primary outcome was endoscopic esophagitis according to intraoperative HH status and concomitant HHR. RESULTS: HH was identified in 115/400 patients (28.8%) and repaired in 75 (65.2%). At 5 years, esophagitis was present in 36/356 patients (10.1%): 27 had LA-A and 9 LA-B esophagitis, with no LA-C or LA-D cases. Barrett's esophagus was identified in 4/356 patients (1.1%), and 88/356 (24.7%) were receiving proton-pump inhibitor therapy. Esophagitis occurred in 4/75 patients with repaired HH (5.3%), 9/40 with unrepaired HH (22.5%), and 23/241 without HH (9.5%) (overall p=0.013). Compared with unrepaired HH, concomitant HHR was associated with lower odds of esophagitis (OR 0.19, 95% CI 0.06-0.68; p=0.011), an association that persisted after stratification for baseline clinical-endoscopic status (Mantel-Haenszel common OR 0.14, 95% CI 0.04-0.57; p=0.003). No Barrett's esophagus was observed among patients undergoing HHR. CONCLUSIONS: Esophagitis was significantly less frequent after concomitant HHR during LSG than when an intraoperatively identified HH was left unrepaired. Although the observational design precludes causal inference, these findings provide long-term endoscopic evidence supporting concomitant HHR when technically feasible.