Background

Post-bariatric, de-novo hiatal hernias are associated with a cluster of symptoms including Bloating (nausea/vomiting), Abdominal pain, Regurgitation, and Food intolerance or dysphagia (BARF). Patients with this cluster are at risk mis-diagnosis, malnutrition and maladaptive eating.

Methods

We reviewed the records of post-bariatric patients who underwent repair of de-novo hiatal hernias from 2012-19.

Results

We repaired de-novo hiatal hernias in 46 patients (age: 58±11yr; RYGB=20, SG=26), 11 years (4-23yr) post-RYGB and 3 years (1-9yr) post Sleeve Gastrectomy (SG). Weight was 195±40 lb, less100 lb from pre-bariatric weight. Five patients had severe protein-calorie malnutrition. Anxiety, depression or bipolar-disorder were present in 47%, 33%, and 13%, respectively. We diagnosed hiatal hernia with a combination of UGI (67%; see Figure), CT scan (50%) and/or EGD (27%). All repairs were done laparoscopically with a posterior cruroplasty after reducing the neo-stomach into the abdomen and without any complications. Mean follow-up is 15±9 months for the entire group. In the 35 patients (RYGB=17; SG=18) with follow-up >4 months weight remained stable; dysphagia or regurgitation improved in >85% of patients; nausea, vomiting or abdominal pain were not changed in 25-30% of patients (Table). Two patients recurred within 18 months and underwent a subsequent second repair that resolved their symptoms.

Conclusions

Hiatal hernias containing the neo-stomach or pouch after stapled procedures present earlier after SG vs RYGB and can be confirmed with a combination of imaging studies and endoscopy. Repair of de-novo hiatal hernia markedly improves symptoms of BARF in most patients and reverses malnutrition.