Laparoscopic Gastric Banding and Crural Repair in the Obese Patient with a Hiatal Hernia

Background: A hiatal hernia is present in up to 50% of patients undergoing bariatric surgery. It has been claimed that laparoscopic adjustable gastric banding (LAGB) can both improve and induce reflux symptoms. The effect of a simultaneous crural repair and gastric banding has not yet been reported. Methods: Since 1999, all patients undergoing LAGB have a simultaneous crural repair if a hiatal hernia is present. Gastroesophageal reflux disease and dysphagia were assessed preoperatively and postoperatively using the modified DeMeester symptom-scoring system and the use of anti-reflux medication. Results: 62 patients with a hiatal hernia have undergone simultaneous LAGB and crural repair, with a median follow up of 14 (3-38) months. There was no mortality, and complications occurred in 3 patients, namely pulmonary embolus, slippage requiring repositioning of the band and persistent dysphagia requiring band removal. 24 months following LAGB and crural repair, median BMI had fallen from 43 to 31 kg/m2 and median excess weight loss was 53%. Modified DeMeester symptom-score fell from a preoperative median of 3 (0-5) to a postoperative median of 0 (0-2) (P < 0.01, Mann Whitney U), and the number of patients on anti-reflux medication decreased from 44 to 6 (P < 0.01, Chi-squared). Conclusion: Crural repair in addition to LAGB does not increase the risk of slippage or dysphagia, significantly improves reflux symptoms and decreases the need for anti-reflux medication.