LAGB could play a role in creating symptomatic HH, but further research is needed confirm causation

Laparoscopic adjustable gastric banding (LAGB) could play in a role in the creation of symptomatic hiatal hernias (HHs) however, further research is needed to underpin the mechanism and confirm causation, according to researchers from the Kingston Hospital NHS Foundation Trust and Queen Mary University of London, London, UK, Texas Tech University Health Sciences Center, Amarillo, USA and the University of Jordan, Amman, Jordan. However, stressed that HHs should potentially be discussed with patients opting for this kind of operation as it can be a reason for re-operation. The findings were featured in the paper, ‘Hiatus Hernia as a Complication of Gastric Banding: A Systematic Review and Meta-Analysis’, published in Cureus.

The authors noted that in LAGB revisions some 27% of prolapses and 53% of pouch dilatations are associated with HHs and although they have been classically associated with bariatric procedures other than gastric banding, there is a growing body of evidence that suggests that HH development might be a direct complication of gastric banding.

Therefore, the study authors systematically assessed the evidence with regard to HHS as a direct complication of gastric banding. Their subsequent literature search highlighted 696 potentially eligible studies. After excluding duplicates, 522 titles and abstracts were evaluated by two reviewers independently after which 27 publications were retrieved, and their manuscripts were thoroughly evaluated for inclusion. In total, five studies (7,033 patients) met all eligibility criteria and were included in this meta-analysis.


Outcomes

Due to the expected variation between studies, random-effects meta-analyses were carried out using the total sample size and number of positives. The meta-analysis indicated that between-study variability was high (I2 = 94%, Chi2 = 68.92, df = 4, < 0.00001, Tau2=1.91). Complication rate ranged between 0.24% to 5.55%; pooled complication rate was 2.17% CI 95% (0.90 - 3.44%), p=0.0008.


Overall, the included studies show a comparable rate of post-operative HH; the fact that HHs can become symptomatic following the adjustable gastric banding (AGB) procedure indicates that AGB plays a role in creating symptomatic hiatal hernias at the very least


The researcher stated that several studies have proposed reasons behind the development of HH after gastric banding:

  • Brown et al (Brown WA, Burton PR, Anderson M, Korin A, Dixon JB, Hebbard G, O'Brien PE: Symmetrical pouch dilatation after laparoscopic adjustable gastric banding: incidence and management. Obes Surg. 2008, 18:1104-8), hypothesised that the main issue is excessive high pressure due to eating too large of a volume or too quickly, within the proximal pouch; such forces could cause distention of the proximal pouch which could result in it pushing up on the pharyngoesophageal ligament, causing hiatal laxity or a secondary sliding HH.

  • Gulkarov et al. (Gulkarov I, Wetterau M, Ren CJ, Fielding GA: Hiatal hernia repair at the initial laparoscopic adjustable gastric band operation reduces the need for reoperation. Surg Endosc. 2008, 22:1035-41) proposed that crural defects at the oesophageal hiatus could allow for the periodic displacement of the gastroesophageal junction up into the thorax [9].

  • Azagury et al. (Azagury DE, Varban O, Tavakkolizadeh A, Robinson MK, Vernon AH, Lautz DB: Does laparoscopic gastric banding create hiatal hernias?. Surg Obes Relat Dis. 2013, 9:48-52) proposed that complications such as concentric pouch dilation, oesophageal dilation and HH are likely to have the same aetiology and classified them together as “backpressure syndrome”; depending on the weakest link, the pressure will induce concentric pouch dilation, oesophageal dilation, or a combination of three.

“A growing body of evidence suggests that symptomatic HH development could be a direct complication of LAGB, as evidenced by the studies in this meta-analysism” the researchers concluded. “Although further research is needed to underpin the mechanism of symptomatic HH development following LAGB and to confirm causation, symptomatic HH development as a complication of LAGB should be potentially discussed with patients opting for this kind of operation, especially since it may be a reason for re-operation.”


Further reading

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