Long-Term Results After Laparoscopic Sleeve Gastrectomy with Concomitant Posterior Cruroplasty: 5-Year Follow-up

  • Cristian Eugeniu BoruEmail author
  • Maria Grazia Coluzzi
  • Francesco de Angelis
  • Gianfranco Silecchia
Original Article



Hiatal hernia (HH) repair during laparoscopic sleeve gastrectomy (LSG) has been advocated to reduce the incidence of postoperative gastroesophageal reflux disease (GERD) and/or intrathoracic migration (ITM). The necessity of intraoperative repair in asymptomatic patients is still controversial. Previous, mid-term results of a prospective, comparative study evaluating posterior cruroplasty concomitant with LSG (group A 48 patients with simple vs. group B 48 reinforced with bioabsorbable mesh) confirmed the safety and effectiveness of simultaneous procedures. Present aim was to report the 60 months follow-up update, evaluating GERD and esophageal lesions’ incidence and HH’s recurrence.


Follow-up was completed in 87.5% of the patients. Recurrent GERD was registered in 6/38 (15.7%, group A) and in 9/46 (19.5%, group B) (p = 1.0000). Grade A esophagitis and GERD was shown in 2 patients (5.2%), respectively 2 (4.3%) of each group (p = 1.0000), and recurrent HH was confirmed subsequently by contrast study and CT scan. Neither Barrett’s lesions nor de novo GERD was found in any patient. Failure of the cruroplasty with ITM was recorded in 7 patients from group A (18.4%) and 2 patients from group B (4.3%) p < 0.05; hence, a repeat posterior, reinforced cruroplasty was performed in all cases. A total of 12 patients (14.2%, 8 respective 4) were converted within 5 years for persistent/recurrent GERD, with only 1 case of de novo (group B).


Accurate patient selection and proper sleeve technique, combined with posterior cruroplasty (simple or reinforced) ensure effectiveness, with a rate of failure (HH recurrence) at 5 years of 10.7%.


Sleeve gastrectomy Posterior cruroplasty Mesh Recurrence GERD Intrathoracic sleeve migration 


Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Informed Consent

For this type of study, formal consent was not required. Additional informed consent was obtained from all individual participants included in the study for which identifying information is included in this article.

Ethical Approval

No ethical approval was required for this study. Permission was granted by the Institutional Review Board for this retrospective study.

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

This article does not contain any studies with human participants or animals performed by any of the authors.


  1. 1.
    Felsenreich DM, Kefurt R, Schermann M, Beckerhinn P, Kristo I, Krebs M, Prager G, Langer FB. Reflux, Sleeve Dilation, and Barrett's Esophagus after Laparoscopic Sleeve Gastrectomy: Long-Term Follow-Up. Obes Surg. 2017; 27(12): 3092–3101.CrossRefGoogle Scholar
  2. 2.
    Genco A, Soricelli E, Casella G, Maselli R, Castagneto-Gissey L, Di Lorenzo N, Basso N. Gastroesophageal reflux disease and Barrett's esophagus after laparoscopic sleeve gastrectomy: a possible, underestimated long-term complication. Surg Obes Relat Dis. 2017; 13(4): 568–574.CrossRefGoogle Scholar
  3. 3.
    Mahawar KK, Carr WR, Jennings N, Balupuri S, Small PK. Simultaneous sleeve gastrectomy and hiatus hernia repair: a systematic review. Obes Surg. 2015; 25(1): 159–66.CrossRefGoogle Scholar
  4. 4.
    Soricelli E, Iossa A, Casella G, Abbatini F, Calì B, Basso N. Sleeve gastrectomy and crural repair in obese patients with gastroesophageal reflux disease and/or hiatal hernia. Surg Obes Relat Dis. 2013; 9(3): 356–61.CrossRefGoogle Scholar
  5. 5.
    Snyder B, Wilson E, Wilson T, Mehta S, Bajwa K, Klein C. A randomized trial comparing reflux symptoms in sleeve gastrectomy patients with or without hiatal hernia repair. Surg Obes Relat Dis. 2016; 12(9): 1681–1688.CrossRefGoogle Scholar
  6. 6.
    Ruscio S, Abdelgawad M, Badiali D, Iorio O, Rizzello M, Cavallaro G, Severi C, Silecchia G. Simple versus reinforced cruroplasty in patients submitted to concomitant laparoscopic sleeve gastrectomy: prospective evaluation in a bariatric center of excellence. Surg Endosc. 2016; 30(6): 2374–81.CrossRefGoogle Scholar
  7. 7.
    Kohn GP, Price RR, DeMeester SR, Zehetner J, Muensterer OJ, Awad Z, Mittal SK, Richardson WS, Stefanidis D, Fanelli RD; SAGES Guidelines Committee. Guidelines for the management of hiatal hernia. Surg Endosc. 2013; 27(12): 4409–28.Google Scholar
  8. 8.
    Drossman DA, Dumitrascu DL (2006) Rome III: new standard for functional gastrointestinal disorders. J Gastrointestin Liver Dis 15(3): 237–241.Google Scholar
  9. 9.
    Gore W. L. & Associates, Inc. (2008) “GORE BIO-A Tissue Reinforcement” [Brochure] AL2973-EN2 June 2008Google Scholar
  10. 10.
    Olson MT, Singhal S, Panchanathan R, Roy SB, Kang P, Ipsen T, Mittal SK, Huang JL, Smith MA, Bremner RM. Primary paraesophageal hernia repair with Gore® Bio-A® tissue reinforcement: long-term outcomes and association of BMI and recurrence. Surg Endosc. 2018; 32(11):4506–4516.Google Scholar
  11. 11.
    Lundell LR, Dent J, Bennett JR, Blum AL, Armstrong D, Galmiche JP, Johnson F, Hongo M, Richter JE, Spechler SJ, Tytgat GN, Wallin L. Endoscopic assessment of oesophagitis: clinical and functional correlates and further validation of the Los Angeles classification. Gut. 1999; 45(2): 172–80.CrossRefGoogle Scholar
  12. 12.
    Sharma P, Dent J, Armstrong D, Bergman JJ, Gossner L, Hoshihara Y, Jankowski JA, Junghard O, Lundell L, Tytgat GN, Vieth M. The development and validation of an endoscopic grading system for Barrett's esophagus: the Prague C & M criteria. Gastroenterology. 2006; 131(5): 1392–9.CrossRefGoogle Scholar
  13. 13.
    Boru CE, Greco F, Giustacchini P, Raffaelli M, Silecchia G. Short-term outcomes of sleeve gastrectomy conversion to R-Y gastric bypass: multi-center retrospective study. Langenbecks Arch Surg. 2018; 403(4): 473–479.Google Scholar
  14. 14.
    Tam V, Winger DG, Nason KS. A systematic review and meta-analysis of mesh vs suture cruroplasty in laparoscopic large hiatal hernia repair. Am J Surg. 2016; 211(1): 226–38.CrossRefGoogle Scholar
  15. 15.
    Schmidt E, Shaligram A, Reynoso JF, Kothari V, Oleynikov D. Hiatal hernia repair with biologic mesh reinforcement reduces recurrence rate in small hiatal hernias. Dis Esophagus. 2014; 27 (1): 13–7.CrossRefGoogle Scholar
  16. 16.
    Sathasivam R, Bussa G, Viswanath Y, Obuobi RB, Gill T, Reddy A, Shanmugam V, Gilliam A, Thambi P. 'Mesh hiatal hernioplasty' versus 'suture cruroplasty' in laparoscopic para-oesophageal hernia surgery; a systematic review and meta-analysis. Asian J Surg. 2019; 42 (1): 53–60.CrossRefGoogle Scholar
  17. 17.
    Li L, Gao H, Zhang C, Tu J, Geng X, Wang J, Zhou X, Pan W, Jing J. The diagnostic value of X-ray, endoscopy, and high-resolution manometry for hiatal hernia: a systematic review and meta-analysis. J Gastroenterol Hepatol. 2019 Jun 17 [Epub ahead of print].
  18. 18.
    Santonicola A, Angrisani L, Vitiello A, Tolone S, Trudgill NJ, Ciacci C, Iovino P. Hiatal hernia diagnosis prospectively assessed in obese patients before bariatric surgery: accuracy of high-resolution manometry taking intraoperative diagnosis as reference standard. Surg Endosc. 2019 May 28. .
  19. 19.
    Koch OO, Asche KU, Berger J, Weber E, Granderath FA, Pointner R. Influence of the size of the hiatus on the rate of reherniation after laparoscopic fundoplication and refundopilication with mesh hiatoplasty. Surg Endosc. 2011; 25 (4): 1024–30.CrossRefGoogle Scholar
  20. 20.
    Antoniou SA, Pointner R, Granderath FA. Hiatal surface area as a basis for a new classification of hiatal hernia. Surg Endosc. 2014; 28(4):1384–5.CrossRefGoogle Scholar
  21. 21.
    Saber AA, Shoar S, Khoursheed M. Intra-thoracic Sleeve Migration (ITSM): an Underreported Phenomenon After Laparoscopic Sleeve Gastrectomy. Obes Surg. 2017; 27(8): 1917–1923.Google Scholar
  22. 22.
    Sebastianelli L, Benois M, Vanbiervliet G, Bailly L, Robert M, Turrin N, Gizard E, Foletto M, Bisello M, Albanese A, Santonicola A, Iovino P, Piche T, Angrisani L, Turchi L, Schiavo L, Iannelli A. Systematic Endoscopy 5 Years After Sleeve Gastrectomy Results in a High Rate of Barrett's Esophagus: Results of a Multicenter Study. Obes Surg. 2019; 29(5): 1462–1469.CrossRefGoogle Scholar

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© The Society for Surgery of the Alimentary Tract 2019

Authors and Affiliations

  1. 1.Division of General Surgery & Bariatric Center of Excellence-IFSO EC, Department of Medico-Surgical Sciences and BiotechnologiesUniversity La Sapienza of RomeLatinaItaly

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