IBC-Oxford University2023_BJSOral_7Ligamentum Teres Augmentation for Hiatus Hernia Repair after Bariatric Surgery: A Systematic Review and Meta-Analysis
Authors: Chaudhry S , Farsi S , Nakanishi H , Parmer C , Ghanem O M , Clapp B 
Published: December 2023

Abstract

Background
Hiatus hernia and symptomatic gastro-oesophageal reflux disease (GORD) are common long-term complications after bariatric surgery. However, no consensus on the best surgical approach to manage those complications has been reached. Despite being regarded as a long-forgotten technique, ligamentum teres cardiopexy (LTC) has been reintroduced as an alternative approach to the suture cruroplasty and mesh hiatoplasty. This meta-analysis aims to investigate the safety and efficacy of ligamentum teres augmentation for hiatus hernia repair after bariatric surgery.

Methods
CENTRAL, Embase, PubMed, and Scopus were searched for articles from their inception to June 2023 by two independent reviewers using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) system. The review was registered prospectively with PROSPERO (CRD42023435312). In this meta-analysis, unsuccessful LTC is defined as failure to reach any of the milestones: Resolution of GORD, no proton-pump inhibitors (PPIs) usage, and manometric pressure over 12 mmHg. Postoperative symptoms are categorised as reflux (heartburn, volume reflux, regurgitation), entrapment (dysphagia, epigastric pain), or others (dumping, diarrhoea, nausea).

Results
Five studies met the eligibility criteria, with a total of 110 patients undergoing LTC for hiatus hernia repair after bariatric surgery. The reported mean age ranged from 35.6 to 52.9 years. The proportion of female patients was 81.8% (n=90). The reported mean follow-up period ranged from 3.5 to 7 months. 43 patients (41%) underwent sleeve gastrectomy (SG), 35 (33%) had Roux-en-Y gastric bypass, and 27 (26%) had one anastomosis gastric bypass. A pooled mean BMIs prior to bariatric surgery and LTC were 45.1 kg/m2 (95%CI: 43.8-46.4; I2=0%) and 29.1 kg/m2 (95%CI: 20.1-38.1; I2=99%). A pooled proportion of reflux symptoms prior to LTC was 83.7% (95%CI: 0.644-1.029; I2=86%, n=75). A pooled mean operative time for LTC was 109 minutes (95%CI: 94-125; I2=0%). A pooled proportion of overall postoperative symptoms were 21.0% (95%CI: 0.103-0.316; I2=33%, n=29), consisting of reflux (14.0%, 95%CI: 0.076-0.204; I2=0%, n=15) and entrapment (14.6%, 95%CI: 0.070-0.221; I2=0%, n=12). A pooled proportion of recurrent intrathoracic gastric migration was 14.6% (95%CI: 0.070-0.221; I2=0%, n=12). A pooled proportion of proton pump inhibitors usage after LTC was 15.6% (95%CI: 0.022-0.290; I2=0%, n=4). A pooled proportion of unsuccessful LTC outcomes was 14.0% (95%CI: 0.076-0.204; I2=0%, n=15). Additionally, subgroup analysis was conducted on the SG cohort. A pooled proportion of overall postoperative symptoms were 13.7% (95%CI: 0.022-0.251; I2=0%, n=4), and unsuccessful LTC outcomes were 13.7% (95%CI: 0.022-0.251; I2=0%, n=4).

Conclusion
Our meta-analysis demonstrated that LTC appears to be a safe and efficacious procedure in the management of hiatus hernia after bariatric surgery for selected patients. Despite the promising results, long-term randomized controlled trials with a larger sample size are necessary to help further strengthen the role of LTC for hiatus hernia repair.