Esophagophrenopexy with hiatal hernia repair during sleeve gastrectomy: safety and early outcomes from a prospective single-center series

Background: Laparoscopic sleeve gastrectomy (LSG) is associated with postoperative gastroesophageal reflux disease (GERD), frequently related to intrathoracic sleeve migration. Hiatal hernia repair (HHR) may mitigate reflux, but recurrence remains common. Objectives: To evaluate the safety and short-term outcomes of adding esophagophrenopexy to HHR during LSG to stabilize the esophagogastric junction and prevent reflux recurrence. Setting: Single-center bariatric surgical unit, Italy. Methods: This retrospective analysis of a prospectively maintained database included consecutive adult patients who underwent LSG with concomitant HHR and esophagophrenopexy between March 2023 and June 2025. This represents a descriptive case series evaluating the safety and early clinical outcomes following the systematic implementation of this combined technique. Demographic, operative, and postoperative variables were analyzed. The primary endpoint was the incidence of esophagophrenopexy-related complications. Secondary endpoints included postoperative GERD symptoms, proton pump inhibitor (PPI) use, and reoperation for reflux or hernia recurrence. Results: Seventy patients were included (mean age: 38.6 ± 11.2 years; 62.9% women; mean BMI: 38.6 ± 5.4 kg/m 2 ). No intraoperative or postoperative complications related to the esophagophrenopexy were observed. At a mean follow-up of 11.1 ± 6.4 months, GERD symptoms were reported by six patients (8.6%), including four with persistent and two with de novo reflux. PPI use significantly decreased from 38.6% preoperatively to 8.6% postoperatively ( P < 0.001). Multivariable analysis identified no independent predictors of postoperative GERD. No patient required reoperation, and no functional symptoms, such as dysphagia or retrosternal discomfort, were reported. Conclusions: Esophagophrenopexy performed in conjunction with sleeve gastrectomy and HHR is a safe and effective technique to reduce postoperative reflux burden and PPI dependence without adding morbidity. These findings may support its routine application in patients with hiatal hernia undergoing LSG.