ArticleFrontiers in surgery2026
Preoperative Hill grade versus hiatal hernia size: which drives the decision for Dor fundoplication during sleeve gastrectomy? A retrospective cohort study.
Article in Frontiers in surgery, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
Background: Reflux risk after sleeve gastrectomy is closely linked to gastroesophageal junction anatomy, but the relative influence of preoperative Hill grade vs. hiatal hernia size on the decision to add concurrent Dor fundoplication remains unclear. Identifying the dominant driver may improve patient selection for an adjunctive anti-reflux procedure. Objective: To compare the relative contributions of Hill grade and hiatal hernia size to the decision for Dor fundoplication during sleeve gastrectomy, and to evaluate whether Dor fundoplication is associated with improved reflux outcomes at 12 months. Methods: This single-centre retrospective cohort study included adult patients who underwent primary sleeve gastrectomy between January 2023 and June 2025. Follow-up was completed and the database locked in June 2026. Patients were divided into Dor and non-Dor groups according to whether concurrent Dor fundoplication was performed. The primary analyses examined factors associated with Dor selection and treatment failure for reflux at 12 months. Secondary outcomes included Results: Among 316 patients (126 Dor, 190 non-Dor), high-risk Hill grade was the strongest independent factor for Dor selection (adjusted OR 3.48, 95% CI 2.02-6.00). Hiatal hernia size showed a weaker association (adjusted OR 1.42 per 1-cm increase, 95% CI 1.10-1.85). Model comparisons confirmed a greater incremental contribution from Hill grade than from hernia size. After overlap weighting, Dor was associated with a lower risk of treatment failure for reflux (adjusted RR 0.63, 95% CI 0.43-0.91), with consistent reductions in Conclusion: In patients undergoing sleeve gastrectomy, preoperative Hill grade drives the decision for concurrent Dor fundoplication more strongly than hiatal hernia size. After adjustment for clinical comparability, Dor fundoplication was associated with a lower risk of treatment failure for reflux at 12 months, without an apparent safety or weight-loss penalty.
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