Should we continue to follow the swallow? Limited value of routine preoperative upper gastrointestinal (UGI) series in pediatric and adolescent metabolic and bariatric surgery patients.

BACKGROUND

Hiatal hernia is frequently encountered intraoperatively during metabolic and bariatric surgery (MBS) in adults with relatively poor diagnostic accuracy on preoperative imaging. However, data on pediatric MBS populations is limited. We aimed to determine the prevalence of hiatal hernias in a pediatric bariatric cohort and evaluate the utility of preoperative upper gastrointestinal (UGI) series.

METHODS

We conducted a retrospective review of 94 patients who underwent preoperative UGI series and sleeve gastrectomy from November 2023 to July 2025. Primary outcomes were the prevalence of hiatal hernias on UGI, concordance between UGI and intraoperative findings, and associations with reflux symptoms.

RESULTS

Hiatal hernia was identified in one patient (1.1%) on preoperative UGI series, which was consistent with intraoperative findings of a hiatal hernia in the same patient who underwent repair. Gastroesophageal reflux was identified on UGI in 19/90 patients (21%). Of 7 patients (7.4%) who had reflux symptoms preoperatively, only 3 had reflux on UGI. Three months postoperatively, 4/90 patients (4.4%) reported reflux symptoms, 2 of whom had preoperative symptoms and reflux on UGI.

CONCLUSIONS

The prevalence of hiatal hernias in the pediatric MBS population is exceedingly low, and preoperative UGI findings failed to demonstrate meaningful findings. This suggests that UGI is not a useful predictive tool in this setting and routine preoperative evaluation for hiatal hernias may not be warranted.