Paraesophageal Hernia Repair With Partial Longitudinal Gastrectomy in Obese Patients

Abstract

Background and Objectives:Treatment of gastroesophageal reflux disease (GERD) with hiatal hernia in obese patients has proven difficult, as studies demonstrate poor symptom control and high failure rates in this patient population. Recent data have shown that incorporating weight loss procedures into the treatment of reflux may improve overall outcomes.Methods:We retrospectively reviewed 28 obese and morbidly obese patients who presented from December 2007 through July 2013 with large or recurrent type 3 or 4 paraesophageal hernia. All of the patients underwent combined paraesophageal hernia repair and partial longitudinal gastrectomy. Charts were retrospectively reviewed, and the patients were contacted to determine symptomatic relief.Results:Mean preoperative body mass index was 38.1 ± 4.9 kg/m2. Anatomic failure of prior fundoplication occurred in 7 patients (25%). The remaining 21 had primary paraesophageal hernia, 3 of which were type 4. Postoperative complications included pulmonary embolism (n = 1), pulmonary decompensation (n = 2), and wound infection (n = 1). Mean hospital stay was 5 ± 3 days. Upper gastrointestinal esophagogram was performed in 21 patients with no immediate recurrence or staple line dehiscence. Mean excess weight loss was 44 ± 25%. All of the patients surveyed experienced near to total resolution of their preoperative symptoms within the first month. At 1 year, symptom scores decreased significantly. At 27 months, however, there was a mild increase in the scores. Return of severe symptoms occurred in 2 patients, both of whom underwent conversion to gastric bypass.Conclusions:Combined laparoscopic paraesophageal hernia repair with longitudinal partial gastrectomy offers a safe, feasible approach to the management of large or recurrent paraesophageal hernia in well-selected obese and morbidly obese patients. Short-term results were promising; however, intermediate results showed increasing rates of reflux symptoms that required medical therapy or conversion to gastric bypass.

Surgical Perspective on Evaluation and Management of Recurrent Reflux After Primary Antireflux Surgery

“…The latter hypothesis is further underscored by our previous experiences where reflux resolution was achieved with concomitant hiatal hernia repair with longitudinal sleeve gastrectomy, but this effect was short-lived only while initial weight loss occurred. 20,21 With weight plateau and/or regain, symptoms recurred suggesting that degree of obesity and patient weight have an intimate relationship with acid reflux pathophysiology. As is the current practice in our institution, Roux en-Y gastric bypass is the preferred procedure for antireflux purposes at index operation among patients with severe obesity and metabolic syndrome, rather than a revisional approach.…”

Surgical Treatment of Paraesophageal Hernias: A Review

“…85 Because of the increased risk of surgical failure in this challenging population, a sleeve gastrectomy or gastric bypass should be considered along with PEH repair. [75][76][77] During the last few years, there has been an increased acceptance of bariatric surgery, however, there are still several obstacles, such as patient preference and lack of insurance coverage. Many patients with severe reflux or hiatal hernia do not meet Medicare requirements for bariatric surgery (BMI >40 kg/m 2 , alone, or 35-40 kg/m 2 , with significant comorbidities).…”

Outcomes of Bariatric Surgery With Concomitant Hiatal Hernia Repair Using an Absorbable Tissue Matrix

“…5 Performing concomitant hiatal hernia repair with both sleeve gastrectomy and laparoscopic gastric bypass has been shown to have similar outcomes, morbidity, and mortality as performing gastric bypass alone. [5][6][7][8] There are data to suggest that performing a hiatal hernia repair at the time of bariatric surgery is at least as safe as performing a hiatal hernia with fundoplication in non-bariatric surgery patients with similar complication and recurrence rates. 4 It is also unclear if there are procedure-specific benefits of hiatal hernia repairs in gastric bypass patients vs. sleeve gastrectomy patients.…”