Combined Paraesophageal Hernia Repair and Partial Longitudinal Gastrectomy in Obese Patients With Symptomatic Paraesophageal Hernias

John H Rodriguez, MD, Kevin El-hayek, MD, Poochong Timratana, MD, Matthew Kroh, MD, Bipan Chand, MD. Cleveland Clinic Foundation


 INTRODUCTION: Obesity is a risk factor for gastroesophageal reflux disease and hiatal hernia. Studies have demonstrated poor symptom control in obese patients undergoing fundoplication. The ideal operation remains elusive, however, addressing both obesity and the anatomic abnormality should be the goal. Hurdles for a bariatric operation exist including insurance coverage, patient desires, and patient suitability when choosing an operation. We present a series of patients who underwent longitudinal partial gastrectomy combined with paraesophageal hernia repair with short-term outcomes.
METHODS AND PROCEDURES: We retrospectively identified 18 obese (BMI > 30 kg/m2) and morbidly obese (BMI > 35 kg/m2) patients who presented between 12/2007 and 8/2011 for management of a large or recurrent paraesophageal hernia. All patients had a combined primary paraesophageal hernia repair and partial longitudinal gastrectomy. Hiatal hernia closure was performed in all with or without mesh overlay reinforcement after complete intraabdominal reduction of the viscera. In addition, greater curvature mobilization and longitudinal resection was performed. Charts were retrospectively reviewed to collect pre-operative, operative, and short-term post-operative results. Quantitative data was analyzed using the Student t test and qualitative data with chi-square testing.
RESULTS: Laparoscopy was successful in all 18 patients. Mean pre-operative BMI was 37.9 +/- 4.8 kg/m2. Mean operative time was 237.5 +/- 81.4 min. On pre-operative endoscopy, 5 patients who had undergone prior fundoplication had anatomic failures (transhiatal migration, wrap disruption, diaphragmatic closure failure) while the remaining 12 had type III and one type IV paraesophageal hernia. Mesh was used to reinforce the hiatus in 15/18 cases. Mesh selection was at the discretion of the surgeon and included 10 biologic (9 Permacol and 1 Strattice) and 5 bioabsorbable (Bio-A). Suspected intraoperative pneumothorax requiring tube thoracostomy occurred in one patient. Post-operative complications included pulmonary embolism (n=1), and pulmonary decompensation (n=2) due to underlying chronic obstructive pulmonary disease. Mean length of stay was 5.3 +/- 3 days. Upper GI esophagram was performed on all patients with no short-term recurrence of paraesophageal hernia. Weight loss was seen in all patients within the first month with a mean BMI drop of 2.9 +/- kg/m2. All patients experienced total to near resolution of pre-operative symptoms within the first month.
CONCLUSION: Combined laparoscopic paraesophageal hernia repair and partial longitudinal gastrectomy is a safe operation in obese and morbidly obese patients with large or recurrent paraesophageal hernias. In short term follow-up, this approach has demonstrated effective symptom control as well as weight loss. Long term follow-up is necessary to determine the durability of this operation in the obese and morbidly obese patients.

Session Number: SS18 – Foregut
Program Number: S106

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