Laparoscopic Roux-en-Y Gastric Bypass for Treamtent of Symptomatic Paraesophageal Hernia in the Morbidly Obese

Brendan M Marr, MD, Mark R Wendling, MD, Dean J Mikami, MD, Bradley J Needleman, MD, Scott Melvin, MD, Kyle A Perry, MD. Ohio State University

BACKGROUND: Laparoscopic paraesophageal hernia (PEH) repair with complete or partial fundoplication has become the procedure of choice in specialized centers for the treatment of symptomatic paraesophageal hernias. While obesity increases the risk of GERD and hiatal hernia, the ideal surgical approach for the treatment of symptomatic PEH in morbidly obese patients is unclear. The aim of this study was to review our experience with laparoscopic PEH repair and concomitant Roux-en-Y gastric bypass (RYGB) for the management of symptomatic PEH in morbidly obese patients.

METHODS: Patients undergoing laparoscopic PEH repair between 2006 and 2011 (n=181) were reviewed. Fourteen patients with morbid obesity and symptomatic PEH underwent laparoscopic PEH repair with RYGB. In all cases, the PEH repair consisted of reduction of the hernia and hernia sac followed by primary posterior cruroplasty without mesh reinforcement. A standard RYGB was then performed with a circular stapled gastrojejunostomy. Outcomes of interest included operative time, body mass index, estimated blood loss, complications, and symptomatic recurrence.

RESULTS: Fourteen patients underwent simultaneous PEH repair with laparoscopic RYGB . Eleven patients (79%) were female and the mean age was 50±10.8 years. Preoperative BMI was 46 ±9.5 kg/m2. Laparoscopic PEH repair with RYGB required 176 ±43.7 minutes and was associated with operative blood loss of 48 ±25.6 ml. One patient developed a minor gastrojejunostomy leak that resolved with conservative management, and postoperative anastomotic stricture requiring endoscopic dilation occurred in 2 patients (14%). Another patient developed C. difficile colitis that resolved with antibiotics. To date, none of these patients have developed a symptomatic hiatal hernia recurrence.

CONCLUSIONS: Symptomatic PEH in the morbidly obese population presents a challenging therapeutic dilemma with a high risk of recurrent hernia. This series demonstrates that laparoscopic PEH repair with concomitant RYGB can be safely performed and provides good short term symptoms relief. Longer-term follow-up of these patients is required to assess the radiographic and symptomatic recurrent PEH rates following this procedure
 

View Poster