Matthew J Davis, MD, John Rodriguez, MD, Andrea Zelisko, MD, Stacy Brethauer, MD, Bipan Chand, MD, Philip Schauer, MD, Kevin El-Hayek, MD, Matthew Kroh, MD. Cleveland Clinic Foundation.
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 following standard repair with fundoplication. Recent data has shown that incorporating weight loss procedures into the treatment of reflux may improve overall outcomes.
This study retrospectively identified 28 obese (body mass index [BMI], >30 kg/m2) and morbidly obese (BMI, >40 kg/m2) patients who presented between December 2007 and July 2013 for management of hiatal hernia with large or recurrent Type 3 or Type 4 paraesophageal hernias. All of the patients underwent a combined paraesophageal hernia repair and partial longitudinal gastrectomy. Charts were retrospectively reviewed to collect preoperative, operative, and intermediate-term postoperative results. Additionally, patients were contacted to determine symptomatic relief. Quantitative data were analyzed using Student’s t test and qualitative data with χ2 testing.
Laparoscopy was successful for all 28 patients. The mean preoperative BMI was 38.1 ± 4.9 kg/m2 (range, 30-48 kg/m2) and the mean operative time was 227 ± 75 min (range 102-373 min). Preoperative endoscopy revealed anatomic failure of prior fundoplication in 7 patients (25%). The remaining 21 patients had primary paraesophageal hernias, 3 of which were Type 4 hernias. Mesh was used to reinforce the hiatus in 19 of the 28 cases (67.9%). The postoperative complications included pulmonary embolism (n = 1), pulmonary decompensation due to underlying chronic obstructive pulmonary disease (n = 2) and wound infection (n = 1). The mean hospital stay was 5 ± 3 days (range 2-15 days). Upper gastrointestinal esophagogram was performed for 21 patients on post-operative day 1 or 2, with no immediate recurrence of paraesophageal hernia or staple-line dehiscence. At a mean follow-up period of 27 months, 21 patients were interviewed by telephone. Weight loss was seen for 20 of the 21 patients contacted, with a mean excess weight loss of 44% ± 25% (range 1-115%). All of the patients surveyed experienced near to total resolution of their preoperative symptoms within the first month. At one year, symptom scores were found to significantly decrease toward asymptomatic from pre-operative levels. After intermediate follow-up at 27 months, however, there was a mild increase in mean symptom scores from those obtained at one year. Severe return of symptoms at or near pre-operative level occurred in 2 patients, both of whom will require conversion to Roux en-Y gastric bypass.
Combined laparoscopic paraesophageal hernia repair and longitudinal partial gastrectomy offers a safe and feasible approach for the management of large or recurrent paraesophageal hernias in well-selected obese and morbidly obese patients. Though short-term results were promising, intermediate results show increasing rates of reflux symptoms that require medical therapy or conversion to gastric bypass.