title: Minimally invasive management of paraesophageal herniation in the high-risk surgical patient.
abstract: BACKGROUND
  Traditional management of symptomatic paraesophageal herniation involves hernia reduction, hiatal closure, and an antireflux procedure or gastropexy. Patients with significant comorbidities may not tolerate operative repair. A new technique, laparoscopic-assisted endoscopic reduction and fixation of the stomach, may provide a minimally invasive treatment alternative.
  
  
  METHODS
  Eleven elderly patients with symptomatic paraesophageal herniation were managed with flexible endoscopy and double percutaneous endoscopic gastrostomy (PEG) tube insertion with or without laparoscopic assistance.
  
  
  RESULTS
  All patients presented with a symptomatic paraesophageal hernia. Mean age was 78.3 years (range 72 to 84). Each was deemed at high risk for definitive repair due to preexisting coronary artery disease as well as at least two other serious comorbidities. Hernia reduction and intra-abdominal fixation of the stomach was achieved in each case using flexible endoscopy and double PEG insertion. Laparoscopic assistance for reduction and gastropexy was utilized in 9 cases. Mean operative time was 61 minutes (range 28 to 104). Average length of stay was 2.8 days (range 0 to 12). One minor and three major postoperative complications occurred. Over a mean follow-up of 4.1 months (range 2 to 7), all patients have resumed oral intake and achieved weight gain.
  
  
  CONCLUSIONS
  Patients with symptomatic paraesophageal herniation require intervention to alleviate symptoms and avoid the complications of gastric incarceration. For the high-risk patient, endoscopic reduction and PEG with laparoscopic assistance appears to provide effective treatment.
authors.affiliation: Departments of General Surgery and Gastroenterology, Carolinas Medical Center, P.O. Box 32861, Charlotte, NC 28232, USA. theniford@carolinas.org
authors.forename: K W
authors.initials: KW
authors.lastname: Kercher
authors.forename: B D
authors.initials: BD
authors.lastname: Matthews
authors.forename: J L
authors.initials: JL
authors.lastname: Ponsky
authors.forename: S L
authors.initials: SL
authors.lastname: Goldstein
authors.forename: R T
authors.initials: RT
authors.lastname: Yavorski
authors.forename: R F
authors.initials: RF
authors.lastname: Sing
authors.forename: B T
authors.initials: BT
authors.lastname: Heniford
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002318:Cardiovascular Diseases / Q000150:complications; D004724:Endoscopy; D004750:Enteral Nutrition; D005260:Female; D005774:Gastrostomy; D006551:Hernia, Hiatal / Q000150:complications / Q000601:surgery*; D006801:Humans; D010535:Laparoscopy; D008297:Male; D019060:Minimally Invasive Surgical Procedures; D011183:Postoperative Complications; D029424:Pulmonary Disease, Chronic Obstructive / Q000150:complications; D012307:Risk Factors