Combined paraesophageal hernia repair and partial longitudinal gastrectomy in obese patients with symptomatic paraesophageal hernias.
BACKGROUND
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.


METHODS
This study retrospectively identified 19 obese (body mass index [BMI], >30 kg/m(2)) and morbidly obese (BMI, >40 kg/m(2)) patients who presented between December 2007 and November 2011 for management of large or recurrent paraesophageal hernia. All the patients underwent a combined primary paraesophageal hernia repair and longitudinal gastrectomy. Charts were retrospectively reviewed to collect preoperative, operative, and short-term postoperative results. Quantitative data were analyzed using Student's t test and qualitative data with χ(2) testing.


RESULTS
Laparoscopy was successful for all 19 patients. The mean preoperative BMI was 37.8 ± 4.1 kg/m(2), and the mean operative time was 236 ± 80 min. Preoperative endoscopy showed that 5 patients who had undergone prior fundoplication experienced anatomic failures, whereas the remaining 14 patients had type 3 and one type 4 paraesophageal Hernia. Mesh was used to reinforce the hiatus in 15 of the 19 cases. The postoperative complications included pulmonary embolism (n = 1) and pulmonary decompensation (n = 2) due to underlying chronic obstructive pulmonary disease. The mean hospital stay was 5.3 ± 3 days. Upper gastrointestinal esophagography was performed for all the patients, with no short-term recurrence of paraesophageal hernia. Weight loss was seen for all the patients during the first month, with a mean BMI drop of 2.7 ± 1 kg/m(2). All the patients experienced near to total resolution of their preoperative symptoms within the first month.


CONCLUSIONS
Combined laparoscopic paraesophageal hernia repair and longitudinal gastrectomy offer a safe and feasible approach for the management of large or recurrent paraesophageal hernias in well-selected obese and morbidly obese patients. In a short-term follow-up period, this approach demonstrated effective symptom control and weight loss.
Department of Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, 9500 Euclid Av, Cleveland, OH 44195, USA. johnhrodriguez@gmail.com
John H
JH
Rodriguez
Matthew
M
Kroh
Kevin
K
El-Hayek
Poochong
P
Timratana
Bipan
B
Chand
D000368:Aged; D005260:Female; D005743:Gastrectomy / Q000379:methods*; D006551:Hernia, Hiatal / Q000209:etiology* / Q000601:surgery*; D059685:Herniorrhaphy / Q000379:methods*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009765:Obesity / Q000150:complications* / Q000601:surgery*; D012189:Retrospective Studies; D011795:Surveys and Questionnaires