title: Combining laparoscopic giant paraesophageal hernia repair with sleeve gastrectomy in obese patients.
abstract: BACKGROUND
  Surgical treatment for giant paraesophageal hernias (PEH) in morbidly obese patients (BMI > 35) continues to be a difficult problem. Prior studies have demonstrated recurrence rates of up to 40% with higher rates in morbidly obese patients. Reports have shown success combining repair with a bariatric procedure to decrease recurrence rates while achieving weight loss. We report mid-term results from a larger series with combining laparoscopic giant PEH repair with sleeve gastrectomy (SG).
  
  
  METHODS
  We reviewed all combined cases of PEH repairs with SG done at a single institution from 2008 to 2013. The surgical technique was standardized and absorbable bio-prosthetic buttress crural closure reinforcement was used selectively. Yearly upper gastrointestinal radiographic (UGI) studies and postoperative Gastroesophageal Reflux Disease Health-Related Quality of Life questionnaires were completed. 33 patients were enrolled; 18 patients (55%) completed the study
  
  
  RESULTS
  No 30-day morbidity or mortality occurred. 16 patients were female; the average age was 55.3 ± 11.4 years (30-72) with follow-up from surgery of 19.9 ± 16.7 months (6-66). The average weight loss was 23.5 ± 12.7 kg (8-57); excess body weight loss was 46 ± 25.8% (18-112). Based on the UGIs, 9/18 (50%) had no evidence of hernia recurrence, while 6/18 (33%) demonstrated a small (<2 cm) recurrence. 3/18 (17%) patients had evidence of moderate recurrence (3-5 cm). Postoperative GERD-HRQL scores revealed an average score of 10 ± 7 (2-26). All patients reported being "satisfied" with their operation and weight loss and also had a significant improvement in foregut symptoms. No patient has required surgical revision and residual symptoms responded to conservative management.
  
  
  CONCLUSIONS
  PEH in morbidly obese patients remain a complex surgical problem. Our case series shows that combination with SG may decrease recurrence rates but more importantly leads to lower rates of reoperation for symptomatic recurrence. Patients also garner the added medical benefits of weight loss.
authors.affiliation: Emory Endosurgery Unit, Department of Surgery, Emory University School of Medicine, Emory University, 1365 Clifton Road, NE, Building A, Suite A5048, Atlanta, GA, 30322, USA, apatel7@emory.edu.
authors.forename: Ankit D
authors.initials: AD
authors.lastname: Patel
authors.forename: Edward
authors.initials: E
authors.lastname: Lin
authors.forename: Nathaniel W
authors.initials: NW
authors.lastname: Lytle
authors.forename: Juan P
authors.initials: JP
authors.lastname: Toro
authors.forename: Jahnavi
authors.initials: J
authors.lastname: Srinivasan
authors.forename: Arvinpal
authors.initials: A
authors.lastname: Singh
authors.forename: John F
authors.initials: JF
authors.lastname: Sweeney
authors.forename: S Scott
authors.initials: SS
authors.lastname: Davis
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D005743:Gastrectomy / Q000379:methods; D006551:Hernia, Hiatal / Q000209:etiology / Q000601:surgery*; D059685:Herniorrhaphy / Q000379:methods*; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D009767:Obesity, Morbid / Q000150:complications / Q000601:surgery*; D011184:Postoperative Period; D011788:Quality of Life; D012008:Recurrence; D012189:Retrospective Studies; D024162:Second-Look Surgery; D015431:Weight Loss