Laparoscopic Hiatus Hernia Repair and Simultaneous Sleeve Gastrectomy: A Novel Approach in the Treatment of Gastroesophageal Reflux Disease Associated with Morbid Obesity

Abstract

Obesity is associated with significantly increased risk of gastroesophageal reflux disease and recurrence of reflux symptoms following surgical intervention, compared to individuals with normal body-mass index (BMI). The severity of reflux symptoms and obesity is associated with a decreased quality of life. In this article, we report a novel approach to the treatment of morbid obesity and hiatus hernia in a 36-year-old female with a BMI of 40 kg/m² who failed the conservative treatment. A laparoscopic hiatal repair, using a commercially available on lay reinforcement biologic mesh and a sleeve gastrectomy performed at the same time was successful in controlling the reflux symptoms and reducing her body weight.

Case Report

A 36-year-old woman with a body-mass index (BMI) of 40 kg/m² presented with a 5-year history of heartburn, chest pain, and acid reflux. After an initial response with proton pump inhibitors, best medical therapy failed to control her reflux symptoms. She had other problems associated with morbid obesity. In 2003, she had a laparoscopic cholecystectomy for gallstone disease. She was suffering from chronic left hip pain and low back pain. Due to her weight, she had to have an elective caeserian section. Snoring during sleep was troublesome and she had developed sleep apnea syndrome. The combination of morbid obesity and its associated problems decreased her quality of life, leading to depression. Despite trying several weight-reduction programs, she failed to achieve any significant weight loss.

The patient underwent the following investigations for her reflux symptoms. Esophagogastroduodenoscopy showed a large hiatus hernia with reflux esophagitis. Urease test and gastric mucosal biopsy were negative for Helicobacter pylori. Barium swallow examination (Fig. 1) showed a hiatus hernia with gastroesophageal reflux. A 24-hour esophageal pH study and manometry revealed hypotonic lower esophageal sphincter, normal motility in the body of the esophagus, total reflux time of 6.3% (normal, <4%), and the total DeMeester score of 26.4 (normal, <14.72). The patient's preoperative weight was 115 kg, height 1.7 m, and BMI was 40 kg/m². Following consultation with the patient, a decision was taken to perform a combined hiatal repair and sleeve gasterectomy to treat both her hiatus hernia and obesity.

FIG. 1.

Preoperative barium swallow.

Management

Under a general anesthetic, the patient was placed in the split-leg position with the surgeon standing between the legs and the assistant on the left-hand side of the patient. A Veress needle was used to create the pneumoperitoneum. Three 12-mm trocars were inserted in the upper abdomen (one on the right, two on the left side) and one 5-mm trocar was inserted laterally in the left-upper quadrant. A Nathanson retractor (Cook Biotech Inc., West Lafayette, IN) was inserted through the subxyphoid 5-mm trocar site to retract the liver. The hiatal hernia sac containing the proximal stomach was reduced. Distal esophagus and gastroesophageal junction was mobilized by using a laparoscopic Harmonic Scalpel (Ethicon Endo-Surgery Inc., Cincinnati, OH) to get a 4-cm tension-free intra-abdominal esophagus. Posterior crural repair was performed with three interrupted sutures of 2-0 Ethibond (Ethicon Inc., Somerville, NJ). For the reinforcement of the repair, an onlay biologic mesh (Surgisis; Cook Biotech Inc.) in “U” configuration was fixed in place (Fig. 2) using hernia staplers. Sleeve gastrectomy was started by dividing the omentum off the greater curve at 8 cm from the pylorus all the way up to the gastroesophageal junction. Adhesions between the stomach and pancreas were released. A 4.8-mm (green) Endo-GIA stapler (Ethicon; Cincinnati, OH)⁴ was fired 8 cm from the pylorus (preserving most of the antrum) toward the angle of His. A 32-F Maloney bougie⁴ was inserted along the lesser curve and the rest of the sleeve gastrectomy was completed, using a 3.8-mm (blue) Endo-GIA stapler. The green staple line was over sewn with 3-0 continuous vicryl sutures. The residual stomach was filled with methylene blue to check for the leak and to measure the capacity. Gastrectomy specimen was retrieved in an endobag through the left-upper quadrant-port wound. No intra-abdominal drain was inserted. The residual stomach measured 150 mL (in vivo), and the resected sleeve of the stomach (Fig. 3) measured 700 mL (ex vivo). There was no perioperative complication.

FIG. 2.

Mesh repair of hiatus hernia.

FIG. 3.

Sleeve gastrectomy specimen.

On postoperative day 1, a gastrograffin swallow showed no evidence of leak and the patient was started on a liquid diet. On postoperative day 2, the patient was discharged home with instructions to take a liquid diet for 2 weeks, followed by a pureed diet for 2 weeks. Three months after the procedure, a subjective reassessment of the symptoms was done. On a score of 1–10 for severity, the heartburn improved from 8 to 3, chest pain from 7 to 3, and reflux from 6 to 1. The patient did not want to undergo pH manometry studies, but agreed to have a barium swallow 3 months after the procedure, which showed no recurrence in reflux or hiatus hernia (Fig. 4). The patient lost 37.5% (100 kg) of her excess body weight (13% decrease in BMI) with improvement in gastroesophageal reflux symptoms.

FIG. 4.

Postoperative barium swallow.

Discussion

Morbid obesity has been shown to be an independent risk factor for hiatus hernia and gastroesophageal reflux disease.^2,3,5,6 Various factors, such as increase in intragastric pressure, gastroesophageal pressure gradient, and axial pressure strain through the diaphragm, have been proposed as the likely cause for this association.⁵ High failure rates are reported following laparoscopic Nissen fundoplication in morbidly obese patients (BMI >35).⁷ Sleeve gastrectomy is a safe, effective restrictive bariatric procedure to treat morbidly obese patients, especially for volume eaters, and to prepare superobese patients for laparoscopic gastric bypass or duodenal switch.⁸ In a prospective, multicenter study of 163 sleeve gastrectomies, Nocca et al. reported low morbidity, low reoperation rate, and lower rate of gastroesophageal reflux by preserving the antrum of the stomach.⁸

There are very few studies available where a simultaneous procedure was performed to treat morbid obesity and hiatus hernia. In one study, Gulkarov et al. showed that hiatal hernia repair done at the time of initial laparoscopic gastric band operation reduces reoperation rate without increasing the risk of complications.⁹ Parikh et al. reported a case of laparoscopic hiatal hernia repair and repeat sleeve gastrectomy for gastroesophageal reflux disease associated with morbid obesity following a failed duodenal switch procedure in a 49-year-old woman (BMI 31 kg/m²). Their patient lost 26 pounds in weight over 6 months after the procedure and her reflux symptoms improved.¹⁰ In another case report, Cuenca-Abente et al. successfully treated a large recurrent paraesophgeal hernia in an obese patient with a sleeve gastrectomy. In their opinion, sleeve gastrectomy is a potentially useful alternative to fundoplication or gastropexy in the treatment of obese patients with complex paraesophageal hernias.¹¹

As there was a delay in funding, we could not offer the patient a Roux-en-Y gastric bypass at that stage. We discussed with the patient the other surgical options available, including their risks and benefits. We reassured the patient that if she regained weight in the future and the funds became available, we would consider her for a Roux-en-Y gastric bypass. The patient chose to go for the sleeve gastrectomy with hiatoplsty. From the published studies and our own experience, sleeve gastrectomy is the next best procedure to Roux-en-Y gastric bypass, in terms of excess weight loss with fewer complications. In this case, we performed a single primary laparoscopic procedure to repair the hiatal hernia there by treating the Gastroesophageal reflux disease and a sleeve gastrectomy to treat the morbid obesity. We use biologic mesh (Surgisis; Cooks) reinforcement on posterior cruroplasty for all medium-sized and large hiatus hernias. Mesh reinforcement of the hiatal hernia repairs has been shown to reduce recurrence, and biologic mesh has never been known to erode into the esophagus.¹²

Preservation of the antrum and the normal gastric-emptying process through the pylorus help reduce gastric intraluminal pressure. Restoring the stretched hiatus to normal by hiatoplasty and strengthening it with a mesh can restore the position and function of the lower esophageal sphincter. Last, but not least, the reduction in body weight achieved after this procedure is responsible for the improvement in the reflux symptoms. As this is still a relatively new approach, we do not know its long-term efficacy. If the reflux symptoms recur, it is difficult to do a fundoplication, as there is not much of a fundus available. Medical treatment might be of great help in such a situation. We need more studies involving more patients to answer this question.

Conclusions

Laparoscopic hiatal hernia repair and sleeve gastrectomy appears to be a safe, effective one-stop procedure to treat hiatus hernia associated with morbid obesity. A study involving a good number of patients with longer follow-up will be helpful to look at the long-term results of this approach.

Footnotes

Disclosure Statement

No competing financial interests exist.

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