Management of Hiatal Hernia in an Obese Middle-Aged Patient with Dysphagia
For an obese middle-aged patient with dysphagia and a hiatal hernia where the gastroesophageal junction is above the diaphragm, laparoscopic Roux-en-Y gastric bypass is the recommended surgical treatment as it addresses both the hiatal hernia and obesity simultaneously.
Diagnostic Findings
- The patient presents with dysphagia relieved by belching, suggesting a mechanical obstruction at the gastroesophageal junction 1
- Barium study confirms hiatal hernia with gastroesophageal junction above the diaphragm and part of the stomach herniated parallel to the esophagus 1
- These findings are consistent with a paraesophageal hiatal hernia requiring surgical intervention 1
Surgical Options Based on Patient Characteristics
For Obese Patients:
- Roux-en-Y gastric bypass is the preferred primary anti-reflux intervention in obese patients with hiatal hernia 1
- This approach provides dual benefits: effective treatment of the hiatal hernia and significant weight loss 2
- Sleeve gastrectomy should be avoided as it has potential to worsen GERD symptoms 1, 3
For Non-Obese Patients:
- Laparoscopic fundoplication would be the standard approach 1
- Type of fundoplication can be tailored based on esophageal motility 1
Fundoplication Considerations
- Partial fundoplication (Toupet) is preferred in patients with esophageal hypomotility or impaired peristaltic reserve when there is concern for postoperative dysphagia 1, 4
- Nissen fundoplication (360° wrap) remains the gold standard for durable relief of GERD symptoms but carries higher risk of postoperative dysphagia 5, 4
- Recent data shows partial posterior wrap (Toupet) has reduced obstructive complications and improved quality of life compared to total (Nissen) fundoplication 4
Preoperative Assessment Requirements
- High-resolution manometry to assess esophageal peristaltic function and exclude achalasia 1, 5
- Complete endoscopic evaluation to document severity of any esophagitis 5
- Confirmation of pathologic GERD is necessary before proceeding with invasive anti-reflux procedures 1
Surgical Approach
- Laparoscopic approach is strongly recommended for stable patients 1, 5
- Anatomical repair should include closure of the diaphragmatic hiatus using non-absorbable sutures 1
- For larger defects (>3 cm), mesh reinforcement may be necessary to prevent recurrence 1
Potential Complications
- Dysphagia (more common with Nissen fundoplication) 5, 4
- Gas bloat syndrome 5, 6
- Recurrent reflux 5
- Hernia recurrence rates can be high (up to 46-47%) at 6 months post-repair 4
Follow-up Recommendations
- Endoscopic surveillance to monitor healing and detect potential complications 5
- Monitoring for symptom recurrence 1, 5
In this specific case of an obese middle-aged patient with a hiatal hernia, Roux-en-Y gastric bypass represents the optimal surgical approach as it effectively addresses both the anatomical defect and the contributing factor of obesity 1, 2.