Comparison Between Laparoscopic Paraesophageal Hernia Repair with Sleeve Gastrectomy and Paraesophageal Hernia Repair Alone in Morbidly Obese Patients AZIZ M. MERCHANT, M.D., MICHAELW. COOK, M.D., JAHNAVI SRINIVASAN, M.D., S. SCOTTDAVIS, M.D., JOHN F. SWEENEY, M.D., EDWARD LIN, D.O. From the Department of Surgery, Emory Endosurgery Unit, Emory University, Atlanta, Georgia Treatment options for morbidly obese patients with complications from large paraesophageal hernias (PEH) are limited. Simple repair of the PEH has a high recurrence rate and may be associated with poor gastric function. We compared a series of patients who underwent repair of large PEH plus gastrostomy tube gastropexy (PEH-GT) with PEH plus sleeve gastrectomy (PEH- SG). Retrospective review of patients undergoing PEH-SG and patients with PEH-GT was per- formed. We assessed symptoms of delayed gastric emptying and reflux postoperatively. In selected patients, gastric-emptying studies and upper gastrointestinal contrast studies were also obtained. All patients with large PEH were repaired laparoscopically with sac resection, primary crural closure using pledgeted sutures, and biologic patch onlay. SG for patients undergoing concomitant weight loss surgery (PEH-SG) was performed with linear endoscopic staplers and staple line reinforcement. Patients undergoing PEH repair alone had a gastrostomy tube gastro- pexy (PEH-GT). Patients had intraoperative endoscopic evaluation and postoperative contrast swallow studies. In a 12-month period, five patients underwent laparoscopic PEH-SG; two of five had previous antireflux surgery and one of five with a previous diagnosis of delayed gastric emptying. Postoperatively, two patients undergoing PEH-SG had readmission for dehydration and odynophagia. Six-month follow-up body mass index was 32 kg/m 2 for the PEH-SG group with no hernia recurrence and complete resolution of gastroesophageal reflux disorder symptoms. Six patients underwent PEH-GT, one for acute incarceration and anemia and four with previous antireflux surgery. Follow up at 8 months demonstrated one recurrence, four of six had severe delayed gastric emptying and reflux, three of six had additional hospitalization for poor oral intake, and three of six underwent reoperation for delayed gastric emptying. There were no perforations, leaks, or deaths in either group. Combined laparoscopic PEH-SG is a clinically reasonable option for patients with morbid obesity with minimal additional risks and decreased incidence of delayed gastric emptying, reflux, and reoperation. T HE PREVALENCE OF hiatal hernia and gastroesoph- ageal reflux disease is significantly higher in morbidly obese patients than in nonobese patients. 1–3 Morbid obesity is a risk factor for recurrence after hiatal hernia repair and antireflux surgery. 4 Treatment options for morbidly obese patients with large para- esophageal hernias (PEH) are currently limited to repair of the paraesophageal hernia with or without a concomitant weight loss operation. Options for weight loss operations with PEH repair include laparoscopic adjustable gastric banding, 5–7 Roux-en-Y gastric bypass, 8, 9 and lateral subtotal sleeve gastrectomy (SG). 10 Laparoscopic gastric banding concurrently with repair of large PEH possesses the theoretical possibility of band erosions, and gastric bypass con- currently with PEH repair adds significant time and a malabsorptive component for which patients may not be prepared. We believe that PEH repair with con- comitant laparoscopic sleeve gastrectomy affords the best option for morbidly obese patients with PEH. Laparoscopic PEH repair with sleeve gastrectomy has been previously reported in the literature as indi- vidual case reports with good outcomes. We began offering PEH repair with sleeve gastrectomy for patients with morbid obesity starting in 2007 because Address correspondence and reprint requests to Edward Lin, D.O., Emory University, Department of Surgery, Emory Endo- surgery Unit, 1364 Clifton Road, Suite H-127, Atlanta, GA 30322. E-mail: elin2@emory.edu. 620