MULTIMEDIA ARTICLE Mesh Repair of a Giant Para-Esophageal Hernia + Sleeve Gastrectomy. Combined Treatment of Intra-Thoracic Stomach and Morbid Obesity: a Video Case Presentation Mehmet Ali Yerdel 1 & İsmail Çalıkoğlu 1 & Görkem Özgen 1 # Springer Science+Business Media, LLC, part of Springer Nature 2020 Abstract Concurrent surgical treatment of an intra-gastric stomach + morbid obesity is demonstrated. Video footage on diagnosis (gas- troscopy and upper GI series) and surgical steps, as well as 2-year outcome (upper GI series), is presented. Although controversy exists regarding the best bariatric option when concomitantly repairing a giant para-esophageal hernia, in the light of recent reports and our own experience, sleeve gastrectomy may be the procedure of choice if reflux is no issue. Keywords Sleeve gastrectomy . Para-esophageal hernia . Intra-thoracic stomach . Hiatal hernia . Morbid obesity . Mesh repair Introduction Obesity, a risk for hiatal hernia, is a pandemic. An increasing number of morbidly obese with varying types/sizes of hiatal hernias are being referred for bariatric surgery. Although less than 5% of all hiatal defects are para-esophageal hernias (PEHs), their clinical significance is much higher than sliding hernias since all PEHs require surgical correction. The best bariatric surgical op- tion, when concurrently repairing a PEH, is controversial. We present a video detailing the diagnosis, management, and 2-year outcome of a morbidly obese patient with intra- thoracic stomach. Case Report The patient was a 55-year-old male with a body mass index (BMI) of 43 kg/m 2 , metabolic syndrome (MetS), epigastric discomfort, and iron deficiency anemia due to bleeding Cameron’s ulcers. He had no symptoms of reflux. Upper GI series, gastroscopy, and the surgical steps are shown in the video. Post-operative recovery was uneventful. Oral intake was started on the day after surgery, following an upper GI study (Fig. 1). He was discharged on day 5 without complications. At the 25th month of follow-up, BMI was 29 kg/m 2 , there was no recurrent herniation (Fig. 1), and anemia and MetS had resolved. He was free of reflux symptoms without acid suppression, although conclusive evidence on the ab- sence of reflux is lacking since no gastroscopy/pH me- ter study was performed. Discussion Intra-thoracic stomach is life-threatening. The threat to the patient is more imminent than the risks posed by morbid obesity/MetS. Many bariatric surgeons feel the presence of a standard PEH should not affect the choice of bariatric procedure in the absence of reflux. However, recent data showing the safety of SG with concomitant PEH repairs deserves attention [1–6]. An excellent recent analysis from accredited bariatric centers across North America revealed less morbidity with SG com- pared with Roux-en-Y gastric bypass (RYGB) done with con- comitant PEH repairs [5]. Electronic supplementary material The online version of this article (https://doi.org/10.1007/s11695-020-04707-w) contains supplementary material, which is available to authorized users. * Mehmet Ali Yerdel yerdel@yerdel.com 1 İstanbul Bariatrics, Obesity and Advanced Laparoscopy Center, Hakkı Yeten Cad, Yeşil Çimen Sok, Polat Tower, Şişli, 34394 İstanbul, Turkey Obesity Surgery https://doi.org/10.1007/s11695-020-04707-w