Laparoscopic Treatment of a Unique Case of Large Sliding Paraesophageal Hiatal Hernia with Intrathoracic Stomach and Achalasia

Abstract

Purpose: We present a unique case of large sliding paraesophageal hiatal hernia, intrathoracic stomach and achalasia in a 54 year old male. Due to the concomitant paraesophageal hiatal hernia and intrathoracic stomach, and the need for surgical treatment, endoscopic management for achalasia was not attempted. The patient underwent laparoscopic paraesophageal hiatal hernia with reduction of intrathoracic stomach, Heller myotomy and Dorr fundoplication. The patient's postoperative course was uneventful and resulted in resolution of his symptoms. Treatment options, including surgical management, and a literature review are discussed. Vignette: A 54 year old male with a history of hypertension and kidney stones presented to us with one year history of progressively worsening dysphagia initially to solids then to liquid solids and liquid. His symptoms included vomiting undigested food. Our work up, including esophagram with upper gastrointestinal follow through (UGIFT) (Figure 1), computed tomography of the chest with oral contrast (Figure 2), upper endoscopy and endoscopic ultrasound (Figure 3), were consistent with the diagnosis of large sliding paraesophageal hiatal hernia, intrathoracic stomach and achalasia. The patient underwent laparoscopic paraesophageal hiatal hernia with reduction of intrathoracic stomach and Heller myotomy and Dorr fundoplication. The patient tolerated the procedure well and had uneventful postoperative course. An UGIFT performed post operatively did not reveal any leak. The patient's diet was advanced and tolerated. The patient's initial symptoms normalized. The patient continued to do very well postoperatively, including tolerating diet, weight gain and a complete resolution of his symptoms at the 3 months follow up interval. (Discussion will be provided).Figure