the increasing rate is accentuated in the united states , where more than one - third of the population is categorized as obese , having a body mass index ( bmi ) greater than 30 kg / m .
a recent review of the economic burden of obesity reported that , over the past 20 years , healthcare costs have increased 2154% for class i obesity ( bmi , 3034.9 ) , 4357% for class ii
these costs were calculated on the a basis of the increases attributable to comorbidities associated with obesity and not simply to the treatment of obesity itself .
included were outcomes , such as increased length of stay for all admissions and increased medical resource usage for nonbariatric surgery .
obesity is a multifactorial condition that has been linked to the development of many other comorbidities and recently has been classified as a unique disease by the american medical association .
one such comorbidity is gastroesophageal reflux disease ( gerd ) , and another is hiatal hernia . the connection between obesity , hiatal hernia , and gerd is well established .
el - serag et al surveyed more than 400 veterans affair volunteers and found that 34.6% of individuals with a bmi exceeding 30 kg / m had gerd symptoms , compared with 17.6% of those with a bmi lower than 25 kg / m .
the nurse 's health study has also been used to investigate the relationship between bmi and gerd . in 2000
both univariate and multivariate analyses in that study found a strong dose - dependent relationship between bmi and frequency of reflux symptoms .
the findings showed a 2- to 3-fold increase in the frequency of reflux symptoms in overweight ( bmi , 2530 kg / m ) and obese ( bmi , > 30 kg / m ) women .
there is a similar relationship between hiatal hernia and obesity . in 1999 , wilson et al found that individuals with a bmi exceeding 30 kg / m were 4.2 times more likely to have hiatal hernia than those with a bmi lower than 25 kg / m .
hiatal hernia also has been found in up to 40% of patients who undergo preoperative esophagogastroduodenoscopy ( egd ) for bariatric surgery .
compared to medical management , antireflux operations for gerd have been found to achieve better symptom control , better quality of life , greater reduction of acid reflux , and fewer treatment failures .
as well , in patients presenting with uncontrolled reflux , the symptoms have often already failed to improve with several over - the - counter medications .
few publications have documented the natural history of nonsurgical management of hiatal hernia . regarding operative repair ,
however , several studies have shown that surgery is safe and feasible and provides short - term resolution of symptoms , especially in the symptomatic population . among these studies , a recent 10-year retrospective review of laparoscopic hiatal hernia repair in giant paraesophageal hernia identified obesity as a risk factor for long - term adverse outcomes . in the nonobese population ,
therefore , surgical options are readily considered for definitive treatment of gerd and hiatal hernia .
however , concomitant obesity complicates this decision , as obesity has also been shown to increase the failure rate of antireflux surgery . because of the increased risk of surgical failure in this challenging population , some groups now recommend consideration of weight loss surgery as a treatment for gerd .
in fact , the most recent society of american gastrointestinal and endoscopic surgeons ( sages ) guidelines on antireflux surgery recommended that gastric bypass be the operation of choice in the morbidly obese population ( bmi , > 35
the alternative , fundoplication , was thought less desirable because of the higher failure rate in this patient group and because it does not correct the underlying problem of obesity .
although there has been increased acceptance of bariatric surgery for gerd and hiatal hernia in the obese population , there are several obstacles , such as patient preference , lack of insurance coverage , and delay in treatment of gerd . many patients with severe reflux or hiatal hernia do not meet medicare requirements for bariatric surgery ( bmi > 40 kg / m , alone , or 3540 kg / m , with significant comorbidities ) .
other patients may meet these requirements , but may prefer not to undergo gastric bypass or are unable to comply with postoperative lifestyle modifications .
the objective of the current study was to analyze outcomes of obese and morbidly obese patients with symptomatic hiatal hernia who underwent surgical repair with the addition of a partial longitudinal gastrectomy during the same operation .
a second series reported positive symptom relief , with no recurrences at a mean of 20 months of postoperative follow - up . in our series ,
a roux - en - y gastric bypass ( rygb ) was not performed because of insurance denial or patient preference .
we hypothesized that the addition of a weight loss component and a tailored esophageal - lengthening concept to the standard structural repair of a hiatal hernia would result in decreased failure rates and improved symptoms in this patient population .
this study was a retrospective analysis of a prospectively maintained database of patients with a bmi greater than 30 kg / m and symptomatic type iii or iv paraesophageal hernia .
the study is a follow - up of a short - term series involving 19 patients .
a review of the patient 's charts was conducted for collection of preoperative data including demographics , bmi , symptoms , use of prescription and nonprescription acid - reducing medication , operative indications , perioperative data ( operative time , technique of crural closure , hospital length of stay , and complications ) , and follow up data ( resolution of symptoms , use of prescription and nonprescription acid - reducing medication , bmi , and further intervention or need for revision ) .
imaging studies , including upper gastrointestinal ( gi ) series , egd , or computed tomographic scan were performed or reviewed if already completed .
patients were also evaluated by a preoperative clearance team consisting of internal medicine and anesthesia practitioners for preoperative risk stratification based on history and medical comorbidities .
the technical aspects of the operation revolved around 3 therapeutic goals : 
 complete reduction of the hernia contents into the abdominal cavity and excision of the hernia sac.enteric mediastinal mobilization for > 3 cm intra - abdominal esophageal length.primary crural closure , with or without mesh reinforcement with acellular porcine dermis 
permacol ( covidien , dublin , ireland ) or strattice ( lifecell , bridgewater , new jersey)or copolymer polyglycolic acid / trimethylene carbonate composite matrix , bio - a ( w. l. gore and associates , flagstaff , arizona).partial longitudinal gastrectomy extending from the incisura angularis to the angle of his with sutured staple line reinforcement .
access to the peritoneal cavity was obtained with an optical trocar , and 4 to 5 working trocars were introduced into the upper abdomen .
the hernia was completely reduced , and the sac was excised to the level of the angle of his .
the esophagus was circumferentially dissected proximally into the mediastinum , to achieve an intra - abdominal esophageal length of 45 cm .
based on the presumed tension and surgeon 's discretion , mesh reinforcement was performed with biologic or bioabsorbable material .
complete reduction of the hernia contents into the abdominal cavity and excision of the hernia sac . enteric mediastinal mobilization for > 3 cm intra - abdominal esophageal length .
permacol ( covidien , dublin , ireland ) or strattice ( lifecell , bridgewater , new jersey)or copolymer polyglycolic acid / trimethylene carbonate composite matrix , bio - a ( w. l. gore and associates , flagstaff , arizona ) .
partial longitudinal gastrectomy extending from the incisura angularis to the angle of his with sutured staple line reinforcement .
the stomach was mobilized , and the short gastric vessels were divided with ultrasonic shears along the greater curvature .
a longitudinal gastrectomy was performed with sequential firings of the endoscopic linear stapler ( echelon flex endopath , ethicon , cincinnati , ohio ) over a bougie dilator or a therapeutic upper endoscope to calibrate the gastrectomy .
the line of transection extended from just proximal to the incisura angularis to the angle of his .
the staple line then was reinforced with a running absorbable suture or staple line reinforcement product ( figure 1 ) .
an intraoperative endoscopy was performed to identify potential leaks and to confirm adequate width of the gastric lumen .
a closed suction drain then was placed along the line of resection in selected cases .
after surgery , most patients ( 24/28 ) underwent an upper gastrointestinal ( ugi ) study .
after a normal contrast study , a liquid diet was initiated and continued throughout the hospital stay .
patients then were seen at a follow - up visit within 4 weeks of discharge and at 3-month intervals as needed . a patient questionnaire ( figure 2 )
was designed to evaluate the main objectives of our study as follows : 
 resolution of symptoms : questions 2 to 8 focused on the presence of upper gi symptoms commonly related to gerd and hiatal hernias . to evaluate the severity of symptoms objectively ,
a severity index score was calculated by assigning 0 to 3 points to each question based on frequency : 0 , absence of symptoms ; 1 , symptoms once a week ; 2 , symptoms 23 days / week ; and 3 , symptoms more than 4 days / week .
the maximum possible score was 21 ( more severe ) , and the minimum score was 0 ( less severe ) .
the pre- and postoperative score for each patient was compared , to assess improvement of symptoms .
patients were also interrogated on the use of prescribed antisecretory medication ( proton pump inhibitor [ ppi]/histamine type 2 receptor [ h2]-blocker ) and over - the - counter medications for related gi symptoms before and after surgery.weight loss : question 1 was used to calculate bmi at the time the questionnaire was conducted.patient satisfaction : questions 1113 evaluated the patient 's perception of improvement and satisfaction with the results .
resolution of symptoms : questions 2 to 8 focused on the presence of upper gi symptoms commonly related to gerd and hiatal hernias . to evaluate the severity of symptoms objectively
, a severity index score was calculated by assigning 0 to 3 points to each question based on frequency : 0 , absence of symptoms ; 1 , symptoms once a week ; 2 , symptoms 23 days / week ; and 3 , symptoms more than 4 days / week .
the maximum possible score was 21 ( more severe ) , and the minimum score was 0 ( less severe ) .
the pre- and postoperative score for each patient was compared , to assess improvement of symptoms .
patients were also interrogated on the use of prescribed antisecretory medication ( proton pump inhibitor [ ppi]/histamine type 2 receptor [ h2]-blocker ) and over - the - counter medications for related gi symptoms before and after surgery .
weight loss : question 1 was used to calculate bmi at the time the questionnaire was conducted .
patient satisfaction : questions 1113 evaluated the patient 's perception of improvement and satisfaction with the results .
bmi and scores were analyzed on a log scale , using additive mixed - modeling techniques , as implemented in the mgcv package in r ( www.r-project.org ) .
the model for bmi includes a random effect for each subject and assumes a first - order autoregressive correlation structure within subjects .
the model for scores includes a random effect for each subject , a random effect for follow - up within each subject , and a first - order autoregressive correlation structure .
changes in ppi use as a function of time were analyzed by using generalized additive modeling techniques and incorporated subject - specific random effects .
comparisons were performed with the multcomp package in r and control the overall error rate at the stated level .
this study was a retrospective analysis of a prospectively maintained database of patients with a bmi greater than 30 kg / m and symptomatic type iii or iv paraesophageal hernia .
the study is a follow - up of a short - term series involving 19 patients .
a review of the patient 's charts was conducted for collection of preoperative data including demographics , bmi , symptoms , use of prescription and nonprescription acid - reducing medication , operative indications , perioperative data ( operative time , technique of crural closure , hospital length of stay , and complications ) , and follow up data ( resolution of symptoms , use of prescription and nonprescription acid - reducing medication , bmi , and further intervention or need for revision ) .
imaging studies , including upper gastrointestinal ( gi ) series , egd , or computed tomographic scan were performed or reviewed if already completed .
patients were also evaluated by a preoperative clearance team consisting of internal medicine and anesthesia practitioners for preoperative risk stratification based on history and medical comorbidities .
the technical aspects of the operation revolved around 3 therapeutic goals : 
 complete reduction of the hernia contents into the abdominal cavity and excision of the hernia sac.enteric mediastinal mobilization for > 3 cm intra - abdominal esophageal length.primary crural closure , with or without mesh reinforcement with acellular porcine dermis 
permacol ( covidien , dublin , ireland ) or strattice ( lifecell , bridgewater , new jersey)or copolymer polyglycolic acid / trimethylene carbonate composite matrix , bio - a ( w. l. gore and associates , flagstaff , arizona).partial longitudinal gastrectomy extending from the incisura angularis to the angle of his with sutured staple line reinforcement .
access to the peritoneal cavity was obtained with an optical trocar , and 4 to 5 working trocars were introduced into the upper abdomen .
the hernia was completely reduced , and the sac was excised to the level of the angle of his .
the esophagus was circumferentially dissected proximally into the mediastinum , to achieve an intra - abdominal esophageal length of 45 cm .
based on the presumed tension and surgeon 's discretion , mesh reinforcement was performed with biologic or bioabsorbable material .
complete reduction of the hernia contents into the abdominal cavity and excision of the hernia sac
permacol ( covidien , dublin , ireland ) or strattice ( lifecell , bridgewater , new jersey)or copolymer polyglycolic acid / trimethylene carbonate composite matrix , bio - a ( w. l. gore and associates , flagstaff , arizona ) .
partial longitudinal gastrectomy extending from the incisura angularis to the angle of his with sutured staple line reinforcement .
the stomach was mobilized , and the short gastric vessels were divided with ultrasonic shears along the greater curvature . a longitudinal gastrectomy was performed with sequential firings of the endoscopic linear stapler ( echelon flex endopath , ethicon , cincinnati , ohio ) over a bougie dilator or a therapeutic upper endoscope to calibrate the gastrectomy .
the line of transection extended from just proximal to the incisura angularis to the angle of his .
the staple line then was reinforced with a running absorbable suture or staple line reinforcement product ( figure 1 ) .
an intraoperative endoscopy was performed to identify potential leaks and to confirm adequate width of the gastric lumen .
a closed suction drain then was placed along the line of resection in selected cases .
after surgery , most patients ( 24/28 ) underwent an upper gastrointestinal ( ugi ) study .
after a normal contrast study , a liquid diet was initiated and continued throughout the hospital stay .
patients then were seen at a follow - up visit within 4 weeks of discharge and at 3-month intervals as needed .
a patient questionnaire ( figure 2 ) was designed to evaluate the main objectives of our study as follows : 
 resolution of symptoms : questions 2 to 8 focused on the presence of upper gi symptoms commonly related to gerd and hiatal hernias . to evaluate the severity of symptoms objectively ,
a severity index score was calculated by assigning 0 to 3 points to each question based on frequency : 0 , absence of symptoms ; 1 , symptoms once a week ; 2 , symptoms 23 days / week ; and 3 , symptoms more than 4 days / week .
the maximum possible score was 21 ( more severe ) , and the minimum score was 0 ( less severe ) .
the pre- and postoperative score for each patient was compared , to assess improvement of symptoms .
patients were also interrogated on the use of prescribed antisecretory medication ( proton pump inhibitor [ ppi]/histamine type 2 receptor [ h2]-blocker ) and over - the - counter medications for related gi symptoms before and after surgery.weight loss : question 1 was used to calculate bmi at the time the questionnaire was conducted.patient satisfaction : questions 1113 evaluated the patient 's perception of improvement and satisfaction with the results .
resolution of symptoms : questions 2 to 8 focused on the presence of upper gi symptoms commonly related to gerd and hiatal hernias . to evaluate the severity of symptoms objectively ,
a severity index score was calculated by assigning 0 to 3 points to each question based on frequency : 0 , absence of symptoms ; 1 , symptoms once a week ; 2 , symptoms 23 days / week ; and 3 , symptoms more than 4 days / week .
the maximum possible score was 21 ( more severe ) , and the minimum score was 0 ( less severe ) .
the pre- and postoperative score for each patient was compared , to assess improvement of symptoms .
patients were also interrogated on the use of prescribed antisecretory medication ( proton pump inhibitor [ ppi]/histamine type 2 receptor [ h2]-blocker ) and over - the - counter medications for related gi symptoms before and after surgery .
weight loss : question 1 was used to calculate bmi at the time the questionnaire was conducted .
patient satisfaction : questions 1113 evaluated the patient 's perception of improvement and satisfaction with the results .
bmi and scores were analyzed on a log scale , using additive mixed - modeling techniques , as implemented in the mgcv package in r ( www.r-project.org ) .
the model for bmi includes a random effect for each subject and assumes a first - order autoregressive correlation structure within subjects .
the model for scores includes a random effect for each subject , a random effect for follow - up within each subject , and a first - order autoregressive correlation structure .
changes in ppi use as a function of time were analyzed by using generalized additive modeling techniques and incorporated subject - specific random effects .
comparisons were performed with the multcomp package in r and control the overall error rate at the stated level .
the patient demographics are listed in table 1 . of the 28 patients , 27 ( 96% ) were women .
the mean preoperative bmi was 38.1  4.9 kg / m ( range , 3048 ) , with 13 patients ( 46.4% ) meeting the criteria for class 2 obesity ( 3540 kg / m ) and 8 ( 28.6% ) meeting the criteria for class 3 obesity ( > 40 kg / m ) .
symptoms at presentation included epigastric pain ( n = 10 ) , reflux / regurgitation ( n = 18 ) , dysphagia ( n = 10 ) , and nausea / emesis ( n = 4 ) . patient demographics and operative data h2b , h2-blocker ; los , length of stay ; pehr , paraesophageal hernia repair . all patients underwent preoperative evaluation with a ugi contrast study , egd ( those studies performed outside of our institution were reviewed ) , or both .
selected patients had a gastric - emptying study or computed tomography as part of their workup , as indicated .
seven patients ( 25% ) had a history of prior hiatal hernia repair with nissen fundoplication , which was performed laparoscopically ( n = 5 ) , laparoscopically with a hand - assisted technique ( n = 1 ) , or via open laparotomy ( n = 1 )
. all 7 of these patients experienced anatomic failures identified during the preoperative workup as defined by transhiatal migration ( n = 6 ) , wrap disruption ( n = 2 ) , and failure of the diaphragmatic closure ( n = 1 ) . of the remaining 21 patients , 16 had type iii and 3 had type iv hernia .
primary hiatal closure was performed in all cases after complete reduction of the hernia and excision of the sac .
permacol mesh was used was in 10 cases ( 56% ) , bio - a in 7 ( 39% ) , and strattice in 1 ( 5% ) .
the procedure was calibrated by using a 36 , 40 , or 50 french maloney dilator .
the gastrectomy staple line was reinforced by imbricated suturing in 27 cases ( 96% ) .
one patient had a nissen fundoplication created with the proximal fundus after longitudinal gastroplasty , and 2 patients had an anterior gastropexy . in 2 patients , additional procedures
the other patient , with a type iv paraesophageal hernia containing transverse colon and spleen , underwent splenectomy for subcapsular bleeding .
one had a liver biopsy performed to evaluate the patient 's hepatomegaly for nonalcoholic steatohepatitis ( nash ) and the second had a left lateral liver resection for a suspect liver lesion .
one patient returned to the operating room for diagnostic laparoscopy and egd on postoperative day 3 for suspected staple line leakage noted during the contrast study .
this patient was later found to have a pulmonary embolism , despite receiving appropriate prophylaxis .
other complications included respiratory failure in 2 patients that necessitated admission to the surgical intensive care unit for respiratory support .
the cause in both cases was decompensation of underlying chronic obstructive pulmonary disease ( copd ) , resulting in a prolonged hospital stay ( 10 and 15 days ) .
finally , there was 1 case of wound infection , which required operative incision and drainage .
the mean length of hospital stay was 5  3 days ( range , 215 ) . within 4 weeks after discharge ,
of the 23 patients , 19 ( 82.6% ) had complete resolution of gastrointestinal symptoms , 2 reported occasional nausea , 1 reported dysphagia , and 1 had reflux symptoms controlled with antisecretory medication .
follow - up data were available for 26 of the 28 patients , as 2 had only recently undergone surgery at the time of collection of data . of these patients ,
21 ( 75% ) completed the telephone survey during a mean follow - up period of 27 months .
the results after the mean follow - up period of 27 months ( range , 546 ) are summarized in table 2 . the symptom severity index ( 021 )
the patients had a mean score of 15  5 ( range , 221 ) .
the mean postoperative symptom severity index was 6  5 ( range , 020 ) .
surgery also was effective in reducing the use of daily antisecretory medications ( ppis / h2-blockers ) , from 96% ( before surgery ) to 62% ( at the time of the survey ) .
the average score at 12 months was about one - tenth of the average score before surgery , and the average score at 24 months was approximately one - fifth of the average score before surgery ( both p < .001 ) .
the average score at 24 months was estimated to be about twice the average score at 12 months , but the difference was not statistically significant ( p = .23 ) .
figure 3 gives the average score as estimated by the model for a 2-year follow - up time .
after a fairly precipitous drop during the 6 months after surgery , the average score did not seem to change appreciably or increased slightly .
pre- and postoperative data average symptom score over the 2-year follow - up . of the 21 patients surveyed , 20 ( 95.2% )
the mean preoperative excess body weight ( ebw ) was 45.3  13.6 kg ( range , 27.376.8 ) . the mean ebw loss was 19.7 kg ( or 44% of ebw )  10.3 kg ( range , 0.438.7 kg , or 1115% ) .
mean preoperative bmi was 38.1  4.9 kg / m ( range , 3048 ) , compared to 31.0  5.4
bmis at 12 and 24 months represent reductions of 20% from preoperative levels ( both p < .001 ) .
change in bmi before and after surgery . regarding ppi use , figure 5 shows the changes in the estimated average probability of ppi use during the 2 years after surgery . before surgery , slightly more than 90% of the patients were on ppis .
the rate of usage decreased in the 2 years after surgery , at which time ppi use was roughly 60% .
the odds of ppi use at 12 months were about one - fifth of those before surgery ( p = .026 ) .
the odds of ppi use at 24 months were about one - tenth of those before surgery ( p = .007 ) .
finally , the odds of ppi use at 24 months were about half of those at 12 months , although the difference was not statistically significant ( p = .15 )
. predicted probability of ppi use . the majority ( 20/28 ; 71% ) of patients surveyed perceived a complete to near complete resolution of symptoms , and all of the patients stated that they would recommend this operation to patients with similar conditions .
treatment failure , defined as recurrence of symptoms at or near the preoperative level , occurred in 2 patients .
one of these patients has since returned to the clinic and reported occasional spasms , persistent reflux including nocturnal cough , and dumping - like symptoms .
some patients did not present for their follow - up appointment , whereas others attended their visit , but did not complete the study . in those studies that were completed ,
only 1 anatomic failure was observed ; however , it was deemed to be clinically insignificant , and the patient was found to be asymptomatic .
failure of antireflux surgery and paraesophageal hernia repair in the obese population has been reported in significantly higher rates than in the population with a normal bmi .
unfortunately , the complex nature of obesity suggests that there are many factors that contribute to the failure of treatment .
lower success rates of operations are seen in the obese population , even in those who do not have symptoms caused by being overweight . in the current study group , this record is compounded by the fact that gerd is caused in part by obesity , and any treatment will be less successful as long as the extra weight is present .
symptom relief was reported by most of our patients in the follow - up survey .
outcomes from the initial short - term study by rodriguez et al showed a significant symptomatic response , in addition to a considerable weight loss . upon follow - up analysis
, we observed a plateau and possible shift toward symptom recurrence , as well as a softening of the weight loss curve . beyond the 1-year mark of the previous study , some patients began experiencing symptom recurrence , which may be interpreted as the  life span  of the antireflux aspect of this approach .
the return of symptoms in our study group was observed to occur only after the initial period of rapid weight loss .
once the rapidity of weight loss decreased , the patients began to experience the discomfort associated with the recurrent reflux .
it follows that a more definitive bariatric approach , providing greater initial weight loss and long - term reinforcement of weight maintenance may result in a more sustained resolution of reflux in this patient group , perhaps in part because of modifications of this operation compared with standard sleeve gastrectomy , including larger bougie size and more proximal stomach transection .
we observed an ebw loss of 44% at a mean follow - up of 26.8 months .
a review of the solitary sleeve gastrectomies reported an ebw loss of 64.7% within a similar time frame .
it should be noted , however , that our patient group differs from the traditional group that undergoes laparoscopic sleeve gastrostomy ( lsg ) in several ways .
first , our patients ' bmi distribution did not exceed 48 , thus excluding the superobese population .
second , the primary end point of our operation was resolution of reflux , not maximal weight loss , which may have affected patients ' postoperative habits regarding diet and lifestyle modification . finally , the longitudinal gastrectomy performed in our patient group was tailored to be wider than traditional lsg , specifically by using a bougie up to 50 french , as opposed to the 36 to 40 french dilators used in traditional lsg .
this widening of the gastrectomy was performed with the intention of preventing the increased reflux disease that occurs with standard lsg .
the softening of the weight loss curve after the initial decrease in weight of the first postoperative year was similar to that observed in both lsg and rygb .
this outcome indicates that , although their initial weight loss was not as significant as that found in a purely bariatric setting , our patients tended to initiate some form of lifestyle modification to maintain their slimmer state .
this concept is important , as regression toward weight gain may complicate the antireflux aspect of this operation and could confound the reports of symptom recurrence .
evaluating symptom resolution in a patient population is difficult , as each patient reports varying degrees of a variety of symptoms for the same condition . in the current group ,
several patients reported minimal initial symptoms , either because of incidental detection of the hernia or because of current pharmacological therapy .
the standardized survey provided an objective set of criteria for patients to report , and , with the aid of frequency options ( days per week ) , patients were also able to describe the degree of symptom resolution or recurrence . with these tools
, we found that all of the patients surveyed reported an improvement of symptoms and most ( 95% ) who underwent this operation had documented weight loss .
the present study , although novel in its approach to combined gerd and obesity treatment , is limited by its small patient group and retrospective design . as a follow - up to the initial short - term study , we observed a change in trajectory in symptom score that tended toward a life span for this procedure .
however , this scoring system is a subjective interpretation by the patient without any correlation with diagnostic imaging or objective follow - up testing .
greater proof of the efficacy of our procedure may be that only 1 patient experienced symptom recurrence severe enough to return for re - evaluation .
a limitation specific to our accumulation of data via survey is the inability to account for outside factors that may have contributed to return of symptoms .
the surveys did not include data on adherence to diet and lifestyle modification , exercise involvement , or smoking status 
repair of paraesophageal hernia in the obese is a challenging clinical scenario , especially when the goal is to achieve reduction in symptoms of gerd .
thus , a new approach is needed that can allow the surgeon to repair the hernia while concomitantly fixing other confounding conditions .
this combined approach , as seen with the addition of a modified bariatric component , has been shown to improve the resolution of symptoms of gerd .
partial longitudinal gastrectomy , as opposed to more definitive bariatric operations , is a viable option as a short - term means of decreasing the impact of obesity on reflux . although more technically demanding than repair of an isolated hernia , the outcome of greater symptom regression and the possibility of avoiding failure of hernia repair make this approach reasonable to pursue in this population .
immediate gerd symptom relief can be achieved through a combined antireflux and weight loss approach , as seen in this cohort . however
the surgical approach described herein may represent a new option for those obese patients who fail to qualify for gastric bypass or would initially prefer to undergo what they deem is a less complicated surgery .
further analysis of larger groups of bariatric patients with reflux is warranted , to determine the efficacy of this combined approach .
longer - term follow - up will aid in observing the natural history of the antireflux aspect of this surgery and will provide a better understanding of the recurrence of reflux after repair .
 background and objectives : treatment of gastroesophageal reflux disease ( gerd ) with hiatal hernia in obese patients has proven difficult , as studies demonstrate poor symptom control and high failure rates in this patient population . 
 recent data have shown that incorporating weight loss procedures into the treatment of reflux may improve overall outcomes.methods:we retrospectively reviewed 28 obese and morbidly obese patients who presented from december 2007 through july 2013 with large or recurrent type 3 or 4 paraesophageal hernia . 
 all of the patients underwent combined paraesophageal hernia repair and partial longitudinal gastrectomy . 
 charts were retrospectively reviewed , and the patients were contacted to determine symptomatic relief.results:mean preoperative body mass index was 38.1  4.9 kg / m2 . 
 anatomic failure of prior fundoplication occurred in 7 patients ( 25% ) . 
 the remaining 21 had primary paraesophageal hernia , 3 of which were type 4 . 
 postoperative complications included pulmonary embolism ( n = 1 ) , pulmonary decompensation ( n = 2 ) , and wound infection ( n = 1 ) . mean hospital stay was 5  3 days . upper gastrointestinal esophagogram was performed in 21 patients with no immediate recurrence or staple line dehiscence . 
 mean excess weight loss was 44  25% . 
 all of the patients surveyed experienced near to total resolution of their preoperative symptoms within the first month . at 1 year 
 , symptom scores decreased significantly . at 27 months , however , there was a mild increase in the scores . 
 return of severe symptoms occurred in 2 patients , both of whom underwent conversion to gastric bypass.conclusions:combined laparoscopic paraesophageal hernia repair with longitudinal partial gastrectomy offers a safe , feasible approach to the management of large or recurrent paraesophageal hernia in well - selected obese and morbidly obese patients . 
 short - term results were promising ; however , intermediate results showed increasing rates of reflux symptoms that required medical therapy or conversion to gastric bypass . 
INTRODUCTION
METHODS
Study Population
Preoperative Workup
Surgical Technique and Postoperative Management
Patient Questionnaire and Evaluation of Outcomes
Statistical Analysis
RESULTS
DISCUSSION
CONCLUSION