Background

A 55 y/o Female, current BMI 31 underwent a laparoscopic ante-colic, ante-gastric Roux-en-Y gastric bypass 6 years prior to presentation to our practice. Her original surgery and recovery were unremarkable and she had excellent weight loss. Recently, she has had a 5-month history of progressive dysphagia, regurgitation, reflux, and cough. Additional symptoms include chest pain and occasional vomiting with relief of symptoms. As part of a workup for her symptoms, an UGI demonstrates gastric pouch migration to the mediastinum with a radiographic diagnosis of “achalasia” due to a birds-beak appearance of the gastrojejunal anastomosis.

Methods

This video shows our robotic technique for exploration of the GE junction revealing a sliding type 1 hiatal hernia. The gastric pouch and GJ anastomosis was reduced and a posterior repair was performed, facilitated with an intra-operative endoscopy. A biosynthetic polymer web scaffold mesh was used to reinforce the repair.

Results

The patient had resolution of most symptoms including reflux and regurgitation. Early after surgery, she had some mild dysphagia and mild gas-bloat syndrome. Both improved with dietary coaching. There was no significant change in her BMI.

Conclusions

New onset GERD symptoms should be carefully evaluated after RYGB surgery. These hiatal hernias can present with atypical symptoms that may or may not be related to eating. As a result, these symptoms should not necessarily be attributed to poor dietary habits. Hiatal hernias can be missed at initial surgery or develop de novo after bariatric surgery, leading to significant nutritional and functional disability.