Presentation
Mild intermittent upper abdominal pain and reflux symptoms. One year previously, she had undergone a sleeve gastrectomy for morbid obesity (BMI 48). Preoperative studies of upper gastrointestinal tract and gastroscopy were normal.
Patient Data
Tortuous esophagus, the gastro-esophageal junction is displaced >2 cm above the esophageal hiatus and part of the gastric tube is seen displaced above the diaphragm.
Widening of esophageal hiatus, dehiscence of diaphragmatic crura (>15 mm) and intrathoracic staple line (noted in the posterior mediastinum along the border of the herniated gastric tube).
Case Discussion
Sleeve gastrectomy (SG) is a frequent surgical procedure for the treatment of morbid obesity. De novo hiatal hernia of the gastric tube can occur as a complication.
The suggested mechanisms responsible for the development of a hiatal hernia after sleeve gastrectomy are:
- dissection of hiatal ligaments (phrenogastric and phreno-oesophagal ligaments during the creation of the gastric tube)
- tubular shape of the gastric sleeve and the difficulty in anchoring the sleeve to the surrounding structures
- rapid weight loss following the SG may lead to enlargement of the hiatal orifice
- regaining of body weight and the dilatation of the whole gastric tube might also be a factor because of the increase in intragastric pressure
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