Laparoscopic Paraesophageal Hernia Reduc- tion with Two Point Fixation via Ponsky PEG Tube in a Patient in their early 90s

PETZINGER CT, PARMELY JD. Laparoscopic Paraesophageal Hernia Reduction with Two Point Fixation via Ponsky PEG Tube in a Patient in their early 90s. Spartan Med. Res. J. Vol. 2, No.1, pp. 74-85, 2017. CONTEXT: Paraesphageal hernia (PEH) repairs have been historically controversial due to widely variable clinician opinions. However, there is little research regarding the use of PEH reduction and gastropexy via a percutaneous endoscopic gastrostomy (PEG) tube. Guidelines by the Society of American Gastrointestinal and Endoscopic Surgeons do advise that the use of gastropexy alone is a valid option in patients with high risk of morbidity and mortality, but is associated with high hernia recurrence rates. CASE REPORT: A male in his early 90s presented with a six-week history of dysphagia, regurgitation and a 30pound weight loss. Imaging revealed a large PEH and the entire stomach within the thoracic cavity. Despite the patient's age and significant risk factors, it was determined that he required surgical intervention due to the severity of his symptoms. The safest course of action was reduction of PEH with two-point gastric fixation, rather than a prolonged repair of the hiatus or mesh implant. RESULTS: Due to the patient’s significant surgical risks, it was determined that the safest surgical approach would be laparoscopic reduction with dual gastropexy via PEG tube gastropexy. This approach was quick, without encroachment into the mediastinum and avoided any complications that mesh implantation could have posed. CONCLUSIONS: Gastropexy is a relatively simple technique with minimal tissue dissection that is tolerated well in elderly patients or those with decreased cardiac and pulmonary status. Regardless of the surgical PEH approach, there are inherent hernia recurrence rates.