Laparoscopic distal gastrectomy with simultaneous hiatal repair for gastric cancer associated with a paraesophageal hernia containing the small intestine: a case report

Abstract

Introduction:

Simultaneous resection of gastric cancer and repair of a paraesophageal hernia (PEH) are rarely reported. In older patients, marked anatomical distortion may make oncologic resection, hernia repair, and reconstruction technically challenging. We report a case of gastric cancer with concomitant type IV PEH managed by laparoscopic distal gastrectomy and simultaneous hiatal repair.

Case presentation:

An 82-year-old man presented with epigastric discomfort. He had a history of endoscopic submucosal dissection for early gastric cancer, chronic obstructive pulmonary disease, and mild cognitive decline. Esophagogastroduodenoscopy revealed a type-1 antral tumor, and biopsy showed well-differentiated tubular adenocarcinoma. Computed tomography demonstrated small-intestinal herniation into the mediastinum through a markedly enlarged hiatus, consistent with type IV PEH. Laparoscopic distal gastrectomy with D1 lymphadenectomy and simultaneous hiatal repair was performed. After reduction of the herniated intestine, the crura were approximated with nonabsorbable sutures. Billroth II reconstruction was selected to minimize anastomotic tension under the distorted anatomy. Transient postoperative pneumonia and cognitive decline were managed conservatively.

Clinical discussion:

This case illustrates the technical challenges of treating gastric cancer complicated by type IV PEH in an older patient. Laparoscopy provided clear visualization of the enlarged hiatus and facilitated safe reduction and repair. Billroth II reconstruction helped reduce anastomotic tension in the setting of altered anatomy.

Conclusions:

Laparoscopic distal gastrectomy with simultaneous hiatal repair may be feasible in patients with gastric cancer and concomitant type IV PEH. Careful reconstruction, selection, and perioperative management of frailty-related complications are essential in older patients.

Introduction

Paraesophageal hernia (PEH) is an age-related condition caused by fibromuscular degeneration of the phrenoesophageal membrane^[1,2^]. Hiatal hernias are generally classified into four types: Type I, sliding hiatal hernia; Type II, true PEH; Type III, combined sliding and paraesophageal hiatal hernia; and Type IV, complex paraesophageal hiatal hernia involving intrathoracic herniation of organs other than the stomach, such as the colon, omentum, small bowel, spleen, or liver[2]. Simultaneous resection of gastric cancer and PEH repair has rarely been reported^[3–7^]. Previous reports have described gastric cancer resection in patients with a PEH or an intrathoracic inverted stomach, including a patient in whom the entire stomach and part of the duodenum were located in the mediastinum[7]. However, reports of laparoscopic distal gastrectomy with simultaneous hiatal repair for gastric cancer associated with a Type IV PEH containing non-duodenal small-intestinal loops remain extremely limited. Therefore, the optimal surgical strategy, particularly the feasibility of a laparoscopic approach and the choice of reconstruction under markedly distorted anatomy, remains unclear. Herein, we report a patient with gastric cancer complicated by a large Type IV PEH who was successfully treated with laparoscopic distal gastrectomy and simultaneous hiatal repair, highlighting key operative considerations in this complex setting. This case has been reported in line with the SCARE 2025 criteria[8].

HIGHLIGHTS

• Simultaneous gastrectomy and paraesophageal hernia repair is rarely reported.

• This case involved a Type IV paraesophageal hernia with herniation of the small intestine.

• Laparoscopic surgery enabled the safe reduction and precise hiatal reconstruction.

• Surgical complexity is increased in elderly patients due to anatomical distortion.

• Tailored reconstruction supported a safe and risk-adapted oncologic approach.

Case presentation

An unemployed 82-year-old Japanese man who was physically independent but institutionalized presented with epigastric discomfort. Six years earlier, he had undergone endoscopic submucosal dissection for early gastric cancer (pT1a, clinically N0M0, stage IA). His medical history included chronic obstructive pulmonary disease, cholelithiasis, and mild cognitive decline, and he was not taking any routine medications. He had no food or drug allergies. Family history was unremarkable. He did not smoke or drink alcohol. His height was 145.5 cm, and his body weight was 51 kg. Laboratory findings at his initial visit showed mildly elevated blood urea nitrogen level (24 mg/dL) and serum creatinine (1.49 mg/dL) levels, with no other significant abnormalities. Tumor markers, including carcinoembryonic antigen and carbohydrate antigen 19-9, were within normal ranges. Physical examination revealed a soft, flat abdomen without palpable masses.

Esophagogastroduodenoscopy performed 2 weeks after the initial visit revealed a type-1 tumor along the lesser curvature of the antrum, and biopsy confirmed well-differentiated tubular adenocarcinoma. Contrast-enhanced computed tomography on the same day demonstrated a large PEH with herniation of small intestinal loops into the mediastinum (Fig. 1A and B). Preoperative computed tomography also revealed multiple well-circumscribed hypodense lesions in the liver, which showed no contrast enhancement and were interpreted as benign hepatic cysts rather than metastatic lesions. The tumor was located adjacent to the herniated intestine, and no distant metastases were detected. The preoperative diagnosis was cT3N0M0, cStage IIA.

Figure 1.

Preoperative findings. Computed tomography images demonstrating a type IV paraesophageal hernia containing herniated loops of small intestine. Red arrows indicate the herniated small intestine. (A) Coronal view. (B) Axial view.

Laparoscopic surgery was performed 1 month after the initial visit using 5 ports with a carbon dioxide pneumoperitoneum. The patient was placed in the reverse Trendelenburg position under general anesthesia. Intraoperatively, the small intestine had herniated through a markedly enlarged esophageal hiatus into the thoracic cavity (Fig. 2A). After reduction of the herniated intestine, distal gastrectomy with D1 lymphadenectomy was performed, followed by Billroth II reconstruction. D1 dissection was selected as a risk-adapted strategy, considering the patient’s advanced age and comorbidities. Cholecystectomy was also performed for concomitant cholelithiasis. The diaphragmatic crura were reapproximated using interrupted nonabsorbable sutures to close the hernial orifice (Fig. 2B). Gastrojejunostomy was performed intracorporeally using a linear stapler, and jejunojejunostomy was completed extracorporeally. The operative time was 278 minutes, with a blood loss of 20 mL. The procedure was performed by experienced gastrointestinal surgeons at a tertiary referral center.

Figure 2.

Intraoperative findings. (A) Herniated small intestine observed within the thoracic cavity through a markedly dilated hiatus. (B) Closure of the diaphragmatic crura with interrupted non-absorbable sutures after reduction of the herniated bowel.

Oral intake was resumed on postoperative day 7, and contrast-enhanced radiography confirmed no anastomotic leakage. The postoperative course was complicated by transient pneumonia and temporary cognitive decline, both of which were managed conservatively. Prolonged rehabilitation was required owing to disuse-related functional decline, and the patient was discharged on postoperative day 48.

Macroscopic examination revealed a type 1 tumor measuring 3.5 × 4.5 cm (Fig. 3). Histopathological analysis demonstrated moderately differentiated tubular adenocarcinoma without lymphovascular invasion or lymph node metastasis. The final pathological stage was pT1bN0M0, pStage IA. The patient was followed up in the outpatient clinic at regular intervals, with blood tests and imaging. He was alive without recurrence after 12 months of follow-up.

Figure 3.

Image of the resected specimen.

Discussion

This case illustrates practical operative considerations in the management of gastric cancer complicated by a large type IV PEH containing non-duodenal small-bowel loops. Although simultaneous gastrectomy and hiatal hernia repair have been described, including laparoscopic- or laparoscopy-assisted procedures for gastric cancer associated with PEH or an intrathoracic inverted stomach, this setting remains technically challenging. Intrathoracic migration of viscera and marked distortion of the gastric and hiatal anatomy may complicate preoperative staging, oncologic resection, reconstruction, and secure crural closure. In the present case, a laparoscopic approach enabled reduction of the herniated bowel, distal gastrectomy with risk-adapted lymphadenectomy, tension-reducing Billroth II reconstruction, and primary hiatal repair. These findings suggest that, in carefully selected frail older patients, a tailored laparoscopic strategy may be feasible when operative planning accounts for both oncologic requirements and PEH-related anatomical distortion.

PEH is a true hernia, the prevalence of which increases with age owing to the degeneration of the phrenoesophageal membrane and diaphragmatic supporting structures^[1,2^]. Previously reported cases of gastric cancer associated with PEH or hiatal hernia are summarized in Supplemental Digital Content 1, Table 1, available at: https://links.lww.com/IJSCR/A130^[3,5–7^] Type IV PEH represents the most advanced form and involves herniation of organs other than the stomach through the esophageal hiatus[9]. Surgical repair is generally recommended for symptomatic or advanced PEH owing to the risks of volvulus, obstruction, and cardiopulmonary compromise[10].

When gastric cancer coexists with an advanced PEH, surgeons must balance oncologic radicality with safe hernia repair. For older patients, decreased physiological reserve and altered anatomy due to a PEH make it difficult to achieve both safe hernia reduction and repair and adequate gastric cancer resection. For this patient, a laparoscopic approach provided important technical advantages, including enhanced visualization of the esophageal hiatus and mediastinum, facilitating the safe reduction of herniated viscera and precise crural closure while minimizing surgical trauma. The discrepancy between the preoperative clinical stage and final pathological stage may reflect the difficulty of accurately assessing tumor depth in the setting of marked anatomical distortion caused by the large PEH. Altered gastric anatomy can limit the accuracy of endoscopic and radiological evaluations. Endoscopic ultrasound was not performed because the large Type IV PEH caused marked anatomical distortion, making the procedure technically difficult and potentially unsafe. Thus, preoperative staging was based on conventional endoscopy, biopsy, and contrast-enhanced computed tomography. In this setting, the distorted intrathoracic position of the stomach and associated wall deformation may have led to overestimation of tumor depth on preoperative imaging.

This case also highlights key operative decision-making. Mesh reinforcement was not used in the present case. Although biosynthetic or slowly absorbable mesh may reduce hernia recurrence after the repair of large Type IV PEHs, the simultaneous distal gastrectomy with Billroth II reconstruction involves gastrointestinal reconstruction in a clean-contaminated operative field. We were concerned that hiatal mesh placement in this setting could increase the risk of local infection, inflammatory fibrosis, postoperative dysphagia, or difficulty in managing potential reconstructive complications^[11,12^].

Fundoplication was also not performed because distal gastrectomy with Billroth II reconstruction made a classic 360° Nissen fundoplication anatomically inapplicable. The operative strategy was therefore focused on safe oncological resection, adequate lymph node dissection, and tension-free reconstruction rather than antireflux fundoplication. Billroth II reconstruction was selected to minimize anastomotic tension and operative complexity in the setting of distorted anatomy. Reconstruction after distal gastrectomy should therefore be individualized according to the patient’s condition and anatomical factors[13].

This report has some limitations. First, it describes a single case. Second, long-term outcomes, including hernia recurrence and oncologic prognosis, were not fully evaluated. Further studies are required to clarify the optimal surgical strategies and long-term outcomes in patients with gastric cancer complicated by advanced PEH.

Conclusion

Laparoscopic distal gastrectomy combined with repair of a large type IV PEH can be safely performed in selected patients. Careful reduction of the herniated viscera, secure crural closure, and reconstruction tailored to altered anatomy and patient frailty are essential for achieving favorable outcomes.

Ethical approval

Ethical approval and consent to participate were not required for this study, in accordance with institutional and national guidelines, as this was a single case report and did not involve invasive procedures or interventions performed for research purposes.

Consent

Written informed consent was obtained from the patient for the publication of the case report and accompanying images.

Sources of funding

The authors received no financial support for the research, authorship, or publication of this article.

Author contributions

Yusuke Matsune: Writing – original draft preparation. Mikio Makuuchi: Supervision. Shiori Yokoi, Osamu Uemichi, Kosuke Yamada, and Takeshi Aoki: Writing – review and editing. All authors reviewed and approved the final manuscript and agree to be accountable for all aspects of the work.

Conflicts of interest disclosure

None.

Research registration unique identifying number (UIN)

Not applicable.

Guarantor

Yusuke Matsune.

Provenance and peer review

Not commissioned; externally peer-reviewed.

Data availability statement

Data sharing is not applicable to this article, as no datasets were generated or analyzed during the current study.

AI use statement

The authors declare that no generative or non-generative artificial intelligence (AI) tools, including large language models (LLMs), were used in the writing, editing, or generation of this manuscript. All content was written and reviewed solely by the authors.