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

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.