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Introduction: Hiatal hernias (HH) are a protrusion of the stomach through the diaphragmatic hiatus with an estimated prevalence of 10% in the adult population in the USA. Paraoesophageal hernias (PEH) are subset of HH characterized by herniation of the gastric fundus with possible involvement of the GE junction and other viscera. They are associated with increased morbidity and mortality if not treated. We report a case of a 78-year-old female with a giant PEH with herniation of nearly 100% of her stomach into the thorax.

Case Description: A 78-year-old female with history of GERD presented with abdominal pain and symptoms of gastric outlet obstruction. Upper GI series (UGI) with barium swallow revealed a giant PEH with organoaxial volvulus. Nearly 100% of the stomach was found in the thorax. She was treated initially with gastric decompression and slowly advancing diet to full liquids and was discharged home. She underwent preoperative workup including EGD, UGI, and medical optimization. 2 weeks later, an elective laparoscopic repair with partial (Dor) fundoplication was performed, and the patient was discharged on PODReti.

Conclusions: Large PEHs carry a high risk of serious complications, such as volvulus, obstruction, bleeding, and ulcerations. When diagnosed, large PEH should be repaired electively, even if asymptomatic. Emergency repair of symptomatic PEH is associated with higher morbidity and mortality, and therefore, every effort should be made to optimize the patient medical conditions preoperatively. Our patient tolerated the procedure well, showed resolution of reflux symptoms, and is doing well one year after repair.

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