Massive Type IV Hiatal Hernia with Gastric Volvulus Complicates Recovery Following Tirzepatide Dose Increase

Massive Type IV paraesophageal hiatal hernias are rare but pose a significant risk of life-threatening complications, including gastric volvulus, incarceration, and herniation of other intra-abdominal organs. Pancreatic herniation and associated pancreatitis are exceptionally uncommon. Current surgical approaches aim for reduction and repair, but recurrence and long-term complications remain substantial challenges, particularly in patients with comorbidities or multi-organ involvement. Understanding potential triggers or exacerbating factors for these complex presentations is crucial for patient management and risk assessment.

This case report details a 74-year-old woman with Barrett's esophagus, COPD, and obesity who presented with nausea, vomiting, and abdominal pain following a recent increase in her tirzepatide dose. Imaging confirmed a massive Type IV paraesophageal hernia with organoaxial gastric volvulus. Initial laparoscopic reduction was aborted due to dense adhesions and a foreshortened esophagus. She subsequently developed progressive herniation involving the stomach, colon, and pancreatic body and tail, necessitating delayed robotic-assisted repair. The patient's complex postoperative course was monitored for recurrences and complications.

The patient's initial laparoscopic repair was unsuccessful due to significant anatomical challenges. Following this, she experienced progressive herniation, ultimately requiring a delayed robotic-assisted repair. Despite this advanced surgical approach, her postoperative course was highly complicated by multiple recurrences, including episodes of volvulus, duodenal obstruction, and mild pancreatitis. She subsequently required an open repair with mesh reinforcement and gastropexy after unsuccessful endoscopic detorsion. This intervention provided temporary improvement, but she later developed recurrent herniation and severe gastroparesis, which was likely secondary to injury to the vagal nerve during the extensive surgical interventions. The case highlights the persistent challenges in achieving definitive repair and preventing long-term sequelae. > The patient experienced multiple recurrences of gastric volvulus and herniation, ultimately developing severe gastroparesis likely due to vagal nerve injury, despite advanced surgical repairs.