Background

The incidence of gastroesophageal reflux disease (GERD) and hiatal hernia (HH) in the bariatric population is as high as 40% and 37%, respectively. Laparoscopic Nissen fundoplication is the treatment of choice for GERD resistant to medical therapy in patients without obesity. In populations with obesity, laparoscopic sleeve gastrectomy (LSG) may be considered. LSG is relatively contraindicated in the presence of Barrett's esophagus (BE) however, and therefore laparoscopic Roux-en-Y gastric bypass (LRYGB) is the most effective surgical option in the setting of obesity, GERD with BE, and associated comorbid conditions.

Methods

We present an interesting finding of an unknown mediastinal mass encountered during HH repair and LRYGB in a 51-year-old male with morbid obesity and chronic GERD, found to have BE on pre-operative screening upper endoscopy.ResultsIn this video, we show the dissection of the posterior mediastinum, excision of an unexpected lipomatous mass, primary posterior HH repair, and a LRYGB.

Results

While its normal anatomic position is in the anterior mediastinum, the thymic tissue can be located anywhere along its embryonic descent, and, in our patient, a benign thymolipoma was found posteriorly. There is no established role for routine upper endoscopy, barium esophagram, or manometry in preoperative workup of bariatric surgery patients. However, endoscopic screening for BE is commonly performed in selected high risk patients as it may affect surgical options.

Conclusions

Our case illustrates the types of masses that may be encountered in the mediastinal space during mobilization of the esophagus during LRYGB and HH repair.