Acute hiatal hernia with oesophageal perforation following Heller's operation

Application of botulinum toxin in pregnancy and its impact on female reproductive health

Introduction: Botulinum toxin (BoNT) is a protein secreted by the anaerobic Gram-negative bacterium Clostridium botulinum. Among the seven known subtypes, type A is the most commonly used in women to treat diseases. It primarily blocks presynaptic release of acetylcholine at the neuromuscular junction, resulting in temporary muscle paralysis; thus, it is suitable for treating dystonia and other systemic diseases. BoNT is used widely for treating diseases that persist throughout, and may worsen during, pregnancy, such as cervical dystonia and achalasia. Thus, it is important to investigate whether BoNT injection during pregnancy causes side effects in pregnant women, fetuses, or newborns.Areas covered: This review highlights the efficiency and safety of BoNT injection in pregnancy. and assessed current literature with respect to the use of BoNT for disease treatment during pregnancy.Expert opinion: BoNT injection does not increase the risk of complications in pregnant women and fetuses. However, the use of BoNT to treat disease during pregnancy requires fully informed consent from patients. In addition, further research is needed to determine how to reduce the side effects of BoNT injection during pregnancy (e.g., by improving drug composition, or adjusting the amount of BoNT or the injection interval).

Diaphragmatic hernia after laparoscopic esophagomyotomy for esophageal achalasia in pregnancy

Background. The optimal treatment for management of esophageal achalasia in pregnancy is controversial. Little information exists about pregnancy outcome after successful myotomy. Case. Achalasia in pregnancy was diagnosed when a patient presented with pneumomediastinum from microrupture of the overdistended esophagus. An attempt at surgical correction failed due to the development of aspiration pneumonia with general anesthesia. Conservative medical therapy was undertaken, but fetal growth restriction developed. The patient underwent interval surgical correction, but subsequent pregnancy 6 months later was complicated by acute diaphragmatic hernia necessitating preterm delivery. Conclusion. Prior to surgery in pregnancy, emptying the dilated esophagus via nasoesophageal tube suctioning maybe warranted to avoid aspiration. Women, despite having undergone successful myotomy, should be counseled on the risks of pregnancy and to avoid pregnancy for at least 1 year thereafter.

Diaphragmatic Hernia after Ivor-Lewis Esophagectomy Manifested as Lower Gastrointestinal Bleeding

Diaphragmatic hernia after esophageal resection is a recognized but rare complication. Parahiatal hernias may result from manipulation and extension of the crura during surgery. This can lead to a wide array of symptoms depending on the extent and organ that is herniated. A high index of suspicion is required because there is no one symptom that is specific for herniation. This report represents the first case of a patient presenting with lower gastrointestinal bleed from a parahiatal hernia after esophageal resection.

Oesophagomyotomy for achalasia: a 22-year experience

To determine the clinical results in achalasia, particularly as regards postoperative gastro-oesophageal reflux, a 22-year personal experience with transthoracic short oesophagomyotomy without an antireflux procedure was analysed. A total of 185 such procedures were performed, of which 179 (97 per cent) were available for analysis. There was an overall improvement rate of 89 per cent over a mean postoperative interval of 9 years. Primary procedures were followed by a 93 per cent rate of improvement. Twenty patients, nine of whom had previously undergone one or more oesophageal operations, were considered as having a poor result. Marked gastro-oesophageal reflux accounted for a poor outcome in nine patients. Although the overall rate of postoperative improvement did not deteriorate significantly with time, the level of improvement did, the proportion of excellent results declining from 54 to 32 per cent (P = 0.02) at 10-20 years after operation. These findings substantiate the view that a short transthoracic oesophagomyotomy without an antireflux procedure provides excellent long-term relief of dysphagia for the patient with oesophageal achalasia and is accompanied by an extremely low risk of serious postoperative gastro-oesophageal reflux.

Esophageal perforation: a continuing challenge

Perforation of the esophagus remains a diagnostic and therapeutic challenge. Currently, the most common cause of perforation is instrumentation of the esophagus, and the incidence of esophageal perforations has increased as the use of endoscopic procedures has become more frequent. Diagnosis depends on a high degree of suspicion and recognition of clinical features, and is confirmed by contrast esophagography or endoscopy. Outcome after esophageal perforation is dependent on the cause and location of the injury, the presence of underlying esophageal disease, and the interval between injury and initiation of treatment. Reinforced primary repair of the perforation is the most frequently employed and preferable approach to the surgical management of esophageal perforations. Nonoperative management consisting of antibiotics and parenteral nutrition is particularly successful for limited esophageal injuries meeting proper selection criteria.

Iatrogenic paraesophageal hiatus hernia

Between January 1970 and January 1990, 101 patients with paraesophageal hiatus hernias were operated on at the Lahey Clinic Medical Center. Thirteen patients had hernias that were identified as being iatrogenic in origin, a prevalence of 13%. Ten hernias were secondary to antireflux procedures, and esophagomyotomy, esophagogastrectomy, and placement of an Angelchik prosthesis accounted for one case each. Symptoms did not differ substantially from those of patients with primary hernias. Incarceration occurred in 2 patients, but neither sustained strangulation. The pathogenesis was most frequently disruption of a previous hiatal closure. Other etiological factors included disruption of the phreno-esophageal membrane by operative dissection, postoperative gastric dilatation, and failure to recognize esophageal shortening or an existing hiatal defect. Abdominal repair was usually possible, but 3 patients required thoracotomy for reduction. There has been one known recurrence during a median follow-up of 41 months.

Incarcerated parahiatal hernia with gastric necrosis

A parahiatal diaphragmatic hernia developed five years after transthoracic Heller myotomy. Failure to recognize this complication resulted in strangulation and necrosis of the gastric fundus. To our knowledge, this is the first reported case of a postoperative parahiatal hernia that did not follow the use of a diaphragmatic counterincision. Prompt recognition of this complication will prevent unnecessary morbidity and mortality.

Acute hiatal hernia after Heller's operation

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