Hiatal hernias

From Silent to Severe: Gastric Perforation Causing Spontaneous Hydropneumothorax Secondary to a Large Hiatal Hernia

Hiatal hernias, characterized by the protrusion of internal organs through the diaphragmatic hiatus, are commonly seen in the elderly age group. While surgical management remains debatable for asymptomatic cases, emergent complications necessitate prompt intervention. Here, we present a case of a 69-year-old female with a history of diaphragmatic hernia, who developed acute hypoxic respiratory failure secondary to acute pleural effusion caused by paraesophageal hernia rupture. Despite initial inconclusive imaging, a CT scan revealed the severity, prompting emergent management. The patient underwent esophageal stent placement, video-assisted thoracoscopic surgery-assisted total lung decortication, and three chest tubes placement, followed by antimicrobial therapy. Favorable outcomes were achieved with multidisciplinary intervention, highlighting the importance of timely recognition and comprehensive diagnostic approaches. This case underscores the potential severity of hiatal hernias, particularly paraesophageal types, necessitating vigilance among clinicians for timely intervention. It also emphasizes the effectiveness of combined surgical and medical multidisciplinary approaches in such emergent situations for optimal patient outcomes.

Repair of type II paraesophageal hernia with Nissen fundoplication in a patient with von Willebrand disease and spondylolisthesis - a clinical case report

Hiatal hernias continue to be fairly common in clinical practice. However, the variety of different symptoms presented by patients may hinder establishing the ultimate diagnosis. Nevertheless, currently, the diagnosis of hiatal hernia can be easily established, based on barium swallow radiography. We would like to present a clinical case report of a patient with complex medical history, including von Willebrand disease, degenerative spinal disease, and chronic sinusitis, who was finally diagnosed with hiatal hernia and treated with a standard laparoscopic Nissen fundoplication. Our case focuses on the significance of comorbidities on patients' symptoms, which sometimes may mislead the therapeutic process.

Gastric necrosis secondary to gastric volvulus in a paraesophageal hernia: a case report

Hiatal hernias are commonly encountered in clinical practice. In certain cases, especially in large hiatal hernias, gastric volvulus can occur. Patients with volvulus typically will present with vomiting, chest pain, shortness of breath, and dysphagia. In extreme cases, gastric volvulus can result in gastric necrosis requiring partial or total gastrectomy. Here we highlight a case of a 76-year-old female with a known large type IV hiatal hernia who was found to have gastric volvulus with necrosis requiring partial sleeve gastrectomy. This case demonstrates the rare, but possible complication of gastric necrosis secondary to gastric volvulus from a large hiatal hernia, prompting emergent surgical intervention.

Is it meaningful to add mesh reinforcement to laparoscopic fundoplication for esophageal hiatal hernias in the patients with high risk of hiatal hernia recurrence?

BACKGROUND

While laparoscopic fundoplication is a standard surgical procedure for patients with esophageal hiatal hernias, the postoperative recurrence of esophageal hiatal hernias is a problem for patients with giant hernias, elderly patients, or obese patients. Although there are some reports indicating that reinforcement with mesh is effective, there are differing opinions regarding the use thereof. The aim of this study is to investigate whether mesh reinforcement is effective for laparoscopic fundoplication in patients with esophageal hiatus hernias.

METHODS

The subjects included 280 patients who underwent laparoscopic fundoplication as the initial surgery for giant esophageal hiatal hernias, elderly patients aged 75 years or older, and obese patients with a BMI of 28 or higher, who were considered at risk of recurrent hiatal hernias based on the previous reports. Of the subject patients, 91 cases without mesh and 86 cases following the stabilization of mesh use were extracted to compare the postoperative course including the pathology, symptom scores, surgical outcome, and recurrence of esophageal hiatus hernias.

RESULTS

The preoperative conditions indicated that the degree of esophageal hiatal hernias was high in the mesh group (p = 0.0001), while the preoperative symptoms indicated that the score of heartburn was high in the non-mesh group (p = 0.0287). Although the surgical results indicated that the mesh group underwent a longer operation time (p < 0.0001) and a higher frequency of intraoperative complications (p = 0.037), the rate of recurrence of esophageal hiatal hernia was significantly low (p = 0.049), with the rate of postoperative reflux esophagitis also tending to be low (p = 0.083).

CONCLUSIONS

Mesh reinforcement in laparoscopic fundoplication for esophageal hiatal hernias contributes to preventing the recurrence of esophageal hiatal hernias when it comes to patient options based on these criteria.

Selective dysfunction of the crural diaphragm in patients with chronic restrictive and obstructive lung disease

BACKGROUND

Gastroesophageal reflux (GER) is known to be associated with chronic lung diseases. The driving force of GER is the transdiaphragmatic pressure (Pdi) generated mainly by costal and crural diaphragm contraction. The latter also enhances the esophagogastric junction (EGJ) pressure to guard against GER.

METHODS

The relationship between Pdi and EGJ pressure was determined using high resolution esophageal manometry in patients with interstitial lung disease (ILD, n = 26), obstructive lung disease (OLD, n- = 24), and healthy subjects (n = 20).

KEY RESULTS

The patient groups did not differ with respect to age, gender, BMI, and pulmonary rehabilitation history. Patients with ILD had significantly higher Pdi but lower EGJ pressures as compared to controls and OLD patients (p < 0.001). In control subjects, the increase in EGJ pressure at all-time points during inspiration was greater than Pdi. In contrast, the EGJ pressure during inspiration was less than Pdi in 14 patients with ILD and 7 patients with OLD. The drop in EGJ pressure was usually seen after the peak Pdi in ILD group (p < 0.0001) and before the peak Pdi in OLD group, (p = 0.08). Nine patients in the ILD group had sliding hiatus hernia, compared to none in control subjects (p = 0.003) and two patients in the OLD, (p = 0.04).

CONCLUSIONS AND INFERENCES

A higher Pdi and low EGJ pressure, and dissociation between Pdi and EGJ pressure temporal relationship suggests selective dysfunction of the crural diaphragm in patients with chronic lung diseases and may explain the higher prevalence of GERD in ILD as seen in previous studies.

Determining the need for a thoracoscopic approach to treat a giant hiatal hernia when abdominal access is poor

BACKGROUND

Giant hernias present a significant challenge for digestive surgeons. The approach taken (laparoscopic vs thoracoscopic) depends largely on the preferences and skills of each surgeon, although in most cases today the laparoscopic approach is preferred.

AIM

To determine whether patients presenting inadequate laparoscopic access to the intrathoracic hernial sac obtain poorer postoperative results than those with no such problem, in order to assess the need for a thoracoscopic approach.

METHODS

For the retrospective series of patients treated in our hospital for hiatal hernia (n = 112), we calculated the laparoscopic field of view and the working area accessible to surgical instruments, by means of preoperative imaging tests, to assess the likely outcome for cases inaccessible to laparoscopy.

RESULTS

Patients with giant hiatal hernias for whom a preoperative calculation suggested that the laparoscopic route would not access all areas of the intrathoracic sac presented higher rates of perioperative complications and recurrence during follow-up than those for whom laparoscopy was unimpeded. The difference was statistically significant. Moreover, the insertion of mesh did not improve results for the non-accessible group.

CONCLUSION

For patients with giant hiatal hernias, it is essential to conduct a preoperative evaluation of the angle of vision and the working area for surgery. When parts of the intrathoracic sac are inaccessible laparoscopically, the thoracoscopic approach should be considered.

Upside-down stomach in paraesophageal hernia: A case report

RATIONALE

Paraesophageal hernias, accounting for a mere 5% to 10% of all hiatal hernias, occasionally present an exceedingly uncommon yet gravely consequential complication characterized by the inversion of the stomach. Delving into the clinical manifestations and optimal therapeutic approaches for patients afflicted by this condition merits substantial exploration.

PATIENT CONCERNS

A 60-year-old man was referred to our hospital with acute onset of severe epigastric pain, abdominal distension, and vomiting. A chest radiograph unveiled an elevated left diaphragmatic dome accompanied by a pronounced rightward shift of the mediastinum. Subsequent abdominal computed tomography imaging delineated the migration of the stomach, spleen, and colon into the left hemithorax, facilitated by a significant diaphragmatic defect.

DIAGNOSES

The diagnosis of a giant paraesophageal hernia with complete gastric inversion was established through a comprehensive evaluation of the patient's clinical manifestations and imaging findings.

INTERVENTIONS

Surgical intervention was performed on the patient. During the procedure, a left diaphragmatic defect measuring approximately 10 × 8 cm was identified and meticulously repositioned, followed by the repair of the diaphragmatic hernia. The herniated contents comprised the pancreas, stomach, spleen, a segment of the colon, and a portion of the greater omentum.

OUTCOMES

The patient experienced a smooth postoperative recuperation and was discharged 12 days following the surgical procedure. Subsequently, during a 7-month follow-up period, the patient continued to exhibit favorable progress and recovery.

LESSONS

Paraesophageal hernias are rare, and the presence of an inverted stomach in a giant paraesophageal hernia is exceptionally uncommon. Clinical presentation lacks distinct features and can lead to misdiagnosis. This case emphasizes the importance of timely surgical intervention guided by imaging, offering valuable clinical insights.

Robotic versus laparoscopic surgery for hiatal hernia repair: a systematic literature review and meta-analysis

The number of robotic hiatal hernia repairs (RHHR) is increasing. However, the superiority of this minimally invasive approach remains controversial. The aim of this study was to evaluate the available literature reporting on outcomes of RHHR compared with laparoscopic hiatal hernia repair (LHHR) in adult patients. The design of this systematic review was developed using the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Web of Science, PubMed, the Cochrane Library, and ClinicalTrials.gov databases were searched. Identified publications were reviewed independently by two authors. High heterogeneity was further explored through sensitivity analysis. The primary endpoint was the development of postoperative complications. Secondary endpoints included operation time, intraoperative complications, 30 day readmission rates and length of stay. The analysis was performed using Stata 17.0 software. A total of 7 studies totaling 10078 patients met the inclusion criteria. Five studies included postoperative complications. The postoperative complications rate was 4.25% (302/7111) in the LHHR group, and 3.49% (38/1088) in the RHHR group. Postoperative complications significantly decreased after RHHR compared with LHHR (OR 0.52; 95% CI 0.36 to 0.75, P = 0.000). Three studies involving 2176 patients reported length of hospital stay. In the three studies, the mean Length of hospital stay was 3.2 days in the RHHR group, and 4.2 days in the LHHR group. Length of hospital stay was decreased by a mean of 0.68 days for RHHR compared with LHHR (WMD, - 0.68 days; 95% CI - 1.32 to - 0.03, P = 0.02). There was no significant difference between the RHHR group and the LHHR group regarding operative time, intraoperative complications, and 30 day readmission (P > 0.05). Our research shows that RHHR may be the better option, as the approach decreases postoperative complications and length of hospital stay.

A Rare Case of Paraesophageal Hernia Repair Complicated by Pancreatic Injury

Esophageal hernias are anatomical defect that affects up to 50% of the population. While they may be asymptomatic, hernias may also result in reflux and dysphagia, among other symptoms. In such cases, hernia repair is warranted. The most common type of repair is laparoscopic Nissen fundoplication, which is usually well-tolerated. Herein, we present a rare case of paraesophageal hernia repair complicated by pancreatic injury and pancreatic leak.

[Lesions of the paravertebral mediastinum]

BACKGROUND

Lesions of the paravertebral mediastinum are rare, and knowledge of possible differential diagnoses is essential for clinical practice.

OBJECTIVE/METHODS

To review common lesions of the paravertebral mediastinum.

RESULTS

The paravertebral mediastinum mainly includes fatty tissue and neurogenic structures. Imaging is commonly performed using computed tomography (CT) and magnetic resonance imaging (MRI). Neurogenic tumors are the most common lesions of the paravertebral mediastinum. Other pathologies include extramedullary hematopoiesis, lipomatous, lymphogenic, inflammatory, and cystic lesions. Moreover, also diaphragmatic hernias, vascular and esophageal pathologies may be found in the paravertebral mediastinum.

Novel "starburst" mesh configuration for paraesophageal and recurrent hiatal hernia repair: comparison with keyhole mesh configuration

BACKGROUND

Controversy exists over the use of mesh, its type and configuration in repair of hiatal hernia. We have used biological mesh for large or recurrent hiatal hernias. We have developed a mesh configuration to better enhance the tensile strength of the hiatus by folding the mesh over the edge of the hiatus-entitled the "starburst" configuration. We report our experience with the starburst configuration, comparing it to our results with the keyhole configuration.

METHODS

Medical records of all patients undergoing either the keyhole or starburst mesh configuration hiatal hernia repair were reviewed between 2017 and 2021. Data gathered included age, sex, type of hernia (sliding, paraesophageal, or recurrent), fundoplication type (none, Nissen, Toupet, Dor, Collis-Nissen, Collis-Toupet, or magnetic sphincter augmentation [MSA]), 30-day complications, and long-term outcomes (hiatal hernia recurrence, reflux-symptom recurrence, dysphagia, dilations, reoperations).

RESULTS

From 7/2017 to 8/2019, 51 cases using the keyhole mesh were completed. Sliding hiatal hernia comprised 4%, paraesophageal hernia (PEH) 64% and recurrent hiatal hernia (RHH) 34% of cases. Distribution of fundoplication type: 2% none, 41% Nissen, 41% Toupet, 8% Dor, 2% Collis-Nissen, and 6% Collis-Toupet. 30-day complication rate 31%. Long-term outcomes: recurrent hiatal hernia 16%, dysphagia 12%, dysphagia requiring dilation(s) 10%, recurrent GERD symptoms 4%, and reoperation 14%. From 10/2020 to 8/2021, 58 cases using the starburst configuration were completed. PEH comprised 60% and RHH 40%. Distribution of fundoplication type: 10% none, 40% Nissen, 43% Toupet, 5% MSA, 2% Collis-Toupet. 30-day complication rate 16%. Long-term outcomes: recurrent hiatal hernia 19%, dysphagia 14%, dilations 5%, recurrent GERD symptoms 9%, and reoperations 3%.

CONCLUSION

The starburst mesh configuration compares favorably with the keyhole configuration with respect to postoperative dysphagia, need for esophageal dilation, and GERD symptom recurrence, with similar recurrence rates. We are continuing to further refine this technique and study the long-term outcomes.

Late presentation of congenital type IV esophageal hiatus hernia in a 9-year-old boy: a case report

Background

Congenital diaphragmatic hernia affects 1 in every 2000–5000 live births. The mediastinum shifts to the opposite side, the lungs are hypoplastic, and the arterioles are abnormal, resulting in pulmonary hypertension. Respiratory and cardiovascular functions are severely impaired at birth, resulting in significant mortality and morbidity as a result of the associated malformations.

Case presentation

A 9-year-old persian boy was referred with complaint of intermittent abdominal pain in the left lower quadrant and an episode of vomiting. The patient was tachypneic, and the abdomen was nontender on examination. Lung sounds on the left side were considerably decreased, whereas heart sounds on the right side were louder. There was no history of underlying disease in the patient. Initial laboratory blood tests, chest x-ray, spiral computed tomography scan, and chest sonography were requested. Blood tests were normal, and chest x-ray revealed a round-shaped lesion with relatively clear boundaries containing air–fluid level and shift of the heart and mediastinum to the right. A spiral computed tomography scan of the lungs demonstrated the shift of the heart and mediastinum to the right side was due to dilated stomach and colon pressure, and chest sonography revealed that half of the stomach was inside the thorax. Laparotomy surgery was performed. The patient had no complications following surgery.

Conclusions

Herniation of abdominal contents through the diaphragmatic hiatus should be suspected in patients with tachypnea and mediastinal shift to the right side. Rapid diagnosis and early surgical treatment are necessary to avert any potentially life-threatening complications.

ACR Appropriateness Criteria® Epigastric Pain

Epigastric pain can have multiple etiologies including myocardial infarction, pancreatitis, acute aortic syndromes, gastroesophageal reflux disease, esophagitis, peptic ulcer disease, gastritis, duodenal ulcer disease, gastric cancer, and hiatal hernia. This document focuses on the scenarios in which epigastric pain is accompanied by symptoms such as heartburn, regurgitation, dysphagia, nausea, vomiting, and hematemesis, which raise suspicion for gastroesophageal reflux disease, esophagitis, peptic ulcer disease, gastritis, duodenal ulcer disease, gastric cancer, or hiatal hernia. Although endoscopy may be the test of choice for diagnosing these entities, patients may present with nonspecific or overlapping symptoms, necessitating the use of imaging prior to or instead of endoscopy. The utility of fluoroscopic imaging, CT, MRI, and FDG-PET for these indications are discussed. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Acute bolus obstruction following surgical treatment of paraesophageal herniation of the greater omentum

Hiatal herniations are most commonly diagnosed during work-up for gastroesophageal reflux disease. Here, we present a patient with retrosternal pain for whom the computed tomography scan showed a lipomatous formation in the lower posterior mediastinum, and further examination indicated the origin to be paraesophageal herniation (PEH) of the greater omentum. This was confirmed by laparoscopy, the herniated part of the greater omentum was repositioned and the hiatal hernia was repaired. During recovery the patient complained of dysphagia, a common and transient postoperative occurrence, but which later proved to be a mechanical obstruction caused by a bolus. This case raises awareness of potential differential diagnoses pre- and postoperatively in conjunction with PEH, and the management of such differential diagnoses is discussed.

Hiatal hernia after robotic-assisted coronary artery bypass graft surgery

Background

The aim of the present study is to determine the incidence/progression of hiatal hernia (HH) after robotic-assisted coronary artery bypass grafting (RA-CABG) surgery.

Methods

We reviewed the pre- and post-operative computed tomography (CT) of 491 patients who underwent RA-CABG between 2000 and 2017. Post-operative CT was acquired prospectively in a research protocol. CT was reviewed to assess the presence and the size of HH.

Results

We found 444/491 (90.4%) had pre-operative CT, while 201/491 (40.9%) had post-operative CT. In total, 155/491 (31.6%) had both pre- and long-term post-operative CT with a mean follow-up of 6.2 (±3.5) years. HH was more prevalent on post-operative CT, 64/155 (41.3%) compared to pre-operative CT, 44/155 (28.4%), P<0.0001. The diameter of pre-existing HH 2.8 (±1.8) cm was significantly greater after surgery 3.9 (±2.5) cm, P<0.0001. As well the volume of the pre-existing HH 5.8 (4.4-9.2) mL (quartile) was significantly greater after surgery 14.1 (7.2-64.9) mL, P<0.0001. 20/155 (12.9%) had a newly developed HH after RA-CABG. A binary multivariate regression including HH risk factors showed that male gender is a predictor of developing a HH after RA-CABG with Hazard Ratio of 3.038, confidence interval (1.10-8.43), P=0.033.

Conclusions

RA-CABG is associated with an increased risk of developing HH and increases the size of pre-existing HH.

Congenital hiatal hernia segregating with a duplication in 9q22.31q22.32 in two families

Congenital hiatal hernia (HH) is a rare congenital defect and is often described on a sporadic basis, but familial cases have also been reported. The mechanism of development is not well understood, and to our knowledge no specific genetic factors have been implicated to date. We report on seven individuals from two families with 9q22 duplication, who have variably associated features including congenital HH in four individuals. One family had an 1.09 Mb 9q22 duplication, and the other family had an overlapping 2.73 Mb 9q22 duplication. We review the genes in this region and discuss BARX1 (BarH-like homeobox gene 1) as a gene of interest.

The use of biosynthetic mesh in giant hiatal hernia repair: is there a rationale? A 3-year single-center experience

PURPOSE

Reinforced prosthetic crural repair is particularly indicated for giant hiatal hernias. The rationale is to reduce the recurrence rate in the long term. The aim of our study is to evaluate the outcomes of laparoscopic giant hiatal hernia repair using a biosynthetic mesh.

METHODS

We retrospectively analyzed 44 patients who underwent laparoscopic mesh-reinforced hiatal closure and fundoplication using a biosynthetic material. Inclusion criterion was large hiatal defects (> 5 cm). Follow-up was scheduled at 6, 12 and 36 months after surgery.

RESULTS

44 patients (29F) with a mean age of 62 years (range 14-85) and mean of BMI 24.5 kg/m² (range 21-29) underwent successful laparoscopic repair. Twenty-six (59.1%) patients had Nissen-Rossetti fundoplication, whereas 18 (40.9%) had Toupet fundoplication. Six-month questionnaire for the evaluation of symptoms was available for 43 patients (97.7%) and for 40 (90.9%) patients at 12 and 36 months. Mean preoperative symptoms score analysis was 1.68 ± 0.73. Mean scores at each follow-up time were significantly improved compared to baseline (p > 0.05). Barium swallow was available in 37 patients (84.1%) at 1 year after surgery. Radiologic recurrence was observed in two patients (4.5%). No patient had symptoms attributable to recurrence or required revisional surgery. There were no mesh-related complications at 3 years follow-up.

CONCLUSIONS

The use of biosynthetic mesh for crural reinforcement is associated with a low incidence of mesh-related complications and with a reasonably low recurrence rate (4.5%) at 36 months. However, additional data with longer follow-up are needed to determine long-term safety and efficacy.

Trans-diaphragmatic Pathologies: Anatomical Background and Spread of Disease on Cross-sectional Imaging

The diaphragm is not only a sheet of muscle separating the abdominal and thoracic cavities: it plays an essential role in ventilation and can act as a gateway for the spread of different disease processes between the abdominal and the thoracic cavity. Careful attention to the appearance of the diaphragm on various imaging modalities is essential to ensure the accurate diagnosis of diaphragmatic disorders, which may be secondary to functional or anatomical derangements.

Management of paraesophageal hernia review of clinical studies: timing to surgery, mesh use, fundoplication, gastropexy and other controversies

Despite paraesophageal hernias (PEH) being a common disorder, several aspects of their management remain elusive. Elective surgery in asymptomatic patients, management of acute presentation, and other technical aspects such as utilization of mesh, fundoplication or gastropexy are some of the debated issues. The aim of this study was to review the available evidence in an attempt to clarify current controversial topics. PEH repair in an asymptomatic patient may be reasonable in selected patients to avoid potential morbidity of an emergent operation. In acute presentation, gastric decompression and resuscitation could allow to improve the patient's condition and refer the repair to a more experienced surgical team. When surgical repair is decided, laparoscopy is the optimal approach in most of the cases. Mesh should be used in selected patients such as those with large PEH or redo operations. While a fundoplication is recommended in the majority of patients to prevent postoperative reflux, a gastropexy can be used in selected cases to facilitate postoperative care.

Robotic voluminous paraesophageal hernia repair: a case report and review of the literature

Background

The treatment for sliding esophageal hernia with mild gastroesophageal reflux is usually conservative, but surgical treatment is recommended for refractory sliding esophageal hernia, paraesophageal hernia liable to prolapse, or paraesophageal hernia with ulceration and/or stenosis. Robotic surgery overcomes laparoscopic pitfalls by providing steady-state three-dimensional visualization, augmented dexterity with endo-wrist movements, and superior ergonomics for the surgeon.

Case presentation

To investigate robotic paraesophageal hernia repair, a literature search was conducted using PubMed with the following key words: mini invasive surgery, robotic surgery, hiatal hernia, and Nissen fundoplication. We present the case of a 44-year-old Italian woman with a 20-year history of gastroesophageal reflux disease refractory to medical treatment, who underwent robotic Nissen fundoplication. In our center, we use the da Vinci® Xi™ Surgical System, which is an advanced tool for minimally invasive surgery.

Conclusions

Various reports published in the literature suggested that the robot-assisted approach was effective and was associated with very low postoperative morbidity and was accompanied by satisfactory symptomatic and anatomical radiological outcomes during a follow-up period.

The robotic approach to paraesophageal repair is safe and effective with low complication rates. With increased experience, the operative time, length of stay, and complications decrease without compromising surgical principles.

New Ovine Polymer-Reinforced Bioscaffold in Hiatal Hernia Repair

Background and Objectives

Biologic and resorbable synthetic materials are used commonly for crural repair reinforcement during laparoscopic hiatal herniorrhaphy. Recently, an ovine polymer-reinforced bioscaffold (OPRBS) has been developed for reinforcement of abdominal wall and hiatal herniorrhaphies. This is the first reported series on use of OPRBS in hiatal hernia repairs.

Methods

A retrospective chart review was conducted for consecutive series of patients (n = 25) undergoing laparoscopic or open hiatal herniorrhaphy between August 2016 and May 2017. Data collected included demographics, comorbidities and symptoms, details of operation, complications, and postoperative followup.

Results

Laparoscopic repair was completed in 23 of 24 patients. Reinforcement with OPRBS was accomplished in all cases. Fundoplication was constructed in 24 of 25 patients (96%). Mean followup was 14.2 months. Good-to-excellent symptom control or resolution has been achieved for heartburn (95%), dysphagia (94.7%), regurgitation (100%), nausea and vomiting (100%), dyspnea (100%), and chest pain or discomfort (85.7%). Postoperative esophagogastroduodenoscopy with dilation resulted in resolution of persistent postoperative dysphagia in two patients (8%). To date there have been no clinical recurrences of hiatal hernia.

Conclusion

OPRBS in hiatal hernia repair have been associated with excellent early patient outcomes in this study. OPRBS represent a new paradigm in hernia repair, as it is the first clinically available biological repair material reinforced with embroidered resorbable or permanent synthetic polymer. Relative weaknesses of the current study include the small sample size (n = 25), and short-term (mean = 14.2 months) followup. Long-term followup and additional studies will be required to confirm these findings.

Perforation of a Peptic Ulcer in a Hiatal Hernia Into the Left Ventricle With Systemic Air and Food Embolism

Perforation of a peptic ulcer into the ventricle is uncommon, and the definitive diagnosis is difficult in living patients. We herein report a case of perforation of a peptic ulcer in a hiatal hernia into the left ventricle with systemic air and food embolism. This is the first case report of the perforation diagnosed by computed tomography and confirmed by autopsy. Computed tomography was useful for the diagnosis of perforation into the ventricle.

Large hiatal hernia with pancreatic body herniation: Case-report

INTRODUCTION

A hiatal hernia can be classified as one of four types according to the position of the gastroesophageal (GE) junction and the extent of herniated stomach. Type IV paraesophageal hiatal hernia (PEHH) is characterized by a large defect in the diaphragmatic hiatus that allows other organs, besides stomach, such as the colon, pancreas, spleen, or small intestine to herniate into the thorax. Herniation of the pancreas through a gastroesophageal hiatus is a rare condition, and only a few cases have been reported in the literature.

CASE REPORT

We present a case of an asymptomatic patient with paraesophageal herniation along with the body and tail of the pancreas.

CONCLUSION

However, surgery is optimal choice for symptomatic patients, it is important for surgeons to consider the risks of different approaches and choose the best intervention.

Preoperative diagnosis of hiatal hernia: barium swallow X-ray, high-resolution manometry, or endoscopy?

Background

The assessment of hiatal hernias (HH) is typically done with barium swallow X‑ray, upper endoscopy, and by high-resolution esophageal manometry (HRM). The aim of this study was to assess the clinical utility of these methods in terms of HH detection and their correlation to gastroesophageal reflux disease (GERD).

Methods

A retrospective comparative analysis of patients with symptoms of GERD was carried out. The performance of endoscopy and HRM in diagnosing HH was assessed, taking barium swallow X‑ray as a reference. Furthermore, statistically comparative analysis between detected hernias and the presence of reflux disease in ambulatory impedance-pH monitoring (MII) was performed.

Results

Overall, 112 patients were analyzed. Barium swallow X‑ray showed no correlation either to HR manometrically or to endoscopically assessed HH. Significant accordance in the detection rate of HH was proved between HRM and gastroesophagoscopy (p < 0.001). Only endoscopically assessed HH showed a significant correlation with GERD (p = 0.047). No correlation between detected hernias and GERD could be found either with HRM or with barium swallow X‑ray.

Conclusions

Barium swallow X‑ray provided the highest rate of HH detection (76.8%). For the reliable exclusion of HH prior to treatment, all three mentioned investigations appear to be necessary in order of low conformity.

Severe Hiatal Hernia as a Cause of Failure to Thrive Discovered by Transthoracic Echocardiogram

A newborn infant with failure to thrive presented for murmur evaluation on day of life three due to a harsh 3/6 murmur. During the evaluation, a retrocardiac fluid filled mass was seen by transthoracic echocardiogram. The infant was also found to have a ventricular septal defect and partial anomalous pulmonary venous return. Eventually, a large hiatal hernia was diagnosed on subsequent imaging. The infant ultimately underwent surgical repair of the hiatal hernia at a tertiary care facility. Hiatal hernias have been noted as incidental extracardiac findings in adults, but no previous literature has documented hiatal hernias as incidental findings in the pediatric population.

Congenital paraesophageal hernia: The Montreal experience

INTRODUCTION

Congenital paraesophageal hernia (CPEH) is the least common congenital diaphragmatic hernia. We performed an extensive review to further define this entity.

METHODS

A retrospective study of children with CPEH (types II-IV hiatal hernias) treated at two children's hospitals over a 25-year period (1988-2013) was performed.

RESULTS

Fourteen patients were diagnosed at a median age of 35 days (range 0-500), with one prenatal diagnosis. The most common symptoms were emesis in type II hernias (50%), and respiratory distress in types III and IV hernias (75% and 50%, respectively). Gastroesophageal reflux was concomitantly diagnosed in 50%, while concurrent congenital anomalies existed in 36%. A correct initial diagnosis was made in only 29% of cases. The diagnosis was most often established by UGI study (64%). The method of repair was laparoscopy in 21%, and laparotomy in 71%. An antireflux procedure was done in 13 (93%) patients. Long-term follow up data was available for 86% of patient. During follow-up, one patient recurred and one required sequential pneumatic esophageal dilations. There were no mortalities.

CONCLUSIONS

CPEH is a rare entity often associated with gastroesophageal reflux disease and other congenital anomalies. Prognosis is excellent, but awareness of this anomaly may lead to earlier diagnosis.

Massive hiatus hernia complicated by jaundice

Giant para-oesophageal hernia may include pancreas with pancreatic complication and rarely jaundice. Repair is feasible and durable by laparoscopy. Magnetic resonance cholangiopancreatography is diagnostic.

Hiatal hernias are correlated with increased severity of non-cystic fibrosis bronchiectasis

BACKGROUND AND OBJECTIVE

Hiatal hernias (HH) are associated with gastro-oesophageal reflux and may contribute to lung disease severity. We aimed to evaluate the prevalence of HH among stable non-cystic fibrosis bronchiectasis (NCFB) patients and determine associations with disease severity.

METHODS

A retrospective cross-sectional cohort study of 100 consecutive NCFB patients in our institution was performed. Data were collected on baseline variables, microbiology, lung function and radiology, according to the modified Bhalla score. Disease severity was assessed using the Bronchiectasis Severity Index (BSI) and FACED severity scores.

RESULTS

Following expert radiological review, 81 patients were deemed suitable for study inclusion (mean age (SD) 62.6 (12.4), females 55 (67.9%), body mass index (BMI) 26.9 (5.7)); 29 (35.8%) were HH positive (HH+). HH+ patients had a trend towards higher BMI (P = 0.07), and a significantly higher proportion had reflux symptoms (HH+ 62.1% vs HH- 28.8%, P < 0.01). The presence of HH+ was associated with cystic bronchiectasis (HH+ 30.1%, HH- 11.5%; P = 0.03), increased number of lobes involved (HH+ 2.62 (1.54), HH- 2.17 (1.42); P = 0.03), increased extent of bronchiectasis, (HH+ 6.2 (4.7), HH- 4.5 (3.1); P = 0.04), decreased parenchymal attenuation (HH+ 1.0 (1.8), HH- 0.2 (0.5); P = 0.03) and reduced per cent predicted forced expiratory volume in 1 s (HH+ 75.4% (24.5), HH- 90.4% (25.5); P = 0.02). There was no lobar predilection. HH+ was associated with increased disease severity scores: BSI (HH+ 4.93 (1.65), HH- 3.25 (2.13); P < 0.001) and FACED (HH+ 2.21 (1.52), HH- 1.35 (1.43); P < 0.01).

CONCLUSIONS

HH+ was associated with worse disease severity in NCFB patients, characterized by decreased lung function, increased extent and severity of radiological disease, and increased composite disease severity scores.

Hiatal hernia repair with gore bio-a tissue reinforcement: our experience

Type I hiatal hernia is associated with gastroesophageal reflux disease (GERD) in 50–90% of cases. Several trials strongly support surgery as an effective alternative to medical therapy. Today, laparoscopic fundoplication is considered as the procedure of choice. However, primary laparoscopic hiatal hernia repair is associated with upto 42% recurrence rate. Mesh reinforcement of the crural closure decreases the recurrence but can lead to complications, above all nonabsorbable ones. We experiment a new totally absorbable mesh by Gore. Case. We present a case of a 65-year-old female patient with a 6-year classic history of GERD. Endoscopy revealed a large hiatal hernia and esophagitis. pH study was positive for acid reflux; esophageal manometry revealed LES intrathoracic dislocation. With laparoscopic approach, the hiatal hernia defect was identified and primarily repaired, by crural closure. Gore Bio-A Tissue Reinforcement was trimmed to fit the defect accommodating the esophagus. Nissen fundoplication was performed. Result. Bio-A mesh was easily placed laparoscopically. It has good handling and could be cut and tailored intraoperatively for optimal adaptation. There were no short-term complications. Conclusion. Crural closure reinforcement can be done readily with this new totally absorbable mesh replaced by soft tissue over six months. However, further data and studies are needed to evaluate long-term outcomes.

Prevalence of hiatal hernia in the morbidly obese

BACKGROUND

Morbidly obese patients commonly have gastroesophageal reflux (GERD) and associated hiatal hernias. As such, some surgeons routinely perform a concomitant hiatal hernia repair during bariatric surgery. However, the intraoperative inspection for a hiatal hernia based on laparoscopic visualization can be misleading. The aim of this study was to assess the prevalence of hiatal hernias in morbidly obese patients based on preoperative upper gastrointestinal (GI) contrast study.

METHODS

Data on 181 patients who underwent routine upper GI contrast study as part of a preoperative workup for bariatric surgery were reviewed. The upper GI studies were examined for the presence of hiatal hernias and GERD. Hiatal hernias were categorized by size as small (≤2 cm), moderate (2-5 cm), or large (>5 cm). GERD was based on radiologic evidence and categorized as mild, moderate, or severe.

RESULTS

The mean age of the cohort was 44 years, with a mean body mass index of 43 kg/m(2). Of the 181 patients overall, based on the upper GI contrast study, the prevalence of hiatal hernia was 37.0% and of GERD was 39.8%; the prevalence of moderate or large hiatal hernia was 4.4%, and the prevalence of moderate or severe GERD was 13.3%.

CONCLUSIONS

Based on upper GI contrast study, we identified the presence of a hiatal hernia in nearly 40% of morbidly obese patients. The results from this study suggest that surgeons should evaluate the morbidly obese patient for the presence of hiatal hernias and perform concomitant repair at the time of the bariatric procedure, particularly in patients undergoing gastric banding and sleeve gastrectomy, while less so in the gastric bypass patient.