1
|
Emergency surgery for hiatus hernias: does technique affect outcomes? A single-centre experience. Updates Surg 2023:10.1007/s13304-023-01482-y. [PMID: 36869223 PMCID: PMC10359210 DOI: 10.1007/s13304-023-01482-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 02/23/2023] [Indexed: 03/05/2023]
Abstract
BACKGROUND Emergency surgery for a hiatus hernia is usually a high-risk procedure in acutely unwell patients. Common surgical techniques include reduction of the hernia, cruropexy then either fundoplication or gastropexy with a gastrostomy. This is an observational study in a tertiary referral centre for complicated hiatus hernias to compare recurrence rates between these two techniques. METHODS Eighty patients are included in this study, from October 2012 to November 2020. This is a retrospective review and analysis of their management and follow-up. Recurrence of the hiatus hernia that mandates surgical repair was the primary outcome of this study. Secondary outcomes include morbidity and mortality. RESULTS In total, 38% of the patients included in the study had fundoplication procedures, 53% had gastropexy, 6% had complete or partial resection of the stomach, 3% had fundoplication and gastropexy and one patient had neither (n = 30, 42, 5, 2,1, respectively). Eight patients had symptomatic recurrence of the hernia which required surgical repair. Three of these patients had acute recurrence and 5 after discharge. 50% had undergone fundoplication, 38% underwent gastropexy and 13% underwent a resection (n = 4, 3, 1) (p value = 0.5). 38% of patient had no complications and 30-day mortality was 7.5% CONCLUSION: To our knowledge, this is the largest single centre review of outcomes following emergency hiatus hernia repairs. Our results show that either fundoplication or gastropexy can be used safely to reduce the risk of recurrence in the emergency setting. Therefore, surgical technique can be tailored based on the patient characteristics and surgeon experience, without compromising the risk of recurrence or post-operative complications. Mortality and morbidity rates were in keeping with previous studies, which is lower than historically documented, with respiratory complications most prevalent. This study shows that emergency repair of hiatus hernias is a safe operation which is often a lifesaving procedure in elderly comorbid patients.
Collapse
|
2
|
Dubina ED, Moazzez A, Park H, Shover A, Kim DY, Simms ER. Predictors of Morbidity and Mortality in Complex Paraesophageal Hernia Repair: A NSQIP Analysis. Am Surg 2020. [DOI: 10.1177/000313481908501025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Paraesophageal hernia (PEH) repair is typically performed electively. Complex PEHs (obstructed or gangrenous) require more urgent repair and can have significant complications. Although elective repair is primarily laparoscopic, limited data are available on the use of laparoscopy for complex cases. Patients undergoing complex PEH repair were identified from the NSQIP database, and predictors of morbidity and mortality were compared for 2473 laparoscopic and 861 open repairs. Compared with the laparoscopic approach, emergent surgeries (36.7% vs 10.8%, P < 0.001) and preoperative sepsis (22.9% vs 7.4%, P < 0.001) were more common in the open group. Operative times were shorter for open repairs (152.6 vs 172.2 minutes, P = 0.03). However, open repair was associated with increased morbidity (28.2% vs 11%, P < 0.001) and mortality (5.2% vs 1.4%, P < 0.001), likely because of higher rates of preoperative comorbidities in the open group. On multivariable regression analysis, preoperative sepsis was associated with increased mortality and morbidity, whereas laparoscopic repair was associated with decreased morbidity. If laparoscopic repair can be safely completed, it is associated with decreased morbidity, despite longer operative times.
Collapse
Affiliation(s)
- Emily D. Dubina
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, California
| | - Ashkan Moazzez
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, California
| | - Hayoung Park
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, California
| | - Andrew Shover
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, California
| | - Dennis Y. Kim
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, California
| | - Eric R. Simms
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, California
| |
Collapse
|
3
|
Ceccarelli G, Pasculli A, Bugiantella W, De Rosa M, Catena F, Rondelli F, Costa G, Rocca A, Longaroni M, Testini M. Minimally invasive laparoscopic and robot-assisted emergency treatment of strangulated giant hiatal hernias: report of five cases and literature review. World J Emerg Surg 2020; 15:37. [PMID: 32487136 PMCID: PMC7268602 DOI: 10.1186/s13017-020-00316-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 05/14/2020] [Indexed: 12/15/2022] Open
Abstract
Background Giant hiatal hernia (GHH) is a condition where one-third of the stomach migrates into the thorax. Nowadays, laparoscopic treatment gives excellent postoperative outcomes. Strangulated GHH is rare, and its emergent repair is associated with significant morbidity and mortality rates. We report a series of five cases of strangulated GHH treated by a minimally invasive laparoscopic and robot-assisted approach, together with a systematic review of the literature. Methods During 10 years (December 2009–December 2019), 31 patients affected by GHH were treated by robot-assisted or conventional laparoscopic surgical approach. Among them, five cases were treated in an emergency setting. We performed a PubMed MEDLINE search about the minimally invasive emergent treatment of GHH, selecting 18 articles for review. Results The five cases were male patients with a mean age of 70 ± 18 years. All patients referred to the emergency service complaining of severe abdominal and thoracic pain, nausea and vomiting. CT scan and endoscopy were the main diagnostic tools. All patients showed stable hemodynamic conditions so that they could undergo a minimally invasive attempt. The surgical approach was robotic-assisted in three patients (60%) and laparoscopic in two (40%). Patients reported no complications or recurrences. Conclusion Reviewing current literature, no general recommendations are available about the emergent treatment of strangulated hiatal hernia. Acute mechanical outlet obstruction, ischemia of gastric wall or perforation and severe bleeding are the reasons for an emergent surgical indication. In stable conditions, a minimally invasive approach is often feasible. Moreover, the robot-assisted approach, allowing a stable 3D view and using articulated instruments, represents a reasonable option in challenging situations.
Collapse
Affiliation(s)
- Graziano Ceccarelli
- General Surgery, "San Giovanni Battista" Hospital, USL Umbria 2, Via Massimo Arcamone 1, 06034, Foligno, Italy
| | - Alessandro Pasculli
- Unit of General Surgery "V. Bonomo", Department of Biomedical Sciences and Human Oncology, University of Bari "A. Moro", Polyclinic of Bari, Piazza Giulio Cesare 11, 70124, Bari, Italy.
| | - Walter Bugiantella
- General Surgery, "San Giovanni Battista" Hospital, USL Umbria 2, Via Massimo Arcamone 1, 06034, Foligno, Italy
| | - Michele De Rosa
- General Surgery, "San Giovanni Battista" Hospital, USL Umbria 2, Via Massimo Arcamone 1, 06034, Foligno, Italy
| | - Fausto Catena
- Department of Emergency and Trauma Surgery, Parma University Hospital, Viale Antonio Gramsci 11, 43126, Parma, Italy
| | - Fabio Rondelli
- General Surgery, "San Giovanni Battista" Hospital, USL Umbria 2, Via Massimo Arcamone 1, 06034, Foligno, Italy
| | - Gianluca Costa
- General Surgery, "San Giovanni Battista" Hospital, USL Umbria 2, Via Massimo Arcamone 1, 06034, Foligno, Italy
| | - Aldo Rocca
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Via Francesco de Sanctis 1, 86100, Campobasso, Italy
| | - Mattia Longaroni
- General Surgery, "San Giovanni Battista" Hospital, USL Umbria 2, Via Massimo Arcamone 1, 06034, Foligno, Italy
| | - Mario Testini
- Unit of General Surgery "V. Bonomo", Department of Biomedical Sciences and Human Oncology, University of Bari "A. Moro", Polyclinic of Bari, Piazza Giulio Cesare 11, 70124, Bari, Italy
| |
Collapse
|
4
|
Arcerito M, Perez MG, Kaur H, Annoreno KM, Moon JT. Robotic Fundoplication for Large Paraesophageal Hiatal Hernias. JSLS 2020; 24:JSLS.2019.00054. [PMID: 32206010 PMCID: PMC7065729 DOI: 10.4293/jsls.2019.00054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Purpose: Laparoscopic fundoplication is now a cornerstone in the treatment of gastro-esophageal reflux disease (GERD) with sliding hernia. The best outcomes are achieved in those patients who have some response to medical treatment compared to those who do not. Robotic fundoplication is considered a novel approach in treating GERD with large paraesophageal hiatal hernias. Our goal was to examine the feasibility of this technique. Methods: Seventy patients (23 males and 47 females) with mean age 64 y old (22–92), preoperatively diagnosed with a large paraesophageal hiatal hernia, were treated with a robotic approach. Biosynthetic tissue absorbable mesh was applied for hiatal closure reinforcement. Fifty-eight patients underwent total fundoplication, 11 patients had partial fundoplication, and one patient had a Collis-Nissen fundoplication for acquired short esophagus. Results: All procedures were completed robotically, without laparoscopic or open conversion. Mean operative time was 223 min (180–360). Mean length of stay was 38 h (24–96). Median follow-up was 29 mo (7–51). Moderate postoperative dysphagia was noted in eight patients, all of which resolved after 3 mo without esophageal dilation. No mesh-related complications were detected. There were six hernia recurrences. Four patients were treated with redo-robotic fundoplication, and two were treated medically. Conclusions: The success of robotic fundoplication depends on adhering to a few important technical principles. In our experience, the robotic surgical treatment of gastroesophageal reflux disease with large paraesophageal hernias may afford the surgeon increased dexterity and is feasible with comparable outcomes compared with traditional laparoscopic approaches.
Collapse
Affiliation(s)
- Massimo Arcerito
- Riverside Medical Clinic Inc., University of California Riverside School of Medicine, Riverside, California
| | - Martin G Perez
- Riverside Medical Clinic Inc., University of California Riverside School of Medicine, Riverside, California
| | - Harpreet Kaur
- Division of General and Vascular Surgery, Riverside Community Hospital, Riverside, California
| | - Kenneth M Annoreno
- Division of General and Vascular Surgery, Riverside Community Hospital, Riverside, California
| | - John T Moon
- Shawnee Mission Medical Center, Shawnee Mission, Kansas
| |
Collapse
|
5
|
Davila DG, Stetler JL, Lin E, Davis SS, Yheulon CG. Laparoscopic Paraesophageal Hernia Repair and Pulmonary Embolism. Surg Laparosc Endosc Percutan Tech 2019; 29:534-538. [PMID: 31436646 DOI: 10.1097/sle.0000000000000708] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Pulmonary embolism (PE) following laparoscopic paraesophageal hernia repair (PEHR) is rare but occurs at a higher frequency than other laparoscopic procedures. We describe a series of patients who developed PEs after PEHR in hopes of capturing potential risk factors for further study. MATERIALS AND METHODS Five cases of PE after PEHR were observed between 2017 and 2018. Individual and perioperative risk factors, and postoperative courses were reviewed. RESULTS Patients had a mean age of 73 years (range, 59 to 86). All were female. Two patients presented acutely. Three patients underwent revisional surgery. The average procedure duration was 248 minutes (range, 162 to 324). All patients had gastrostomy tubes placed. The diagnosis of PE occurred within 3 to 19 days postoperatively. Four were treated with 3 months of oral anticoagulation; 1 was managed expectantly. CONCLUSIONS Highly complex cases, marked by revisional status, need for mesh, large hernia size, and percutaneous endoscopic gastrostomy placement are likely at increased risk for PEs. Preoperative venous thromboembolism chemoprophylaxis should be considered in the majority of laparoscopic PEHR patients.
Collapse
Affiliation(s)
- Daniel G Davila
- Division of General and GI Surgery, Emory University School of Medicine, Atlanta, GA
| | | | | | | | | |
Collapse
|
6
|
Wirsching A, El Lakis MA, Mohiuddin K, Pozzi A, Hubka M, Low DE. Acute Vs. Elective Paraesophageal Hernia Repair: Endoscopic Gastric Decompression Allows Semi-Elective Surgery in a Majority of Acute Patients. J Gastrointest Surg 2018; 22:194-202. [PMID: 28770418 DOI: 10.1007/s11605-017-3495-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 06/30/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Historically, patients presenting acutely with paraesophageal hernia and requiring urgent operation demonstrated inferior outcomes compared to patients undergoing elective repair. METHODS A prospective IRB-approved database was used to retrospectively review 570 consecutive patients undergoing paraesophageal hernia repair between 2000 and 2016. RESULTS Thirty-eight patients presented acutely (6.7%) and 532 electively. Acute presentation was associated with increased age (74 vs. 69 years) but similar age-adjusted Charlson comorbidity scores. A history of chest pain, intrathoracic stomach ≥75%, and mesoaxial rotation were more common in acute presentations. Emergency surgery was required in three patients (8%), and 35 patients were managed in a staged approach with guided decompression prior to semi-elective surgery. Acute presentation was associated with an increased hospital stay (5 (2-13) days vs. 4 (1-27) days, p = 0.001). There was no difference in postoperative Clavien-Dindo severity scores. One patient in the elective group died, and the overall mortality was 0.2%. CONCLUSION Our findings suggest that a majority of patients presenting with acute paraesophageal hernia can undergo a staged approach instead of urgent surgery with comparable outcomes to elective operations in high-volume centers. We suggest elective repair for patients presenting with a history of chest pain, intrathoracic stomach ≥75%, and a mesoaxial rotation.
Collapse
Affiliation(s)
- Andrea Wirsching
- General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Ave, Seattle, WA, 98111, USA
| | - Moustapha A El Lakis
- General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Ave, Seattle, WA, 98111, USA
| | - Kamran Mohiuddin
- General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Ave, Seattle, WA, 98111, USA
| | - Agostino Pozzi
- General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Ave, Seattle, WA, 98111, USA
| | - Michal Hubka
- General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Ave, Seattle, WA, 98111, USA
| | - Donald E Low
- General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, 1100 Ninth Ave, Seattle, WA, 98111, USA.
| |
Collapse
|
7
|
Vasudevan V, Reusche R, Nelson E, Kaza S. Robotic paraesophageal hernia repair: a single-center experience and systematic review. J Robot Surg 2017; 12:81-86. [PMID: 28374223 DOI: 10.1007/s11701-017-0697-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 03/14/2017] [Indexed: 12/29/2022]
Abstract
Robotic Surgery is becoming increasingly used in general surgery. The objective of this study is to evaluate the safety, effectiveness and short-term (less than 1 year) outcomes of Robotic Paraesophageal Hernia (RPEH) Surgery using the DaVinci Surgical Robot system (Intuitive Surgical, CA) in a large community hospital. This is a retrospective cohort study of 28 consecutive patients who underwent robotic paraesophageal hernia repair January 2011-March 2013 in this institution. Data and outcomes collected for analysis include patient demographics, operating times, conversion, complications, mortality and recurrence. The mean age of the patients was 68.7 +/- 12.7 years, 82% were females and the mean BMI was 29 +/- 6.3. The mean operative time, including the robot docking time, was 83.6 + 24 min. The average length of hospital stay (LOS) was 2.8 +/- 1.9 days. There were no conversions to open or laparoscopic procedures. Postoperative complications were noted in 3 patients (10.7%), including one mortality (3.4%). One symptomatic recurrence (3.4%) was noted during the 12-month follow-up period. Robotic Paraesophageal repair is a safe (similar rate of complication and mortality to literature for laparoscopic procedure) and an effective (paraeshopageal hernia repaired without high recurrence) procedure with acceptable complication rates even in older patients with high operative risks.
Collapse
Affiliation(s)
- Vanitha Vasudevan
- Department of Surgery, University of Miami Miller School of Medicine Palm Beach Regional Campus, 5301 S congress Ave, Atlantis, FL, 33462, USA
| | - Ryan Reusche
- Department of Surgery, Mayo Clinic, 200 1st st SW, Rochester, MN, 55905, USA.
| | - Erek Nelson
- Department of Surgery, Mayo Clinic, 200 1st st SW, Rochester, MN, 55905, USA
| | - Srinivas Kaza
- Department of Surgery, University of Miami Miller School of Medicine Palm Beach Regional Campus, 5301 S congress Ave, Atlantis, FL, 33462, USA
| |
Collapse
|
8
|
Tam V, Luketich JD, Winger DG, Sarkaria IS, Levy RM, Christie NA, Awais O, Shende MR, Nason KS. Non-Elective Paraesophageal Hernia Repair Portends Worse Outcomes in Comparable Patients: a Propensity-Adjusted Analysis. J Gastrointest Surg 2017; 21:137-145. [PMID: 27492355 PMCID: PMC5209749 DOI: 10.1007/s11605-016-3231-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 07/26/2016] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Patients undergoing non-elective paraesophageal hernia repair (PEHR) have worse perioperative outcomes. Because they are usually older and sicker, however, these patients may be more prone to adverse events, independent of surgical urgency. Our study aimed to determine whether non-elective PEHR is associated with differential postoperative outcome compared to elective repair, using propensity-score weighting. METHODS We abstracted data for patients undergoing PEHR (n = 924; non-elective n = 171 (19 %); 1997-2010). Using boosted regression, we generated a propensity-weighted dataset. Odds of 30-day/in-hospital mortality and major complications after non-elective surgery were determined. RESULTS Patients undergoing non-elective repair were significantly older, had more adverse prognostic factors, and significantly more major complications (38 versus 18 %; p < 0.001) and death (8 versus 1 %; p < 0.001). After propensity weighting, median absolute percentage bias across 28 propensity-score variables improved from 19 % (significant imbalance) to 5.6 % (well-balanced). After adjusting propensity-weighted data for age and comorbidity score, odds of major complications were still nearly two times greater (OR 1.67, CI 1.07-2.61) and mortality nearly three times greater (OR 2.74, CI 0.93-8.1) than for elective repair. CONCLUSIONS Even after balancing significant differences in baseline characteristics, non-elective PEHR was associated with worse outcomes than elective repair. Symptomatic patients should be referred for elective repair by experienced surgeons.
Collapse
Affiliation(s)
- Vernissia Tam
- University of Pittsburgh Department of General Surgery, Pittsburgh, PA
| | | | - Daniel G. Winger
- University of Pittsburgh Clinical and Translational Science Institute, Pittsburgh, PA
| | | | - Ryan M. Levy
- Department of Cardiothoracic Surgery, Pittsburgh, PA
| | | | - Omar Awais
- Department of Cardiothoracic Surgery, Pittsburgh, PA
| | | | | |
Collapse
|
9
|
Practice Patterns and Outcomes After Hospital Admission With Acute Para-esophageal Hernia in England. Ann Surg 2016; 264:854-861. [DOI: 10.1097/sla.0000000000001877] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
10
|
Paraesophageal hernia repair in the emergency setting: is laparoscopy with the addition of a fundoplication the new gold standard? Surg Endosc 2015; 30:1790-5. [PMID: 26194263 DOI: 10.1007/s00464-015-4447-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 07/13/2015] [Indexed: 01/10/2023]
Abstract
BACKGROUND Laparoscopic repair of paraesophageal hernia (PEH) with fundoplication is currently the preferred elective strategy, but emergent cases are often done open without an anti-reflux (AR) procedure. This study examined PEH repair in elective and urgent/emergent settings and investigated patient characteristic influence on the use of adjunctive techniques, such as AR procedures or gastrostomy tube (GT) placement. METHODS Utilizing the University HealthSystem Consortium Clinical Database Resource Manager, selected discharge data were retrieved using International Classification of Disease 9 diagnosis codes for PEH and procedure specific codes. Chi-squared and paired t tests were applied (α = 0.05). RESULTS Discharge data from October 2010 through June 2014 indicated 7950 patients (≥18 years) underwent PEH surgery, 84.7 % were performed laparoscopically and 15.3 % open. 24.6 % of cases were classified urgent/emergent upon admission, and almost 70 % of these were completed laparoscopically. Open paraesophageal hernia repairs (OHR) represented a higher proportion of urgent/emergent cases but were only 30 % of this total. Laparoscopic paraesophageal hernia repair (LHR) patients were more likely to receive an AR procedure in all situations (54.9 % LHR vs. 26.3 % OHR). Almost 90 % of elective PEH repairs in this cohort were laparoscopic. Elective cases were more commonly associated with AR procedures than emergent cases which frequently incorporated GT placement. CONCLUSION We demonstrate that laparoscopic PEH repair has become accepted in emergent cases. Open PEH repair is often reserved for emergent surgeries and less commonly includes an AR procedure. Laparoscopy with an AR procedure is clearly the standard of care in elective surgery. The decision to perform an open or laparoscopic surgery, with or without adjunctive techniques, may be based more on the physician's comfort with laparoscopic surgery and surgical practices than the patient's condition. Long-term follow-up studies are needed to determine the functional outcomes of these strategies.
Collapse
|