Trans-hiatal herniation following esophagectomy or gastrectomy: retrospective single-center experiences with a potential surgical emergency

Postoperative obstruction of recurrent esophageal hiatal hernia: A case report

RATIONALE

Surgical repair is considered the optimal treatment for hiatal hernia (HH); however, postoperative complications, such as obstruction, can occur, which may complicate recovery. This case report details a patient who experienced postoperative obstruction following laparoscopic adhesiolysis combined with transabdominal HH repair and Nissen fundoplication for recurrent esophageal HH.

PATIENT CONCERNS

A 64-year-old female presented with a 3-year history of worsening shortness of breath during physical activity. She also reported upper abdominal pain, postprandial vomiting, and difficulty swallowing, all of which significantly compromised her quality of life. The patient had a 5-year history of diabetes, with no notable family or genetic history. Three years prior, she underwent laparoscopic HH repair at a local hospital, but specific details of that surgery were not available.

DIAGNOSES

HH was confirmed through computed tomography scans of the chest and upper abdomen, as well as serial examinations of the upper digestive tract.

INTERVENTION

On March 9, 2023, the patient underwent laparoscopic abdominal adhesion release, transabdominal HH repair, and Nissen fundoplication. Postoperatively, she received parenteral nutrition, acid inhibition, and symptomatic treatment for deswelling to alleviate abdominal pain and vomiting. However, the patient was unable to tolerate oral intake due to obstruction.

OUTCOMES

A contrast study revealed high obstruction at the distal esophagus, specifically at the junction of the stomach and esophagus, likely at the cardia. Subsequently, on April 6, 2023, the patient underwent a second laparoscopic exploration and adhesiolysis under general anesthesia. Postoperatively, the patient recovered well and was discharged on April 14, 2023. During the 12-month follow-up on April 30, 2024, she reported returning to normal daily activities with no complaints of discomfort.

LESSONS

This case highlights that laparoscopic adhesiolysis combined with transabdominal HH repair and Nissen fundoplication can effectively address recurrent esophageal HH along with postoperative obstruction. The findings provide important insights for the individualization of surgical procedures for patients with HH.

Presentation and management of post-esophagectomy or Gastrectomy Hiatal Hernia

PURPOSE

Hiatal hernia may development after esophagectomy or Gastrectomy. Post- esophago-gastric hiatal hernia is a rare but challenging condition. Nearly half of reported cases involve emergent situations, underscoring the urgency of addressing this condition. However, there is currently no consensus on the optimal treatment approach for this type of hernia.

METHODS

All consecutive patients who underwent repair for Post- esophago-gastric hiatal hernia over the past five years were retrospectively reviewed. Patient characteristics and perioperative data were collected. The primary outcomes, repair methods, and surgical results following post-esophago-gastric hiatal repair were analyzed.

RESULTS

A total of eight patients with post-esophago-gastric hiatal hernia were included in this study. All patients presented with emergent conditions, specifically bowel obstruction. Laparoscopic repair was successful in four cases, with a conversion rate to open surgery of 50% (4 out of 8). Primary suture was performed in three cases, while biological mesh repair was carried out in four cases, and one case was left unrepaired. Bowel gangrene and perforation occurred in one case. The most notable postoperative complications included wound infection and pleural fluid collection. Importantly, there were no instances of hernia recurrence during the follow-up period, which ranged from 2 to 55 months, with a 100% follow-up rate observed.

CONCLUSION

Post-esophago-gastric hiatal hernia is a rare yet significant condition, often presenting emergently and linked to higher morbidity and mortality rates. Therefore, symptomatic patients warrant surgical repair, and immediate intervention should be provided to those with acute-onset symptoms and clinical signs of bowel obstruction. Primary suture repair, with or without biological mesh, appears to be a durable method of repair.

Postoperative Hiatal Hernia after Ivor Lewis Esophagectomy-A Growing Problem in the Age of Minimally Invasive Surgery

BACKGROUND

Even though minimally invasive esophagectomy is a safe and oncologically effective procedure, several authors have reported an increased risk of postoperative hiatal hernia (PHH). This study evaluates the incidence and risk factors of PHH after hybrid minimally invasive (HMIE) versus open esophagectomy (OE).

METHODS

A retrospective single-center analysis was performed on patients who underwent Ivor Lewis esophagectomy between January 2009 and April 2018. Computed tomography scans and patient files were reviewed to identify the PHH.

RESULTS

306 patients were included (152 HMIE; 154 OE). Of these, 23 patients (8%) developed PHH. Most patients (13/23, 57%) were asymptomatic at the time of diagnosis and only 4 patients (17%) presented in an emergency setting with incarceration. The rate of PHH was significantly higher after HMIE compared to OE (13.8% vs. 1.3%, p < 0.001). No other risk factors for the development of PHH were identified in uni- or multi-variate analysis. Surgical repair of PHH was performed in 19/23 patients (83%). The recurrence rate of PHH after surgical repair was 32% (6/19 patients).

CONCLUSIONS

The development of PHH is a relevant complication after hybrid minimally invasive esophagectomy. Although most patients are asymptomatic, surgical repair is recommended to avoid incarceration with potentially fatal outcomes. Innovative techniques for the prevention and repair of PHH are urgently needed.

Two years later: Is the SARS-CoV-2 pandemic still having an impact on emergency surgery? An international cross-sectional survey among WSES members

BACKGROUND

The SARS-CoV-2 pandemic is still ongoing and a major challenge for health care services worldwide. In the first WSES COVID-19 emergency surgery survey, a strong negative impact on emergency surgery (ES) had been described already early in the pandemic situation. However, the knowledge is limited about current effects of the pandemic on patient flow through emergency rooms, daily routine and decision making in ES as well as their changes over time during the last two pandemic years. This second WSES COVID-19 emergency surgery survey investigates the impact of the SARS-CoV-2 pandemic on ES during the course of the pandemic.

METHODS

A web survey had been distributed to medical specialists in ES during a four-week period from January 2022, investigating the impact of the pandemic on patients and septic diseases both requiring ES, structural problems due to the pandemic and time-to-intervention in ES routine.

RESULTS

367 collaborators from 59 countries responded to the survey. The majority indicated that the pandemic still significantly impacts on treatment and outcome of surgical emergency patients (83.1% and 78.5%, respectively). As reasons, the collaborators reported decreased case load in ES (44.7%), but patients presenting with more prolonged and severe diseases, especially concerning perforated appendicitis (62.1%) and diverticulitis (57.5%). Otherwise, approximately 50% of the participants still observe a delay in time-to-intervention in ES compared with the situation before the pandemic. Relevant causes leading to enlarged time-to-intervention in ES during the pandemic are persistent problems with in-hospital logistics, lacks in medical staff as well as operating room and intensive care capacities during the pandemic. This leads not only to the need for triage or transferring of ES patients to other hospitals, reported by 64.0% and 48.8% of the collaborators, respectively, but also to paradigm shifts in treatment modalities to non-operative approaches reported by 67.3% of the participants, especially in uncomplicated appendicitis, cholecystitis and multiple-recurrent diverticulitis.

CONCLUSIONS

The SARS-CoV-2 pandemic still significantly impacts on care and outcome of patients in ES. Well-known problems with in-hospital logistics are not sufficiently resolved by now; however, medical staff shortages and reduced capacities have been dramatically aggravated over last two pandemic years.

Diaphragmatic herniation after esophagogastric surgery: systematic review and meta-analysis

Introduction

The anatomy of the esophageal hiatus is altered during esophagogastric surgery with an increased risk of postoperative hiatus hernia (HH). The purpose of this article was to examine the current evidence on the surgical management and outcomes associated with HH after esophagogastric surgery for cancer.

Materials and methods

Systematic review and meta-analysis. Web of Science, PubMed, and EMBASE data sets were consulted.

Results

Twenty-seven studies were included for a total of 404 patients requiring surgical treatment for HH after esophagogastric surgery. The age of the patients ranged from 35 to 85 years, and the majority were males (82.3%). Abdominal pain, nausea/vomiting, and dyspnea were the commonly reported symptoms. An emergency repair was required in 51.5%, while a minimally invasive repair was performed in 48.5%. Simple suture cruroplasty and mesh reinforced repair were performed in 65% and 35% of patients, respectively. The duration between the index procedure and HH repair ranged from 3 to 144 months, with the majority (67%) occurring within 24 months. The estimated pooled prevalence rates of pulmonary complications, anastomotic leak, overall morbidity, and mortality were 14.1% (95% CI = 8.0–22.0%), 1.4% (95% CI = 0.8–2.2%), 35% (95% CI = 20.0–54.0%), and 5.0% (95% CI = 3.0–8.0%), respectively. The postoperative follow-up ranged from 1 to 110 months (mean = 24) and the pooled prevalence of HH recurrence was 16% (95% CI = 13.0–21.6%).

Conclusions

Current evidence reporting data for HH after esophagogastric surgery is narrow. The overall postoperative pulmonary complications, overall morbidity, and mortality are 14%, 35%, and 5%, respectively. Additional studies are required to define indications and treatment algorithm and evaluate the best technique for crural repair at the index operation in an attempt to minimize the risk of HH.