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Turner B, Kastenmeier A, Gould JC. Interval operative management in patients admitted with acute obstruction due to incarcerated paraesophageal hernia. Surg Endosc 2024:10.1007/s00464-024-11157-3. [PMID: 39120627 DOI: 10.1007/s00464-024-11157-3] [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: 06/17/2024] [Accepted: 08/04/2024] [Indexed: 08/10/2024]
Abstract
BACKGROUND Acute incarcerated paraesophageal hernias (PEH) have historically been considered a surgical emergency. Emergent operations have a higher rate of morbidity and mortality compared to elective surgery. Our institution has adopted a strategy of initial conservative management in patients presenting with acute obstruction from an incarcerated PEH who are clinically stable. Patients are given at least 24 h for their symptoms to improve (selective nasogastric decompression). If symptoms resolve, contrast on an upper GI study passes to the small bowel, and liquids are tolerated, patients are discharged with planned interval repair. We sought to characterize the outcomes of this interval surgical strategy for incarcerated PEH. METHODS A retrospective chart review was performed to identify patients admitted to a single institution between October 2019 and September 2023 with an incarcerated PEH. Patients taken directly to surgery within 24 h were excluded. RESULTS A total of 45 patients admitted with obstruction from an incarcerated PEH were identified. Ten patients (22%) were taken urgently to surgery due to clinical instability and were excluded. Of the remaining 35 patients, 23 (66%) resolved their obstruction with conservative non-operative management and were offered planned interval PEH repair (successful conservative management). In the successful conservative management cohort, there was one unplanned readmission before interval PEH repair. Average time between discharge and repair was 25 days. Complication rates did not differ in those who failed and in those who had a successful conservative management result. The cumulative length of stay for those who succeeded in conservative management (including days for the interval surgery) was equivalent with those who underwent PEH repair during the index admission. CONCLUSION A trial of conservative management in clinically stable patients with symptomatic incarcerated PEH appears to be safe and often avoids emergent repair without increasing perioperative complications or total days in the hospital.
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Affiliation(s)
- Brexton Turner
- Division of Minimally Invasive and Gastrointestinal Surgery, Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI, 53226, USA
| | - Andrew Kastenmeier
- Division of Minimally Invasive and Gastrointestinal Surgery, Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI, 53226, USA
| | - Jon C Gould
- Division of Minimally Invasive and Gastrointestinal Surgery, Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI, 53226, USA.
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DeMeester SR, Bernard L, Schoppmann SF, McKay SC, Roth JS. Updated Markov Model to Determine Optimal Management Strategy for Patients with Paraesophageal Hernia and Symptoms, Cameron Ulcer, or Comorbid Conditions. J Am Coll Surg 2024; 238:1069-1082. [PMID: 38359322 DOI: 10.1097/xcs.0000000000001040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
BACKGROUND The current paradigm of watchful waiting (WW) in people 65 years or older with an asymptomatic paraesophageal hernia (PEH) is based on a now 20-year-old Markov analysis. Recently, we have shown that elective laparoscopic hernia repair (ELHR) provides an increase in life-years (L-Ys) compared with WW in most healthy patients aged 40 to 90 years. However, elderly patients often have comorbid conditions and may have complications from their PEH such as Cameron lesions. The aim of this study was to determine the optimal strategy, ELHR or WW, in these patients. STUDY DESIGN A Markov model with updated variables was used to compare L-Ys gained with ELHR vs WW in hypothetical people with any type of PEH and symptoms, Cameron lesions, and/or comorbid conditions. RESULTS In men and women aged 40 to 90 years with PEH-related symptoms and/or Cameron lesions, ELHR led to an increase in L-Ys over WW. The presence of comorbid conditions impacted life expectancy overall, but ELHR remained the preferred approach in all but 90-year-old patients with symptoms but no Cameron lesions. CONCLUSIONS Using a Markov model with updated values for key variables associated with management options for patients with a PEH, we showed that life expectancy was improved with ELHR in most men and women aged 40 to 90 years, particularly in the presence of symptoms and/or Cameron lesions. Comorbid conditions increase the risk for surgery, but ELHR remained the preferred strategy in the majority of symptomatic patients. This model can be used to provide individualized management guidance for patients with a PEH.
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Affiliation(s)
- Steven R DeMeester
- From the Center for Advanced Surgery, The Oregon Clinic, Portland, OR (DeMeester)
| | - Lisa Bernard
- Bernard Consulting, Selkirk, Ontario, Canada (Bernard)
| | | | | | - J Scott Roth
- Department of Surgery, The University of Kentucky, Lexington, KY (Roth)
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Brandalise A, Herbella FAM, Luna RA, Szachnowicz S, Sallum RAA, Domene CE, Volpe P, Cavazzolla LT, Furtado ML, Claus CMP, Farah JFDM, Crema E. BRAZILIAN HERNIA AND ABDOMINAL WALL SOCIETY STATEMENT ON LARGE HIATAL HERNIAS MANAGEMENT. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2024; 36:e1787. [PMID: 38324849 PMCID: PMC10841492 DOI: 10.1590/0102-672020230069e1787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 10/21/2023] [Indexed: 02/09/2024]
Abstract
Large hiatal hernias, besides being more prevalent in the elderly, have a different clinical presentation: less reflux, more mechanical symptoms, and a greater possibility of acute, life-threatening complications such as gastric volvulus, ischemia, and visceral mediastinal perforation. Thus, surgical indications are distinct from gastroesophageal reflux disease-related sliding hiatal hernias. Heartburn tends to be less intense, while symptoms of chest pain, cough, discomfort, and tiredness are reported more frequently. Complaints of vomiting and dysphagia may suggest the presence of associated gastric volvulus. Signs of iron deficiency and anemia are found. Surgical indication is still controversial and was previously based on high mortality reported in emergency surgeries for gastric volvulus. Postoperative mortality is especially related to three factors: body mass index above 35, age over 70 years, and the presence of comorbidities. Minimally invasive elective surgery should be offered to symptomatic individuals with good or reasonable performance status, regardless of age group. In asymptomatic and oligosymptomatic patients, besides obviously identifying the patient's desire, a case-by-case analysis of surgical risk factors such as age, obesity, and comorbidities should be taken into consideration. Attention should also be paid to situations with greater technical difficulty and risks of acute migration due to increased abdominal pressure (abdominoplasty, manual labor, spastic diseases). Technical alternatives such as partial fundoplication and anterior gastropexy can be considered. We emphasize the importance of performing surgical procedures in cases of large hiatal hernias in high-volume centers, with experienced surgeons.
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Affiliation(s)
- André Brandalise
- Centro Médico de Campinas, Robotic Surgery Program - Campinas (SP), Brazil
| | | | - Renato Abrantes Luna
- Universidade Federal do Estado do Rio de Janeiro, Faculty of Medicine and Surgery, Hospital Federal dos Servidores do Estado - Rio de Janeiro (RJ), Brazil
| | - Sergio Szachnowicz
- Universidade de São Paulo, Department of Gastroenterology - São Paulo (SP), Brazil
| | | | | | - Paula Volpe
- Centro Integrado de Medicina Avançada - São Paulo (SP), Brazil
| | - Leandro Totti Cavazzolla
- Universidade Federal do Rio Grande do Sul, University Hospital, General Surgery Unit - Porto Alegre (RS), Brazil
| | - Marcelo Lopes Furtado
- Sociedade Brasileira de Hérna e Parede Abdominal, Hospital Pintagueiras, Videolaparoscopic Surgery Service - Jundiaí, São Paulo (SP), Brazil
| | - Christiano Marlo Paggi Claus
- Universidade Positivo, Postgraduate Program in Minimally Invasive Surgery, Department of Surgical Clinic - Curitiba (PR), Brazil
| | | | - Eduardo Crema
- Universidade Federal do Triângulo Mineiro, Digestive Surgical Unit - Uberaba (MG), Brazil
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DeMeester SR, Bernard L, Schoppmann SF, Kloosterman R, Roth JS. Elective Laparoscopic Paraesophageal Hernia Repair Leads to an Increase in Life Expectancy Over Watchful Waiting in Asymptomatic Patients: An Updated Markov Analysis. Ann Surg 2024; 279:267-275. [PMID: 37818675 DOI: 10.1097/sla.0000000000006119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2023]
Abstract
OBJECTIVE The aim of this study was to perform an updated Markov analysis to determine the optimal management strategy for patients with an asymptomatic paraesophageal hernia (PEH): elective laparoscopic hernia repair (ELHR) versus watchful waiting (WW). BACKGROUND Currently, it is recommended that patients with an asymptomatic PEH not undergo repair based on a 20-year-old Markov analysis. The current recommendation might lead to preventable hospitalizations for acute PEH-related complications and compromised survival. METHODS A Markov model with updated variables was used to compare life-years (L-Ys) gained with ELHR versus WW in patients with a PEH. One-way sensitivity analyses evaluated the robustness of the analysis to alternative data inputs, while probabilistic sensitivity analysis quantified the level of confidence in the results in relation to the uncertainty across all model inputs. RESULTS At age 40 to 90, ELHR led to greater life expectancy than WW, particularly in women. The gain in L-Ys (2.6) was greatest in a 40-year-old woman and diminished with increasing age. Sensitivity analysis showed that alternative values resulted in modest changes in the difference in L-Ys, but ELHR remained the preferred strategy. Probabilistic analysis showed that ELHR was the preferred strategy in 100% of 10,000 simulations for age 65, 98% for age 80, 90% for age 85, and 59% of simulations in 90-year-old women. CONCLUSIONS This updated analysis showed that ELHR leads to an increase in L-Ys over WW in healthy patients aged 40 to 90 years with an asymptomatic PEH. In this new paradigm, all patients with a PEH, regardless of symptoms, should be referred for the consideration of elective repair to maximize their life expectancy.
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Affiliation(s)
| | | | | | | | - J Scott Roth
- Department of Surgery, The University of Kentucky, Lexington, KY
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5
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Wong LY, Parsons N, David EA, Burfeind W, Berry MF. The Impact of Age and Need for Emergent Surgery in Paraesophageal Hernia Repair Outcomes. Ann Thorac Surg 2023; 116:138-145. [PMID: 36702291 DOI: 10.1016/j.athoracsur.2023.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 01/08/2023] [Accepted: 01/14/2023] [Indexed: 01/24/2023]
Abstract
BACKGROUND Observation of paraesophageal hernias (PEHs) may lead to emergent surgery for hernia-related complications. This study evaluated urgent or emergent repair outcomes to quantify the possible sequelae of failed conservative PEH management. METHODS The impact of operative status (elective vs urgent or emergent) on perioperative mortality or major morbidity for patients who underwent hiatal hernia repair for a PEH diagnosis from 2012 to 2021 in the Society of Thoracic Surgery General Thoracic Surgery Database was evaluated with multivariable logistic regression models. RESULTS Overall, 2082 (10.9%) of 19,122 patients with PEHs underwent urgent or emergent repair. Patients undergoing nonelective surgery were significantly older than patients undergoing elective surgery (median age, 73 years [interquartile range, 63-82 years] vs 66 years [interquartile range, 58-74 years]) and had a lower preoperative performance score (P < .001). Nonelective surgical procedures were more likely to be performed through the chest or by laparotomy rather than by laparoscopy (20% vs 11.4%; P < .001), and they were associated with longer hospitalizations (4 days vs 2 days; P < .001), higher operative mortality (4.5% vs 0.6%; P < .001), and higher major morbidity (27% vs 5.5%; P < .001). Nonelective surgery was a significant independent predictor of major morbidity in multivariable analysis (odds ratio, 2.06; P < .001). Patients more than the age of 80 years had higher operative mortality (4.3% vs 0.6%; P < 0.001) and major morbidity (19% vs 6.1%; P < .001) than younger patients overall, and these older patients more often had nonelective surgery (26% vs 8.6%; P < .001) CONCLUSIONS: The operative morbidity of PEH repair is significantly increased when surgery is nonelective, particularly for older patients. These results can inform the potential consequences of choosing watchful waiting vs elective PEH repair.
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Affiliation(s)
- Lye-Yeng Wong
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California.
| | | | - Elizabeth A David
- Division of Cardiothoracic Surgery, University of Colorado, Aurora, Colorado
| | - William Burfeind
- Department of Cardiothoracic Surgery, St Luke's University Health Network, Bethlehem, Pennsylvania
| | - Mark F Berry
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California
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6
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Collins ML, Mack SJ, Till BM, Whitehorn GL, Tofani C, Chojnacki K, Grenda T, Evans NR, Okusanya OT. Defining risk factors for mortality after emergent hiatal hernia repair in the era of minimally invasive surgery. Am J Surg 2023; 225:1056-1061. [PMID: 36653267 DOI: 10.1016/j.amjsurg.2023.01.012] [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: 10/28/2022] [Revised: 12/06/2022] [Accepted: 01/09/2023] [Indexed: 01/12/2023]
Abstract
BACKGROUND Risk factors for mortality following emergent hiatal hernia (HH) repair in the era of minimally invasive surgery remain poorly defined. METHODS Data was obtained from the National Inpatient Sample (NIS), National Readmissions Database, and National Emergency Department Sample for patients undergoing HH repair between 2010 and 2018. Univariate and multivariate logistic regression analyses reported with odds ratio (OR) and 95% confidence intervals (CI) were performed to identify factors associated mortality. RESULTS Via the NIS, mortality rate was 2.2% (147 patients). Via the NEDS, the mortality rate was 3.6% (303 patients). On multivariate analysis, predictors of mortality included age (OR 1.05, CI: 1.04,1.07), male sex (OR 1.49, CI: 1.06,2.11), frailty (OR 2.49, CI: 1.65,3.75), open repair (OR 3.59, CI: 2.50,5.17), and congestive heart failure (OR 2.71, CI: 1.81,4.06). CONCLUSIONS There are multiple risk factors for mortality after hiatal hernia repair. There is merit to a laparoscopic approach even in emergent settings.
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Affiliation(s)
- Micaela L Collins
- Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut St, Suite 100, Philadelphia, PA, 19107, USA; Thomas Jefferson University Hospital, Department of Surgery, Division of Esophageal and Thoracic Surgery, 211 South 9th St, Suite 300, Philadelphia, PA, 19107, USA.
| | - Shale J Mack
- Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut St, Suite 100, Philadelphia, PA, 19107, USA; Thomas Jefferson University Hospital, Department of Surgery, Division of Esophageal and Thoracic Surgery, 211 South 9th St, Suite 300, Philadelphia, PA, 19107, USA
| | - Brian M Till
- Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut St, Suite 100, Philadelphia, PA, 19107, USA; Thomas Jefferson University Hospital, Department of Surgery, Division of Esophageal and Thoracic Surgery, 211 South 9th St, Suite 300, Philadelphia, PA, 19107, USA
| | - Gregory L Whitehorn
- Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut St, Suite 100, Philadelphia, PA, 19107, USA; Thomas Jefferson University Hospital, Department of Surgery, Division of Esophageal and Thoracic Surgery, 211 South 9th St, Suite 300, Philadelphia, PA, 19107, USA
| | - Christina Tofani
- Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut St, Suite 100, Philadelphia, PA, 19107, USA; Thomas Jefferson University Hospital, Division of Gastroenterology, 132 S 10th St #480, Philadelphia, PA, 19107, USA
| | - Karen Chojnacki
- Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut St, Suite 100, Philadelphia, PA, 19107, USA; Thomas Jefferson University Hospital, Department of Surgery, Division of Minimally Invasive General Surgery, 1015 Walnut St, Curtis Building Suite 620, Philadelphia, PA, 19107, USA
| | - Tyler Grenda
- Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut St, Suite 100, Philadelphia, PA, 19107, USA; Thomas Jefferson University Hospital, Department of Surgery, Division of Esophageal and Thoracic Surgery, 211 South 9th St, Suite 300, Philadelphia, PA, 19107, USA
| | - Nathaniel R Evans
- Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut St, Suite 100, Philadelphia, PA, 19107, USA; Thomas Jefferson University Hospital, Department of Surgery, Division of Esophageal and Thoracic Surgery, 211 South 9th St, Suite 300, Philadelphia, PA, 19107, USA
| | - Olugbenga T Okusanya
- Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut St, Suite 100, Philadelphia, PA, 19107, USA; Thomas Jefferson University Hospital, Department of Surgery, Division of Esophageal and Thoracic Surgery, 211 South 9th St, Suite 300, Philadelphia, PA, 19107, USA
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7
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Impact of surgical repair on type IV paraesophageal hernias (PEHs). Surg Endosc 2021; 36:5467-5475. [PMID: 34796379 DOI: 10.1007/s00464-021-08828-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 10/19/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Paraesophageal hernias (PEHs; types II-III-IV) account for about 5% of all hiatal hernias (HHs). The peculiarity of PEHs is the presence of a herniated sac which contains a more or less important part of the stomach, along with other abdominal organs in type IV PEHs. Surgical treatment is more complex since it requires a reduction not only of the herniated content but also of the "container," namely the sac adherent to mediastinal structures. Since type III and IV PEHs are mostly grouped together as large PEHs, there is a lack of articles in the literature with regards to clear surgical outcomes, as well as management algorithms in type IV PEHs. This study aims to compare outcomes in type IV vs. type III PEHs after surgical repair. METHODS A retrospective study of patients who underwent laparoscopic PEH hernia repair (LPEHR) was conducted in a single institution between 2006 and 2020. Patient baseline characteristics and surgical outcomes were analyzed. RESULTS A total of 103 patients were included in the analysis. Patients presenting with type IV PEHs (12/103) were significantly older than patients with type III PEHs (91/104) (75.25 ± 7.15 vs. 66.91 ± 13.58 respectively (p = 0.039), and more fragile with a higher Charlson Comorbidity Index (CCI) (4.25 ± 1.48 vs. 2.96 ± 1.72, p = 0.016). Operative time was significantly longer (243 ± 101.73 vs. 133.38 ± 61.76, p = 0.002), and postoperative morbidity was significantly higher in type IV PEH repair (50% vs. 8.8% type III, p = 0.000). CONCLUSION Patients with type IV PEHs appear to be older and frailer. The higher incidence of postoperative complications in patients with type IV PEHs should advocate for a precise indication for surgical treatment, which should be performed in centers of expertise.
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Elective paraesophageal hernia repair in elderly patients: an analysis of ACS-NSQIP database for contemporary morbidity and mortality. Surg Endosc 2021; 36:1407-1413. [PMID: 33712938 DOI: 10.1007/s00464-021-08425-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 02/27/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Elective paraesophageal hernia (PEH) repair in asymptomatic or minimally symptomatic patients ≥ 65 years of age remains controversial. The widely cited Markov Monte Carlo decision analytic model recommends watchful waiting in this group, unless the mortality rate for elective repair was to reach ≤ 0.5%; at which point, surgery would become the optimal treatment. We hypothesized that with advances in minimally invasive surgery, perioperative care, and practice specialization, that mortality threshold has been reached in the contemporary era. However, the safety net would decrease as age increases, particularly in octogenarians. METHODS We identified 12,422 patients from the 2015-2017 ACS-NSQIP database, who underwent elective minimally invasive PEH repair, of whom 5476 (44.1%) were with age ≥ 65. Primary outcome was 30-day mortality. Secondary outcomes were length of stay (LOS), operative time, pneumonia, pulmonary embolism, unplanned intubation, sepsis, bleeding requiring transfusion, readmission, and return to OR. RESULTS Patients age ≥ 65 had a higher 30-day mortality (0.5% vs 0.2%; p < 0.001). Subset analysis of patients age 65-80 and > 80 showed a 30-day mortality of 0.4% vs. 1.8%, respectively (p < 0.001). Independent predictors of mortality in patients ≥ 65 years were age > 80 (OR 5.23, p < 0.001) and COPD (OR 2.59, p = 0.04). Patients ≥ 65 had a slightly higher incidence of pneumonia (2% vs 1.2%; p < 0.001), unplanned intubation (0.8% vs 0.5%; p < 0.05), pulmonary embolism (0.7% vs 0.3%; p = 0.001), bleeding requiring transfusion (1% vs 0.5%; p < 0.05), and LOS (2.38 vs 1.86 days, p < 0.001) with no difference in sepsis, return to OR or readmission. CONCLUSION This is the largest series evaluating elective PEH repair in the recent era. While morbidity and mortality do increase with age, the mortality remains below 0.5% until age 80. Our results support consideration for a paradigm shift in the management of patients < 80 years toward elective repair of PEH.
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Bujoreanu I, Abrar D, Lampridis S, Date R. Do Poor Functional Outcomes and Higher Morbidity Following Emergency Repair of Giant Hiatus Hernia Warrant Elective Surgery in Asymptomatic Patients? Front Surg 2021; 8:628477. [PMID: 33644111 PMCID: PMC7905348 DOI: 10.3389/fsurg.2021.628477] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 01/18/2021] [Indexed: 11/26/2022] Open
Abstract
Background: Patients with a giant hiatus hernia may present with acute symptoms caused by obstruction, strangulation, perforation and uncontrolled bleeding. Emergency surgical repair has been associated with significant mortality and even greater morbidity. The aim of this study is to investigate the short-term outcomes following emergency repair of giant hiatus hernias. Methods: Data were retrospectively collected for all patients who underwent emergency surgical repair of giant hiatus hernia in a university teaching hospital between 2009 and 2019. Outcomes were short-term morbidity and mortality. We also assessed the association of clinical predictor covariates, including age, ASA class and time to surgery, with risk for major morbidity. Results: Thirty-seven patients with a median age of 68 years were identified. Following surgery, 9 patients (24.3%) developed organ dysfunction that required admission to the intensive care unit. Two patients (5.4%) underwent revision surgery and 3 (8.1%) developed pneumothorax that necessitated chest drain insertion. The commonest complication was pneumonia, which occurred in 13 patients (35.1%). Two deaths (5.4%) occurred within 30 days from surgery. Conclusions: Emergency repair of giant hiatus hernia is associated with high rates of major morbidity, which includes poor functional status, further interventions, repeat surgery, and admission to the intensive care unit. Larger studies are warranted for long-term follow-up to assess post-operative quality of life is needed for asymptomatic patients and for those undergoing emergency surgery.
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Affiliation(s)
- Iulia Bujoreanu
- General Surgery Department, Royal Preston Hospital, Preston, United Kingdom
| | - Daniya Abrar
- General Surgery Department, Royal Preston Hospital, Preston, United Kingdom
| | - Savvas Lampridis
- Thoracic Surgery Department, 424 General Military Hospital, Thessaloniki, Greece
| | - Ravindra Date
- Department of Cancer, The University of Manchester, Manchester, United Kingdom
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10
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Dreifuss NH, Schlottmann F, Molena D. Management of paraesophageal hernia review of clinical studies: timing to surgery, mesh use, fundoplication, gastropexy and other controversies. Dis Esophagus 2020; 33:5848914. [PMID: 32476002 PMCID: PMC8344298 DOI: 10.1093/dote/doaa045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 04/14/2020] [Accepted: 05/02/2020] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Nicolás H Dreifuss
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | - Francisco Schlottmann
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina,Address correspondence to: Francisco Schlottmann, MD MPH, Department of Surgery, Hospital Alemán of Buenos Aires, Av. Pueyrredon 1640, C1118AAT Buenos Aires, Argentina.
| | - Daniela Molena
- Division of Thoracic Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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11
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Hietaniemi H, Ilonen I, Järvinen T, Kauppi J, Andersson S, Sintonen H, Räsänen J. Health-related quality of life after laparoscopic repair of giant paraesophageal hernia: how does recurrence in CT scan compare to clinical success? BMC Surg 2020; 20:109. [PMID: 32434571 PMCID: PMC7238581 DOI: 10.1186/s12893-020-00772-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 05/11/2020] [Indexed: 11/13/2022] Open
Abstract
Background Computed tomography (CT) is widely used in the diagnosis of giant paraesophageal hernias (GPEH) but has not been utilised systematically for follow-up. We performed a cross-sectional observational study to assess mid-term outcomes of elective laparoscopic GPEH repair. The primary objective of the study was to evaluate the radiological hernia recurrence rate by CT and to determine its association with current symptoms and quality of life. Methods All non-emergent laparoscopic GPEH repairs between 2010 to 2015 were identified from hospital medical records. Each patient was offered non-contrast CT and sent questionnaires for disease-specific symptoms and health-related quality of life. Results The inclusion criteria were met by 165 patients (74% female, mean age 67 years). Total recurrence rate was 29.3%. Major recurrent hernia (> 5 cm) was revealed by CT in 4 patients (4.3%). Radiological findings did not correlate with symptom-related quality of life. Perioperative mortality occurred in 1 patient (0.6%). Complications were reported in 27 patients (16.4%). Conclusions Successful laparoscopic repair of GPEH requires both expertise and experience. It appears to lead to effective symptom relief with high patient satisfaction. However, small radiological recurrences are common but do not affect postoperative symptom-related patient wellbeing.
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Affiliation(s)
- Henriikka Hietaniemi
- Department of General Thoracic and Esophageal Surgery, Helsinki University Hospital, Haartmaninkatu 4, 00290, Helsinki, Finland. .,Department of Surgery, Clinicum, University of Helsinki, Helsinki, Finland.
| | - Ilkka Ilonen
- Department of General Thoracic and Esophageal Surgery, Helsinki University Hospital, Haartmaninkatu 4, 00290, Helsinki, Finland.,Department of Surgery, Clinicum, University of Helsinki, Helsinki, Finland
| | - Tommi Järvinen
- Department of General Thoracic and Esophageal Surgery, Helsinki University Hospital, Haartmaninkatu 4, 00290, Helsinki, Finland.,Department of Surgery, Clinicum, University of Helsinki, Helsinki, Finland
| | - Juha Kauppi
- Department of General Thoracic and Esophageal Surgery, Helsinki University Hospital, Haartmaninkatu 4, 00290, Helsinki, Finland.,Department of Surgery, Clinicum, University of Helsinki, Helsinki, Finland
| | - Saana Andersson
- Department of General Thoracic and Esophageal Surgery, Helsinki University Hospital, Haartmaninkatu 4, 00290, Helsinki, Finland.,Department of Surgery, Clinicum, University of Helsinki, Helsinki, Finland
| | - Harri Sintonen
- Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Jari Räsänen
- Department of General Thoracic and Esophageal Surgery, Helsinki University Hospital, Haartmaninkatu 4, 00290, Helsinki, Finland.,Department of Surgery, Clinicum, University of Helsinki, Helsinki, Finland
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Shea B, Boyan W, Decker J, Almagno V, Binenbaum S, Matharoo G, Squillaro A, Borao F. Emergent Repair of Paraesophageal Hernias and the Argument for Elective Repair. JSLS 2019; 23:JSLS.2019.00015. [PMID: 31285652 PMCID: PMC6600053 DOI: 10.4293/jsls.2019.00015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background and Objectives: A feared complication of large paraesophageal hernias is incarceration necessitating emergent repair. According to previous studies, patients who require an emergent operation are subject to increased morbidity compared with patients undergoing elective operations. In this study, we detail patients who underwent hernia repair emergently and compare their outcomes with elective patients. Methods: A retrospective analysis was performed of the paraesophageal hernia repair operations between 2010 and 2016. Patients were divided into 2 groups: patients with hernias that were repaired electively and patients with hernias that were repaired emergently. Perioperative complications and follow-up data regarding morbidity, mortality, and recurrence were also recorded. A propensity analysis was used to compare emergent and elective groups. Results: Thirty patients had hernias repaired emergently, and 199 patients underwent elective procedures. Patients undergoing emergent repair were more likely to have a type IV hernia, have a partial gastrectomy or gastrostomy tube insertion as part of their procedure, have a postoperative complication, and have a longer hospital stay. However, propensity analysis was used to demonstrate that when characteristics of the emergent and elective groups were matched, differences in these factors were no longer significant. Having an emergent operation did not increase a patient's risk for recurrence. Conclusion: Patients who had their hernias repaired emergently experienced complications at similar rates as those of elective patients with advanced age or comorbid conditions as demonstrated by the propensity analysis. The authors therefore recommend evaluation of all paraesophageal hernias for elective repair, especially in younger patients who are otherwise good operative candidates.
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Affiliation(s)
- Brian Shea
- Monmouth Medical Center, Department of Surgery, Long Branch, New Jersey
| | - William Boyan
- Monmouth Medical Center, Department of Surgery, Long Branch, New Jersey
| | - Jonathan Decker
- Monmouth Medical Center, Department of Surgery, Long Branch, New Jersey
| | - Vincent Almagno
- Monmouth Medical Center, Department of Surgery, Long Branch, New Jersey
| | - Steven Binenbaum
- Monmouth Medical Center, Department of Surgery, Long Branch, New Jersey
| | - Gurdeep Matharoo
- Monmouth Medical Center, Department of Surgery, Long Branch, New Jersey
| | - Anthony Squillaro
- Monmouth Medical Center, Department of Surgery, Long Branch, New Jersey
| | - Frank Borao
- Monmouth Medical Center, Department of Surgery, Long Branch, New Jersey
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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.
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Affiliation(s)
- Daniel G Davila
- Division of General and GI Surgery, Emory University School of Medicine, Atlanta, GA
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Staerkle RF, Rosenblum I, Köckerling F, Adolf D, Bittner R, Kirchhoff P, Lehmann FS, Hoffmann H, Glauser PM. Outcome of laparoscopic paraesophageal hernia repair in octogenarians: a registry-based, propensity score-matched comparison of 360 patients. Surg Endosc 2018; 33:3291-3299. [PMID: 30535542 PMCID: PMC6722048 DOI: 10.1007/s00464-018-06619-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 12/03/2018] [Indexed: 12/30/2022]
Abstract
Background Paraesophageal hernias (PEH) tend to occur in elderly patients and the assumed higher morbidity of PEH repair may dissuade clinicians from seeking a surgical solution. On the other hand, the mortality rate for emergency repairs shows a sevenfold increase compared to elective repairs. This analysis evaluates the complication rates after elective PEH repair in patients 80 years and older in comparison with younger patients. Methods In total, 3209 patients with PEH were recorded in the Herniamed Registry between September 1, 2009 and January 5, 2018. Using propensity score matching, 360 matched pairs were formed for comparative analysis of general, intraoperative, and postoperative complication rates in both groups. Results Our analysis revealed a disadvantage in general complications (6.7% vs. 14.2%; p = 0.002) for patients ≥ 80 years old. No significant differences were found between the two groups for intraoperative (4.7% vs. 5.8%, p = 0.627) and postoperative complications (2.2% vs. 2.8%, p = 0.815) or for complication-related reoperations (1.7% vs. 2.2%, p = 0.791). Conclusions Despite a higher risk of general complications, PEH repair in octogenarians is not in itself associated with increased rates of intraoperative and postoperative complications or associated reoperations. Therefore, PEH repair can be safely offered to elderly patients with symptomatic PEH, if general medical risk factors are controlled. Electronic supplementary material The online version of this article (10.1007/s00464-018-06619-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ralph F Staerkle
- Department of General and Visceral Surgery, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Ilan Rosenblum
- Department of General and Visceral Surgery, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Ferdinand Köckerling
- Department of Surgery and Center for Minimally Invasive Surgery, Academic Teaching Hospital of Charité Medical School, Vivantes Hospital, Neue Bergstrasse 6, 13585, Berlin, Germany
| | - Daniela Adolf
- StatConsult GmbH, Halberstädter Straße 40 a, 39112, Magdeburg, Germany
| | - Reinhard Bittner
- Winghofer Medicum Hernia Center, Winghofer Straße 42, 72108, Rottenburg am Neckar, Germany
| | - Philipp Kirchhoff
- Department of General and Visceral Surgery, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Frank S Lehmann
- Division of Gastroenterology and Hepatology, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Henry Hoffmann
- Department of General and Visceral Surgery, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Philippe M Glauser
- Department of General and Visceral Surgery, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland.
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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.
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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.
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Jejunal Diverticular Perforation Causing Small Bowel Obstruction in a Type 4 Hiatal Hernia: A Rare Case Report of a Nonagenarian Patient and Review of Relevant Literature. Case Rep Surg 2017; 2017:8412927. [PMID: 29130015 PMCID: PMC5654331 DOI: 10.1155/2017/8412927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 08/14/2017] [Indexed: 11/17/2022] Open
Abstract
Type IV paraesophageal hernia (PEH) is very rare and is characterized by the intrathoracic herniation of the abdominal viscera other than the stomach into the chest. We describe a case of a 90-year-old male patient who presented at our emergency department complaining of epigastric pain that he had experienced over the past few hours and getting progressively worse. On the day after admission, his pain became severe. Chest radiography revealed an intrathoracic intestinal gas bubble; emergency exploratory laparotomy identified a type IV PEH with herniation of only the jejunum with perforated diverticula on mesenteric side through a hiatal defect into mediastinum. There are a few published cases of small bowel herniation into the thoracic cavity in the literature. Our patient represents a rare case of an individual diagnosed with type IV PEH with herniation of jejunum with perforated diverticula.
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