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Sovpel IV, Sedakov IE, Sovpel OV, Shapovalova YA, Balaban VV. [Surgical treatment of hiatal hernia complicated by short esophagus: a prospective study]. Khirurgiia (Mosk) 2023:31-38. [PMID: 37186648 DOI: 10.17116/hirurgia202305131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
OBJECTIVE To analyze immediate and long-term postoperative results in patients with hiatal hernia complicated by short esophagus. MATERIAL AND METHODS We prospectively analyzed postoperative outcomes in 113 patients with hiatal hernia who underwent surgery between 2013 and 2021. The main group consisted of 54 patients with length of intra-abdominal segment of esophagus <4 cm who underwent Collis procedure or esophagus >4 cm and indications for Nissen fundoplication cuff. The control group consisted of 59 patients and indications for esophageal lengthening procedure only if length of intra-abdominal segment of esophagus was less than 2 cm. This surgery was started with anterolateral vagotomy, and Collis procedure was performed in case of ineffective vagotomy. Nissen fundoplication was performed for abdominal segment of esophagus >2 cm. RESULTS In the main group, 17 (31.5%) patients with intra-abdominal segment of esophagus <4 cm required Collis procedure. In the control group, length of intra-abdominal segment of esophagus <2 cm was observed in 6 (10.2%) patients. In all cases, anterolateral vagotomy was performed. Surgery time was 189 (80-290) and 136 (90-320) min, respectively (p=0.001). Postoperative complications in the main group occurred in 8 (14.8%) patients, in the control group - 4 (6.8%) patients (p=0.281). One (1.7%) patient died in the control group. The follow-up period was 38 (12-66) months. In long-term period, recurrence developed in 2 (3.7%) and 11 (20%) patients, respectively (p=0.026). High satisfaction with postoperative outcomes was observed in 51 (94.4%) and 46 (79.3%) patients, respectively (p=0.038). CONCLUSION Uncorrected shortening of the esophagus can be one of the main risk factors of recurrence in long-term period. Expanding the indications for Collis gastroplasty can reduce the incidence of poor outcomes without affecting the incidence of postoperative complications.
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Affiliation(s)
- I V Sovpel
- Gorky Donetsk National Medical University, Donetsk, Russia
- Professor Bondar Republican Cancer Center, Donetsk, Russia
| | - I E Sedakov
- Gorky Donetsk National Medical University, Donetsk, Russia
- Professor Bondar Republican Cancer Center, Donetsk, Russia
| | - O V Sovpel
- Gorky Donetsk National Medical University, Donetsk, Russia
- Professor Bondar Republican Cancer Center, Donetsk, Russia
| | - Yu A Shapovalova
- Gorky Donetsk National Medical University, Donetsk, Russia
- Professor Bondar Republican Cancer Center, Donetsk, Russia
| | - V V Balaban
- Sechenov First Moscow State Medical University, Moscow, Russia
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2
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Sovpel IV, Ishchenko RV, Sedakov IE, Sovpel OV, Balaban VV. [Collis gastroplasty in surgical treatment of hiatal hernia]. Khirurgiia (Mosk) 2021:30-37. [PMID: 34029033 DOI: 10.17116/hirurgia202106130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To analyze the early and long-term postoperative outcomes after Collis gastroplasty in the treatment of patients with hiatal hernia complicated by gastroesophageal reflux disease and shortening of the esophagus. MATERIAL AND METHODS Postoperative outcomes after Collis gastroplasty were analyzed in 22 patients with hiatal hernia and shortening of the esophagus. The control group consisted of 166 patients after simple repair of hiatal hernia without Collis procedure. RESULTS In case of Collis gastroplasty, surgery time was 185 (160-250) min. Intraoperative complications were observed in 3 (13.6%) patients, incidence of postoperative complications - 18.2%. There were no lethal outcomes in this group of patients. Mild functional dysphagia was observed in 2 (9.1%) patients. Length of hospital stay was 7.8±2.4 days. Mean follow-up was 34 (6-52) months. There were no anatomical recurrences. A relapse of gastroesophageal reflux was noted in 1 (4.6%) case. GERD-HRQL score was 4.8±2.2 points. Additional Collis gastroplasty did not affect the immediate and long-term results of surgical treatment in comparison with simple cruroraphy and fundoplication. CONCLUSION Unreduced shortening of the esophagus may be followed by high incidence of recurrent hiatal hernia and GERD in long-term period. In case of shortening of the esophagus, surgery should include Collis gastroplasty. This effective and safe procedure does not impair treatment outcomes. Indications and optimal technique of Collis gastroplasty require clarification and further research.
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Affiliation(s)
- I V Sovpel
- Gorky Donetsk National Medical University, Donetsk, Ukraine.,Bondar Republican Oncology Center, Donetsk, Ukraine
| | - R V Ishchenko
- Federal Scientific and Clinical Center for Specialized Types of Medical Care and Medical Technologies, Moscow, Russia
| | - I E Sedakov
- Gorky Donetsk National Medical University, Donetsk, Ukraine.,Bondar Republican Oncology Center, Donetsk, Ukraine
| | - O V Sovpel
- Gorky Donetsk National Medical University, Donetsk, Ukraine.,Bondar Republican Oncology Center, Donetsk, Ukraine
| | - V V Balaban
- Sechenov First Moscow State Medical University, Moscow, Russia
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3
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Bhargava A, Andrade R. Giant paraesophageal hernia: What do we really know? JTCVS Tech 2020; 3:367-372. [PMID: 34317934 PMCID: PMC8305721 DOI: 10.1016/j.xjtc.2020.08.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 06/10/2020] [Accepted: 08/10/2020] [Indexed: 01/07/2023] Open
Affiliation(s)
- Amit Bhargava
- Division of Thoracic and Foregut Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minn
| | - Rafael Andrade
- Division of Thoracic and Foregut Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minn
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4
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Degrandi O, Laurent E, Najah H, Aldajani N, Gronnier C, Collet D. Laparoscopic Surgery for Recurrent Hiatal Hernia. J Laparoendosc Adv Surg Tech A 2020; 30:883-886. [PMID: 32208044 DOI: 10.1089/lap.2020.0118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Surgical treatment of hiatal hernia (HH) is well standardized. However, recurrence is observed in 15%-60% of cases, and is challenging to manage. The aim of this study was to analyze the causes of surgical failure and provide some guidelines for treatment. The symptoms of recurrent HH vary widely, and include persistent reflux, dysphagia, and permanent discomfort, leading to a marked change in the quality of life. Morphological and functional pretherapeutic evaluation is necessary to determine whether the symptoms are due to recurrent HH, and to understand the cause of failure. Redo surgery is technically difficult and challenging, and should only be used in symptomatic patients whose symptoms are definitively those of recurrent HH.
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Affiliation(s)
- Olivier Degrandi
- Centre for Digestive System Diseases, Department of Oesogastric and Endocrine Surgery, Magellan, University Hospital of Bordeaux, Pessac, France.,Department of Tissus Engineering, University of Bordeaux, Bordeaux, France
| | - Eva Laurent
- Centre for Digestive System Diseases, Department of Oesogastric and Endocrine Surgery, Magellan, University Hospital of Bordeaux, Pessac, France.,Department of Tissus Engineering, University of Bordeaux, Bordeaux, France
| | - Haythem Najah
- Centre for Digestive System Diseases, Department of Oesogastric and Endocrine Surgery, Magellan, University Hospital of Bordeaux, Pessac, France.,Department of Tissus Engineering, University of Bordeaux, Bordeaux, France
| | - Nour Aldajani
- Centre for Digestive System Diseases, Department of Oesogastric and Endocrine Surgery, Magellan, University Hospital of Bordeaux, Pessac, France.,Department of Tissus Engineering, University of Bordeaux, Bordeaux, France
| | - Caroline Gronnier
- Centre for Digestive System Diseases, Department of Oesogastric and Endocrine Surgery, Magellan, University Hospital of Bordeaux, Pessac, France.,Department of Tissus Engineering, University of Bordeaux, Bordeaux, France
| | - Denis Collet
- Centre for Digestive System Diseases, Department of Oesogastric and Endocrine Surgery, Magellan, University Hospital of Bordeaux, Pessac, France.,Department of Tissus Engineering, University of Bordeaux, Bordeaux, France
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5
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6
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Abstract
The transthoracic approach to PEH repair has been displaced by the laparoscopic methods of repair for valuable reasons. Despite the pressures of performing minimally invasive surgery, the experienced esophageal surgeon will appreciate the benefits of the transthoracic repair in select circumstances as outlined in this article. In this writing, we discussed our indications, the salient anatomy and important steps in performing a successful transthoracic PEH repair.
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7
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Omura N, Tsuboi K, Yano F. Minimally invasive surgery for large hiatal hernia. Ann Gastroenterol Surg 2019; 3:487-495. [PMID: 31549008 PMCID: PMC6749952 DOI: 10.1002/ags3.12278] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 06/26/2019] [Accepted: 06/28/2019] [Indexed: 12/19/2022] Open
Abstract
The majority of large hiatal hernias are paraesophageal hiatal hernias (PEH). Once prolapse of the stomach to the chest cavity reaches a high degree, it is called an intrathoracic stomach. More than 25 years have elapsed since laparoscopic surgery was carried out as minimally invasive surgery for PEH. The feasibility and safety thereof has nearly been established. PEH may cause serious complications such as strangulation and perforation. The outcome of elective repair of PEH is better than emergent repair, so we should carry out elective repair as much as possible. Although not a major clinical problem, following PEH repair the rate of anatomical recurrence increases with age. In order to reduce the recurrence rate, mesh reinforcement by crural repair has been widely performed. Although this improves the short-term outcomes, the long-term outcomes are unclear. For PEH repair, fundoplication and gastropexy are believed desirable. We should select the procedure associated with a lower incidence of dysphagia and so on following surgery. While relaxing incision is useful for primary tension-free closure, it has not contributed to improvement in the recurrence rate.
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Affiliation(s)
- Nobuo Omura
- Department of SurgeryNational Hospital Organization Nishisaitama‐Chuo National HospitalTokyoJapan
- Department of SurgeryThe Jikei University School of MedicineTokyoJapan
| | - Kazuto Tsuboi
- Department of SurgeryThe Jikei University School of MedicineTokyoJapan
| | - Fumiaki Yano
- Department of SurgeryThe Jikei University School of MedicineTokyoJapan
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8
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Gallyamov EA, Lutsevich OE, Kubyshkin VA, Erin SA, Agapov MA, Presnov KS, Busyrev YB, Gallyamov EE, Gololobov GY, Zryanin AM, Starkov GA, Tolstykh MP. [Redo laparoscopic surgery for recurrent gastroesophageal reflux disease and hiatal hernia]. Khirurgiia (Mosk) 2019:26-31. [PMID: 30855587 DOI: 10.17116/hirurgia201902126] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To assess mechanisms of recurrent gastroesophageal reflux disease and the ability to perform adequate surgical correction after previous surgery. MATERIAL AND METHODS The authors from various surgical centers have operated 2678 patients with gastroesophageal reflux disease and hiatal hernia for the period 1993-2018. 127 (4.74%) patients underwent redo surgery for recurrent disease, 46 of them were previously operated in other clinics. RESULTS Median follow-up after redo surgery was 63 months (12-139). Satisfactory functional result was achieved in 76.4% of patients.
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Affiliation(s)
- E A Gallyamov
- Sechenov First Moscow State Medical University of Healthcare Ministry of the Russia, Moscow, Russia; Central Clinical Hospital of Civil Aviation, Moscow, Russia
| | - O E Lutsevich
- Evdokimov Moscow State University of Medicine and Dentistry of Healthcare Ministry of the Russia Russia, Moscow, Russia
| | - V A Kubyshkin
- University's Clinic of Lomonosov Moscow State University, Moscow, Russia
| | - S A Erin
- Spasokukotsky Municipal Clinical Hospital, Russia, Moscow, Russia
| | - M A Agapov
- University's Clinic of Lomonosov Moscow State University, Moscow, Russia
| | - K S Presnov
- Central Clinical Hospital of Civil Aviation, Moscow, Russia
| | - Yu B Busyrev
- Sechenov First Moscow State Medical University of Healthcare Ministry of the Russia, Moscow, Russia
| | - E E Gallyamov
- Sechenov First Moscow State Medical University of Healthcare Ministry of the Russia, Moscow, Russia
| | - G Yu Gololobov
- Sechenov First Moscow State Medical University of Healthcare Ministry of the Russia, Moscow, Russia
| | - A M Zryanin
- University's Clinic of Lomonosov Moscow State University, Moscow, Russia
| | - G A Starkov
- Central Clinical Hospital of Civil Aviation, Moscow, Russia
| | - M P Tolstykh
- Evdokimov Moscow State University of Medicine and Dentistry of Healthcare Ministry of the Russia Russia, Moscow, Russia
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9
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Weitzendorfer M, Pfandner R, Antoniou SA, Schwaiger-Hengstschläger C, Emmanuel K, Koch OO. Short-term results after laparoscopic repair of giant hiatal hernias with pledgeted sutures: a retrospective analysis. Hernia 2019; 23:397-401. [PMID: 30684104 PMCID: PMC6456475 DOI: 10.1007/s10029-019-01890-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Accepted: 01/14/2019] [Indexed: 11/29/2022]
Abstract
Purpose This study investigates if pledgeted sutures for hiatal closure could be an alternative to mesh for the surgical treatment of large hiatal hernia. Methods Forty-one patients who underwent laparoscopic 270° Toupet fundoplication with pledgeted sutured crura between September 2014 and April 2017 were evaluated with regard to recurrence of hiatal hernia at 3 months and 1 year after surgery. Indication for pledgets was a hiatal surface area of at least 5.60 cm2, or migration of more than 1/3 of the stomach into the thorax or preoperative hernia size > 5 cm. The integrity of repair was assessed using a barium swallow test 3 months and 1 year after surgery. Results All operations could be completed laparoscopically with no intraoperative complications. Until study end no complications related to the pledgets have occurred. Forty-four of 50 patients (88.0%) completed the follow-up radiographic examination 3 months (mean 12.7 weeks) after surgery, and 37 patients (74.0%; mean 55.1 weeks) 1 year after surgery. Postoperative recurrence was diagnosed in 3/44 patients (6.8%) at 3 months, and in 4/37 patients (10.8%) at 1 year follow-up. Only one patient was symptomatic, 1 year after surgery (2.7%). All other patients with reherniations were asymptomatic at time of the study. Conclusions Utilization of pledgets to reinforce hiatal sutures seems safe and shows a quite low early recurrence rate compared to other methods. Long-term data will allow firm conclusions as to whether pledgeted sutures are an appropriate solution for the treatment of giant hiatal hernias.
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Affiliation(s)
- M Weitzendorfer
- Department of Surgery, Paracelsus Medical University, Müllner Hauptstraße 48, 5020, Salzburg, Austria
| | - R Pfandner
- Department of General and Visceral Surgery, Ordensklinikum Linz Barmherzige Schwestern, Linz, Austria
| | - S A Antoniou
- Department of Colorectal Surgery, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | | | - K Emmanuel
- Department of Surgery, Paracelsus Medical University, Müllner Hauptstraße 48, 5020, Salzburg, Austria
| | - O O Koch
- Department of Surgery, Paracelsus Medical University, Müllner Hauptstraße 48, 5020, Salzburg, Austria.
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10
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Thinking About Hiatal Hernia Recurrence After Laparoscopic Repair: When Should It Be Considered a True Recurrence? A Different Point of View. Int Surg 2018. [DOI: 10.9738/intsurg-d-17-00123.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background:
High rates of recurrence after laparoscopic hiatal hernia repair have been published. Most of these recurrences are asymptomatic and only diagnosed by endoscopic or radiologic studies. The definition of hiatal hernia recurrence is still under discussion.
Objective:
This study aimed to define a true hiatal hernia recurrence using a score and classification criteria considering the presence of symptoms and size of the recurrence.
Patients and Methods:
A total of 153 patients with giant hiatal hernia larger than 10 cm in diameter underwent an operation using a laparoscopic approach. Of these patients, 129 had a complete follow-up (3–5 years) after surgery, and they were the only ones included in this study. The IT system of our hospital was our database for data registration. A score and classification were designed for definition of a “true” hiatal hernia recurrence, based on postoperative symptoms and the presence or not of a hiatal hernia in both radiologic and endoscopic evaluations.
Results:
Hiatal hernia recurrence based on endoscopic and/or radiologic hiatal hernia was found in 55 patients (42.6%), and only 28 of them (50.9%) had recurrent symptoms. Applying the score and proposed classification, no recurrence was considered in 18 patients (13.9%). Symptomatic and true recurrence were considered in 22.9% of patients (29 patients). Reoperation was needed for 7 patients (5.4%) because of symptomatic and radiologic recurrence.
Conclusions:
Postoperative symptoms, endoscopic findings, or radiologic findings are important for the definition of the type of recurrence and for the indication of appropriate treatment. The proposed score and classification are useful in order to specify the hiatal hernia recurrence and treatment.
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11
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Stringham JR, Phillips JV, McMurry TL, Lambert DL, Jones DR, Isbell JM, Lau CL, Kozower BD. Prospective study of giant paraesophageal hernia repair with 1-year follow-up. J Thorac Cardiovasc Surg 2017; 154:743-751. [PMID: 28502624 DOI: 10.1016/j.jtcvs.2017.03.138] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 02/13/2017] [Accepted: 03/06/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Evaluating giant paraesophageal hernia (GPEH) repair requires long-term follow-up. GPEH repair can have associated high recurrence rates, yet this incidence depends on how recurrence is defined. Our objective was to prospectively evaluate patients undergoing GPEH repair with 1-year follow-up. METHODS Patients undergoing elective GPEH repair between 2011 and 2014 were enrolled prospectively. Postoperatively, patients were evaluated at 1 month and 1 year. Radiographic recurrence was evaluated by barium swallow and defined as a gastroesophageal junction located above the hiatus. Quality of life was evaluated pre- and postoperatively with the use of a validated questionnaire. RESULTS One-hundred six patients were enrolled. The majority of GPEH repairs were performed laparoscopically (80.2%), and 7.5% were redo repairs. At 1-year follow-up, 63.4% of patients were symptom free, and radiographic recurrence was 32.7%. Recurrence rate was 18.8% with standard definition (>2 cm of stomach above the diaphragm). Quality of life scores at 1 year were significantly better after operative repair, even in patients with radiographic recurrence (7.0 vs 22.5 all patients, 13.0 vs 22.5 with recurrence; P < .001). Patients with small radiographic recurrences have similar satisfaction and symptom severity to patients with >2 cm recurrences. CONCLUSIONS GPEH repair can be performed with low operative mortality and morbidity. The rate of recurrence at 1 year depends on the definition used. Patient satisfaction and symptom severity are similar between patients with radiographic and greater than 2 cm hernia recurrences. Longer follow-up and critical assessment of our results are needed to understand the true impact of this procedure and better inform perioperative decision making.
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Affiliation(s)
- John R Stringham
- Division of Thoracic and Cardiovascular Surgery, University of Virginia Health Sciences Center, Charlottesville, Va
| | - Jennifer V Phillips
- Division of Thoracic and Cardiovascular Surgery, University of Virginia Health Sciences Center, Charlottesville, Va
| | - Timothy L McMurry
- Division of Public Health Sciences, University of Virginia Health Sciences Center, Charlottesville, Va
| | - Drew L Lambert
- Department of Radiology, University of Virginia Health Sciences Center, Charlottesville, Va
| | - David R Jones
- Division of Thoracic Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - James M Isbell
- Division of Thoracic Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Christine L Lau
- Division of Thoracic and Cardiovascular Surgery, University of Virginia Health Sciences Center, Charlottesville, Va
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Mo.
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12
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Derksen WJ, Oor JE, Yilmaz A, Hazebroek EJ. Simultaneous thoraco-laparoscopic repair of giant hiatal hernias: an alternative approach. Dis Esophagus 2017; 30:1-6. [PMID: 26822464 DOI: 10.1111/dote.12452] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Laparoscopic repair of giant hiatal hernias with intrathoracic displacement of organs is recommended to relieve troublesome symptoms in patients. During this procedure, incomplete excision of the hernia sac from the mediastinum and omission of creating a 'non-tension-free position' of the cardio-esophageal junction into the abdominal cavity are associated with hiatal hernia recurrence. Giant hiatal hernias therefore often require a thoracotomy or thoracoscopy, to free dense adhesions higher up the chest. These procedures may increase the risk of perioperative morbidity due to lengthy operating times. We developed an operation procedure for giant hiatal hernia repair containing all the benefits of minimal invasive surgery, with overview of both thoracic and abdominal herniated structures. Three patients with a giant hiatal hernia were treated by a simultaneous thoraco-laparoscopic approach, which proved to be technically feasible and safe. Simultaneous thoraco-laparoscopic hernia repair can be considered a reasonable treatment option in selected cases such as type IV hernias, hernia recurrence or traumatic diaphragmatic herniation.
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Affiliation(s)
- W J Derksen
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - J E Oor
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - A Yilmaz
- Thoracic surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - E J Hazebroek
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
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13
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Affiliation(s)
- A Duranceau
- Department of Surgery, Division of Thoracic Surgery, Université de Montréal, Montreal, Quebec, Canada
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14
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Mattioli S, Lugaresi M, Ruffato A, Daddi N, Di Simone MP, Perrone O, Brusori S. Collis-Nissen gastroplasty for short oesophagus. Multimed Man Cardiothorac Surg 2015; 2015:mmv032. [PMID: 26585969 DOI: 10.1093/mmcts/mmv032] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 09/26/2015] [Indexed: 06/05/2023]
Abstract
The Collis-Nissen procedure is performed for the surgical treatment of 'true short oesophagus'. When this condition is strongly suspected radiologically, the patient is placed in the 45° left lateral position on the operating table with the left chest and arm lifted to perform a thoracostomy in the V-VI space, posterior to the axillary line. The hiatus is opened and the distal oesophagus is widely mobilized. With intraoperative endoscopy, the position of the oesophago-gastric junction in relationship to the hiatus is determined and the measurement of the length of the intra-abdominal oesophagus is performed to decide either to carry out a standard anti-reflux procedure or to lengthen the oesophagus. If the oesophagus is irreversibly short ('true short oesophagus'), the short gastric vessels are divided and the gastric fundus is mobilized. An endostapler is introduced into the left chest. The left thoracoscopic approach is suitable to control effectively the otherwise blind passage of the endostapler into the mediastinum and upper abdomen (if a second optic is not used). The tip of the stapler is clearly visible while 'walking' on the left diaphragm. The Collis gastroplasty is performed over a 46 Maloney bougie. A floppy Nissen fundoplication and the hiatoplasty complete the procedure.
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Affiliation(s)
- Sandro Mattioli
- Division of Thoracic Surgery, Centre for the Study and Research on Diseases of the Esophagus, Alma Mater Studiorum - University of Bologna, GVM Care and Research, Cotignola, Italy Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum - University of Bologna, Bologna, Italy PhD Course in Cardio-Nephro-Thoracic Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Marialuisa Lugaresi
- Division of Thoracic Surgery, Centre for the Study and Research on Diseases of the Esophagus, Alma Mater Studiorum - University of Bologna, GVM Care and Research, Cotignola, Italy
| | - Alberto Ruffato
- Division of Thoracic Surgery, Centre for the Study and Research on Diseases of the Esophagus, Alma Mater Studiorum - University of Bologna, GVM Care and Research, Cotignola, Italy
| | - Niccolò Daddi
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Massimo Pierluigi Di Simone
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Ottorino Perrone
- Division of Thoracic Surgery, Centre for the Study and Research on Diseases of the Esophagus, Alma Mater Studiorum - University of Bologna, GVM Care and Research, Cotignola, Italy PhD Course in Cardio-Nephro-Thoracic Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Stefano Brusori
- Cardio-Thoracic Radiology Unit, Policlinico Sant'Orsola-Malpighi, University of Bologna, Bologna, Italy
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15
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Lugaresi M, Mattioli B, Perrone O, Daddi N, Di Simone MP, Mattioli S. Results of left thoracoscopic Collis gastroplasty with laparoscopic Nissen fundoplication for the surgical treatment of true short oesophagus in gastro-oesophageal reflux disease and Type III-IV hiatal hernia. Eur J Cardiothorac Surg 2015; 49:e22-30. [PMID: 26518379 DOI: 10.1093/ejcts/ezv381] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 09/21/2015] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES Controversy exists regarding surgery for true short oesophagus (TSOE). We compared the results of thoracoscopic Collis gastroplasty-laparoscopic Nissen procedure for the treatment of TSOE with the results of standard laparoscopic Nissen fundoplication. METHODS Between 1995 and 2013, the Collis-Nissen procedure was performed in 65 patients who underwent minimally invasive surgery when the length of the abdominal oesophagus, measured intraoperatively after maximal oesophageal mediastinal mobilization, was ≤1.5 cm. The results of the Collis-Nissen procedure were frequency-matched according to age, sex and period of surgical treatment with those of 65 standard Nissen fundoplication procedures in patients with a length of the abdominal oesophagus >1.5 cm. Postoperative mortality and morbidity were evaluated according to the Accordion classification. The patients underwent a timed clinical-instrumental follow-up that included symptoms assessment, barium swallow and endoscopy. Symptoms, oesophagitis and global results were graded according to semi-quantitative scales. The results were considered to be excellent in the absence of symptoms and oesophagitis, good if symptoms occurred two to four times a month in the absence of oesophagitis, fair if symptoms occurred two to four times a week in the presence of hyperaemia, oedema and/or microscopic oesophagitis and poor if symptoms occurred on a daily basis in the presence of any grade of endoscopic oesophagitis, hiatal hernia of any size or type, or the need for antireflux medical therapy. The follow-up time was calculated from the time of surgery to the last complete follow-up. RESULTS The postoperative mortality rate was 1.5% for the Collis-Nissen and 0 for the Nissen procedure. The postoperative complication rate was 24% for the Collis-Nissen and 7% for Nissen (P = 0.001) procedure. The complication rate for the Collis-Nissen procedure was 43% in the first 32 cases and 6% in the last 33 cases (P < 0.0001). The median follow-up period was 96 months. The results were: excellent in 27% of Collis-Nissen and 29% of Nissen; good in 64% of Collis-Nissen and 55% of Nissen; fair in 3% of Collis-Nissen and 11% of Nissen and poor in 6% of Collis-Nissen and 5% of Nissen (P = 0.87). CONCLUSIONS In patients affected by a TSOE, the Collis-Nissen procedure may achieve equally satisfactory results as the standard Nissen procedure in uncomplicated patients. CLINICAL REGISTRATION NUMBER NCT02288988.
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Affiliation(s)
- Marialuisa Lugaresi
- Division of Thoracic Surgery, Alma Mater Studiorum-University of Bologna, Bologna, Italy Center for the Study and Research on Diseases of the Oesophagus, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Benedetta Mattioli
- Department of Medical and Surgical Sciences-DIMEC, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Ottorino Perrone
- Division of Thoracic Surgery, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Niccolò Daddi
- Department of Medical and Surgical Sciences-DIMEC, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Massimo Pierluigi Di Simone
- Center for the Study and Research on Diseases of the Oesophagus, Alma Mater Studiorum-University of Bologna, Bologna, Italy Department of Medical and Surgical Sciences-DIMEC, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Sandro Mattioli
- Division of Thoracic Surgery, Alma Mater Studiorum-University of Bologna, Bologna, Italy Center for the Study and Research on Diseases of the Oesophagus, Alma Mater Studiorum-University of Bologna, Bologna, Italy Department of Medical and Surgical Sciences-DIMEC, Alma Mater Studiorum-University of Bologna, Bologna, Italy GVM Care & Research, Cotignola, Italy
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Wang Z, Bright T, Irvine T, Thompson SK, Devitt PG, Watson DI. Outcome for Asymptomatic Recurrence Following Laparoscopic Repair of Very Large Hiatus Hernia. J Gastrointest Surg 2015; 19:1385-90. [PMID: 25822063 DOI: 10.1007/s11605-015-2807-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 03/17/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Radiological follow-up following repair of large hiatus hernias have identified recurrence rates of 20-30%, although most are small and asymptomatic. Whether patients will eventually develop clinical problems is uncertain. This study evaluated the outcome for individuals identified with an asymptomatic hiatus hernia following previous repair vs. asymptomatic controls. METHODS One hundred fifteen asymptomatic patients who had previously undergone sutured repair of a large hiatus hernia and then underwent barium meal X-ray 6-60 months after surgery within a clinical trial were identified and divided into two cohorts: with (n = 41) vs. without (n = 74) an asymptomatic hernia. Heartburn, dysphagia, and satisfaction with surgery were assessed prospectively using a standardized questionnaire applying analogue scales. Consumption of antisecretory medication and revision surgery were also determined. To determine the natural history of asymptomatic recurrent hiatus hernia, outcomes for the two groups were compared at 1 and 5 years and at most recent (late) follow-up. RESULTS Outcomes were available at 1 year for 98.2% and 5 years or the latest follow-up (range 6-237 months) for 100%. Heartburn and dysphagia scores were low and satisfaction scores high in both groups at all follow-up points, but heartburn scores and medication use were higher in the recurrent hernia group. At late follow-up, 94.6% of the recurrent hernia group vs. 98.5% without a hernia regarded their original decision for surgery to be correct. Two patients in recurrent hernia group underwent revision surgery. CONCLUSIONS Patients with an initially asymptomatic recurrent hiatus hernia are more likely to report heartburn and use antisecretory medication at later follow-up than controls. However, overall clinical outcomes remain good, with high satisfaction and low surgical revision rates. Additional interventions to reduce the risk of recurrence might not be warranted.
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Affiliation(s)
- Zhenyu Wang
- Flinders University Department of Surgery, Flinders Medical Centre, Bedford Park, Adelaide, South Australia, Australia
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Hiatal hernia repair with or without esophageal lengthening: is there a difference? INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2014; 8:341-7. [PMID: 24346582 DOI: 10.1097/imi.0000000000000012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The need for esophageal lengthening (EL) as part of hiatal hernia (HH) repair is perceived to elevate perioperative risk and provide functionally inferior outcomes. Our objectives were to determine the risk factors of undergoing EL and to compare outcomes between operations with and without EL. We hypothesized that operative and functional outcomes for HH repair were similar in patients whether they required EL or not. METHODS We reviewed institutional experience with EL as part of HH repair. The patients underwent symptom evaluation before and after surgery using a validated tool. RESULTS Between 1999 and 2009, a total of 375 patients underwent HH repair. The operative approach was thoracotomy, 153 (41%); laparotomy, 18 (5%); laparoscopy, 167 (44%); or combined, 37 (10%). Of these, 168 (45%) required EL. There was a higher need for thoracotomy in the patients undergoing EL (79/168 vs 74/207, χ = 4.88, P = 0.034). The incidence of perioperative complications (leak, pneumonia, ileus, respiratory failure, and bleeding) was similar between the groups. Sixty-five selected patients undergoing EL were compared with 63 patients with comparable demographics not requiring EL. In a well-validated questionnaire that assessed symptoms before and after surgery, the patients undergoing EL showed significant improvement in their heartburn (76.8%), dysphagia (67.6%), regurgitation (71.7%), chest pain (91.9%), and nausea (86.5%) (P < 0.05). The patients not undergoing EL also showed significant improvement in their heartburn (81.1%), dysphagia (71.1%), regurgitation (64.4%), chest pain (64.1%), and nausea (61.0%) (P < 0.05). Improvement in symptoms, the continued use of antacid medications, and overall surgery satisfaction score were statistically similar between the two groups. CONCLUSIONS Operative and functional outcomes for HH repair with or without EL are acceptable and comparable. Thoracic surgeons should use EL without reservations for appropriate indications.
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Novel combined VATS/laparoscopic approach for giant and complicated paraesophageal hernia repair: description of technique and early results. Surg Endosc 2014; 29:185-91. [PMID: 24969852 DOI: 10.1007/s00464-014-3662-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2014] [Accepted: 05/03/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND The laparoscopic approach for repair of giant and/or recurrent paraesophageal hernias (PEH) is challenging, due to limited access to the dissection of the hernia sac into the proximal mediastinum and esophageal mobilization through the diaphragmatic hiatus. An esophageal lengthening procedure is often necessary, due to the difficulty in obtaining adequate intra-abdominal esophageal length. We, therefore, developed a VATS and laparoscopic technique, which allows for safe and extensive thoracic dissection and intra-abdominal gastric fixation and cruroplasty, yet preserving the benefits of minimally invasive surgery. METHODS We use a standard VATS approach. The hernia sac, optimally visualized, is dissected posteriorly from the thoracic aorta, inferiorly from its diaphragmatic attachments, anteriorly from the pericardium, and laterally from the mediastinal pleura. The esophagus is completely mobilized up to the aortic arch, and the anterior vagus nerve is released from its bronchial branches. The hernia sac is then opened, dissected, and completely removed. The hernia content is then reduced into the abdomen laparoscopically, the short gastric vessels are divided and the gastric fundus is completely mobilized. The hiatus is closed with interrupted sutures, and the cruroplasty is buttressed with a biological mesh. A floppy Nissen or a partial fundoplication and a gastropexy are done for reflux control and gastric fixation. RESULTS From January 2012 to January 2014, we treated 18 patients (7 with type III PEH and 11 with type IV) with the above-described procedure. Six patients had previous history of antireflux surgery. We performed a planned laparotomy instead of laparoscopy in two patients, who needed concurrent repair of complex incisional hernias. We did not need esophageal lengthening procedures, nor experienced damages to thoracic structures in any patient. CONCLUSIONS Our newly developed surgical approach has proven to be safe and feasible. This technique represents a good option for treatment of giant and complicated PEH.
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Puri V, Jacobsen K, Bell JM, Crabtree TD, Kreisel D, Krupnick AS, Patterson GA, Meyers BF. Hiatal Hernia Repair with or without Esophageal Lengthening. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2013. [DOI: 10.1177/155698451300800504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine at Barnes-Jewish Hospital, St Louis, MO USA
| | - Kyle Jacobsen
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine at Barnes-Jewish Hospital, St Louis, MO USA
| | - Jennifer M. Bell
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine at Barnes-Jewish Hospital, St Louis, MO USA
| | - Traves D. Crabtree
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine at Barnes-Jewish Hospital, St Louis, MO USA
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine at Barnes-Jewish Hospital, St Louis, MO USA
| | - Alexander S. Krupnick
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine at Barnes-Jewish Hospital, St Louis, MO USA
| | - G. Alexander Patterson
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine at Barnes-Jewish Hospital, St Louis, MO USA
| | - Bryan F. Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine at Barnes-Jewish Hospital, St Louis, MO USA
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The choice of primary repair or mesh repair for paraesophageal hernia: a decision analysis based on utility scores. Ann Surg 2013; 257:655-64. [PMID: 23364700 DOI: 10.1097/sla.0b013e3182822c8c] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Controversy exists on the use of mesh in the repair of paraesophageal hernias (PEH). This debate centers around the type of mesh used, its value in preventing recurrence, its short- and long-term complications, and the consequences of those complications compared with primary repair. Decision analysis is a method to account for the important aspects of a clinical decision. The purpose of this study was to determine whether or not the addition of mesh would be superior in PEH repair. METHODS A decision analysis model of the choice between primary repair and mesh repair of a PEH was constructed. The essential features of the decision were the rate of perioperative complications, PEH recurrence rate, reoperation rate after recurrence, rate of symptomatic recurrence, and type of outcome after reoperation. The literature was reviewed to obtain data for the decision analysis and the average rates used in the baseline analysis. A utility score was used as the outcome measure, with a perfect outcome receiving a score of 100 and death 0. Sensitivity analysis was used to determine if changing the rates of recurrence or reoperation changed the dominant treatment. RESULTS Using the baseline analysis, mesh repair was slightly superior to primary repair (utility score 99.59 vs 99.12, respectively). However, if recurrence rates were similar, primary repair would be slightly superior; whereas if reoperation rates were similar, mesh repair would be superior. Using sensitivity analysis, there are combinations of recurrence rates and reoperation rates that would make one repair superior to the other. However, these differences are relatively small. CONCLUSIONS Depending on what the decision-maker accepts as the recurrence and reoperation rates for these types of repair, either mesh or primary repair may be the treatment of choice. However, the differences between the two are small, and, perhaps, clinically inconsequential.
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Antonoff MB, D'Cunha J, Andrade RS, Maddaus MA. Giant paraesophageal hernia repair: Technical pearls. J Thorac Cardiovasc Surg 2012; 144:S67-70. [DOI: 10.1016/j.jtcvs.2012.03.065] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2011] [Accepted: 03/22/2012] [Indexed: 11/30/2022]
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Nason KS, Levy RM, Witteman BP, Luketich JD. The laparoscopic approach to paraesophageal hernia repair. J Gastrointest Surg 2012; 16:417-26. [PMID: 22160778 PMCID: PMC4114521 DOI: 10.1007/s11605-011-1690-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2011] [Accepted: 09/13/2011] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Laparoscopic paraesophageal hernia repair continues to be one of the most challenging procedures facing the minimally invasive surgeon. DISCUSSION A thorough understanding of the tenets of the operation and advanced skills in minimally invasive laparoscopy are needed for long-term freedom from symptomatic and anatomic recurrence. These include complete reduction of the hernia sac from the mediastinum back into the abdomen with careful preservation of the integrity of muscle and peritoneal lining of the crura, aggressive and complete mobilization of the esophagus to the level of the inferior pulmonary vein, vagal preservation, clear identification of the gastroesophageal junction to allow accurate assessment of the intraabdominal esophageal length, and use of Collis gastroplasty when esophageal lengthening is required for a tension-free intraabdominal repair. Liberal mobilization of the phrenosplenic and phrenogastric attachments substantially increases the mobility of the left limb of the crura, allowing for a tension-free primary closure in a large percentage of patients. CONCLUSION The following describes our current approach to laparoscopic paraesophageal hernia repair following a decade of refinement in a high-volume center.
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Affiliation(s)
- Katie S. Nason
- Department of Cardiothoracic Surgery, Division of Thoracic Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Ryan M. Levy
- Department of Cardiothoracic Surgery, Division of Thoracic Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Bart P.L. Witteman
- Department of Cardiothoracic Surgery, Division of Thoracic Surgery, University of Pittsburgh, Pittsburgh, PA
| | - James D. Luketich
- Department of Cardiothoracic Surgery, Division of Thoracic Surgery, University of Pittsburgh, Pittsburgh, PA
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Nason KS, Luketich JD, Awais O, Abbas G, Pennathur A, Landreneau RJ, Schuchert MJ. Quality of life after collis gastroplasty for short esophagus in patients with paraesophageal hernia. Ann Thorac Surg 2011; 92:1854-60; discussion 1860-1. [PMID: 21944737 DOI: 10.1016/j.athoracsur.2011.06.030] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2011] [Revised: 06/08/2011] [Accepted: 06/14/2011] [Indexed: 10/17/2022]
Abstract
BACKGROUND Collis gastroplasty is an important component of laparoscopic giant paraesophageal hernia (GPEH) repair in patients with persistent shortened esophagus after aggressive laparoscopic mobilization. Concerns remain, however, regarding symptomatic outcomes compared with fundoplication alone. This study assessed the impact of Collis gastroplasty on quality of life after laparoscopic GPEH repair. METHODS We performed 795 nonemergent laparoscopic GPEH repairs with fundoplication (with Collis, n = 454; fundoplication alone, n = 341). Radiographic follow-up and symptom assessment were obtained a median 22 months and 20 months, respectively, after fundoplication alone and 36 and 33 months, respectively, after Collis (p < 0.001). Radiographic recurrence, reoperation for recurrent hernia or intolerable symptoms, overall symptom improvement, and quality of life were examined. RESULTS Compared with fundoplication alone, Collis patients had significantly larger GPEH (p = 0.027) and fewer comorbidities (p = 0.002). Radiographic recurrences were similar (p = 0.353). Symptom improvement was significant for both (p < 0.001), although Collis was associated with better pain resolution (p < 0.001) and less gas bloat (p = 0.003). Quality of life was good to excellent in 88% (90% Collis versus 86% fundoplication alone, p = 0.17). CONCLUSIONS Symptomatic outcomes after laparoscopic fundoplication with Collis gastroplasty are excellent and comparable with those of fundoplication alone. These results confirm that utilization of Collis gastroplasty, based on intraoperative assessment for shortened esophagus, is not detrimental to the overall outcome or quality of life associated with the laparoscopic approach to GPEH. Collis gastroplasty is recommended as an important procedure in the surgeon's armamentarium for laparoscopic repair of GPEH.
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Affiliation(s)
- Katie S Nason
- Department of Cardiothoracic Surgery, University of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15232, USA.
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Awais O, Luketich JD, Schuchert MJ, Morse CR, Wilson J, Gooding WE, Landreneau RJ, Pennathur A. Reoperative Antireflux Surgery for Failed Fundoplication: An Analysis of Outcomes in 275 Patients. Ann Thorac Surg 2011; 92:1083-9; discussion 1089-90. [DOI: 10.1016/j.athoracsur.2011.02.088] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Revised: 02/24/2011] [Accepted: 02/24/2011] [Indexed: 11/30/2022]
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Laparoscopic repair of paraesophageal hernia. Long-term follow-up reveals good clinical outcome despite high radiological recurrence rate. Ann Surg 2011; 253:291-6. [PMID: 21217518 DOI: 10.1097/sla.0b013e3181ff44c0] [Citation(s) in RCA: 151] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE The purpose of this report is to evaluate and compare the long-term objective and subjective outcome after laparoscopic paraesophageal hernia repair (LPHR). BACKGROUND Short-term symptomatic results of LPHR are often excellent. However, a high recurrence rate is detected at objective radiographic follow-up. METHODS Retrospective review of a prospectively gathered database of consecutive patients undergoing LPHR with and without reinforced crural repair at a single institution. Subjective and objective outcomes were assessed by using a structured symptoms questionnaire, Gastrointestinal Quality-of-Life Index, satisfaction score, and barium esophagogram. RESULTS From September 1991 to September 2005, LPHR was performed in 85 patients (median age, 66 years) with (25 patients) and without (60 patients) reinforced crural repair. Two patients (3%) underwent laparoscopic reoperation, for severe dysphagia and for symptomatic recurrence, respectively. Subjective outcome, available for 64 patients (75%), improved significantly at median follow-up of 118 months with a postoperative median Gastrointestinal Quality-of-Life Index score of 116. Radiographic recurrence (median follow-up, 99 months) occurred in 23 (66%) of the 35 patients, independently of age at operation, type of paresophageal hiatal hernias, and crural reinforcement, and showed no impact on quality of life. CONCLUSIONS Although providing excellent symptomatic results, long-term objective evaluation of LPHR reveals a high recurrence rate even with reinforced cruroplasty. A tailored, lengthening gastroplasty and reinforced cruroplasty based on objective intraoperative evaluation, and not only on surgeon's personal judgment, may be the answer to recurrences.
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Fuchs KH, Breithaupt W, Schulz T, Reinisch A. Experience with flexible stapling techniques in laparoscopic and conventional surgery. Surg Endosc 2010; 25:1783-90. [DOI: 10.1007/s00464-010-1463-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2010] [Accepted: 10/22/2010] [Indexed: 11/29/2022]
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Mitiek MO, Andrade RS. Giant hiatal hernia. Ann Thorac Surg 2010; 89:S2168-73. [PMID: 20494004 DOI: 10.1016/j.athoracsur.2010.03.022] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2009] [Revised: 03/08/2010] [Accepted: 03/09/2010] [Indexed: 12/17/2022]
Abstract
A giant hiatal hernia (HH) is a hernia that includes at least 30% of the stomach in the chest, although a uniform definition does not exist; most commonly, a giant HH is a type III hernia with a sliding and paraesophageal component. The etiology of giant HH is not entirely clear, and two potential mechanisms exist: (1) gastroesophageal reflux disease (GERD) leads to esophageal scarring and shortening with resulting traction on the gastroesophageal junction and gastric herniation; and (2) chronic positive pressure on the diaphragmatic hiatus combined with a propensity to herniation leads to gastric displacement into the chest, resulting in GERD. The short esophagus and GERD are key concepts to understanding the pathophysiology of giant HH, and these concepts are critical to address this problem appropriately. A successful repair of giant HH requires adherence to basic hernia repair principles (ie, hernia sac excision, tension-free repair), recognition and correction of a short esophagus, and a well-performed antireflux procedure. Recurrence rates for open giant HH repairs in expert hands range between 2% and 12%; large series have demonstrated that meticulous laparoscopic surgical technique can emulate the results of open giant HH repair.
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Affiliation(s)
- Mohi O Mitiek
- Department of Surgery, Division of General Thoracic and Foregut Surgery, University of Minnesota, Minneapolis, Minnesota 55455, USA
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Luketich JD, Nason KS, Christie NA, Pennathur A, Jobe BA, Landreneau RJ, Schuchert MJ. Outcomes after a decade of laparoscopic giant paraesophageal hernia repair. J Thorac Cardiovasc Surg 2009; 139:395-404, 404.e1. [PMID: 20004917 DOI: 10.1016/j.jtcvs.2009.10.005] [Citation(s) in RCA: 170] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2009] [Revised: 09/10/2009] [Accepted: 10/01/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Laparoscopic repair of giant paraesophageal hernia is a complex operation requiring significant laparoscopic expertise. Our objective was to compare our current approach and outcomes for laparoscopic repair of giant paraesophageal hernia with our previous experience. METHODS A retrospective review of patients undergoing nonemergency laparoscopic repair of giant paraesophageal hernia, stratified by early versus current era (January 1997-June 2003 and July 2003-June 2008), was performed. We evaluated clinical outcomes, barium esophagogram, and quality of life. RESULTS Laparoscopic repair of giant paraesophageal hernia was performed in 662 patients (median age 70 years, range 19-92 years) with a median percentage of herniated stomach of 70% (range 30%-100%). With time, use of Collis gastroplasty decreased (86% to 53%), as did crural mesh reinforcement (17% to 12%). Current era patients were 50% more likely to have a Charlson comorbidity index score greater than 3. Thirty-day mortality was 1.7% (11/662). Mortality and complication rates were stable with time, despite increasing comorbid disease in current era. Postoperative gastroesophageal reflux disease health-related quality of life scores were available for 489 patients (30-month median follow-up), with good to excellent results in 90% (438/489). Radiographic recurrence (15.7%) was not associated with symptom recurrence. Reoperation occurred in 3.2% (21/662). CONCLUSIONS With time, we have obtained significant minimally invasive experience and refined our approach to laparoscopic repair of giant paraesophageal hernia. Perioperative morbidity and mortality remain low, despite increased comorbid disease in the current era. Laparoscopic repair provided excellent patient satisfaction and symptom improvement, even with small radiographic recurrences. Reoperation rates were comparable to the best open series.
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Affiliation(s)
- James D Luketich
- Division of Thoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
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D'Journo XB, Martin J, Bensaidane S, Ferraro P, Duranceau A. Elongation gastroplasty with transverse fundoplasty: The Jeyasingham repair. J Thorac Cardiovasc Surg 2009; 138:1192-9. [DOI: 10.1016/j.jtcvs.2008.11.067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2008] [Revised: 10/07/2008] [Accepted: 11/02/2008] [Indexed: 11/29/2022]
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Laparoscopic repair of giant paraesophageal hernia results in long-term patient satisfaction and a durable repair. J Gastrointest Surg 2008; 12:2066-75; discussion 2075-7. [PMID: 18841422 DOI: 10.1007/s11605-008-0712-7] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2008] [Accepted: 09/18/2008] [Indexed: 01/31/2023]
Abstract
BACKGROUND Laparoscopic repair of giant paraesophageal hernia (LRGPEH) is routinely performed in many centers, but high recurrence rates have led to concerns regarding this approach. We evaluate long-term recurrence rates, symptom improvement and correlation with radiographic recurrence, and risk factors for recurrence in our cohort of patients. METHODS A cohort of consecutive patients with a minimum of 5 years potential follow-up (1997-2003) post-LRGPEH was identified from a prospective database. Clinical outcomes, barium esophagram (BE), and quality-of-life (QoL) measures were obtained. RESULTS Laparoscopic repair was successful in 185/187 patients. Routine clinical follow-up (median 77 months) was available for all patients. Detailed questionnaires and BE were obtained in 65% and 82% of patients. Gastroesophageal Reflux Disease Health-Related QoL (GERD-HRQoL) scores were excellent to good in 86.7%. BE (median 51 months) demonstrated radiographic hernia recurrence in 15% of patients, but without consistent symptom association. There was a trend toward increased risk of radiographic recurrence in patients with a history of pulmonary disease (p = 0.08). Seven reoperations (4.4%) were performed for symptomatic recurrence (median 44 months postoperative). CONCLUSIONS LRGPEH performed in our minimally invasive center of excellence resulted in a durable repair with a high degree of satisfaction and preservation of GERD-related QoL at a median follow-up of over 6 years.
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Itano H, Okamoto S, Kodama K, Horita N. Transthoracic Collis-Nissen repair for massive type IV paraesophageal hernia. Gen Thorac Cardiovasc Surg 2008; 56:446-50. [PMID: 18791669 DOI: 10.1007/s11748-008-0253-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2007] [Accepted: 03/07/2008] [Indexed: 10/21/2022]
Abstract
An 80-year-old woman presented with type IV massive hiatal hernia with intrathoracic upside-down stomach and transverse colon. She was dyspneic and vomited upon consuming food or water. Consequently, she developed aspiration pneumonia. Both esophagoscopy and upper gastrointestinal series demonstrated significant cephalad displacement of the gastroesophageal junction. A Collis-Nissen hernial repair by muscle-sparing mini-thoracotomy was performed successfully. To date, 3 years after surgery, the patient is enjoying normal oral intake, has an excellent activities of daily living level, and there is no hernia recurrence. Cases of massive paraesophageal hernia are frequently associated with esophageal shortening that causes tension on the repairs and late failure. Advantages of the transthoracic approach in such cases include feasibility of direct esophageal mobilization, accurate assessment of esophageal tension, and facilitation of Collis gastroplasty. The true indication for transthoracic Collis-Nissen repair among cases of paraesophageal hiatal hernia with a short esophagus should be acknowledged more in the era of laparoscopy.
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Affiliation(s)
- Hideki Itano
- Department of Thoracic Surgery, Kure Kyosai Hospital, 2-3-28 Nishi-Chuo, Kure, Hiroshima 737-8505, Japan.
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Diaphragmatic hernias after sequential left ventricular assist device explantation and orthotopic heart transplant: Early results of laparoscopic repair with polytetrafluoroethylene. J Thorac Cardiovasc Surg 2008; 135:38-43. [DOI: 10.1016/j.jtcvs.2007.09.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2007] [Revised: 08/23/2007] [Accepted: 09/07/2007] [Indexed: 11/18/2022]
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