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Randle RJ, Liou DZ, Lui NS. Management of Paraesophageal Hernias. Thorac Surg Clin 2024; 34:163-170. [PMID: 38705664 DOI: 10.1016/j.thorsurg.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
Paraesophageal hernias are classified according to the altered anatomic relationships between the gastroesophageal junction or stomach and the diaphragmatic hiatus. Herniation of these structures into the mediastinum may produce common complaints such as reflux, chest pain, and dysphagia. The elective repair of these hernias is well tolerated and significantly improves quality of life among patients with symptomatic disease. The hallmarks of a quality repair include the circumferential mobilization of the esophagus to generate 3 cm of tension-free intra-abdominal length and the performance of a fundoplication.
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Affiliation(s)
- Ryan J Randle
- Department of Surgery, Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, Mail Code L223, Portland, OR, USA; Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford School of Medicine, 300 Pasteur Drive, Falk Building, Stanford, CA 94305, USA. https://twitter.com/radonrandle
| | - Douglas Z Liou
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford School of Medicine, 300 Pasteur Drive, Falk Building, Stanford, CA 94305, USA. https://twitter.com/DouglasLiou
| | - Natalie S Lui
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford School of Medicine, 300 Pasteur Drive, Falk Building, Stanford, CA 94305, USA.
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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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Wisniowski P, Putnam LR, Lipham J. Use of magnetic sphincter augmentation as an adjunct procedure in paraesophageal hernia repair. Dis Esophagus 2023; 36:doad022. [PMID: 37317931 DOI: 10.1093/dote/doad022] [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: 09/27/2022] [Revised: 03/22/2023] [Indexed: 06/16/2023]
Abstract
Magnetic sphincter augmentation (MSA) is an anti-reflux procedure with comparable outcomes to fundoplication, yet its use in patients with larger hiatal or paraesophageal hernias has not been widely reported. This review discusses the history of MSA and how its utilization has evolved from initial Food and Drug Administration (FDA) approval in 2012 for patients with small hernias to its contemporary use in patients with paraesophageal hernias and beyond.
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Affiliation(s)
- Paul Wisniowski
- Department of Surgery, Division of Upper GI and General Surgery, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
- Department of Surgery, Division of Upper GI, General, and Bariatric Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA
| | - Luke R Putnam
- Department of Surgery, Division of Upper GI and General Surgery, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
- Department of Surgery, Division of Upper GI, General, and Bariatric Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA
| | - John Lipham
- Department of Surgery, Division of Upper GI and General Surgery, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
- Department of Surgery, Division of Upper GI, General, and Bariatric Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA
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Sherrill W, Rossi I, Genz M, Matthews BD, Reinke CE. Non-elective paraesophageal hernia repair: surgical approaches and short-term outcomes. Surg Endosc 2020; 35:3405-3411. [PMID: 32671522 DOI: 10.1007/s00464-020-07782-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 07/01/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND The majority of laparoscopic paraesophageal hernia (PEH) repairs are performed electively. We aimed to investigate the frequency of non-elective laparoscopic (MIS) PEH repair and compare 30-day outcomes to elective MIS repairs and non-elective open repairs. We hypothesized that an increasing percentage of non-elective PEH repairs would be performed laparoscopically and that this population would have improved outcomes compared to non-elective open PEH counterparts. METHODS The 2011-2016 NSQIP PUFs were used to identify patients who underwent PEH repair. Case status was classified as open vs. MIS and elective versus non-elective. Preoperative patient characteristics, operative details, discharge destination, and 30-day postoperative complication rates were compared. Logistic regression was used to examine the impact of case status on 30-day mortality. RESULTS We identified 20,010 patients who underwent PEH. There were an increasing number of MIS PEH repairs in NSQIP between 2011 and 2016. Non-elective repairs were performed in 2,173 patients and 73.4% of these were completed laparoscopically. Elective MIS patients were younger, had a higher BMI, and were more likely to be functionally independent (p < 0.01) than their non-elective counterparts. Non-elective MIS patients had a higher wound class and ASA class compared to their elective counterparts. Compared to elective MIS cases, non-elective MIS PEH repair was associated with increased odds of mortality, even after controlling for patient characteristics (OR = 1.76, p = 0.02). There was no statistically significant difference in mortality for non-elective MIS vs. non-elective open PEH repair. There is an increase in non-elective PEH repairs recorded in NSQIP over time studied. CONCLUSIONS The population undergoing non-elective MIS PEH repairs is different from their elective MIS counterparts and experience a higher postoperative mortality rate. While the observed increased utilization of MIS techniques in non-elective PEH repairs likely provides benefits for the patient, there remain differences in outcomes for these patients compared to elective PEH repairs.
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Affiliation(s)
- William Sherrill
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, USA.
| | - Isolina Rossi
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, USA
| | - Michael Genz
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, USA
| | - Brent D Matthews
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, USA
| | - Caroline E Reinke
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, USA
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Tawfik A, Thomas AJ, Menias CO, Nada A, Shaaban AM, Gaballah AH, Morani AC, Jensen CT, Elsayes KM. Trans-diaphragmatic Pathologies: Anatomical Background and Spread of Disease on Cross-sectional Imaging. Curr Probl Diagn Radiol 2020; 50:252-261. [PMID: 32624297 DOI: 10.1067/j.cpradiol.2020.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 05/10/2020] [Accepted: 05/26/2020] [Indexed: 11/22/2022]
Abstract
The diaphragm is not only a sheet of muscle separating the abdominal and thoracic cavities: it plays an essential role in ventilation and can act as a gateway for the spread of different disease processes between the abdominal and the thoracic cavity. Careful attention to the appearance of the diaphragm on various imaging modalities is essential to ensure the accurate diagnosis of diaphragmatic disorders, which may be secondary to functional or anatomical derangements.
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Affiliation(s)
- Aya Tawfik
- Department of Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Aaron J Thomas
- Department of Radiology, Brigham and Women's Hospital, Boston, MA
| | | | - Ayman Nada
- Department of Radiology, University of Missouri, Columbia, MO
| | - Akram M Shaaban
- Department of Diagnostic Radiology, University of Utah, Salt Lake City, UT
| | | | - Ajaykumar C Morani
- Department of Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Corey T Jensen
- Department of Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Khaled M Elsayes
- Department of Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX.
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Incarcerated paraesophageal hernia and gastric volvulus: Management options for the acute care surgeon, an Eastern Association for the Surgery of Trauma master class video presentation. J Trauma Acute Care Surg 2020; 88:e146-e148. [PMID: 32118829 DOI: 10.1097/ta.0000000000002651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Kamarajah SK, Boyle C, Navidi M, Phillips AW. Critical appraisal of the impact of surgical repair of type II-IV paraoesophageal hernia (POH) on pulmonary improvement: A systematic review and meta-analysis. Surgeon 2020; 18:365-374. [PMID: 32046901 DOI: 10.1016/j.surge.2020.01.006] [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: 08/18/2019] [Revised: 12/30/2019] [Accepted: 01/14/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Paraoesophageal hernia (POH) comprising type II-IV hiatal hernia often presents with pulmonary symptoms such as shortness of breath. However, impact of surgical repair on improvement in pulmonary symptoms is unclear. OBJECTIVE This systematic review and meta-analysis aimed at characterising impact of POH repair on patient reported improvement in pulmonary symptoms. METHODS This systematic review identified studies reported pulmonary symptoms in patients with undergoing surgical repair for Type II-IV POH from 1st January 2001 to 1st December 2018. Primary outcome was improvement in pulmonary symptoms. Secondary outcomes were improvement in other patient-reported outcomes such as heartburn, regurgitation, chest pain, and dysphagia and intraoperative and postoperative outcomes. RESULTS This systematic review identified 27 studies (n = 4428 patients) reporting assessment of pulmonary symptoms. However, only 21 studies (n = 2902 patients) reported preoperative and postoperative pulmonary symptoms and hence these were included in the final meta-analysis. There was significant improvement in pulmonary symptoms following POH repair (OR: 8.40, CI95%: 4.91-14.35, p < 0.001), with improvement in all types of POH. Rates of overall and major complications were 16% and 5%, respectively. Rates of conversion, 30-day mortality, reoperation and recurrence were 2%, 1% 4% and 12% respectively. CONCLUSION This review demonstrates that POH repair is associated with improvement in pulmonary symptoms with acceptable low laparoscopic conversion rates, morbidity, mortality and recurrence rates.
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Affiliation(s)
- Sivesh K Kamarajah
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle University NHS Foundation Trust Hospitals, Newcastle Upon Tyne, UK; Institute of Cellular Medicine, Newcastle University, Newcastle Upon Tyne, UK
| | - Charlie Boyle
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle University NHS Foundation Trust Hospitals, Newcastle Upon Tyne, UK
| | - Maziar Navidi
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle University NHS Foundation Trust Hospitals, Newcastle Upon Tyne, UK
| | - Alexander W Phillips
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle University NHS Foundation Trust Hospitals, Newcastle Upon Tyne, UK.
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Tomida H, Hayashi M, Hashimoto S. Massive hiatal hernia involving prolapse of the entire stomach and pancreas resulting in pancreatitis and bile duct dilatation: a case report. Surg Case Rep 2020; 6:11. [PMID: 31919679 PMCID: PMC6952484 DOI: 10.1186/s40792-020-0773-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 12/31/2019] [Indexed: 12/26/2022] Open
Abstract
Background Hiatal hernia is defined by the permanent or intermittent prolapse of any abdominal structure into the chest through the diaphragmatic esophageal hiatus. Prolapse of the stomach, intestine, transverse colon, and spleen is relatively common, but herniation of the pancreas is a rare condition. We describe a case of acute pancreatitis and bile duct dilatation secondary to a massive hiatal hernia of pancreatic body and tail. Case presentation An 86-year-old woman with hiatal hernia who complained of epigastric pain and vomiting was admitted to our hospital. Blood tests revealed a hyperamylasemia and abnormal liver function test. Computed tomography revealed prolapse of the massive hiatal hernia, containing the stomach and pancreatic body and tail, with peripancreatic fluid in the posterior mediastinal space as a sequel to pancreatitis. In addition, intrahepatic and extrahepatic bile ducts were seen to be dilated and deformed. After conservative treatment for pancreatitis, an elective operation was performed. There was a strong adhesion between the hernial sac and the right diaphragmatic crus. After the stomach and pancreas were pulled into the abdominal cavity, the hiatal orifice was closed by silk thread sutures (primary repair), and the mesh was fixed in front of the hernial orifice. Toupet fundoplication and intraoperative endoscopy were performed. The patient had an uneventful postoperative course post-procedure. Conclusion A rare massive hiatal hernia, involving the stomach and pancreatic body and tail, can cause acute pancreatitis with bile duct dilatation. The etiology can be flexure of the main pancreatic and extrahepatic bile ducts. Symptomatic herniation is best treated with surgery. Elective surgery is thought to be safer than emergent surgery in patients with serious complications.
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Affiliation(s)
- Hidenori Tomida
- Department of General Surgery, Asamananroku Komoro Medical Center, 3-3-21 Aioicho, Komoro, Nagano, 384-8588, Japan.
| | - Masahiro Hayashi
- Department of General Surgery, Asamananroku Komoro Medical Center, 3-3-21 Aioicho, Komoro, Nagano, 384-8588, Japan
| | - Shinichi Hashimoto
- Department of General Surgery, Asamananroku Komoro Medical Center, 3-3-21 Aioicho, Komoro, Nagano, 384-8588, Japan
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Choi S, Tang A, Murthy S, Raja S. Preoperative Evaluation and Clinical Decision Making for Giant Paraesophageal Hernias: Who Gets an Operation? Thorac Surg Clin 2019; 29:415-419. [PMID: 31564398 DOI: 10.1016/j.thorsurg.2019.07.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Giant paraesophageal hernias can present as an asymptomatic incidentally detected paraesophageal hernia to an emergent gastric volvulus with concern for ischemia. In the acute setting, the preoperative evaluation aims to determine the extent of complications from gastric volvulus. In the elective setting, preoperative testing defines the gastroesophageal anatomy and function to select the optimal operation. Through thoughtful preoperative evaluation, the best operative approach can be tailored to each patient.
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Affiliation(s)
- Sarah Choi
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Andrew Tang
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Sudish Murthy
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Siva Raja
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Laparoscopic gastric fundus tamponade: a novel adaptation of the Toupet fundoplication for large paraesophageal hernia repair. Surg Endosc 2019; 34:4803-4811. [PMID: 31741156 DOI: 10.1007/s00464-019-07256-1] [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: 07/11/2019] [Accepted: 11/11/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Laparoscopic repair of large paraesophageal hiatal hernia with defects too large to close primarily or greater than 8 cm is technically challenging. The ideal repair remains unclear and is often debated. Utilizing the gastric fundus as an autologous patch to obliterate and tamponade large hiatal defects may offer a new solution. The aim of this study was to evaluate the short-term outcomes following partial posterior fundoplication with gastric fundus tamponade. METHODS Retrospective chart review and prospective patient follow up was conducted on patients who underwent laparoscopic hiatal hernia repair between 2015 and 2019 by a single surgeon. Basic demographics, pre-operative diagnoses, operative technique, and clinical outcomes were recorded. RESULTS Fifteen patients underwent the described technique for repair of large paraesophageal hiatal hernia. All procedures were completed laparoscopically with a short post-operative length of stay (mean of 3 days) and no 30-day readmissions. The majority of patients reported resolution of their pre-operative symptoms. Only one patient required surgery for emergent indications and the same patient was the only mortality in the study, which was secondary to respiratory failure, necrotizing pneumonia, and sepsis as a result of gastric volvulus and obstruction. CONCLUSION Utilizing the gastric fundus as an autologous patch to repair large hiatal hernia may be a safe and efficacious solution with good short-term outcomes. However, further studies should be conducted to elucidate long-term results.
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Wirsching A, Klevebro F, Boshier PR, Hubka M, Kuppusamy MK, Kirtland SH, Low DE. The other explanation for dyspnea: giant paraesophageal hiatal hernia repair routinely improves pulmonary function. Dis Esophagus 2019; 32:doz032. [PMID: 31220858 DOI: 10.1093/dote/doz032] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 03/13/2019] [Accepted: 03/28/2019] [Indexed: 12/11/2022]
Abstract
Paraesophageal hiatal hernias (PEHs) are most commonly associated with gastrointestinal symptoms; less widely appreciated is their potentially important influence on respiratory function. We hypothesize that surgical repair of PEH will significantly improve not only gastrointestinal symptoms, but also preoperative dyspnea and spirometry scores. A prospective Institutional Review Board-approved database was used to review all patients undergoing PEH repair from 2000 to 2016. Patients with pre- and postoperative pulmonary function tests assessed by spirometry were included. Postoperative changes in spirometry measurements were compared to PEH size as reflected by the percentage of intrathoracic stomach observed on preoperative contrast studies. Patients were stratified according to improvement in forced expiratory volume in 1 second (FEV1). Patients with >12% ('significant') improvement in FEV1 after surgery were compared to the remaining patient population. In total, 299 patients met the inclusion criteria. Symptomatic improvement in respiratory function was noted in all patients after PEH repair. Age, gender, BMI, presenting symptoms, Charlson comorbidity index as well as preoperative comorbidities did not significantly impact the functional outcome. Spirometry results improved in 80% of the patients, 21% of whom showed an improvement of >20% compared to the preoperative level. 'Significant' improvement in respiratory function was seen in 122 of 299 (41%) patients. Patients presenting with moderate and severe preoperative pulmonary obstruction demonstrated 'significant' improvement in FEV1 in 48% and 40% of cases, respectively. Large PEHs, characterized by a percentage of intrathoracic stomach >75%, was strongly associated with 'significant' improvement in FEV1 (P = 0.001). PEHs can impact subjective and objective respiratory status and surgical repair can result in a significant improvement in dyspnea and pulmonary function score that is independent of preoperative pulmonary disease. Gastric herniation of more than 75% was associated with higher possibility for improvement of pulmonary function tests. Patients with persistent and unexplained dyspnea and coexistent PEH should be assessed by an experienced surgeon for consideration of elective repair.
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Affiliation(s)
| | | | | | | | | | - Steve H Kirtland
- Department of Pulmonary Medicine, Virginia Mason Medical Center, Seattle, USA
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Petrosyan M, Shah AA, Chahine AA, Guzzetta PC, Sandler AD, Kane TD. Congenital paraesophageal hernia: Contemporary results and outcomes of laparoscopic approach to repair in symptomatic infants and children. J Pediatr Surg 2019; 54:1346-1350. [PMID: 30072216 DOI: 10.1016/j.jpedsurg.2018.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 07/05/2018] [Accepted: 07/12/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND Congenital paraesophageal hernia (CPEH) is a rare diaphragmatic anomaly for which repair has primarily been described by laparotomy, although, more recent case series describe laparoscopic repair. In reports with over five patients, the predominant approach has been with laparotomy. The purpose of our study was to review our recent institutional experience and results with exclusively laparoscopic repair of CPEH in infants and children. METHODS An IRB approved retrospective review of all patients with CPEH who underwent laparoscopic treatment at a tertiary children's hospital from 2010 to 2017 was performed. We included only those patients from our own institution with primary CPEH, or CPEH with prior repair (s) at other centers, with recurrence presenting for operation. Data including demographics, diagnostic studies, operative details, complications, outcomes, and follow up were analyzed. Age at diagnosis was 1 day to 25 years of age (mean 2.5 years). RESULTS A total 28 patients underwent 30 operations to treat CPEH. All operations were completed laparoscopically with no conversions to open. There were 6 Type II, 16 Type III, and 6 Type IV CPEH patients. Seventeen patients were less than one year of age (61%). Weight at time of repair was 10.3 kg (1.2-44 kg). Twelve patients were less than 5 kg (43%), eight patients (28.5%) were less than 10 kg, and 8 were more than 10 kg (28.5%). Operative time averaged 125 min (range 61-247 min). Three patients underwent initial CPEH repair (s) (open: 2 and laparoscopic: 1) at other institutions before laparoscopic revision was performed at our hospital (11%). Crural repair was performed in all patients, fundoplication in 26 (93%) and concomitant gastrostomy was performed in 14 patients (50%). Complications included two patients with recurrent hiatal hernias, which were redone laparoscopically (2/28 or 7% recurrence) and 1 capnothorax requiring pigtail drainage postoperatively. There were no deaths, no requirement for esophageal dilations, or esophageal lengthening. One patient required laparoscopic gastrostomy six weeks post initial repair for failure to thrive. Follow-up ranged from 4 months to 8 years (average 36 months). CONCLUSION Congenital paraesophageal hernia in infants and children is uncommon. Based on our experience, the laparoscopic approach to repair is feasible, even for neonates, with excellent results, acceptably low recurrence rate, and may even be considered for revisional operations. STUDY TYPE Clinical research paper. LEVEL OF EVIDENCE Type IV.
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Affiliation(s)
- Mikael Petrosyan
- Children's National Medical Center, Division of General & Thoracic Surgery, 111 Michigan Avenue NW., Washington, DC, 20010
| | - Adil A Shah
- Children's National Medical Center, Division of General & Thoracic Surgery, 111 Michigan Avenue NW., Washington, DC, 20010; Howard University School of Medicine, Department of Surgery, Washington, DC. 20010
| | - A Alfred Chahine
- Children's National Medical Center, Division of General & Thoracic Surgery, 111 Michigan Avenue NW., Washington, DC, 20010
| | - Philip C Guzzetta
- Children's National Medical Center, Division of General & Thoracic Surgery, 111 Michigan Avenue NW., Washington, DC, 20010
| | - Anthony D Sandler
- Children's National Medical Center, Division of General & Thoracic Surgery, 111 Michigan Avenue NW., Washington, DC, 20010
| | - Timothy D Kane
- Children's National Medical Center, Division of General & Thoracic Surgery, 111 Michigan Avenue NW., Washington, DC, 20010.
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Pagel PS, Thorsen TN, Kugler NW, Haberman KM, Haasler GB, Otterson MF. Acute Onset of Nausea and Vomiting, Diffuse Abdominal Pain, and Profound Metabolic Acidosis 3 Years After Total Gastrectomy. J Cardiothorac Vasc Anesth 2019; 33:3214-3216. [PMID: 31101510 DOI: 10.1053/j.jvca.2019.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 04/16/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Paul S Pagel
- Anesthesia Service, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI.
| | - Thomas N Thorsen
- Anesthesia Service, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI
| | - Nathan W Kugler
- General Surgery Service, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI
| | - Kathryn M Haberman
- General Surgery Service, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI
| | - George B Haasler
- Cardiothoracic Surgery Service, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI
| | - Mary F Otterson
- General Surgery Service, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI
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Olson MT, Singhal S, Panchanathan R, Roy SB, Kang P, Ipsen T, Mittal SK, Huang JL, Smith MA, Bremner RM. Primary paraesophageal hernia repair with Gore® Bio-A® tissue reinforcement: long-term outcomes and association of BMI and recurrence. Surg Endosc 2018; 32:4506-4516. [PMID: 29761272 DOI: 10.1007/s00464-018-6200-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 04/21/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Laparoscopic repair remains the gold-standard treatment for paraesophageal hernia (PEH). We analyzed long-term symptomatic outcomes and surgical reintervention rates after primary PEH repair with onlay synthetic bioabsorbable mesh (W. L. Gore & Associates, Inc., Flagstaff, AZ) and examined body mass index (BMI) as a possible risk factor for poor outcomes and for recurrence. METHODS We queried a prospectively maintained database to identify patients who underwent laparoscopic primary PEH repair with onlay patch of a bioprosthetic absorbable mesh (Bio-A® Gore®) between 05/28/2009 and 12/31/2013. Electronic health records were accessed to record demographic and operative data and were reviewed up to the present to identify any repeat procedures. Patients were grouped according to preoperative BMI (A: BMI < 25; B: BMI = 25-29.9; C: BMI = 30-34.9; D: BMI ≥ 35). Patients completed standardized satisfaction and symptom surveys. RESULTS In total, 399 patients were included. Most patients (n = 261; 65.4%) were women. Mean age was 59.6 ± 13.4 years; mean BMI was 29.9 ± 5.0 kg/m2. The patients were grouped as follows: A, 53 patients (13.3%); B, 166 (41.6%); C, 115 (28.8%); D: 65 (16.3%). Four procedures (1.0%) were converted from laparoscopy to open procedures. All patients underwent an antireflux procedure (225 Nissen, 170 Toupet, 4 Dor). A mean follow-up of 44.7 ± 22.8 months was available for 305 patients (76.4%). 24/305 patients (7.9%) underwent reoperation, and the number of reoperations did not differ among groups (P = 0.64). Long-term symptomatic outcomes were available for 217/305 patients (71.1%) at a mean follow-up of 54.0 ± 13.1 months; no significant difference was observed among groups. 194/217 patients (89.4%) reported good to excellent satisfaction, with no significant differences among the groups. CONCLUSIONS Laparoscopic primary PEH repair with onlay Bio-A® mesh is a safe and feasible procedure with excellent long-term patient-centered outcomes and acceptable symptomatic recurrence rate. BMI does not appear to be related to the need for surgical reintervention.
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Affiliation(s)
- Michael T Olson
- Grand Canyon University College of Science, Engineering, and Technology, Phoenix, AZ, USA.,Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W. Thomas Road, Ste. 500, Phoenix, AZ, 85013, USA
| | - Saurabh Singhal
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W. Thomas Road, Ste. 500, Phoenix, AZ, 85013, USA
| | - Roshan Panchanathan
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W. Thomas Road, Ste. 500, Phoenix, AZ, 85013, USA.,University of Arizona College of Medicine, Phoenix, AZ, USA
| | - Sreeja Biswas Roy
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W. Thomas Road, Ste. 500, Phoenix, AZ, 85013, USA
| | - Paul Kang
- University of Arizona College of Public Health, Phoenix, AZ, USA
| | - Taylor Ipsen
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W. Thomas Road, Ste. 500, Phoenix, AZ, 85013, USA.,Midwestern University College of Osteopathic Medicine, Glendale, AZ, USA
| | - Sumeet K Mittal
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W. Thomas Road, Ste. 500, Phoenix, AZ, 85013, USA
| | - Jasmine L Huang
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W. Thomas Road, Ste. 500, Phoenix, AZ, 85013, USA
| | - Michael A Smith
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W. Thomas Road, Ste. 500, Phoenix, AZ, 85013, USA
| | - Ross M Bremner
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W. Thomas Road, Ste. 500, Phoenix, AZ, 85013, USA.
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A Decreased Preload Due to a Loaded Stomach: A Rare Presentation of a Paraesophageal Hernia. Ann Thorac Surg 2017; 104:e451-e453. [DOI: 10.1016/j.athoracsur.2017.07.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 06/26/2017] [Accepted: 07/05/2017] [Indexed: 11/23/2022]
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Andolfi C, Jalilvand A, Plana A, Fisichella PM. Surgical Treatment of Paraesophageal Hernias: A Review. J Laparoendosc Adv Surg Tech A 2016; 26:778-783. [PMID: 27398823 PMCID: PMC6445204 DOI: 10.1089/lap.2016.0332] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
The management of paraesophageal hernia (PEH) can be challenging due to the lack of consensus regarding indications and principles of operative treatment. In addition, data about the pathophysiology of the hernias are scant. Therefore, the goal of this review is to shed light and describe the classification, pathophysiology, clinical presentation, and indications for treatment of PEHs, and provide an overview of the surgical management and a description of the technical principles of the repair.
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Affiliation(s)
- Ciro Andolfi
- Department of Surgery, University of Chicago, Chicago, Illinois
| | | | - Alejandro Plana
- Department of Surgery, University of Chicago, Chicago, Illinois
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17
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Suture Cruroplasty Versus Prosthetic Hiatal Herniorrhaphy for Large Hiatal Hernia: A Meta-analysis and Systematic Review of Randomized Controlled Trials. Ann Surg 2016; 263:258-66. [PMID: 26445468 DOI: 10.1097/sla.0000000000001267] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim was to conduct a meta-analysis of randomized controlled trials (RCTs) comparing 2 methods of hiatal closure for large hiatal hernia and to evaluate their strengths and flaws. METHODS Prospective RCTs comparing suture cruroplasty versus prosthetic hiatal herniorrhaphy for large hiatal hernia were selected by searching PubMed, Medline, Embase, Science Citation Index, Current Contents, and the Cochrane Central Register of Controlled Trials published between January 1991 and October 2014. The outcome variables analyzed included operating time, complications, recurrence of hiatal hernia or wrap migration, and reoperation. These outcomes were unanimously decided to be important because they influence the practical approach toward patient management. Random effects model was used to calculate the effect size of both dichotomous and continuous data. Heterogeneity among the outcome variables of these trials was determined by the Cochran's Q statistic and I index. The meta-analysis was prepared in accordance with Preferred Reporting of Systematic Reviews and Meta-Analyses guidelines. RESULTS Four RCTs were analyzed totaling 406 patients (Suture = 186, Prosthesis = 220). For only 1 of the 4 outcomes, ie, reoperation rate (OR 3.73, 95% CI 1.18, 11.82, P = 0.03), the pooled effect size favored prosthetic hiatal herniorrhaphy over suture cruroplasty. For other outcomes, comparable effect sizes were noted for both groups which included recurrence of hiatal hernia or wrap migration (OR 2.01, 95% CI 0.92, 4.39, P = 0.07), operating time (SMD -0.46, 95% CI -1.16, -0.24, P = 0.19) and complication rates (OR 1.06, 95% CI 0.45, 2.50, P = 0.90). CONCLUSIONS On the basis of our meta-analysis and its limitations, we believe that the prosthetic hiatal herniorrhaphy and suture cruroplasty produces comparable results for repair of large hiatal hernias. In the future, a number of issues need to be addressed to determine the clinical outcomes, safety, and effectiveness of these 2 methods for elective surgical treatment of large hiatal hernias. Presently, the use of prosthetic hiatal herniorrhaphy for large hiatal hernia cannot be endorsed routinely and the decision for the placement of mesh needs to be individualized based on the operative findings and the surgeon's recommendation.
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Aljehani Y. Unusual Cause of Retrosternal Chest Pain. SAUDI JOURNAL OF MEDICINE & MEDICAL SCIENCES 2016; 4:142-145. [PMID: 30787719 PMCID: PMC6298317 DOI: 10.4103/1658-631x.178372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Yasser Aljehani
- Department of Surgery, Thoracic Surgery Division, King Fahd Hospital of the University, University of Dammam, Dammam, Saudi Arabia
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19
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Hiatus Hernia: A Rare Cause of Acute Pancreatitis. Case Rep Med 2016; 2016:2531925. [PMID: 27066077 PMCID: PMC4811074 DOI: 10.1155/2016/2531925] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 02/07/2016] [Indexed: 12/24/2022] Open
Abstract
Hiatal hernia (HH) is the herniation of elements of the abdominal cavity through the esophageal hiatus of the diaphragm. A giant HH with pancreatic prolapse is very rare and its causing pancreatitis is an even more extraordinary condition. We describe a case of a 65-year-old man diagnosed with acute pancreatitis secondary to pancreatic herniation. In these cases, acute pancreatitis may be caused by the diaphragmatic crura impinging upon the pancreas and leading to repetitive trauma as it crosses the hernia; intermittent folding of the main pancreatic duct; ischemia associated with stretching at its vascular pedicle; or total pancreatic incarceration. Asymptomatic hernia may not require any treatment, while multiple studies have supported the recommendation of early elective repair as a safer route in symptomatic patients. In summary, though rare, pancreatic herniation should be considered as a cause of acute pancreatitis. A high index of suspicion for complications is warranted in cases like these.
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Lugaresi M, Mattioli B, Daddi N, Di Simone MP, Perrone O, Mattioli S. Surgery for Type III-IV hiatal hernia: anatomical recurrence and global results after elective treatment of short oesophagus with open and minimally invasive surgery. Eur J Cardiothorac Surg 2015; 49:1137-43. [PMID: 26377635 DOI: 10.1093/ejcts/ezv280] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 07/14/2015] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES Type III-IV hiatal hernia (HH) is associated with a true short oesophagus in more than 50% of cases; dedicated treatment of this condition might be appropriate to reduce the recurrence rate after surgery. A case series of patients receiving surgery for Type III-IV hernia was examined for short oesophagus, and the results were analysed. METHODS From 1980 to 1994, 60 patients underwent an open surgical approach, and the position of the oesophago-gastric junction was visually localized; from 1995 to 2013, 48 patients underwent a minimally invasive approach, and the oesophago-gastric junction was objectively localized using a laparoscopic-endoscopic method. The patients underwent a timed clinical-instrumental follow-up that included symptoms assessment, barium swallow and endoscopy. 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, HH 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 Among the open surgery patients, 78% underwent abdominal fundoplication, 10% the Belsey Mark IV procedure, 8% laparotomic Collis-Nissen fundoplication and 3% the Pearson operation. Among the minimally invasive surgery patients, 44% underwent a laparoscopic floppy Nissen procedure and 56% a left thoracoscopic Collis-laparoscopic Nissen procedure. The postoperative mortality and complication rates were 1.6% (1/60) and 15% for open surgery and 4.1% (2/48) and 12.5% for minimally invasive surgery. A total of 105 patients were followed up for a median period of 96 months. Five relapses occurred after open surgery (5/59, 8%) and two after minimally invasive surgery (2/46, 4%). Among the 105 patients, excellent, good, fair and poor outcomes were observed in 38%, 44%, 9% and 9%, respectively. CONCLUSIONS These data suggested that the selective treatment of short oesophagus in association with a Type III-IV hernia reduced the anatomical recurrence rate and achieved satisfactory outcomes. CLINICALTRIALSGOV ID NCT01606449.
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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
| | - 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
| | - Ottorino Perrone
- Division of Thoracic Surgery, 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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Lebenthal A, Waterford SD, Fisichella PM. Treatment and controversies in paraesophageal hernia repair. Front Surg 2015; 2:13. [PMID: 25941675 PMCID: PMC4403251 DOI: 10.3389/fsurg.2015.00013] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 03/31/2015] [Indexed: 01/24/2023] Open
Abstract
Background Historically all paraesophageal hernias were repaired surgically, today intervention is reserved for symptomatic paraesophageal hernias. In this review, we describe the indications for repair and explore the controversies in paraesophageal hernia repair, which include a comparison of open to laparoscopic paraesophageal hernia repair, the necessity of complete sac excision, the routine performance of fundoplication, and the use of mesh for hernia repair. Methods We searched Pubmed for papers published between 1980 and 2015 using the following keywords: hiatal hernias, paraesophageal hernias, regurgitation, dysphagia, gastroesophageal reflux disease, aspiration, GERD, endoscopy, manometry, pH monitoring, proton pump inhibitors, anemia, iron-deficiency anemia, Nissen fundoplication, sac excision, mesh, and mesh repair. Results Indications for paraesophageal hernia repair have changed, and currently symptomatic paraesophageal hernias are recommended for repair. In addition, it is important not to overlook iron-deficiency anemia and pulmonary complaints, which tend to improve with repair. Current practice favors a laparoscopic approach, complete sac excision, primary crural repair with or without use of mesh, and a routine fundoplication.
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Affiliation(s)
- Abraham Lebenthal
- Department of Surgery, Brigham and Women's Hospital, Boston VA Health Care System , Boston, MA , USA ; Division of Thoracic Surgery, Brigham and Women's Hospital, Boston VA Health Care System , Boston, MA , USA
| | - Stephen D Waterford
- Department of General Surgery, Massachusetts General Hospital , Boston, MA , USA
| | - P Marco Fisichella
- Department of Surgery, Brigham and Women's Hospital, Boston VA Health Care System , Boston, MA , USA
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Wolfe M, Wilkinson-Ryan I, Hagemann AR, Thaker PH. A case of ovarian cancer metastases causing a symptomatic paraesophageal hernia. Am J Obstet Gynecol 2014; 211:568.e1-2. [PMID: 25068565 DOI: 10.1016/j.ajog.2014.07.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Revised: 07/20/2014] [Accepted: 07/22/2014] [Indexed: 11/26/2022]
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Bonrath EM, Grantcharov TP. Contemporary management of paraesophaegeal hernias: establishing a European expert consensus. Surg Endosc 2014; 29:2180-95. [PMID: 25361649 DOI: 10.1007/s00464-014-3918-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 09/22/2014] [Indexed: 01/24/2023]
Abstract
BACKGROUND The surgical treatment of paraesophageal hernias remains a challenge due to the lack of consensus regarding principles of operative treatment. The objectives of this study were to achieve consensus on key topics through expert opinion using a Delphi methodology. METHODS A Delphi survey combined with a face-to-face meeting was conducted. A panel of European experts in foregut surgery from high-volume centres generated items in the first survey round. In subsequent rounds, the panel rated agreement with statements on a 5-point Likert-type scale. Internal consistency (consensus) was predefined as Cronbach's α > .80. Items that >70 % of the panel either rated as irrelevant/unimportant, or relevant/important were selected as consensus items, while topics that did not reach this cut-off were termed "undecided/controversial". RESULTS Three survey rounds were completed: 19 experts from 10 countries completed round one, 18 continued through rounds two and three. Internal consistency was high in rounds two and three (α > .90). Fifty-eight additional/revised items derived from comments and free-text entries were included in round three. In total, 118 items were rated; consensus agreement was achieved for 70 of these. Examples of consensus topics are the relevance of the disease profile for assessing surgical urgency and complexity, the role of clinical history as the mainstay of patient follow-up, indications for revision surgery, and training and credentialing recommendations. Topics with the most "undecided/controversial" items were follow-up, postoperative care and surgical technique. CONCLUSIONS This Delphi study achieved expert consensus on key topics in the operative management of paraesophageal hernias, providing an overview of the current opinion among European foregut surgeons. Moreover, areas with substantial variability in opinions were identified reflecting the current lack of empirical evidence and opportunities for future research.
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Affiliation(s)
- E M Bonrath
- University of Toronto, 30 Bond Street, Toronto, ON, M5B1W8, Canada,
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24
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Soon E, Vickery C, Pulimood T. Stomach versus lungs: the case of a giant hiatal hernia. Thorax 2014; 70:200-1. [PMID: 24813192 DOI: 10.1136/thoraxjnl-2013-205080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Elaine Soon
- Department of Medicine, West Suffolk NHS Trust, Bury St Edmunds, Suffolk UK Department of Medicine, Addenbrookes' Hospital, Cambridge, UK
| | - Craig Vickery
- Department of Surgery, West Suffolk NHS Trust, Bury St Edmunds, Suffolk UK
| | - Thomas Pulimood
- Department of Medicine, West Suffolk NHS Trust, Bury St Edmunds, Suffolk UK
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Long-term outcome and quality of life after laparoscopic treatment of large paraesophageal hernia. World J Surg 2014; 37:1878-82. [PMID: 23604303 DOI: 10.1007/s00268-013-2047-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Laparoscopy has been widely used for surgical repair of large paraesophageal hernias (PEHs). The technique, however, entails substantial technical difficulties, such as repositioning the stomach in the abdominal cavity, sac excision, closure of the hiatal gap, and fundoplication. Knowledge of the long-term outcome (>10 years) is scarce. The aim of this article was to evaluate the long-term results of this approach, primarily the anatomic hernia recurrence rate and the impact of the repair on quality of life. METHODS We identified all patients who underwent laparoscopic repair for PEH between November 1997 and March 2007 and who had a minimum follow-up of 48 months. In March 2011, all available patients were scheduled for an interview, and a radiologic examination with barium swallow was performed. During the interview the patients were asked about the existence/persistence of symptoms. An objective score test, the gastrointestinal quality of life index (GIQLI), was also administered. RESULTS A total of 77 patients were identified: 17 men (22 %) and 60 women (78 %). The mean age at the time of fundoplication was 64 years (range 24-87 years) and at the review time 73 years (range 34-96 years). The amount of stomach contained within the PEH sac was <50 % in 39 patients (50 %), >50 % in 31 (40 %), and 100 % (intrathoracic stomach) in 7 (9.5 %). A 360º PTFe mesh was used to reinforce the repair in six cases and a polyethylene mesh in three. In May 2011, 55 of the 77 patients were available for interview (71 %), and the mean follow-up was 107 months (range 48-160 months). Altogether, 43 patients (66 %) were asymptomatic, and 12 (21 %) reported symptoms that included dysphagia in 7 patients, heartburn in 3, belching in 1, and chest pain in 1. Esophagography in 43 patients (78 %) revealed recurrence in 20 (46 %). All recurrences were small sliding hernias (<3 cm long). In all, 37 patients (67 %) answered the GIQLI questionnaire. The mean GIQLI score was 111 (range 59-137; normal 147). Patients with objective anatomic recurrence had a quality of life index of 110 (range 89-132) versus 122 in the nonrecurrent hernia group (range 77-138, p < 0.01). Mesh was used to buttress the esophageal hiatus in nine patients. One patient died during the follow-up period. Five of the remaining eight patients (62 %) developed dysphagia, a mesh-related symptom. Three patients required reoperation because of mesh-related complications. Esophagography revealed recurrence in four (50 %) of the eight patients. GIQLI scores were similar in patients with recurrence (126, range 134-119) and without it (111, range 133-186) (p > 0.05). CONCLUSIONS Long-term follow-up (up to 160 months) in our study showed that laparoscopic PEH repair is clinically efficacious but is associated with small anatomic recurrences in ≤50 % of patients. Further studies are needed to identify the anatomic, pathologic, and physiological factors that may impair outcome, allowing the procedure to be tailored to each patient.
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Boyce K, Campbell W, Taylor M. Acute pancreatitis secondary to an incarcerated paraoesophageal hernia: a rare cause for a common problem. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2014; 7:25-7. [PMID: 24653652 PMCID: PMC3956883 DOI: 10.4137/ccrep.s13079] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Revised: 11/06/2013] [Accepted: 11/07/2013] [Indexed: 12/27/2022]
Abstract
This is a rare case report of acute pancreatitis secondary to a massive incarcerated paraoesophageal hernia. The pathogenesis resulted from obstruction of the distal pancreatic duct after displacement of the pancreatic head and body into the thorax as part of a Type IV paraoesophageal hernia. Although this condition is rare, the patient made steady progress following laparotomy and open repair of hernia. She made a good recovery after prompt therapy, therefore, this report can be a guide to the diagnosis and treatment of similar conditions.
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Affiliation(s)
- Kathryn Boyce
- Department of Hepatobiliary Surgery, Belfast Trust, Mater Hospital, Belfast, Northern Ireland
| | - William Campbell
- Department of Hepatobiliary Surgery, Belfast Trust, Mater Hospital, Belfast, Northern Ireland
| | - Mark Taylor
- Department of Hepatobiliary Surgery, Belfast Trust, Mater Hospital, Belfast, Northern Ireland
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Kumar P, Turp M, Fellows S, Ellis J. Pancreatic herniation: a rare cause of acute pancreatitis? BMJ Case Rep 2013; 2013:bcr2013201979. [PMID: 24343805 PMCID: PMC3888546 DOI: 10.1136/bcr-2013-201979] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Acute pancreatitis is a common and potentially fatal condition, with several well-known causes including gallstones, excessive alcohol consumption and specific medications. We report a case of an 89-year-old man presenting with acute pancreatitis, which we believe to be secondary to a diaphragmatic herniation of the pancreas. This extremely rare anatomical abnormality can be found incidentally in the asymptomatic patient or may present with a variety of acute symptoms. However, there have been only isolated reports of these cases presenting as acute pancreatitis. While the majority of acute pancreatitis cases can be explained by common causes, it is important that clinicians be aware of and should consider investigating for other more unusual possibilities, such as pancreatic herniation, before labelling an episode as 'idiopathic'.
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Affiliation(s)
- Prashant Kumar
- Department of Surgery, Milton Keynes General Hospital, Milton Keynes, Bucks, UK
| | - Matthew Turp
- Department of Surgery, Milton Keynes General Hospital, Milton Keynes, Bucks, UK
| | - Sarah Fellows
- Department of Surgery, Milton Keynes General Hospital, Milton Keynes, Bucks, UK
| | - Jonathan Ellis
- Department of Radiology, Milton Keynes General Hospital, Milton Keynes, Bucks, UK
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Toydemir T, Çipe G, Karatepe O, Yerdel MA. Laparoscopic management of totally intra-thoracic stomach with chronic volvulus. World J Gastroenterol 2013; 19:5848-5854. [PMID: 24124329 PMCID: PMC3793138 DOI: 10.3748/wjg.v19.i35.5848] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Accepted: 08/06/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the outcomes of patients who underwent laparoscopic repair of intra-thoracic gastric volvulus (IGV) and to assess the preoperative work-up.
METHODS: A retrospective review of a prospectively collected database of patient medical records identified 14 patients who underwent a laparoscopic repair of IGV. The procedure included reduction of the stomach into the abdomen, total sac excision, reinforced hiatoplasty with mesh and construction of a partial fundoplication. All perioperative data, operative details and complications were recorded. All patients had at least 6 mo of follow-up.
RESULTS: There were 4 male and 10 female patients. The mean age and the mean body mass index were 66 years and 28.7 kg/m2, respectively. All patients presented with epigastric discomfort and early satiety. There was no mortality, and none of the cases were converted to an open procedure. The mean operative time was 235 min, and the mean length of hospitalization was 2 d. There were no intraoperative complications. Four minor complications occurred in 3 patients including pleural effusion, subcutaneous emphysema, dysphagia and delayed gastric emptying. All minor complications resolved spontaneously without any intervention. During the mean follow-up of 29 mo, one patient had a radiological wrap herniation without volvulus. She remains symptom free with daily medication.
CONCLUSION: The laparoscopic management of IGV is a safe but technically demanding procedure. The best outcomes can be achieved in centers with extensive experience in minimally invasive esophageal surgery.
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Parker DM, Rambhajan A, Johanson K, Ibele A, Gabrielsen JD, Petrick AT. Urgent laparoscopic repair of acutely symptomatic PEH is safe and effective. Surg Endosc 2013; 27:4081-6. [DOI: 10.1007/s00464-013-3064-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Accepted: 06/06/2013] [Indexed: 12/11/2022]
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Markakis C, Tomos P, Spartalis ED, Lampropoulos P, Grigorakos L, Dimitroulis D, Lachanas E, Agathos EA. The Belsey Mark IV: an operation with an enduring role in the management of complicated hiatal hernia. BMC Surg 2013; 13:24. [PMID: 23829509 PMCID: PMC3717073 DOI: 10.1186/1471-2482-13-24] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Accepted: 06/26/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Belsey Mark IV operation has been used for the management of hiatal hernia for over 40 years, but with the introduction of laparoscopic techniques its role has become questionable. To determine the current role of this procedure we present a contemporary series of patients. METHODS We reviewed fifteen consecutive patients, mean age of 63 years, who underwent a Belsey Mark IV fundoplication for gastroesophageal reflux in the presence of a hiatal hernia in our Department from January 2005 to March 2011. Indications for the thoracic approach included paraesophageal hernias, recurrent hiatal hernias and previous upper abdominal surgery. RESULTS There was no operative mortality. Immediate postoperative morbidity included 1 case of bleeding, 1 case of pneumonia and 1 case of atrial fibrillation. The mean length of stay was 5.9 days. After a mean follow-up time of 49 months, all patients reported total or partial alleviation of their symptoms. No hernia recurrence was detected during barium swallow examination. CONCLUSIONS The Belsey approach is a procedure that can be useful as an alternative in selected cases when there are co-morbidities complicating the transabdominal (laparoscopic) approach.
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Affiliation(s)
- Charalampos Markakis
- 2nd Propaedeutic Department of Surgery, Laiko General Hospital, University of Athens, Tritonos 20 Str, Paleo Faliro, 17561 Athens, Greece.
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Van Der Westhuizen L, Dunphy KM, Knott B, Carbonell AM, Smith DE, Cobb WS. The Need for Fundoplication at the Time of Laparoscopic Paraesophageal Hernia Repair. Am Surg 2013. [DOI: 10.1177/000313481307900616] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Most authors recommend an antireflux operation at the time of laparoscopic paraesophageal hernia (PEH) repair. A fundoplication combats the potential postoperative reflux resulting from disruption of the hiatal anatomy and may minimize recurrence. The purpose of this study is to evaluate the differences in postoperative dysphagia, reflux symptoms, and hiatal hernia recurrence in patients with and without a fundoplication at the time of laparoscopic paraesophageal hernia repair. Patients undergoing laparoscopic PEH repair from July 2006 to June 2012 were identified. Open repairs and reoperative cases were excluded. Patient characteristics, operative details, complications, and postoperative outcomes were recorded. Over the six-year period, 152 laparoscopic PEH repairs were performed. Mean age was 65.8 years (range, 31 to 92) and average body mass index was 29.9 kg/m2 (range, 18 to 52 kg/m2). Concomitant fundoplication was performed in 130 patients (86%), which was determined based on preoperative symptoms and esophageal motility. Mean operative times were similar with fundoplication (188 minutes) and without (184.5 minutes). At a mean follow-up of 13.9 months, there were 19 recurrences: 12.3 per cent (16 of 130) in the fundoplication group and 13.6 per cent (three of 22) in those without. Dysphagia lasting greater than six weeks was present in eight patients in the fundoplication group (6.2%) and in none in those without ( P = 0.603). Eighteen percent of patients without a fundoplication reported postoperative reflux compared with 5.4 per cent of patients with a fundoplication ( P = 0.055). In the laparoscopic repair of PEH, the addition of a fundoplication minimizes postoperative reflux symptoms without additional operative time. Neither dysphagia nor hiatal hernia recurrence is affected by the presence of a fundoplication.
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Affiliation(s)
| | - Kaitlyn M. Dunphy
- From Greenville Hospital System University Medical Center, Greenville, South Carolina
| | - Brianna Knott
- From Greenville Hospital System University Medical Center, Greenville, South Carolina
| | - Alfredo M. Carbonell
- From Greenville Hospital System University Medical Center, Greenville, South Carolina
| | - Dane E. Smith
- From Greenville Hospital System University Medical Center, Greenville, South Carolina
| | - William S. Cobb
- From Greenville Hospital System University Medical Center, Greenville, South Carolina
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Haurani C, Carlin AM, Hammoud ZT, Velanovich V. Prevalence and resolution of anemia with paraesophageal hernia repair. J Gastrointest Surg 2012; 16:1817-20. [PMID: 22843082 DOI: 10.1007/s11605-012-1967-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2012] [Accepted: 07/06/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Paraesophageal hernias may produce a variety of clinical sequelae including anemia and esophagogastric ulcerations or erosions. We examined the prevalence of anemia in patients with paraesophageal hernias and frequency of anemia resolution with hernia repair. METHODS Patients undergoing paraesophageal hernia repairs from July 1996 to September 2010 were included. Data gathered included age, gender, type of hernia, presence of symptomatic anemia, presence of esophagogastric ulcer/erosion, type of repair, and anemia resolution. RESULTS One hundred eighty-three patients underwent paraesophageal hernia repair; of these, 68 (37%) were anemic. Of these anemic patients, 39 (57%) were symptomatic from their anemia or specifically referred for anemia, and 20 (29%) had esophagogastric ulceration/erosion. Fifty-eight had documented follow-up. Overall, of these, 35 (60%) had resolution of their anemia. Seventy percent of symptomatic patients had resolution of their anemia, compared to 48% of asymptomatic patients (p = 0.1). Of patients with esophagogastric ulceration/erosion, 85% were symptomatic and 88% had resolution of anemia, compared to 50% of patients without ulceration/erosion (p = 0.015). CONCLUSIONS Anemia was a common finding in patients with paraesophageal hernia and most patients were symptomatic because of their anemia. Those patients with esophageal or gastric ulceration/erosion were very likely to have symptomatic anemia, and, interestingly, these patients were more likely to have their anemia resolve with paraesophageal hernia repair.
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Affiliation(s)
- Chady Haurani
- Department of Surgery, Henry Ford Health System, 2799 West Grand Blvd., Detroit, MI 48202, USA.
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Carrott PW, Hong J, Kuppusamy M, Koehler RP, Low DE. Clinical ramifications of giant paraesophageal hernias are underappreciated: making the case for routine surgical repair. Ann Thorac Surg 2012; 94:421-6; discussion 426-8. [PMID: 22742845 DOI: 10.1016/j.athoracsur.2012.04.058] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Revised: 04/12/2012] [Accepted: 04/16/2012] [Indexed: 12/11/2022]
Abstract
BACKGROUND We propose that the symptoms associated with paraesophageal hernia (PEH) are more diverse than previously suggested, and symptoms and clinical manifestations correlate to the anatomy of the hernia. METHODS Patients undergoing surgery for PEH were reviewed from a prospective, institutional review board-approved, single-center database. Presenting symptoms, anatomy of the PEH, demographics, and outcomes were analyzed from 2000 to 2010. Presenting symptoms were assessed for incidence and improvement after surgery. Size and configuration of the PEH were assessed with respect to presenting symptoms. RESULTS The study included 270 consecutive patients, 63% were female, and the median age was 70 years (range, 39 to 94 years). The most common presenting symptoms were heartburn in 175 patients (65%), early satiety in 136 patients (50%), chest pain in 130 patients (48%), dyspnea in 130 patients (48%), dysphagia in 129 patients (48%), regurgitation in 128 patients (47%), and anemia in 112 patients (41%). Two hundred sixty-nine patients (99.6%) had at least one symptom; the median number of symptoms was 4 (range, 0 to 10). The type of PEH was II (n=10), III (n=206), and IV (n=54), and the percent intrathoracic stomach was less than 50% (n=33), 50% to 74% (n=86), 75% to 99% (n=55), and 100% (n=96). Paraesophageal hernia type was significantly associated with heartburn (type II/III; p=0.005) and dyspnea (type IV; p=0.007). Significant associations included lower percent intrathoracic stomach with regurgitation (p=0.04); higher percent intrathoracic stomach with early satiety (p=0.02), decreased meal size (p=0.007), and dyspnea (p<0.001); and 50% to 74% intrathoracic stomach with anemia (p=0.001). With a median postoperative follow-up of 103 days, symptoms were subjectively better in patients with dyspnea (67%), early satiety (79%), regurgitation (92%), dysphagia (81%), chest pain (76%), and heartburn (93%). CONCLUSIONS Paraesophageal hernia is associated with a greater diversity of symptomatic presentation than previously thought. Asymptomatic patients are rare, and size and configuration of the hernia are associated with specific symptoms. Patients with large PEHs should be assessed by an experienced surgeon for elective repair.
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Affiliation(s)
- Philip W Carrott
- Section of General Thoracic Surgery, Virginia Mason Medical Center, Seattle, Washington
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Repair of giant paraesophageal hernias routinely produces improvement in respiratory function. J Thorac Cardiovasc Surg 2011; 143:398-404. [PMID: 22104674 DOI: 10.1016/j.jtcvs.2011.10.025] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2011] [Revised: 09/14/2011] [Accepted: 10/20/2011] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Assessment of the clinical impact of giant paraesophageal hernias have historically focused on upper gastrointestinal symptoms. This study assesses the effect of paraesophageal hernia repair on respiratory function. METHODS All patients undergoing repair of giant paraesophageal hernia were prospectively entered into a database approved by the institutional review board. Patients had symptoms documented preoperatively, including dyspnea. Pulmonary function tests (PFTs) were done preoperatively and repeated a median of 106 days after repair (range, 16-660 days). RESULTS Preoperative and postoperative PFTs were obtained in 120 unselected patients treated for paraesophageal hernia between 2000 and 2010. Patients' median age was 74 years (range, 45-91 years), 74 (62%) were female, and median body mass index was 28.0 (range, 16.8-46.6). Median length of stay was 4 days (range, 3-10 days), and perioperative mortality was zero. Hernias were classified as type II in 3 (3%) patients, III in 92 (77%), and IV in 25 (21%). Percent of intrathoracic stomach was assigned from preoperative contrast studies and grouped as less than 50% (n = 6; 5%), 50% to 74% (n = 35; 29%), 75% to 99% (n = 29; 24%), and 100% (n = 50; 42%). Preoperative symptoms included heartburn 71 (59%), early satiety 65 (54%), dyspnea 63 (52%), chest pain 48 (40%), dysphagia 56 (47%), regurgitation 47 (39%), and anemia 44 (37%). PFTs significantly improved after paraesophageal hernia repair (mean volume change, percent reference change): forced vital capacity +0.30 L,+10.3%pred; FEV(1) +0.23 L,+10.4%pred (all P < .001); diffusion capacity of the lung for carbon monoxide +0.58 mL · mm Hg(-1) · min(-1) (P = .004), and +2.9%pred (P = .002). Greater improvements were documented in older patients with significant subjective respiratory symptoms and higher percent of intrathoracic stomach (P < .01). CONCLUSIONS Paraesophageal hernia has a significant effect on respiratory function, which is largely underappreciated. This study demonstrates that these repairs can be done safely and supports routine consideration for elective repair; older patients with borderline respiratory function may achieve substantial improvements in their respiratory status and quality of life.
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Li J, Rosenthal RJ, Roy M, Szomstein S, Sesto M. Experience of laparoscopic paraesophageal hernia repair at a single institution. Am J Surg 2011; 204:60-5. [PMID: 21992807 DOI: 10.1016/j.amjsurg.2011.06.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2010] [Revised: 06/06/2011] [Accepted: 06/06/2011] [Indexed: 12/24/2022]
Abstract
BACKGROUND Paraesophageal hernia patients are often elderly with complicating medical comorbidities, making surgical management complex in formulating a management strategy. METHODS Between January 2005 and July 2009, 93 patients underwent surgical treatment of paraesophageal hernia, including 8 recurrent cases after multiple repairs. Open transabdominal surgeries were performed in 14 (15%) patients, and combined thoracotomy was performed in 1 (1%). Laparoscopic surgeries were performed in 78 (84%) patients with 4 (5%) conversions. Artificial prosthetics were used in 27 (29%) patients. Fundoplication was performed in 82 (88%) patients. Gastropexy or feeding tube gastrostomy was performed in 10 (11%) patients. RESULTS The average length of the surgery was 125 minutes (range, 51-304 min). The mean blood loss was 100 mL. The average length of stay was 4 days (range, 1-14 d). There were 2 mortalities (2%) and 4 re-operations, with a recurrence rate of 2%. CONCLUSIONS Laparoscopic paraesophageal hernia repair can be performed safely with acceptable results when following a standard approach.
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Affiliation(s)
- Jihui Li
- Section of Minimally Invasive Surgery and the Bariatric and Metabolic Institute, Cleveland Clinic, 2950 Cleveland Clinic Blvd., Weston, FL 33331, USA
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Louie BE, Blitz M, Farivar AS, Orlina J, Aye RW. Repair of symptomatic giant paraesophageal hernias in elderly (>70 years) patients results in improved quality of life. J Gastrointest Surg 2011; 15:389-96. [PMID: 21246416 DOI: 10.1007/s11605-010-1324-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2010] [Accepted: 08/09/2010] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Giant paraesophageal hernias (PEH) involve herniation ofstomach and/or other viscera into the mediastinum. These are usually symptomatic and commonly occur in the elderly. The benefits and risks of operating on elderly patients with giant PEH have not been clearly elucidated. MATERIALS AND METHODS We performed a retrospective chart review of consecutive patients aged 70 or greater with giant PEHs undergoing repair.Quality of life data were gathered using QOLRAD, GERD-HRQL and adysphagia severity score. RESULTS Fifty-eight patients (34 females), median 78 years old, presented for repair. Nine patients presented urgently. There was no 30-day mortality. Major morbidity was 15.5%. At mean follow-up of 1.3 years, 81% were symptom free compared to baseline (p < 0.0001). Both short-term (p < 0.001) and long term QOLRAD (p < 0.001) scores improved significantly, as did GERD HRQL scores (p < 0.001). Dysphagia scores worsened in the short term but returned to baseline at long term follow up. CONCLUSIONS Symptomatic giant PEH in this elderly population can be repaired with symptomatic improvement, minimal morbidity and mortality in both the elective and urgent setting. The decision to operate should be made by a physician experienced in managing this complex patient population.
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Affiliation(s)
- Brian E Louie
- Division of Thoracic and Foregut Surgery, Swedish Cancer Institute and Medical Center, Suite 850, 1101 Madison Street, Seattle, WA 98105, USA.
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Coughlin M, Fanous M, Velanovich V. Herniated pancreatic body within a paraesophageal hernia. World J Gastrointest Surg 2011; 3:29-30. [PMID: 21394323 PMCID: PMC3052411 DOI: 10.4240/wjgs.v3.i2.29] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2010] [Revised: 01/15/2011] [Accepted: 01/21/2011] [Indexed: 02/06/2023] Open
Abstract
A hiatal hernia can be classified as one of four types according to the position of the gastroesophageal (GE) junction and the extent of herniated stomach. Type I, or sliding hernias, account for up to 95% of all hiatal hernias and occur when the GE junction migrates into the posterior mediastinum through the hiatus. Type II occurs when the fundus herniates through the hiatus alongside a normally positioned GE junction. Type III is a combination of types I and II hernias with a displaced GE junction as well as stomach protruding through the hiatus. Type IV paraesophageal hernias are the rarest of the hiatal hernias. Usually, colon or small bowel is herniated within the mediastinum along with the stomach. We present a case of a paraesophageal hernia with the mid-body of the pancreas as part of the hernia contents.
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Affiliation(s)
- Megan Coughlin
- Megan Coughlin, Medhat Fanous, Vic Velanovich, Division of General Surgery, Henry Ford Hospital, Detroit, MI 49202, United States
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