Management of Complications in Paraesophageal Hernia Repair

A case of conservatively managed gastric perforation at a recurrent hiatal hernia site after laparoscopic paraesophageal repair

INTRODUCTION AND IMPORTANCE

Gastric perforation due to a hiatal hernia is a rare cause of acute abdominal pain that often requires surgical intervention. Conservative management for this condition is an effective option in certain cases, although fewer reports of this exist. Herein, we report a unique case of gastric perforation caused by a recurrent hiatal hernia that was successfully treated with conservative management.

CASE PRESENTATION

A 74-year-old man developed a high fever and an elevated inflammatory response on the third day after a laparoscopic paraesophageal hernia repair using a mesh. Computed tomography confirmed the recurrence of the hiatal hernia, with gastric fundal prolapse into the mediastinum and surgical emphysema in the gastric wall. This was followed by a gastric perforation within the mediastinum. The patient was treated using an ileus tube through the perforation site.

CLINICAL DISCUSSION

In similar cases, if the clinical symptoms are mild, there are no signs of serious infection, and the perforation remains in the mediastinum and can be appropriately drained, conservative treatment is considered an option.

CONCLUSION

Under favorable conditions, conservative management can be an option for gastric perforation in patients with recurrent hiatal hernias, which is a serious potential postoperative complication.

A Rare Case of Paraesophageal Hernia Repair Complicated by Pancreatic Injury

Esophageal hernias are anatomical defect that affects up to 50% of the population. While they may be asymptomatic, hernias may also result in reflux and dysphagia, among other symptoms. In such cases, hernia repair is warranted. The most common type of repair is laparoscopic Nissen fundoplication, which is usually well-tolerated. Herein, we present a rare case of paraesophageal hernia repair complicated by pancreatic injury and pancreatic leak.

Thoracoscopic approach as surgical management of esophageal epiphrenic diverticulum

BACKGROUND

Management of diverticulum of the lower esophagus or epiphrenic diverticulum can be performed using the abdominal or thoracic approach. In some cases, the thoracic approach is preferred, but few studies have described thoracoscopic resection. The objective of the present study was to investigate the thoracoscopic approach for management of epiphrenic esophageal diverticulum.

MATERIAL AND METHODS

From 2008 to 2018, all patients undergoing surgery for epiphrenic esophageal diverticulum by the thoracoscopic approach were included in this single-center, retrospective, observational study. Data on diverticulum, surgery and follow-up were assessed.

RESULTS

During the study period, 14 patients underwent surgery. Two patients had two diverticula. The mean location of the superior edge of the diverticulum was 7cm (2-14cm) above the gastro-esophageal junction. The mean size of the diverticulum was 39 millimeters (20-60). Thoracoscopic approach was used in all patients. No conversion to thoracotomy was required. Mean operative time was 168min (120-240). No postoperative mortality occurred. The overall complication rate was 40% (6 complications out of 15 resections), with three major complications including leaks (n=2) and a case of bronchoesophageal fistula (n=1). Median length of hospital stay was 12 days (8-40). At a mean postoperative follow-up of 20.7 months (5-71), 85% of patients had complete disappearance of preoperative symptoms without recurrence of the diverticulum on the barium swallow study test.

CONCLUSION

Thoracoscopic approach as management of epiphrenic diverticulum is feasible, with acceptable short-term morbidity. The thoracoscopic approach is also effective in resolving preoperative symptoms.

Tension-free hiatal hernia repair with biological mesh: A real-world experience

Laparoscopic Nissen fundoplication and esophagoplasty are the standards for gastroesophageal reflux disease (GERD) and hiatal hernia (HH) repair. Biologically derived mesh is also associated with reduced recurrence. This study attempted to evaluate the effectiveness of a biological mesh in the 4K laparoscopic repair of HH. This retrospective study reviewed patients with a severe GERD complicated with HH from August 2019 to August 2020. All patients underwent the HH repair using a biological mesh under a 4K laparoscope accompanying Nissen fundoplication. Up to 16 months postoperatively, GERD-health-related quality-of-life (GERD-HRQL) scale, radiologic studies on HH recurrence, and symptoms were recorded. The mean surgical time and postoperative hospital stay were 70.9 ± 8.72 min, 4.8 ± 0.76 days, respectively. The postoperative symptom relief rate was 96.5%, and no recurrence exhibited during follow-up. Dysphagia occurred in 10 (9.43%) patients. There were no intraoperative vagus nerve injury or postoperative complications, mesh infection, and reoperation for mesh. The tension-free repair of HH with the biological mesh is an option for clinical use, with effectiveness and few short-term complications being reported.

Paraesophageal hernia repair with laparoscopic Toupet fundoplication: impact on pulmonary function, respiratory symptoms and quality of life

BACKGROUND

Paraesophageal hiatal hernia (PEH) is characterized by protrusion of intra-abdominal organs into the posterior mediastinum. Respiratory symptoms and reduced pulmonary function have been described as possibly related to lung compression.

OBJECTIVE

To assess the effect of laparoscopic Toupet fundoplication (LTF) for PEH repair on pulmonary function, measured with pulmonary function tests (PFTs), and respiratory symptoms.

METHODS

Retrospective, single-center, cohort study (November 2015-2020). All patients that completed pre- and postoperative (12 months) PFTs assessment were included. The gastroesophageal reflux disease health-related quality of life (GERD-HRQL), reflux symptom index (RSI) and short form-36 (SF-36) were used.

RESULTS

Overall, 71 patients were included. The median age was 67.1 years and the majority were females (78.8%). Baseline PFTs were within normal limits in 91% of patients. At 12 month follow-up, total lung capacity (TLC) (4.77 vs. 5.07 L; p = 0.0251), vital capacity (VC) (2.97 vs. 3.31 L; p = 0.0065), forced expiratory volume in one second (FEV1) (2.07 vs. 2.44 L; p < 0.001) and forced vital capacity (FVC) (2.78 vs. 3.19 L; p < 0.001) were significantly improved. No significant differences were found for diffusing capacity of lung for carbon monoxide (DLCO) (17.09 vs. 17.24; p = 0.734), and FEV1/FVC (0.77 vs. 0.77; p = 0.967). Interestingly, improvements were more pronounced in patients with large PEH (type IIIb and IV). At 12 month follow-up, both gastrointestinal and respiratory symptoms were significantly improved and 94% of patients were satisfied with the operation. The GERD-HRQL (18.1 ± 7.9 vs. 4.01 ± 2.4; p = 0.001), RSI (37.8 ± 9.7 vs. 10.6 ± 8.9; p < 0.001) and all SF-36 items were improved.

CONCLUSIONS

LTF for the treatment of PEH is safe and seems to be effective up to 12 month follow-up with improved lung volumes, spirometry values, quality of life, gastrointestinal and respiratory symptoms.

IMPACT OF BODY MASS INDEX ON PERIOPERATIVE OUTCOMES FOR COMPLEX HIATUS HERNIA BY VIDEOLAPAROSCOPY

BACKGROUND:

The influence of body mass index on perioperative complications of hiatal hernia surgery is controversial in the surgical literature.

AIMS:

The aim of this study was to evaluate the influence of body mass index on perioperative complications and associated risk factors for its occurrence.

METHODS:

Two groups were compared on the basis of body mass index: group A with body mass index <32 kg/m² and group B with body mass index ³32 kg/m². A multivariate analysis was carried out to identify independent predictors for complications. Complications were classified based on the Clavien-Dindo score.

RESULTS:

A total of 49 patients were included in this study, with 30 in group A and 19 in group B. The groups were compared based on factors, such as age, Charlson Comorbidity Index, surgical techniques used, type and location of hiatal hernia, and length of stay. Findings showed that 70% of patients had complex hiatal hernia. In addition, 14 complications also occurred: 7 pleuropulmonary and 7 requiring reoperation. From the seven reoperated, there were three recurrences, two gastrointestinal fistulas, one diaphragmatic hernia, and one incisional hernia. Complications were similar in both the groups, with type IV hiatal hernia being the only independent predictor.

CONCLUSIONS:

Body mass index does not affect perioperative complications in anti-reflux surgery and type IV hiatal hernia is an independent predictor of its occurrence.

Treatment strategy for laparoscopic hiatal hernia repair

INTRODUCTION

According to the anatomy-function-pathology classification, the recurrence rates of A2 and A3 hiatal hernia (HH) after laparoscopic fundoplication are higher than the rate of A1 HH. Therefore, we introduced mesh reinforcement for A2 and A3 cases. In addition, gastropexy was added to A3 cases. We present the strategy for HH repair.

METHODS

In all, 537 patients (mean age 55.4 ± 16.7 years, 219 women) who underwent primary laparoscopic fundoplication for HH from January 1995 to October 2019 were included. They were divided into three groups by A factor (A1:A2:A3 = 296:156:85). Their clinical data were collected in a prospective fashion and retrospectively reviewed.

RESULTS

The median age (years) of the patients in each group was A1:A2:A3 = 46:63:74 years, and age was directly proportional to the size of HH (P < 0.0001). The proportion of females was significantly higher in A3 than in other classes (P < 0.0001). Preoperative reflux esophagitis was severe in A2 (P < 0.0001) and operation time (min) was directly proportional to HH size (A1:A2:A3 = 135:167:193, P < 0.0001). The recurrence rate of conventional laparoscopic fundoplication was 15% (46/304), and it was higher for A2 and A3 than for A1 (P = 0.027). However, with reinforcement of the hiatus using a mesh and gastropexy, the recurrence rates decreased.

CONCLUSION

Combining mesh reinforcement and gastropexy may reduce the recurrence rate of para- and mixed-type HH.

Impact of Paraesophageal Hernia Repair on Respiratory Function: A Systematic Review

Background and Objectives: Surgical repair of hiatal and paraesophageal hernia is widely accepted for the treatment of gastroesophageal reflux symptoms. The respiratory benefit of this surgery is less clear. The objective of this review is to quantify the benefit to pulmonary function and subjective dyspnea of paraesophageal hernia repair with the aim of refining the indications and contraindications for elective paraesophageal hernia repair.

Methods: Articles were gathered from systematic searches of the Medline Complete Database via the Creighton University Health Sciences Library literature search services. Publications with both pre and postoperative pulmonary function data or both pre and postoperative subjective dyspnea data with regards to surgical paraesophageal hernia repair were included.

Results: Six studies were included in this review. The majority of studies in this review show improvement in pulmonary function postoperatively with regards to FEV1, FVC, and VC when stratified by % intrathoracic stomach (ITS), particularly in groups >50% ITS. No significant change was seen in postoperative DLCO or FEV1/FVC.

Conclusion: Paraesophageal hernia repair has shown to improve pulmonary function both objectively and subjectively. This review was limited by the paucity of literature on the subject as well as the lack of a standardized method for measurement of %ITS.