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Pavelko Y, Bustos R, Gruessner S, Hassan C. Acute Hiatal Hernia with Incarcerated Proximal Half of Recent Sleeve Gastrectomy: Super Rare Complication. Obes Surg 2020; 31:469-471. [PMID: 33179217 DOI: 10.1007/s11695-020-05101-2] [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: 07/07/2020] [Revised: 10/29/2020] [Accepted: 10/29/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND Vertical sleeve gastrectomy (VSG) has become the most commonly performed operation for the treatment of morbid obesity (JAMA. 312(9):959-61, 2014). Nevertheless, VSG is still associated with some early postoperative complications (JAMA. 312(9):959-61, 2014; Surg Obes Relat Dis. 9(5):816-29, 2013; Obes Surg. 27(8):1944-1951, 2017). Hiatal hernia is a complication that has been widely described in the literature, but not in the immediate postoperative course (Obes Surg. 17(7):962-9, 2007). We, herein, report a case of an acute postoperative hiatal hernia after sleeve gastrectomy. METHODS A 29-year-old female (BMI 38.54 kg/m2) presented to our center and her options for metabolic surgery were discussed. Laparoscopic sleeve gastrectomy (LSG) was the chosen procedure. Preoperative assessment includes a chest x-ray, and standard lab-work up was within a normal limit. Barium swallow did not show any evidence of hiatal hernia. She underwent a LSG. On POD 1, she was able to pass the bariatric clears trial and was discharged home. Three days after discharge, the patient was complaining of constant nausea and vomiting, and chest pain, and was diagnosed with acute hiatal hernia with the incarceration of the proximal sleeve. The patient was taken to the operating room. RESULTS Postoperatively, the patient started on the usual bariatric clinical pathway which she tolerated well and was discharged on the POD 4. The operative time was 156 min. The estimated blood loss was 50 ml. CONCLUSIONS Our report highlights the need for more broad differential diagnosis in early post sleeve gastrectomy patients. Those who are presented with nausea and vomiting in the early postoperative period should be evaluated for possible post sleeve hiatal hernia with a potential risk of strangulation.
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Affiliation(s)
- Yevhen Pavelko
- UI Health-Division of General, Minimally Invasive & Robotic Surgery, Department of Surgery, University of Illinois at Chicago, 820 South Wood Street, Rm 609, Clinical Sciences North Chicago, Chicago, IL, 60612, USA.
| | - Roberto Bustos
- UI Health-Division of General, Minimally Invasive & Robotic Surgery, Department of Surgery, University of Illinois at Chicago, 820 South Wood Street, Rm 609, Clinical Sciences North Chicago, Chicago, IL, 60612, USA
| | - Stephan Gruessner
- UI Health-Division of General, Minimally Invasive & Robotic Surgery, Department of Surgery, University of Illinois at Chicago, 820 South Wood Street, Rm 609, Clinical Sciences North Chicago, Chicago, IL, 60612, USA
| | - Chandra Hassan
- UI Health-Division of General, Minimally Invasive & Robotic Surgery, Department of Surgery, University of Illinois at Chicago, 820 South Wood Street, Rm 609, Clinical Sciences North Chicago, Chicago, IL, 60612, USA
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Köckerling F, Trommer Y, Zarras K, Adolf D, Kraft B, Weyhe D, Fortelny R, Schug-Paß C. What are the differences in the outcome of laparoscopic axial (I) versus paraesophageal (II-IV) hiatal hernia repair? Surg Endosc 2017; 31:5327-5341. [PMID: 28597286 PMCID: PMC5715051 DOI: 10.1007/s00464-017-5612-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 05/16/2017] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Comparison of elective laparoscopic repair of axial vs paraesophageal hiatal hernias reveals relevant differences in both the patient collectives and the complexity of the procedures. MATERIALS AND METHODS The present uni- and multivariable analysis of data from the Herniamed Registry compares the outcome for 2047 (67.3%) (type I) axial with 996 (32.7%) (types II-IV) paraesophageal primary hiatal hernias following laparoscopic repair. RESULTS Compared with the patients with axial hiatal hernias, patients with paraesophageal hiatal hernia were nine years older, had a higher ASA score (ASA III/IV: 34.8 vs 13.7%; p < 0.001), and more often at least one risk factor (38.8 vs 21.4%; p < 0.001). This led in the univariable analysis to significantly more general postoperative complications (6.0 vs 3.0%; p < 0.001). Reflecting the greater complexity of the procedures used for laparoscopic repair of paraesophageal hiatal hernias, significantly higher intraoperative organ injury rates (3.7 vs 2.3%; p = 0.033) and higher postoperative complication-related reoperation rates (2.1 vs 1.1%; p = 0.032) were identified. Univariable analysis did not reveal any significant differences in the recurrence and pain rates on one-year follow-up. Multivariable analysis did not find any evidence that the use of a mesh had a significant influence on the recurrence rate. CONCLUSION Surgical repair of paraesophageal hiatal hernia calls for an experienced surgeon as well as for corresponding intensive medicine competence because of the higher risks of general and surgical postoperative complications.
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Affiliation(s)
- F Köckerling
- Department of Surgery and Center for Minimally Invasive Surgery, Academic Teaching Hospital of Charité Medical School, Vivantes Hospital, Neue Bergstrasse 6, 13585, Berlin, Germany.
| | - Y Trommer
- Department of General, Visceral and Minimally Invasive Surgery, Helios Hospital, Campus 6, 38518, Gifhorn, Germany
| | - K Zarras
- Department of Visceral, Minimally Invasive and Oncologic Surgery, Marien Hospital, Rochusstrasse 2, 40479, Düsseldorf, Germany
| | - D Adolf
- StatConsult GmbH, Halberstädter Strasse 40 A, 39112, Magdeburg, Germany
| | - B Kraft
- Department of General and Visceral Surgery, Diakonie Hospital, Rosenbergstrasse 38, 70176, Stuttgart, Germany
| | - D Weyhe
- Department of General and Visceral Surgery, Pius Hospital, University Hospital of Visceral Surgery, Georgstrasse 12, 26121, Oldenburg, Germany
| | - R Fortelny
- Department of General, Visceral and Oncologic Surgery, Wilhelminenhospital, Montleartstrasse 37, 1160, Vienna, Austria
| | - C Schug-Paß
- Department of Surgery and Center for Minimally Invasive Surgery, Academic Teaching Hospital of Charité Medical School, Vivantes Hospital, Neue Bergstrasse 6, 13585, Berlin, Germany
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Long-term clinical outcomes after intrathoracic stomach surgery: a decade of longitudinal follow-up. Surg Endosc 2017; 32:1954-1962. [PMID: 29052066 DOI: 10.1007/s00464-017-5890-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 09/13/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND A subset of patients with large paraesophageal hernias have more than 75% of the stomach herniated above the diaphragm; such cases are referred to as intrathoracic stomach (ITS). Herein, we report longitudinal symptomatic outcomes over a decade after surgical ITS repair in a large patient cohort. METHODS Patients who underwent surgical treatment for ITS from 01/2004 to 05/2016 were studied. Preoperative and follow-up data were prospectively collected. Patients completed a standardized symptom questionnaire 1 year postoperatively and at 2-year intervals thereafter. RESULTS In total, 235 patients were reviewed. The mean age was 70.0 ± 11.6 years; 174 patients (74.0%) were women. Surgical procedures included 7 transthoracic repairs and 228 transabdominal repairs (222 laparoscopic, 2 open, 4 laparoscopic-to-open conversions). Anti-reflux procedures were performed in 173 patients (73.6%). 33 patients (14.0%) had mesh reinforcement of hiatal closure; 11 (4.7%) underwent Collis gastroplasty. Follow-up symptom questionnaires at 1, 3, 5, 7, 9, and 11 years were available for 81, 48, 47, 30, 33, and 38% of patients, respectively. Significant and lasting symptom improvement was reported at all follow-up time points. Mean satisfaction scores of 9.3, 9.1, 9.3, 9.0, 9.5, and 9.8 on a 1-10 scale were recorded at the aforementioned intervals. CONCLUSIONS Long-term clinical outcomes confirm that laparoscopic ITS repair is safe and durable, and is associated with a high degree of patient satisfaction and symptom resolution.
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Le Page PA, Furtado R, Hayward M, Law S, Tan A, Vivian SJ, Van der Wall H, Falk GL. Durability of giant hiatus hernia repair in 455 patients over 20 years. Ann R Coll Surg Engl 2015; 97:188-93. [PMID: 26263802 DOI: 10.1308/003588414x14055925060839] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION The surgical management of symptomatic giant hiatus hernia (GHH) aims to improve quality of life (QoL) and reduce the risk of life threatening complications. Previous reports are predominantly those with small sample sizes and short follow-up periods. The present study sought to assess a large cohort of patients for recurrence and QoL over a longer time period. METHODS This was a follow-up study of a prospectively collected database of 455 consecutive patients. Primary repair of GHH was evaluated by endoscopy/barium meal for recurrence and a standardised symptom questionnaire for QoL. Recurrence was assessed for size, elapsed time, oesophagitis and symptoms. RESULTS Objective and subjective review was achieved in 91.9% and 68.6% of patients. The median age was 69 years (range: 15-93 years) and 64% were female. Laparoscopic repair was completed in 95% (mesh in 6% and Collis gastroplasty in 7%). The 30-day mortality rate was 0.9%. The proportion of patients alive at five and ten years were 90% and 75% respectively. Postoperative QoL scores improved from a mean of 95 to 111 (p<0.01) and were stable over time (112 at 10 years). The overall recurrence rate was 35.6% (149/418) at 42 months; this was 11.5% (48/418) for hernias >2cm and 24.2% (101/418) for <2cm. The rate of new recurrence at 0-1 years was 13.7% (>2cm = 3.4%, <2cm = 10.3%), at 1-5 years it was 30.8% (>2cm = 9.5%, <2cm = 21.3%), at 5-10 years it was 40.1% (>2cm = 13.8%, <2cm = 26.3%) and at over 10 years it was 50.0% (>2cm = 25.0%, <2cm = 25.0%). Recurrence was associated with oesophagitis but not decreased QoL. Revision surgery was required in 4.8% of cases (14.8% with recurrence). There were no interval major GHH complications. CONCLUSIONS Surgery has provided sustained QoL improvements irrespective of recurrence. Recurrence occurred progressively over ten years and may predispose to oesophagitis.
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Affiliation(s)
- P A Le Page
- 1 Concord Repatriation General Hospital, NSW , Australia
| | - R Furtado
- 1 Concord Repatriation General Hospital, NSW , Australia
| | - M Hayward
- 2 University of Sydney, NSW , Australia
| | - S Law
- 2 University of Sydney, NSW , Australia
| | - A Tan
- 2 University of Sydney, NSW , Australia
| | - S J Vivian
- 3 Sydney Heartburn Clinic, Lindfield, NSW , Australia
| | | | - G L Falk
- 1 Concord Repatriation General Hospital, NSW , Australia.,2 University of Sydney, NSW , Australia.,3 Sydney Heartburn Clinic, Lindfield, NSW , Australia
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Alizai PH, Schmid S, Otto J, Klink CD, Roeth A, Nolting J, Neumann UP, Klinge U. Biomechanical analyses of prosthetic mesh repair in a hiatal hernia model. J Biomed Mater Res B Appl Biomater 2014; 102:1485-95. [PMID: 24599834 DOI: 10.1002/jbm.b.33128] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2013] [Revised: 01/16/2014] [Accepted: 02/18/2014] [Indexed: 01/05/2023]
Abstract
Recurrence rate of hiatal hernia can be reduced with prosthetic mesh repair; however, type and shape of the mesh are still a matter of controversy. The purpose of this study was to investigate the biomechanical properties of four conventional meshes: pure polypropylene mesh (PP-P), polypropylene/poliglecaprone mesh (PP-U), polyvinylidenefluoride/polypropylene mesh (PVDF-I), and pure polyvinylidenefluoride mesh (PVDF-S). Meshes were tested either in warp direction (parallel to production direction) or perpendicular to the warp direction. A Zwick testing machine was used to measure elasticity and effective porosity of the textile probes. Stretching of the meshes in warp direction required forces that were up to 85-fold higher than the same elongation in perpendicular direction. Stretch stress led to loss of effective porosity in most meshes, except for PVDF-S. Biomechanical impact of the mesh was additionally evaluated in a hiatal hernia model. The different meshes were used either as rectangular patches or as circular meshes. Circular meshes led to a significant reinforcement of the hiatus, largely unaffected by the orientation of the warp fibers. In contrast, rectangular meshes provided a significant reinforcement only when warp fibers ran perpendicular to the crura. Anisotropic elasticity of prosthetic meshes should therefore be considered in hiatal closure with rectangular patches.
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Affiliation(s)
- Patrick Hamid Alizai
- Department of General, Visceral and Transplantation Surgery, RWTH Aachen University Hospital, 52074, Aachen, Germany
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Bell RCW, Fearon J, Freeman KD. Allograft dermal matrix hiatoplasty during laparoscopic primary fundoplication, paraesophageal hernia repair, and reoperation for failed hiatal hernia repair. Surg Endosc 2013; 27:1997-2004. [PMID: 23299134 PMCID: PMC3661044 DOI: 10.1007/s00464-012-2700-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Accepted: 10/30/2012] [Indexed: 11/03/2022]
Abstract
BACKGROUND Hiatal repair failure is the nemesis of laparoscopic paraesophageal hernia repair as well as the major cause of failure of primary fundoplication and reoperation on the hiatus. Biologic prosthetics offer the promise of reinforcing the repair without risks associated with permanent prosthetics. DESIGN Retrospective evaluation of safety and relative efficacy of laparoscopic hiatal hernia repair using an allograft (acellular dermal matrix) onlay. Patients with symptomatic failures underwent endoscopic or radiographic assessment of hiatal status. RESULTS Greater than 6-month follow-up was available for 252 of 450 consecutive patients undergoing laparoscopic allograft-reinforced hiatal hernia repair between January 2007 and March 2011. No erosions, strictures, or persisting dysphagia were encountered. Adhesions were minimal in cases where reoperation was required. Failure of the hiatal repair at median 18 months (6-51 months) was significantly (p < 0.005) different between groups: group A (primary fundoplication with axial hernia ≤ 2 cm), 3.7 %; group B (primary fundoplication with axial hernia 2-5 cm), 7.1 %; group G (giant/paraesophageal), 8.8 %; group R (reoperative), 23.4 %. Additionally, mean time to failure was significantly shorter in group R (247 days) compared with the other groups (462-489 days). CONCLUSIONS Use of allograft reinforcement to the hiatus is safe at 18 months median follow-up. Reoperations had a significantly higher failure rate and shorter time to failure than the other groups despite allograft, suggesting that primary repairs require utmost attention and that additional techniques may be needed in reoperations. Patients with hiatal hernias >2 cm axially had a recurrence rate equal to that of patients undergoing paraesophageal hiatal hernia repair, and should be treated similarly.
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Affiliation(s)
- Reginald C W Bell
- SurgOne P.C., Swedish Medical Center, 401 W Hampden Place Suite 230, Englewood, CO 80110, USA.
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Frantzides CT, Carlson MA, Loizides S, Papafili A, Luu M, Roberts J, Zeni T, Frantzides A. Hiatal hernia repair with mesh: a survey of SAGES members. Surg Endosc 2009; 24:1017-24. [PMID: 19997755 DOI: 10.1007/s00464-009-0718-6] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2009] [Accepted: 08/29/2009] [Indexed: 12/16/2022]
Abstract
BACKGROUND Primary repair of large hiatal hernia is associated with a high recurrence rate. The use of mesh may reduce this recurrence rate. The indication for mesh use, the type of mesh to use, and the placement technique are controversial. A survey of surgeon practice was undertaken to obtain a better understanding of the controversies surrounding this clinical problem. METHODS A questionnaire on the technique and results of mesh hiatal herniorrhaphy was sent to 1,192 members of the Society of Gastrointestinal and Endoscopic Surgeons (SAGES). RESULTS There were 275 responses; 261 of these were analyzed. A total of 5,486 hiatal hernia repairs with mesh were reported; 77% and 23% were performed laparoscopically vs open, respectively. The most common indication for mesh usage was an increased size hiatal defect (46% of respondents). The most common mesh types were biomaterial (28%), polytetrafluoroethylene (25%), and polypropylene (21%). Suture anchorage was the most common fixation technique (56% of respondents). The findings showed a failure rate of 3%, a stricture rate of 0.2%, and an erosion rate of 0.3%. Biomaterial tended to be associated with failure, whereas nonabsorbable mesh tended to be associated with stricture and erosion. CONCLUSIONS The use of mesh during hiatal hernia repair resulted in a reported recurrence rate which appeared to be lower than that obtained historically without mesh. No one mesh type was clearly superior in terms of avoiding failure and complication.
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