Hiatal hernia in pediatric patients: laparoscopic versus open approaches

Paraesophageal Hernia in a Newborn Mimicking Esophageal Atresia

A defect of the esophageal hiatus can lead to herniation of the stomach or other abdominal organs into the thoracic cavity, a condition called hiatal hernia. They constitute a rare clinical entity during infancy and childhood and their symptoms can be non-specific or subtle, making the diagnosis difficult even for experienced clinicians. In all cases, surgical treatment of the defect is necessary because of life-threatening complications.

We present a rare case of a newborn with congenital paraesophageal hernia (CPEH) and microgastria, who was initially referred to our center with the diagnosis of esophageal atresia due to the inability to pass an orogastric tube beyond 15 cm from the gum margin. A contrast study revealed the CPEH. The patient underwent emergent surgery and has had no signs of recurrence until now.

Although the diagnosis can be very tricky and mimic other conditions, a high level of suspicion should exist especially in patients with persistent symptoms of gastroesophageal reflux or recurrent respiratory infections. In neonates, signs and symptoms can be indicative of esophageal obstruction which should be ruled out with an upper gastrointestinal (GI) study.

Laparoscopic versus Open Pediatric Surgery: Three Decades of Comparative Studies

INTRODUCTION

 Despite its wide acceptance, the superiority of laparoscopic versus open pediatric surgery has remained controversial. There is still a call for well-founded evidence. We reviewed the literature on studies published in the last three decades and dealing with advantages and disadvantages of laparoscopy compared to open surgery.

MATERIALS AND METHODS

 Studies comparing laparoscopic versus open abdominal procedures in children were searched in PubMed/MEDLINE. Reports on upper and lower gastrointestinal as hepatobiliary surgery and on surgery of pancreas and spleen were included. Advantages and disadvantages of laparoscopic surgery were analyzed for different types of procedures. Complications were categorized using the Clavien-Dindo classification.

RESULTS

 A total of 239 studies dealing with 19 types of procedures and outcomes in 929,157 patients were analyzed. We identified 26 randomized controlled trials (10.8%) and 213 comparative studies (89.2%). The most frequently reported advantage of laparoscopy was shorter hospital stay in 60.4% of studies. Longer operative time was the most frequently reported disadvantage of laparoscopy in 52.7% of studies. Clavien-Dindo grade I to III complications (mild-moderate) were less frequently identified in laparoscopic compared to open procedures (80.3% of studies). Grade-IV complications (severe) were less frequently reported after laparoscopic versus open appendectomy for perforated appendicitis and more frequently after laparoscopic Kasai's portoenterostomy. We identified a decreased frequency of reporting on advantages after laparoscopy and increased reporting on disadvantages for all surgery types over the decades.

CONCLUSION

 Laparoscopic compared with open pediatric surgery seems to be beneficial in most types of procedures. The number of randomized controlled trials (RCTs) remains limited. However, the number of reports on disadvantages increased during the past decades.

Follow-Up Report of Laparoscopic Fundoplication in Different Types of Esophageal Hiatal Hernia in Children

Background: Esophageal hiatal hernia can be classified into four types. It has been reported that most complications occurred in type II-IV hernia patients compared with type I hernia. This study aimed to investigate and compare the efficacy, complications, and long-time outcomes after laparoscopic fundoplication between type I and type II-IV hernia patients. Materials and Methods: Medical records of 110 children who underwent laparoscopic fundoplication during 2008-2017 in our institution were retrospectively analyzed. Information of postoperative symptoms, complications, and quality of life (QOL) were compared between different types. Results: All 110 children underwent laparoscopic fundoplication, and none converted to open surgery. Type I and type II-IV each accounted for 50.9% and 42.8%. There was no significant difference in the perioperative data between type I and type II-IV esophageal hiatal hernia. The follow-up information of 81 children was obtained. The scores of postoperative symptoms were comparable between type I and type II-IV group, except the severity score of reflux symptom was higher in type I hernia patients (P = .032). The difference in the incidence of postoperative complications and recurrence after laparoscopic fundoplication between type I and type II-IV hernia was not significant. The QOL in three aspects improved significantly after laparoscopic fundoplication in all types of esophageal hiatal hernia. Conclusions: Laparoscopic fundoplication was an effective approach for all types of esophageal hiatal hernia. Type II-IV hernia could obtain a comparable therapeutic effect and long-time outcome compared with type I hernia despite its increased complexity of the anatomy and the required laparoscopic repair procedure.

Hiatal and paraesophageal hernia repair in pediatric patients

Hiatal and paraesophageal hernia (HH/PEH) can be congenital, resulting from embryologic abnormalities/genetic predisposition, or acquired, most commonly after gastroesophageal surgery such as fundoplication. Minimizing circumferential esophageal dissection at the time of Nissen fundoplication has been shown to decrease the risk of acquired HH/PEH from 36.5% to 12.2%. Gastrointestinal, respiratory, and constitutional symptoms, including anemia and failure to thrive, are common with high rates of associated gastroesophageal reflux. Chest x-ray is often abnormal and upper GI confirms the diagnosis. Treatment is surgical with the goal of reducing the hernia contents, excising the hernia sac, closing the crura, and performing an antireflux procedure. The laparoscopic approach is safe and effective.