Strangulation of the stomach and the transverse colon following laparoscopic esophageal hiatal hernia repair

Surgical treatment of GERD. Comperative study of WTP vs. Toupet fundoplication - results of 151 consecutive cases

INTRODUCTION

Gastroesophageal reflux disease (GERD) is recognized as one of the most common disorders of the upper gastrointestinal tract (GIT). The best choice of management for advanced GERD is laparoscopic surgery.

AIM

To compare and evaluate the results of surgical treatment of GERD patients operated on using two different techniques.

MATERIAL AND METHODS

Between 2001 and 2012, 353 patients (211 female and 142 male), aged 17-76 years (mean 44), underwent laparoscopic antireflux surgery. The study included patients who underwent a Toupet fundoplication or Wroblewski Tadeusz procedure (WTP).

RESULTS

The mean age of the group was 47.77 years (17-80 years). Forty-nine (32.45%) patients had severe symptoms, 93 (61.58%) had mild symptoms and 9 (5.96%) had a single mild but intolerable sign of GERD. Eighty-six (56.95%) patients had a Toupet fundoplication and 65 (43.04%) had a WTP. The follow-up period was 18-144 months. The average operating time for Toupet fundoplication and the WTP procedure was 164 min (90-300 min) and 147 min (90-210 min), respectively. The perioperative mortality rate was 0.66%. The average post-operative hospitalization period was 5.4 days (2-16 post-operative days (POD) = Toupet) vs. 4.7 days (2-9 POD = WTP). No reoperations were performed. No major surgical complications were identified.

CONCLUSIONS

Wroblewski Tadeusz procedure due to a low percentage of post-operative complications, good quality of life of patients and a zero recurrence rate of hiatal hernia should be a method of choice.

Type IV paraesophageal hernia as a cause of ileus: Report of a case

INTRODUCTION

Type IV paraesophageal hernias (PEHs) have been rarely reported in the literature. Transverse colon is the most common viscus to herniate in this category.

PRESENTATION OF CASE

Herein we present a case with an emergent admission of a 66 year old man with type IV PEH with small intestine into the hernia sac.

DISCUSSION

The diagnosis of PEHs can be challenging due to their extremely low incidence and the non-specific symptoms and can be easily missed from the initial differential diagnosis.

CONCLUSION

In this case, the hernia was diagnosed early and managed successfully with an immediate laparotomy.

Laparoscopic treatment of type III and IV hiatal hernia - authors' experience

Introduction

There are four types of hiatal hernias, and diagnosis is established on the basis of gastroscopy in the majority of cases. Type III represents a mixed type in which the abdominal esophagus as well as the gastric cardia and fundus protrude into the thorax through the pathologically widened esophageal hiatus. Type IV, the so-called upside down stomach, can be considered an evolutionary form of type III, and refers to herniation of nearly the whole stomach (except for the cardia and pylorus) into the thorax. Types III and IV of hiatal hernias represent a group of rare diaphragmatic defects; thus, most centers do not possess considerable experience in their treatment. Frequently, laparoscopic treatment is implemented, although, according to some authors, conversion to laparotomy, thoracotomy, or thoracolaparotomy is necessary in selected cases.

Aim

To analyze the outcomes of laparoscopic treatment of the largest hiatal hernias, i.e. type III and IV hernias.

Material and methods

A total of 25 patients diagnosed with type III and IV hiatal hernia were included in further analysis.

Results

As many as 19 out of 25 patients (76%) assessed the outcome of the surgery as evidently positive and reported marked improvement in the quality of life.

Conclusions

The laparoscopic technique constitutes an excellent and safe method of repair of even the most complex defects in the esophageal hiatus. Therefore, the minimally invasive technique combined with an anti-reflux procedure should be the method of choice in patients with type III and IV hernia.

Esophageal stents for less invasive treatment of mediastinitis

Introduction

In spite of the progress in diagnosis and therapeutic options, esophageal perforation resulting in mediastinitis is a very serious condition with a high morbidity.

Aim

To evaluate the use of esophageal stents for the treatment of patients suffering from mediastinitis.

Material and methods

Retrospective (2008–2012) analysis of a group of patients requiring surgical treatment. The evaluation was focused on the cause of perforation, stent type and its parameters, the surgical method used, duration of stenting and total length of treatment.

Results

In total, 16 patients were treated by stenting. All patients were treated with the stent being placed across the defect in the esophagus. Mediastinitis was accessed and drained with the aid of a thoracotomy or thoracolaparotomy (8 cases), or using a combination of a laparotomy/laparostomy and pleural drainage (5 cases). The most basic interventions were either pleural or external cervical drainage (3 and 1 cases, respectively). One patient, in whom a stricture had developed at the healed perforation, was subjected to esophageal resection. Four patients died. The average period that the stent was left in situ was 53.7 days. The average period of hospitalization of those patients who survived was 53.4 days.

Conclusions

Using stents in therapy neither increased survival (mortality of 25%), nor decreased the length of therapy of patients once mediastinitis had developed. The main advantage of stenting is the preservation of the native esophagus and the reduced extent of surgical mediastinal drainage.