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

Hiatal Hernia of Stomach and Lesser Omentum in a Cadaver: Is It a Type III or IV?

Hiatal hernias, protrusions of abdominal viscera through the esophageal hiatus, are classified into four types. Types I and II involve ascent of the stomach without affecting the gastroesophageal junction. Types III and IV involve the gastroesophageal junction. Type IV specifically may have stomach as well as other abdominal organ involvement, such as pancreas or omentum. Among these types, type IV is the most complex and rare form, accounting for only 0.1% of all cases of hiatal hernias. This report presents a case of a type IV hiatal hernia involving the lesser omentum and a significant portion of the stomach in an 86-year-old male cadaver with a history of mediastinal surgery. To our knowledge, this presentation in a cadaver has not previously been reported in the literature.  This case highlights classification inconsistencies in the literature, particularly regarding type IV hiatal hernias. It is unclear given the current classification system, whether this presentation would be considered a type III or type IV hiatal hernia as it fits both criteria and there are several interpretations of the criteria of a type IV hiatal hernia. Inconsistencies in the classification system may impede standardization of care. This report highlights the need for a more precise classification system that better accounts for anatomical changes and clinical presentation.

Adjuvant Botulinum Toxin Type A on the Management of Giant Hiatal Hernia: A Case Report

The management of giant hiatal hernias (HHs) remains challenging and is associated with a high risk of recurrence. Currently, several strategies are used to reduce recurrence, and a newly proposed trend is the administration of adjuvant botulinum toxin type A (BTX), a procedure already performed in complex ventral hernias. Here, we present a case of a 63-year-old man with a giant paraesophageal HH type IV containing the entire stomach and transverse colon with loss of domain, who underwent adjuvant BTX and subsequently laparoscopic hiatoplasty with a biological mesh with partial fundoplication. At six months' follow-up, the patient reported a significant improvement in the quality of life without dysphagia or gastroesophageal reflux and with a good respiratory function. A control computed tomography was performed, which documented a partial recurrence of HH, completely asymptomatic. This clinical case showed the successful treatment of a giant HH using adjuvant BTX injection to increase abdominal wall compliance as had already been described in the treatment of complex ventral hernia. Thus, the use of BTX is a promising strategy for selected cases of giant HHs mainly if there is a loss of domain; however, more case series and controlled trials are needed to show the reproducibility of the benefit of this strategy.

Laparoscopic repair of giant hiatal hernia for elderly patients

Background

Giant hiatal hernias are more common in older patients and can significantly reduce their quality of life. However, open surgery for patients of advanced age is thought to be associated with high morbidity and mortality. The aim of this retrospective study was to evaluate the safety of laparoscopic giant hiatal hernia repair for elderly patients as compared to younger patients.

Methods

From January 2015 to January 2020, 152 consecutive patients underwent laparoscopic mesh repair of giant hiatal hernia. Two cases of missing follow up were excluded. Patients were divided into an elderly group (N=62, age ≥75) and a younger group (N=88, age <75). Interrupted non-absorbable suture was applied for crus closure and as an additional reinforcement, the mesh was fixed with absorbable tacks or medical glue. Procedure-related complications, score-based variation tendency of symptoms, gastrointestinal quality of life index (GIQLI), mortality, recurrence rate, hemoglobin, and the use of PPI were investigated.

Results

All patients underwent the procedure uneventfully. Dor fundoplication was used in 39 patients (62.9%) in the elderly group and 44 (50.0%) in the younger group and no case was converted to open. While the elderly group had a significantly higher percentage of ASA Class level 3 and cardiovascular and cerebrovascular diseases as compared to the younger group, the two groups had similar operative times, intraoperative blood loss, and percentage of intrathoracic stomach. Elderly group patients tended to have higher perioperative complications including pneumonia (3.2%) and atelectasis (3.2%) without statistical significance, as well as transfer to the intensive care unit compared, to younger patients (9.7% vs. 3.2%; P=0.144). The mean post-operative hospital stay was also significantly shorter in the younger group (2.8 days) compared with the elderly group (3.5 days; P=0.001). There was no mortality, recurrence, mesh-related complications such as visceral erosion, adhesion, or severe dysphagia during follow up in the two groups, and both groups demonstrated significant improvement in GIQLI scores and hemoglobin. The percentage of patients who needed PPI was also reduced in both groups.

Conclusions

Laparoscopic mesh repair of giant hiatal hernia for elderly patients is safe and effective when performed at experienced centers.

Preoperative botulinum toxin type A: A case report of a proposed new strategy for giant hiatal hernia management

The use of preoperative ventral botulinum toxin for giant hiatal hernia management.

Minding the Gap: Clinical Manifestations of a Rare Type IV Hiatal Hernia

Hiatal hernias are classified according to the increasing severity of protruding intra-abdominal viscera through the esophageal hiatus (types I-IV). Herein is the case of an elderly patient presenting with recent-onset dyspnea, postprandial gastroesophageal reflux, and hypoxemia. Imaging revealed a rare type IV hiatal hernia implicating the stomach and part of the pancreas. This case highlights the seemingly benign clinical manifestations of a massive hiatal hernia, despite its ability to complicate treatment or exacerbate comorbid conditions.

Critical appraisal of the impact of surgical repair of type II-IV paraoesophageal hernia (POH) on pulmonary improvement: A systematic review and meta-analysis

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, CI_95%: 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.

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.

Dynamics of quality of life improvement after floppy Nissen fundoplication for gastroesophageal reflux disease

Introduction

Gastroesophageal reflux disease (GERD) has a negative impact on global quality of life (QOL) of patients. In patients affected by GERD, laparoscopic Nissen fundoplication is one of the most commonly performed laparoscopic procedures worldwide.

Aim

To prospectively analyze the dynamics of QOL as well as severity of pain in patients with GERD, before and after laparoscopic floppy Nissen fundoplication.

Material and methods

The study involved 104 consecutive patients operated on for GERD in whom laparoscopic floppy Nissen fundoplication was performed. QOL was assessed before surgery and 1, 3, 6, 12 and 24 months after. The following instruments were used: FACIT-G, FACIT-TS-G, GIQLI, GERD symptom scale.

Results

It was found that symptom relief and quality of life improvement presented different dynamics in the postoperative course. Observations revealed relief of symptoms 1 month after surgery and improvement in QOL related to the gastrointestinal tract and pain 3 months after surgery. Global QOL increased significantly as late as 12 months after surgery.

Conclusions

Gastroesophageal reflux disease is a chronic disease of long duration, leading to impairment of quality of life. Patients, apart from typical symptoms of GERD, suffer from pain of significant severity. QOL improves significantly after surgery. Surgical treatment results in relief of GERD symptoms, which leads to gradual improvement of QOL.

Incidence of true short esophagus among patients submitted to laparoscopic Nissen fundoplication

Introduction

The last two decades have observed development of surgical treatment of benign conditions of the gastroesophageal junction (GEJ), including anti-reflux surgery, due to the growing popularity of the laparoscopic approach. Migration of the fundoplication band and recurrent hiatal hernia are a result of the lack of correct diagnosis and appropriate management of the so-called short esophagus. According to various authors, short esophagus is present in up to 60% of patients qualified for anti-reflux surgery. However, some researchers question the existence of this condition.

Aim

To analyze the prevalence of short esophagus in patients subjected to laparoscopic Nissen fundoplication.

Material and methods

The study included 202 patients who were subjected to laparoscopic Nissen fundoplication.

Results

As many as 96% of the patients qualified for the surgical treatment showed supradiaphragmatic location of the high pressure zone. The extent of GEJ protrusion ranged from 0 cm to 3 cm (mean: 2 cm). The extent of dissection within the mediastinum was determined by the level of GEJ protrusion, and ranged from 5 cm to 12 cm (mean: 6 cm). Upon complete mobilization of the esophagus within the mediastinum, no cases of significantly shortened esophagus, precluding downward retraction of at least a 2.5-cm segment below the diaphragmatic crura, were documented. Therefore, none of the patients required Collis gastroplasty.

Conclusions

The presence of “true” short esophagus is a sporadic finding among patients qualified for anti-reflux surgery. Mediastinal dissection of the esophagus and its mobilization at an appropriate, individually defined level seems a sufficient treatment in the vast majority of these patients.