The phrenico-esophageal ligament: an anatomical study

Deep Diaphragmatic Breathing-Anatomical and Biomechanical Consideration

Background: Deep diaphragmatic breathing (DDB) involves slow and fully contraction of the diaphragm with expansion of the belly during inhalation, and slow and fully contraction of the abdominal muscles with reduction of the belly during exhalation. It is the key component of the holistic mind-body exercises commonly used for patients with multimorbidity. Purpose: The purpose of this study was to re-visit and address the fundamental anatomical and biomechanical consideration of the DDB with the relevant literature. Method: Peer-reviewed publications from last the 15 years were retrieved, reviewed, and analyzed. Findings: In this article, we described the updated morphological and anatomical characteristics of the diaphragm. Then, we elucidated in a biomechanical approach how and why the DDB can work on the gastrointestinal, cardiopulmonary, and nervous systems as well as on regulating the intra-abdominopelvic pressure and mind-body interaction to coordinate the diaphragm-pelvic floor-abdominal complex for a variety of physical and physiological activities. Conclusion: Understanding of this updated DDB knowledge may help holistic healthcare professionals including holistic nurses provide better patient education and care management during the DDB or DDB-based mind-body intervention time.

Upside-down stomach in paraesophageal hernia: A case report

RATIONALE

Paraesophageal hernias, accounting for a mere 5% to 10% of all hiatal hernias, occasionally present an exceedingly uncommon yet gravely consequential complication characterized by the inversion of the stomach. Delving into the clinical manifestations and optimal therapeutic approaches for patients afflicted by this condition merits substantial exploration.

PATIENT CONCERNS

A 60-year-old man was referred to our hospital with acute onset of severe epigastric pain, abdominal distension, and vomiting. A chest radiograph unveiled an elevated left diaphragmatic dome accompanied by a pronounced rightward shift of the mediastinum. Subsequent abdominal computed tomography imaging delineated the migration of the stomach, spleen, and colon into the left hemithorax, facilitated by a significant diaphragmatic defect.

DIAGNOSES

The diagnosis of a giant paraesophageal hernia with complete gastric inversion was established through a comprehensive evaluation of the patient's clinical manifestations and imaging findings.

INTERVENTIONS

Surgical intervention was performed on the patient. During the procedure, a left diaphragmatic defect measuring approximately 10 × 8 cm was identified and meticulously repositioned, followed by the repair of the diaphragmatic hernia. The herniated contents comprised the pancreas, stomach, spleen, a segment of the colon, and a portion of the greater omentum.

OUTCOMES

The patient experienced a smooth postoperative recuperation and was discharged 12 days following the surgical procedure. Subsequently, during a 7-month follow-up period, the patient continued to exhibit favorable progress and recovery.

LESSONS

Paraesophageal hernias are rare, and the presence of an inverted stomach in a giant paraesophageal hernia is exceptionally uncommon. Clinical presentation lacks distinct features and can lead to misdiagnosis. This case emphasizes the importance of timely surgical intervention guided by imaging, offering valuable clinical insights.

Reevaluation of the topographical anatomy of the mid-thigh: A magnetic resonance and ultrasound imaging study

Adductor canal (AC) and sciatic nerve (SN) blockades are commonly used during total knee arthroplasties for postoperative pain control. Medical professionals have begun to utilize single injection combined regional anesthesia methods due to increased patient comfort. In this study, we examined the topographical anatomy of the mid-thigh, which is recommended as the appropriate intervention level for combined AC and SN blockades, in order to provide a safe approach for clinicians. We examined 184 thigh magnetic resonance images (MRI) from 98 patients. We measured the diameter of the mid-thigh, anterior thigh muscle thickness, subcutaneous adipose tissue thickness, and SN depth on the MRIs. We obtained ultrasound (US) images of the vastoadductor membranes (VAM) of 26 volunteers, and measured the vertical distances between the greater trochanter and the adductor tubercle (A) and the greater trochanter and the upper edge of the VAM (B). We then proportioned B to A in order to determine in which part of the thigh the AC was located. The AC was in the distal third of the thigh, and the SN's depth was located in the third quarter of the thigh's diameter. Only the adductor magnus, and no neurovascular structure, was at risk of injury between the AC and the SN. The upper edge of the VAM was 6.5 cm below the mid-thigh, therefore it is not appropriate to suggest performing an AC blockade at mid-thigh. We think that it is safe to perform a combined AC and SN blockade in a single injection in selected patients.

Reconstruction of the phreno-esophageal ligament (R-PEL) prevents the intrathoracic migration (ITM) after concomitant sleeve gastrectomy and hiatal hernia repair

BACKGROUND

Laparoscopic Sleeve Gastrectomy (LSG) is the most attractive bariatric procedure, but the postoperative intrathoracic gastric migration (ITM) and "de novo" GERD are major concerns. The main objective of our study was to evaluate the efficiency of the concomitant HHR with or without partial reconstruction of phreno-esophageal ligament (R-PEL) to prevent ITM after LSG. The secondary objectives focused on procedure's metabolic and GERD-related outcomes.

PATIENTS AND METHOD

Consecutive patients who underwent primary LSG and concomitant HHR were included in a single-center prospective study. According to the HHR surgical technique, two groups were analyzed and compared: Group A included patients receiving crura approximation only and Group B patients with R-PEL. The patients' evolution of co-morbidities, GERD symptoms, radiologic, and endoscopic details were prospectively analyzed.

RESULTS

Two hundred seventy-three patients undergoing concurrent HHR and LSG were included in the study (Group A and B, 146 and 127 patients) The mean age and BMI were 42.6 ± 11.3 and 43.4 ± 6.8 kg/m². The 12-month postoperative ITM was radiologically found in more than half of the patients in Group A, while in group B, the GEJ's position appeared normal in 91.3% of the patients, meaning that R-PEL reduced 7 times the rate of ITM. The percentage of no-improvement and "de novo" severe esophagitis (Los Angeles C) was 4 times higher in group A 3.4% vs. 0.8% with statistical significance, and correlated to ITM. The GERD symptoms were less frequent in Group B vs Group A, 21.3% vs 37%, with statistical significance. No Barrett's esophagus and no complication were recorded in any of the patients.

CONCLUSION

Concurrent LSG and HHR by crura approximation only has a very high rate of ITM in the first postoperative year (over 50%). R-PEL is an innovative technique which proved to be very efficient in preventing the ITM after HHR.

Morphological characteristics of the posterior neck muscles and anatomical landmarks for botulinum toxin injections

PURPOSE

Cervical dystonia is a common movement disorder for which botulinum toxin (BoNT) is the first choice treatment. Injecting the specific neck muscles can be challenging because of their thin morphology and deep locations. We, therefore, designed a study to investigate the locations of the posterior neck muscles to help the physician predict the locations of the targeted neck muscles and to protect the vertebral vessels from injury during deep injections.

METHODS

The posterior neck region was divided into four quadrants by imaginary lines passing vertically and transversely through the spinous process of C2 vertebra (C2_sp). The thicknesses and depth of the posterior neck muscles were measured in ten formaldehyde-fixed adult male cadavers. These muscles were located and a projection of them was drawn on the neck. Using the measurements, colored latex in place of BoNT was injected into them in one cadaver. The cadaver was dissected to investigate whether the muscles were colored.

RESULTS

2 cm above the C2_sp, trapezius, splenius capitis (SPC) and semispinalis capitis (SSC) were colored at depths of 10.70 mm, 11.88 mm and 15.91 mm, respectively. 2 cm below the C2_sp, the trapezius, SPC and SSC were colored at depths of 20.89 mm, 23.25 mm and 27.63 mm, respectively. The posterior neck muscles were had taken up their assigned colors when they were injected according to the results obtained in this study. The vertebral vessels were not colored.

CONCLUSIONS

Although BoNT injection into the posterior neck muscles is challenging, we think that it can be practically and safely applied using the measurements obtained in this study.

Esophageal physiology-an overview of esophageal disorders from a pathophysiological point of view

The esophagus serves the principal purpose of transporting food from the pharynx into the stomach. A complex interplay between nerves and muscle fibers ensures that swallowing takes place as a finely coordinated event. Esophageal function can be tested by a variety of methods, endoscopy, manometry, and reflux monitoring being some of the most important. Regarding pathophysiology, motor disorders, such as achalasia, often cause dysphagia and/or chest pain. Functional esophageal disorders are a heterogeneous group with hypersensitivity as a dominant pathophysiological factor. Gastroesophageal reflux disease often causes symptoms, such as heartburn and regurgitation, and a spectrum of disease, ranging from minimal mucosal damage visible only in the microscope to esophageal ulcers and strictures in the most severe cases. Eosinophilic esophagitis is an immune-mediated condition that can result in significant dysphagia and associated luminal narrowing. In the following, we will provide an overview of the most common esophageal disorders from a combined pathophysiological and clinical view.

Tissue engineering of the gastroesophageal junction

The gastroesophageal junction has been of clinical interest for some time due to its important role in preventing reflux of caustic stomach contents upward into the esophagus. Failure of this role has been identified as a key driver in gastroesophageal reflux disease, cancer of the lower esophagus, and aspiration-induced lung complications. Due to the large population burden and significant morbidity and mortality related to reflux barrier dysfunction, there is a pressing need to develop tissue engineering solutions which can replace diseased junctions. While good progress has been made in engineering the bodies of the esophagus and stomach, little has been done for the junction between the two. In this review, we discuss pertinent topics which should be considered as tissue engineers begin to address this anatomical region. The embryological development and adult anatomy and histology are discussed to provide context about the native structures which must be replicated. The roles of smooth muscle structures in the esophagus and stomach, as well as the contribution of the diaphragm to normal anti-reflux function are then examined. Finally, engineering considerations including mechanics and current progress in the field of tissue engineering are presented.

New Ovine Polymer-Reinforced Bioscaffold in Hiatal Hernia Repair

Background and Objectives

Biologic and resorbable synthetic materials are used commonly for crural repair reinforcement during laparoscopic hiatal herniorrhaphy. Recently, an ovine polymer-reinforced bioscaffold (OPRBS) has been developed for reinforcement of abdominal wall and hiatal herniorrhaphies. This is the first reported series on use of OPRBS in hiatal hernia repairs.

Methods

A retrospective chart review was conducted for consecutive series of patients (n = 25) undergoing laparoscopic or open hiatal herniorrhaphy between August 2016 and May 2017. Data collected included demographics, comorbidities and symptoms, details of operation, complications, and postoperative followup.

Results

Laparoscopic repair was completed in 23 of 24 patients. Reinforcement with OPRBS was accomplished in all cases. Fundoplication was constructed in 24 of 25 patients (96%). Mean followup was 14.2 months. Good-to-excellent symptom control or resolution has been achieved for heartburn (95%), dysphagia (94.7%), regurgitation (100%), nausea and vomiting (100%), dyspnea (100%), and chest pain or discomfort (85.7%). Postoperative esophagogastroduodenoscopy with dilation resulted in resolution of persistent postoperative dysphagia in two patients (8%). To date there have been no clinical recurrences of hiatal hernia.

Conclusion

OPRBS in hiatal hernia repair have been associated with excellent early patient outcomes in this study. OPRBS represent a new paradigm in hernia repair, as it is the first clinically available biological repair material reinforced with embroidered resorbable or permanent synthetic polymer. Relative weaknesses of the current study include the small sample size (n = 25), and short-term (mean = 14.2 months) followup. Long-term followup and additional studies will be required to confirm these findings.

The development of the dorsal mesentery in human embryos and fetuses

The vertebrate intestine has a continuous dorsal mesentery between pharynx and anus that facilitates intestinal mobility. Based on width and fate the dorsal mesentery can be subdivided into that of the caudal foregut, midgut, and hindgut. The dorsal mesentery of stomach and duodenum is wide and topographically complex due to strong and asymmetric growth of the stomach. The associated formation of the lesser sac partitions the dorsal mesentery into the right-sided "caval fold" that serves as conduit for the inferior caval vein and the left-sided mesogastrium. The thin dorsal mesentery of the midgut originates between the base of the superior and inferior mesenteric arteries, and follows the transient increase in intestinal growth that results in small-intestinal looping, intestinal herniation and, subsequently, return. The following fixation of a large portion of the abdominal dorsal mesentery to the dorsal peritoneal wall by adhesion and fusion is only seen in primates and is often incomplete. Adhesion and fusion of mesothelial surfaces in the lesser pelvis results in the formation of the "mesorectum". Whether Toldt's and Denonvilliers' "fasciae of fusion" identify the location of the original mesothelial surfaces or, alternatively, represent the effects of postnatal wear and tear due to intestinal motility and intra-abdominal pressure changes, remains to be shown. "Malrotations" are characterized by growth defects of the intestinal loops with an ischemic origin and a narrow mesenteric root due to insufficient adhesion and fusion.

Low back pain and gastroesophageal reflux in patients with COPD: the disease in the breath

COPD is a worsening condition that leads to a pathologic degeneration of the respiratory system. It represents one of the most important causes of mortality and morbidity in the world, and it is characterized by the presence of associated comorbidity. This article analyzes gastroesophageal reflux disease (GERD) and low back pain (LBP) in patients with COPD and tries to produce anatomo-clinical considerations on the reasons of the presence of these comorbidities. The considerations of the authors are based on the anatomic functions and characteristics of the respiratory diaphragm that are not always considered, from which elements useful to comprehend the symptomatic status of the patient can be deduced, finally improving the therapeutic approach. The information contained in the article can be of help to the clinician and for physiotherapy, and to all health professionals who gravitate around the patient’s care, improving the approach to the diaphragm muscle.

Mesoesophagus and other fascial structures of the abdominal and lower thoracic esophagus: a histological study using human embryos and fetuses

A term "mesoesophagus" has been often used by surgeons, but the morphology was not described well. To better understand the structures attaching the human abdominal and lower thoracic esophagus to the body wall, we examined serial or semiserial sections from 10 embryos and 9 fetuses. The esophagus was initially embedded in a large posterior mesenchymal tissue, which included the vertebral column and aorta. Below the tracheal bifurcation at the fifth week, the esophagus formed a mesentery-like structure, which we call the "mesoesophagus," that was sculpted by the enlarging lungs and pleural cavity. The pneumatoenteric recess of the pleuroperitoneal canal was observed in the lowest part of the mesoesophagus. At the seventh week, the mesoesophagus was divided into the upper long and lower short parts by the diaphragm. Near the esophageal hiatus, the pleural cavity provided 1 or 2 recesses in the upper side, while the fetal adrenal gland in the left side was attached to the lower side of the mesoesophagus. At the 10th and 18th week, the mesoesophagus remained along the lower thoracic esophagus, but the abdominal esophagus attached to the diaphragm instead of to the left adrenal. The mesoesophagus did not contain any blood vessels from the aorta and to the azygos vein. The posterior attachment of the abdominal esophagus seemed to develop to the major part of the phrenoesophageal membrane with modification from the increased mass of the left fetal adrenal. After postnatal degeneration of the fetal adrenal, the abdominal esophagus might again obtain a mesentery. Consequently, the mesoesophagus seemed to correspond to a small area containing the pulmonary ligament and aorta in adults.

Hiatal hernia repair with gore bio-a tissue reinforcement: our experience

Type I hiatal hernia is associated with gastroesophageal reflux disease (GERD) in 50–90% of cases. Several trials strongly support surgery as an effective alternative to medical therapy. Today, laparoscopic fundoplication is considered as the procedure of choice. However, primary laparoscopic hiatal hernia repair is associated with upto 42% recurrence rate. Mesh reinforcement of the crural closure decreases the recurrence but can lead to complications, above all nonabsorbable ones. We experiment a new totally absorbable mesh by Gore. Case. We present a case of a 65-year-old female patient with a 6-year classic history of GERD. Endoscopy revealed a large hiatal hernia and esophagitis. pH study was positive for acid reflux; esophageal manometry revealed LES intrathoracic dislocation. With laparoscopic approach, the hiatal hernia defect was identified and primarily repaired, by crural closure. Gore Bio-A Tissue Reinforcement was trimmed to fit the defect accommodating the esophagus. Nissen fundoplication was performed. Result. Bio-A mesh was easily placed laparoscopically. It has good handling and could be cut and tailored intraoperatively for optimal adaptation. There were no short-term complications. Conclusion. Crural closure reinforcement can be done readily with this new totally absorbable mesh replaced by soft tissue over six months. However, further data and studies are needed to evaluate long-term outcomes.

Anatomic connections of the diaphragm: influence of respiration on the body system

The article explains the scientific reasons for the diaphragm muscle being an important crossroads for information involving the entire body. The diaphragm muscle extends from the trigeminal system to the pelvic floor, passing from the thoracic diaphragm to the floor of the mouth. Like many structures in the human body, the diaphragm muscle has more than one function, and has links throughout the body, and provides the network necessary for breathing. To assess and treat this muscle effectively, it is necessary to be aware of its anatomic, fascial, and neurologic complexity in the control of breathing. The patient is never a symptom localized, but a system that adapts to a corporeal dysfunction.

Hiatal hernias

Esophageal hiatal hernias have been reported to affect anywhere from 10 to 50% of the population. Hiatal hernias are characterized by a protrusion of the stomach into the thoracic cavity through a widening of the right crus of the diaphragm. There are four types of esophageal hiatal hernias: sliding (type I), paraesophageal (type II), and combined (type III), which include elements of types I and II, and giant paraesophageal (type IV). Each type may present with different symptoms and complications. The potential severity of symptoms necessitates proper and prompt diagnosis. Diagnosis is established with the use of barium swallow on chest radiographs. Treatment for sliding hernias involves laparoscopic fundoplication. The aim of our paper is to review the extensive literature regarding hiatal hernias in an effort to enhance awareness and diagnosis of this pathology.

Three-dimensional high-resolution reconstruction of the human gastro-oesophageal junction

The aim of this study was to obtain detailed information regarding the three-dimensional structure of the gastro-oesophageal region, and, in particular, the fiber orientation of the different muscle layers of the junction. This was achieved by a study of an en bloc resection of the gastro-oesophageal junction (GOJ) harvested from a human cadaver. The excised tissue block was suspended in a cage to preserve anatomical relationships, fixed in formalin and embedded in wax. The tissue block was then processed by a custom-built extended-volume imaging system to obtain the microstructural information using a digital camera which acquires images at a resolution of 8.2 microm/pixel. The top surface of the tissue block was sequentially stained and imaged. At each step, the imaged surface was milled off at a depth of 50 microm. The processing of the tissue block resulted in 650 images covering a length of 32.25 mm of the GOJ. Structures, including the different muscle and fascial layers, were then traced out from the cross-sectional images using color thresholding. The traced regions were then aligned and assembled to provide a three-dimensional representation of the GOJ. The result is the detailed three-dimensional microstructural anatomy of the GOJ represented in a new way. The next stage will be to integrate key physiological events, including peristalsis and relaxation, into this model using mathematical modeling to allow accurate visual tools for training health professionals and patients.