A surgical emergency due to an incarcerated paraesophageal hernia

Gastric resection with intrathoracic anastomosis in a hiatal hernia - A case report

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Severe complication of hiatal hernia with gastric and esophageal necrosis

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Acute total gastrectomy with esophagojejunoanastomosis via right-sided thoracotomy

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Simultaneous resection of multiple jejunal diverticula present

Para-oesophageal and parahiatal hernias in an Asian acute care tertiary hospital: an underappreciated surgical condition

INTRODUCTION

The prevalence of hiatal hernias and para-oesophageal hernias (PEHs) is lower in Asian populations than in Western populations. Progressive herniation can result in giant PEHs, which are associated with significant morbidity. This article presents the experience of an Asian acute care tertiary hospital in the management of giant PEH and parahiatal hernia.

METHODS

Surgical records dated between January 2003 and January 2013 from the Department of Surgery, Changi General Hospital, Singapore, were retrospectively reviewed.

RESULTS

Ten patients underwent surgical repair for giant PEH or parahiatal hernia during the study period. Open surgery was performed for four patients with giant PEH who presented emergently, while elective laparoscopic repair was performed for six patients with either giant PEH or parahiatal hernia (which were preoperatively diagnosed as PEH). Anterior 180° partial fundoplication was performed in eight patients, and mesh reinforcement was used in six patients. The electively repaired patients had minimal or no symptoms during presentation. Gastric volvulus was observed in five patients. There were no cases of mortality. The median follow-up duration was 16.3 months. There were no cases of mesh erosion, complaints of dysphagia or recurrence of PEH in all patients.

CONCLUSION

Giant PEH and parahiatal hernia are underdiagnosed in Asia. Most patients with giant PEH or parahiatal hernia are asymptomatic; they often present emergently or are incidentally diagnosed. Although surgical outcomes are favourable even with a delayed diagnosis, there should be greater emphasis on early diagnosis and elective repair of these hernias.

Gastric outlet obstruction secondary to paraesophageal herniation of gastric antrum after laparoscopic fundoplication

The most common causes of acute gastric outlet obstruction (GOO) are duodenal and type 3 gastric ulcers. However, mechanical or functional causes may also lead to this pathology. Acute GOO is characterized by delayed gastric emptying, anorexia, or nausea accompanied by vomiting. Herein we report a 56-year-old man diagnosed with GOO secondary to paraesophageal hiatal herniation of gastric antrum after laparoscopic fundoplication. Because of the rarity of this disease, common gastrointestinal complaints may mislead the emergency physician to diagnose a nonsurgical gastrointestinal disease if a detailed history and physical examinations are not obtained.

Evaluation and management of patients with symptoms after anti-reflux surgery

Over the past two decades, there has been an increase in the number of anti-reflux operations being performed. This is mostly due to the use of laparoscopic techniques, the increasing prevalence of gastroesophageal reflux disease (GERD) in the population, and the increasing unwillingness of patients to take acid suppressive medications for life. Laparoscopic fundoplication is now widely available in both academic and community hospitals, has a limited length of stay and postoperative recovery time, and is associated with excellent outcomes in carefully selected patients. Although the operation has low mortality and postoperative morbidity, it is associated with late postoperative complications, such as gas bloat syndrome, dysphagia, diarrhea, and recurrent GERD symptoms. This review summarizes the diagnostic evaluation and appropriate management of such postoperative complications. If a reoperation is needed, it should be performed by experienced foregut surgeons.

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.

Resorbable synthetic mesh supported with omentum flap in the treatment of giant hiatal hernia

Covering a large hiatal hernia with a mesh has become a basic procedure in the last few years. However, mesh implants are associated with high complication rates (esophageal erosion, perforation, fistula, etc.). We propose using a synthetic resorbable mesh supported with an omental flap as a possible solution to this problem. A 54-year-old female patient with a large hiatal defect (9 cm) was laparoscopically implanted with a synthetic resorbable mesh supported with an omental flap. The surgical procedure was successful and the patient was discharged on postoperative day 2. On a follow-up examination 6 months after surgery, she remained free of relapse or complication signs. Supporting an implanted resorbable mesh with an omental flap may be a solution to the problems posed by large esophageal hiatus defects. However, more studies based on larger patient samples and longer follow-up periods are necessary.

Management of acute upside-down stomach

Background

Upside-down stomach (UDS) is characterized by herniation of the entire stomach or most gastric portions into the posterior mediastinum. Symptoms may vary heavily as they are related to reflux and mechanically impaired gastric emptying. UDS is associated with a risk of incarceration and volvulus development which both might be complicated by acute gastric outlet obstruction, advanced ischemia, gastric bleeding and perforation.

Case presentation

A 32-year-old male presented with acute intolerant epigastralgia and anterior chest pain associated with acute onset of nausea and vomiting. He reported on a previous surgical intervention due to a hiatal hernia. Chest radiography and computer tomography showed an incarcerated UDS. After immediate esophago-gastroscopy, urgent laparoscopic reduction, repair with a 360° floppy Nissen fundoplication and insertion of a gradually absorbable GORE® BIO-A®-mesh was performed.

Conclusion

Given the high risk of life-threatening complications of an incarcerated UDS as ischemia, gastric perforation or severe bleeding, emergent surgery is indicated. In stable patients with acute presentation of large paraesophageal hernia or UDS exhibiting acute mechanical gastric outlet obstruction, after esophago-gastroscopy laparoscopic reduction and hernia repair followed by an anti-reflux procedure is suggested. However, in cases of unstable patients open repair is the surgical method of choice. Here, we present an exceptionally challenging case of a young patient with a giant recurrent hiatal hernia becoming clinically manifest in an incarcerated UDS.

Open versus laparoscopic hiatal hernia repair

Laparoscopic repair of paraesophageal hiatal hernia where only a portion of the stomach is in the chest, is associated with a lower mortality rate than open repair.

Background:

The literature reports the efficacy of the laparoscopic approach to paraesophageal hiatal hernia repair. However, its adoption as the preferred surgical approach and the risks associated with paraesophageal hiatal hernia repair have not been reviewed in a large database.

Method:

The Nationwide Inpatient Sample dataset was queried from 1998 to 2005 for patients who underwent repair of a complicated (the entire stomach moves into the chest cavity) versus uncomplicated (only the upper part of the stomach protrudes into the chest) paraesophageal hiatal hernia via the laparoscopic, open abdominal, or open thoracic approach. A multivariate analysis was performed controlling for demographics and comorbidities while looking for independent risk factors for mortality.

Results:

In total, 23,514 patients met the inclusion criteria. By surgical approach, 55% of patients underwent open abdominal, 35% laparoscopic, and 10% open thoracic repairs. Length of stay was significantly reduced for all patients after laparoscopic repair (P < .001). Age ≥60 years and nonwhite ethnicity were associated with significantly higher odds of death. Laparoscopic repair and obesity were associated with lower odds of death in the uncomplicated group.

Conclusion:

Laparoscopic repair of paraesophageal hiatal hernia is associated with a lower mortality in the uncomplicated group. However, older age and Hispanic ethnicity increased the odds of death.

Intrathoracic gastric volvulus: an autopsy case report

First described by Berti in 1866, gastric volvulus (GV) is an uncommon and potentially lethal entity. GV occurs when the stomach twists by more than 180º resulting in obstruction of the alimentary tract, visceral ischemia, necrosis, and perforation. It is classified according to the rotation axis in organoaxial, mesenteroaxial or a combination of both. The clinical presentation can be acute, and is usually severe or chronic, which sometimes may be asymptomatic. It predominantly occurs in the fifth decade of life, but children, mainly those under the age of 1 year, may be affected. No ethnicity or gender was observed to show predominance. This entity is related to gastric, diaphragmatic disorders as well as laxity of gastric ligaments. Acute GV may complicate with incarceration and strangulation of the stomach when gastric necrosis ensues. These cases show a mortality rate of 60%. The authors report the fatal case of a surgically treated GV in a 43-year-old female patient who looked for medical care only after 1 month of initial symptoms. Diagnosis was confirmed with a thoracic and abdominal axial computed tomography. Besides the entire stomach being herniated and twisted into the thoracic cavity, the pancreas was pulled up through the hiatal orifice, provoking acute pancreatitis. Because of gastric necrosis and perforation, gastroenteric fluid drained into the mediastinum and left pleural space. The postoperative outcome was unfavorable resulting in the patient's death. The authors call attention to the severeness of the disease, and therefore the need of precocity of diagnosis and surgical treatment.

Laparoscopic approach to acute abdomen from the Consensus Development Conference of the Società Italiana di Chirurgia Endoscopica e nuove tecnologie (SICE), Associazione Chirurghi Ospedalieri Italiani (ACOI), Società Italiana di Chirurgia (SIC), Società Italiana di Chirurgia d'Urgenza e del Trauma (SICUT), Società Italiana di Chirurgia nell'Ospedalità Privata (SICOP), and the European Association for Endoscopic Surgery (EAES)

BACKGROUND

In January 2010, the SICE (Italian Society of Endoscopic Surgery), under the auspices of the EAES, decided to revisit the clinical recommendations for the role of laparoscopy in abdominal emergencies in adults, with the primary intent being to update the 2006 EAES indications and supplement the existing guidelines on specific diseases.

METHODS

Other Italian surgical societies were invited into the Consensus to form a panel of 12 expert surgeons. In order to get a multidisciplinary panel, other stakeholders involved in abdominal emergencies were invited along with a patient's association. In November 2010, the panel met in Rome to discuss each chapter according to the Delphi method, producing key statements with a grade of recommendations followed by commentary to explain the rationale and the level of evidence behind the statements. Thereafter, the statements were presented to the Annual Congress of the EAES in June 2011.

RESULTS

A thorough literature review was necessary to assess whether the recommendations issued in 2006 are still current. In many cases new studies allowed us to better clarify some issues (such as for diverticulitis, small bowel obstruction, pancreatitis, hernias, trauma), to confirm the key role of laparoscopy (such as for cholecystitis, gynecological disorders, nonspecific abdominal pain, appendicitis), but occasionally previous strong recommendations have to be challenged after review of recent research (such as for perforated peptic ulcer).

CONCLUSIONS

Every surgeon has to develop his or her own approach, taking into account the clinical situation, her/his proficiency (and the experience of the team) with the various techniques, and the specific organizational setting in which she/he is working. This guideline has been developed bearing in mind that every surgeon could use the data reported to support her/his judgment.

Posterior thoracic esophagostomy as an esophageal sparing procedure

A diverting (posterior) thoracic esophagostomy is a rare, but acceptable, surgical option in some cases. The goal is to save as much esophageal length as possible with a view to future reconstructive surgery. We herein report a 41-year-old woman, in whom a posterior thoracic esophagostomy was successfully created and used for reestablishing further physiological alimentary continuity in a second stage.