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Corbett JM, Eriksson SE, Sarici IS, Jobe BA, Ayazi S. Complications After Paraesophageal Hernia Repair. Thorac Surg Clin 2024; 34:355-369. [PMID: 39332860 DOI: 10.1016/j.thorsurg.2024.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2024]
Abstract
Paraesophageal hernia repair (PEHR) is a challenging operation both technically and because the affected patient population is typically older with more comorbidities. As a result, PEHR is associated with substantial morbidity. Morbidity and mortality following PEHR vary significantly depending on the acuity of the operation and size of the hernia. In addition to a higher risk for general peri- and postoperative complications there are a variety of other foregut specific complications to consider including, acute perioperative, early, and late reherniation, mesh-related complications, perforation, gastroparesis, pulmonary and insufflation-related complications, among others. This review focuses on the complication-specific data on incidence, recognition etiology and management.
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Affiliation(s)
- Julie M Corbett
- Foregut Division, Surgical Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 454, Pittsburgh, PA 15224, USA
| | - Sven E Eriksson
- Foregut Division, Surgical Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 454, Pittsburgh, PA 15224, USA; Chevalier Jackson Research Foundation, Esophageal Institute, Western Pennsylvania Hospital, Pittsburgh, PA, USA
| | - Inanc Samil Sarici
- Foregut Division, Surgical Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 454, Pittsburgh, PA 15224, USA; Chevalier Jackson Research Foundation, Esophageal Institute, Western Pennsylvania Hospital, Pittsburgh, PA, USA
| | - Blair A Jobe
- Foregut Division, Surgical Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 454, Pittsburgh, PA 15224, USA; Chevalier Jackson Research Foundation, Esophageal Institute, Western Pennsylvania Hospital, Pittsburgh, PA, USA; Department of Surgery, Drexel University, Philadelphia, PA, USA
| | - Shahin Ayazi
- Foregut Division, Surgical Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 454, Pittsburgh, PA 15224, USA; Chevalier Jackson Research Foundation, Esophageal Institute, Western Pennsylvania Hospital, Pittsburgh, PA, USA; Department of Surgery, Drexel University, Philadelphia, PA, USA; 4815 Liberty Avenue, Suite 454, Pittsburgh, PA 15224, USA.
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DeMeester SR, Bernard L, Schoppmann SF, Kloosterman R, Roth JS. Elective Laparoscopic Paraesophageal Hernia Repair Leads to an Increase in Life Expectancy Over Watchful Waiting in Asymptomatic Patients: An Updated Markov Analysis. Ann Surg 2024; 279:267-275. [PMID: 37818675 DOI: 10.1097/sla.0000000000006119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2023]
Abstract
OBJECTIVE The aim of this study was to perform an updated Markov analysis to determine the optimal management strategy for patients with an asymptomatic paraesophageal hernia (PEH): elective laparoscopic hernia repair (ELHR) versus watchful waiting (WW). BACKGROUND Currently, it is recommended that patients with an asymptomatic PEH not undergo repair based on a 20-year-old Markov analysis. The current recommendation might lead to preventable hospitalizations for acute PEH-related complications and compromised survival. METHODS A Markov model with updated variables was used to compare life-years (L-Ys) gained with ELHR versus WW in patients with a PEH. One-way sensitivity analyses evaluated the robustness of the analysis to alternative data inputs, while probabilistic sensitivity analysis quantified the level of confidence in the results in relation to the uncertainty across all model inputs. RESULTS At age 40 to 90, ELHR led to greater life expectancy than WW, particularly in women. The gain in L-Ys (2.6) was greatest in a 40-year-old woman and diminished with increasing age. Sensitivity analysis showed that alternative values resulted in modest changes in the difference in L-Ys, but ELHR remained the preferred strategy. Probabilistic analysis showed that ELHR was the preferred strategy in 100% of 10,000 simulations for age 65, 98% for age 80, 90% for age 85, and 59% of simulations in 90-year-old women. CONCLUSIONS This updated analysis showed that ELHR leads to an increase in L-Ys over WW in healthy patients aged 40 to 90 years with an asymptomatic PEH. In this new paradigm, all patients with a PEH, regardless of symptoms, should be referred for the consideration of elective repair to maximize their life expectancy.
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Affiliation(s)
| | | | | | | | - J Scott Roth
- Department of Surgery, The University of Kentucky, Lexington, KY
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Ogo T, Nishiyama Y, Ishihara K, Tsukahara K, Inokuchi M. A case of conservatively managed gastric perforation at a recurrent hiatal hernia site after laparoscopic paraesophageal repair. Int J Surg Case Rep 2023; 106:108266. [PMID: 37156199 DOI: 10.1016/j.ijscr.2023.108266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 04/21/2023] [Accepted: 04/22/2023] [Indexed: 05/10/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Gastric perforation due to a hiatal hernia is a rare cause of acute abdominal pain that often requires surgical intervention. Conservative management for this condition is an effective option in certain cases, although fewer reports of this exist. Herein, we report a unique case of gastric perforation caused by a recurrent hiatal hernia that was successfully treated with conservative management. CASE PRESENTATION A 74-year-old man developed a high fever and an elevated inflammatory response on the third day after a laparoscopic paraesophageal hernia repair using a mesh. Computed tomography confirmed the recurrence of the hiatal hernia, with gastric fundal prolapse into the mediastinum and surgical emphysema in the gastric wall. This was followed by a gastric perforation within the mediastinum. The patient was treated using an ileus tube through the perforation site. CLINICAL DISCUSSION In similar cases, if the clinical symptoms are mild, there are no signs of serious infection, and the perforation remains in the mediastinum and can be appropriately drained, conservative treatment is considered an option. CONCLUSION Under favorable conditions, conservative management can be an option for gastric perforation in patients with recurrent hiatal hernias, which is a serious potential postoperative complication.
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Affiliation(s)
- Taichi Ogo
- Department of Surgery, Musashino Red Cross Hospital, Japan.
| | - Yu Nishiyama
- Department of Surgery, Musashino Red Cross Hospital, Japan
| | - Kei Ishihara
- Department of Surgery, Musashino Red Cross Hospital, Japan
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Emergency surgery for hiatus hernias: does technique affect outcomes? A single-centre experience. Updates Surg 2023:10.1007/s13304-023-01482-y. [PMID: 36869223 PMCID: PMC10359210 DOI: 10.1007/s13304-023-01482-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 02/23/2023] [Indexed: 03/05/2023]
Abstract
BACKGROUND Emergency surgery for a hiatus hernia is usually a high-risk procedure in acutely unwell patients. Common surgical techniques include reduction of the hernia, cruropexy then either fundoplication or gastropexy with a gastrostomy. This is an observational study in a tertiary referral centre for complicated hiatus hernias to compare recurrence rates between these two techniques. METHODS Eighty patients are included in this study, from October 2012 to November 2020. This is a retrospective review and analysis of their management and follow-up. Recurrence of the hiatus hernia that mandates surgical repair was the primary outcome of this study. Secondary outcomes include morbidity and mortality. RESULTS In total, 38% of the patients included in the study had fundoplication procedures, 53% had gastropexy, 6% had complete or partial resection of the stomach, 3% had fundoplication and gastropexy and one patient had neither (n = 30, 42, 5, 2,1, respectively). Eight patients had symptomatic recurrence of the hernia which required surgical repair. Three of these patients had acute recurrence and 5 after discharge. 50% had undergone fundoplication, 38% underwent gastropexy and 13% underwent a resection (n = 4, 3, 1) (p value = 0.5). 38% of patient had no complications and 30-day mortality was 7.5% CONCLUSION: To our knowledge, this is the largest single centre review of outcomes following emergency hiatus hernia repairs. Our results show that either fundoplication or gastropexy can be used safely to reduce the risk of recurrence in the emergency setting. Therefore, surgical technique can be tailored based on the patient characteristics and surgeon experience, without compromising the risk of recurrence or post-operative complications. Mortality and morbidity rates were in keeping with previous studies, which is lower than historically documented, with respiratory complications most prevalent. This study shows that emergency repair of hiatus hernias is a safe operation which is often a lifesaving procedure in elderly comorbid patients.
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Abstract
A 63-year-old male with a history of hiatal hernia presented with one day of hematemesis and acute peritonitis. Computed tomographic imaging revealed perigastric pneumoperitoneum concerning perforated viscus. Exploratory laparotomy revealed a Type III hiatal hernia with a perforated posterior gastric ulcer, which was reduced and repaired. This report describes a case of acute abdomen secondary to hiatal hernia, a rare presentation of hiatal hernia, along with its surgical management and postoperative care.
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Affiliation(s)
- Dieter Brummund
- Department of General Surgery, Aventura Hospital and Medical Center, Aventura, USA
| | - Angela Chang
- Department of Anesthesiology, Aventura Hospital and Medical Center, Miami, USA
| | - Michael Renda
- Department of General Surgery, Kendall Regional Medical Center, Miami, USA
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