Postoperative diaphragmatic hernia with upside-down stomach: a case report

A 31-year-old man presented to our hospital’s Emergency Department with sudden epigastric pain and vomiting. He had undergone endoscopic resection via the retroperitoneal route for a retroperitoneal tumor located in the left diaphragmatic crus of the esophageal hiatus at another hospital 8 months previously. Radiography and computed tomography showed inversion of the stomach beyond the diaphragm into the thoracic cavity, with the gastroesophageal junction serving as the fulcrum point. This finding led to a diagnosis of postoperative diaphragmatic hernia accompanied by an upside-down stomach (UDS). The prolapsed stomach in the thoracic cavity was reduced to the abdominal cavity using laparoscopic surgery. The postoperative course was favorable, and the patient was discharged from the hospital on postoperative day 7. No recurrence has been observed in the past 5 years. The pathological condition of a UDS observed in esophageal hiatal hernias may be found in postoperative diaphragmatic hernias. Laparoscopic surgery for a postoperative diaphragmatic hernia with a UDS is considered a useful surgical procedure. Laparoscopic surgery can simultaneously confirm the viability of the herniated organs, reduce the organs to the abdominal cavity, and close and reinforce the diaphragm.

Paraesophageal hernia and iron deficiency anemia: Mechanisms, diagnostics and therapy

There is ample clinical evidence suggesting that the presence of large axial or paraesophageal hernias may lead to iron deficiency anemia. So-called Cameron lesions, as well as other small mucosa erosions, in the sliding area of these diaphragmatic hernias lead to invisible chronic blood loss and consequently to iron depletion. While the spectrum of symptoms in these patients is large, anemia is often not the only indication and typically not the primary indication for surgical correction of diaphragmatic hernias. Drug treatment with proton pump inhibitors and iron substitution can alleviate anemia, but this is not always successful. To exclude other possible bleeding sources in the gastrointestinal tract, a comprehensive diagnostic program is necessary and reviewed in this manuscript. Additionally, we discuss controversies in the surgical management of paraesophageal hernias.

Acute intrathoracic gastric volvulus with retrograde gastric intussusception: A case report of a rare surgical emergency with review of the literature

•

The acute intrathoracic gastric volvulus is a rare condition.

•

The gastrogastric intussusception is very very rare.

•

The gastric volvulus and the gastrogastric intussusception are surgical emergencies.

•

Any delay in diagnosis and treatment can prove fatal.

•

Emergent laparotomy or laparoscopy is considered the correct treatment.

Introduction

The gastric volvulus is a rare condition in which the stomach, or part of it, rotates on its axis, for over 180°, constituting a surgical emergency. Even more rare is gastro-gastric intussusception. A delay in their diagnosis and treatment can have fatal consequences

Presentation of case

An 82-year-old woman was admitted to the Surgery Unit with a two-day history of abdominal pain associated at first with coffee vomiting and, subsequently, with unproductive retching and oligoanuria. Physical examination showed severe dehydration, fever, at the abdominal level, palpation caused a marked tenderness of all quadrants, with signs of peritonism.

Laboratory test showed showed neutrophilic hyperleukocytosis and high C reactive protein level. Abdominal computed tomography revealed an acute intrathoracic gastric volvulus and a gastrogastric intussuception. The patient was submitted to exploratory laparotomy, subtotal gastrectomy with Roux en Y anastomosis and simple plastic of the esophageal hiatus. At the end of the surgery, however, the patient died of your septic shock.

Discussion

The traditional treatment for a patient with acute gastric volvulus is an immediate surgical intervention to derotate the stomach and prevent vascular insufficiency.

In the presence of necrosis or gastric perforation, resection should be performed.

The few cases of gastrogastric intussusception described in the literature have been treated with sub-total gastrectomy and gastro-jejunal anastomosis. Any delay in diagnosis and treatment can prove fatal.

Conclusion

Intrathoracic Gastric Volvulus and, even more, retrograde gastrointestinal intussusception are very rare pathologies, difficult to diagnose.

Laparoscopic repair of an excessive Morgagni hernia in an adult presenting as upside-down stomach

•

Morgagni hernias represents a rare subtype of diaphragmatic congenital hernias manifesting usually during early childhood.

•

An innocuous or asymptomatic presentation render diagnosis of Morgagni hernias a challenging procedure.

•

In our case, an adult female patient presented with a giant Morgagni hernia, initially diagnosed as a paraesophageal hernia.

•

Early treatment of such cases is advised due to potential fatal complications. Laparoscopic surgery is considered the best approach.

Introduction

Morgagni hernia is defined as the intrathoracic protrusion of abdominal viscera through a defect in the anterior diaphragm. It represents an uncommon type of diaphragmatic congenital hernia.

Case presentation

A 68-year-old female patient was admitted in our department due to progressive epigastric discomfort for the past four months. A preoperative diagnosis of a paraesophageal hernia was set through computer tomography, with gastric portions and parts of small bowel protruding inside the thoracic cavity. Intraoperatively, an excessive diaphragmatic defect was detected in the anterior side of the diaphragm. Reduction of the hernia’s contents inside the abdominal cavity was achieved through laparoscopy, with the additional fixation of an intraperitoneal non-absorbable mesh for reinforcement of the diaphragmatic wall. Patient was discharged uneventfully on the 4th postoperative day.

Discussion

Morgagni hernias refer to a rare type of diaphragmatic congenital hernias, usually identified during childhood, leaving only a small number of cases observed in the adult population. Its diagnosis can pose a challenge due to the non-specific and usually asymptomatic presentation. An early surgical management is advised due to an increased number of potentially lethal complications, such as gastric incarceration and obstruction. Treatment consist of open surgical techniques through a trans-thoracic or a trans-abdominal approach, although a paradigm shift in the 21st century considers minimal invasive laparoscopic surgery the treatment of choice.

Conclussion

A high index of clinical suspicion is required for diagnosis of Morgagni hernias, while prompt management is advised. Laparoscopy is considered the best approach in the hands of an experienced surgeon.

Postprandial cardiogenic syncope caused by gastric polyp-induced pyloric obstruction in an elderly woman with a giant hiatal hernia: a case report

Background

Hiatal hernias are common. In some reports, hiatal hernias have been implicated in causing dyspnea, syncope, and heart failure.

Case presentation

An 82-year-old woman with a hiatal hernia was admitted to our hospital because she had experienced postprandial syncope during the last few years. Esophagogastroduodenoscopy revealed a large hiatal hernia and a pedunculated polyp of the stomach antrum that fit into the pylorus. An upper gastrointestinal contrast study showed that the entire stomach had relocated to the thoracic cavity and that the body of the stomach was located above the fundus, resulting in a so-called upside-down stomach. Contrast-enhanced computed tomography revealed that a large portion of the stomach, transverse colon, and part of the pancreas were present in the mediastinum. We then performed transthoracic echocardiography followed by a water pouring test using a nasogastric tube. After instillation of 2000 ml of saline, the left atrium was markedly compressed and the area of the mitral annulus was reduced. We determined that stomach dilation by the hiatal hernia and gastric polyp had caused the syncope. The patient underwent laparoscopic hiatal hernia repair and endoscopic gastric polypectomy, and she experienced no syncopal episodes for 5 months postoperatively.

Conclusions

Clinicians should recognize that a large hiatal hernia may be a risk factor for syncope.

Laparoscopic repair of giant hiatal hernia. A single center experience

INTRODUCTION

Giant hiatal hernia is a rare clinical entity with possibly serious complications, diagnosed mostly among older patients. The laparoscopic repair of such hernias is a therapeutic option, performed mostly in specialized centers by experienced surgeons.

METHODS

From 1997 to 2012 fifty-five patients with giant hiatal hernia (median age of 72) were primarily treated by laparoscopic surgery at the surgical department of the Catholic Clinic Oberhausen. Demographic data, operating times, conversion rate, morbidity and mortality were recorded prospectively. Follow-up was conducted by means of a mailed questionnaire.

RESULTS

Intraoperative complications occurred in 1,8% of the cases (n = 1). In this single case the procedure was converted to an open procedure due to technical difficulties imposed by hepatomegaly. The median operating time was 96 min (range, 30 to 350). Our rate of postoperative complications was 14,5% (n = 8). The median postoperative hospital stay was nine days. 14,5% (n = 8) of our patients underwent a redo-surgery for symptomatic recurrence. The median follow-up was 64 months by means of a self-designed questionnaire. 34,5% (19/55) of the questioned patients responded to our survey. The difference between pre- and postoperative symptom intensity was found to be significant for heartburn (p < 0,001) and retrosternal/epigastric pain (p = 0,028). The difference was not found to be statistically significant for dysphagia (p = 0,8) and bloating (p = 0,3). 85% of the questioned patients stated they would have the operation again, if necessary. 80% reported an improvement of their overall quality of life.

DISCUSSION

The laparoscopic repair of large hiatal hernias is a safe approach with an intraoperative complication rate of 1,8%, low post-operative morbidity (14,5%) and very low mortality (1,8%). There is a high patient satisfaction (85%) and a good postoperative quality of life (80%).

CONCLUSION

The laparoscopic approach for repair of large hiatal hernias is a relatively safe method with significant long-term efficacy in terms of symptom control and quality of life.

Gastric Cancer Arising from an Upside-Down Stomach through a Paraesophageal Hiatal Hernia

We report the rare case of an elderly patient with an advanced gastric cancer arising from an upside-down stomach through a paraesophageal hiatal hernia (PEH). An 82-year-old man presented with appetite loss and anemia. Upper gastrointestinal endoscopy revealed a type 1 tumor located in the middle body of the stomach. An upper gastrointestinal series and computed tomography showed organoaxial rotation of the stomach, which was located in the mediastinum, through a PEH, indicating an upside-down stomach. The preoperative diagnosis was gastric cancer arising from an upside-down stomach through a PEH. The patient underwent total gastrectomy with lymph node dissection and closure of the hernial orifice. Although a large PEH is a chronic disorder, gastric malignancies should be considered in patients with PEH manifested as an upside-down stomach due to its anatomical characteristics, and careful preoperative diagnosis is mandatory.

Recurrent upside-down stomach after endoscopic repositioning and gastropexy treated by laparoscopic surgery

Patients with an upside-down stomach usually receive surgical treatment. In high-risk patients, endoscopic repositioning and gastropexy can be performed. However, the risk of recurrence after endoscopic treatment is not known. We treated a case of recurrent upside-down stomach after endoscopic therapy that indicated the limits of endoscopic treatment and risk of recurrence. An 88-year-old woman was treated three times for vomiting in the past. She presented to our hospital with periodic vomiting and an inability to eat, and a diagnosis of upside-down stomach was made. Endoscopic repositioning and gastropexy were performed. The anterior stomach wall was fixed to the abdominal wall in three places as widely as possible. Following treatment, she became symptom-free. Three months later, she was hospitalized again because of a recurrent upside-down stomach. Laparoscopic repair of hernias and gastropexy was performed. Using a laparoscope, two causes of recurrence were found. One cause was that the range of adherence between the stomach and the abdominal wall was narrow (from the antrum only to the lower corpus of stomach), so the upper corpus of stomach was rotated and herniated into the esophageal hiatus. The other cause was adhesion between the omentum and the esophageal hiatus which caused the stomach to rotate and repeatedly become herniated. Although endoscopic treatment for upside-down stomach can be a useful alternative method in high-risk patients, its ability to prevent recurrence is limited. Moreover, a repeated case caused by adhesions has risks of recurrence.

Recurrent upside-down stomach after endoscopic repositioning and gastropexy treated by laparoscopic surgery

Patients with an upside-down stomach usually receive surgical treatment. In high-risk patients, endoscopic repositioning and gastropexy can be performed. However, the risk of recurrence after endoscopic treatment is not known. We treated a case of recurrent upside-down stomach after endoscopic therapy that indicated the limits of endoscopic treatment and risk of recurrence. An 88-year-old woman was treated three times for vomiting in the past. She presented to our hospital with periodic vomiting and an inability to eat, and a diagnosis of upside-down stomach was made. Endoscopic repositioning and gastropexy were performed. The anterior stomach wall was fixed to the abdominal wall in three places as widely as possible. Following treatment, she became symptom-free. Three months later, she was hospitalized again because of a recurrent upside-down stomach. Laparoscopic repair of hernias and gastropexy was performed. Using a laparoscope, two causes of recurrence were found. One cause was that the range of adherence between the stomach and the abdominal wall was narrow (from the antrum only to the lower corpus of stomach), so the upper corpus of stomach was rotated and herniated into the esophageal hiatus. The other cause was adhesion between the omentum and the esophageal hiatus which caused the stomach to rotate and repeatedly become herniated. Although endoscopic treatment for upside-down stomach can be a useful alternative method in high-risk patients, its ability to prevent recurrence is limited. Moreover, a repeated case caused by adhesions has risks of recurrence.

Metabolic alkalosis, acute renal failure and epileptic seizures as unusual manifestations of an upside-down stomach

Upside-down stomach represents a critical and rare manifestation of hiatal hernias. Here we report on a 60-year-old male patient who was admitted to our hospital with epileptic seizures and dehydration. Laboratory tests revealed severe metabolic alkalosis (pH 7.56) with low potassium (2.7 mmol/l), hypochloremia (<60 mmol/l), increased hematocrit (53%) and high levels of serum creatinine (651 µmol/l). Based on a history of recurrent vomiting, gastroscopy and computed tomography were performed. Both diagnostics showed an upside-down stomach with signs of incarceration. Upon infusion of sodium chloride 0.9%, acid-base state, electrolyte balance and renal function became improved. Subsequently, the patient was referred to the department of surgery for hiatoplasty with fundoplication. This case report highlights severe metabolic and neurological disorders as unusual and life-threatening complications of an upside-down stomach.