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Lara FJP, Zubizarreta Jimenez R, Moya Donoso FJ, Hernández Gonzalez JM, Prieto-Puga Arjona T, del Rey Moreno A, Pitarch Martinez M. Preoperative calculation of angles of vision and working area in laparoscopic surgery to treat a giant hiatal hernia. World J Gastrointest Surg 2021; 13:1638-1650. [PMID: 35070069 PMCID: PMC8727182 DOI: 10.4240/wjgs.v13.i12.1638] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 06/21/2021] [Accepted: 11/28/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Giant hiatal hernias still pose a major challenge to digestive surgeons, and their repair is sometimes a highly complex task. This is usually performed by laparoscopy, while the role of the thoracoscopic approach has yet to be clearly defined.
AIM To preoperatively detect patients with a giant hiatal hernia in whom it would not be safe to perform laparoscopic surgery and who, therefore, would be candidates for a thoracoscopic approach.
METHODS In the present study, using imaging test we preoperatively simulate the field of vision of the camera and the working area (instrumental access) that can be obtained in each patient when the laparoscopic approach is used.
RESULTS From data obtained, we can calculate the access angles that will be obtained in a preoperative computerised axial tomography coronal section, according to the location of the trocar. We also provide the formula for performing the angle calculations If the trocars are placed in loss common situations, thus enabling us to determine the visibility and manoeuvrability for any position of the trocars.
CONCLUSION The working area determines the cases in which we can operate safely and those in which certain areas of the hernia cannot be accessed, which is when the thoracoscopic approach would be safer.
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Elhage SA, Kao AM, Katzen M, Shao JM, Prasad T, Augenstein VA, Heniford BT, Colavita PD. Outcomes and CT scan three-dimensional volumetric analysis of emergent paraesophageal hernia repairs: predicting patients who will require emergent repair. Surg Endosc 2021; 36:1650-1656. [PMID: 34471979 PMCID: PMC8409264 DOI: 10.1007/s00464-021-08415-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 02/23/2021] [Indexed: 12/02/2022]
Abstract
Introduction Elective repair versus watchful waiting remains controversial in paraesophageal hernia (PEH) patients. Generation of predictive factors to determine patients at greatest risk for emergent repair may prove helpful. The aim of this study was to evaluate patients undergoing elective versus emergent PEH repair and supplement this comparison with 3D volumetric analysis of hiatal defect area (HDA) and intrathoracic hernia sac volume (HSV) to determine risk factors for increased likelihood of emergent repair. Methods A retrospective review of a prospectively enrolled, single-center hernia database was performed on all patients undergoing elective and emergent PEH repairs. Patients with adequate preoperative computed tomography (CT) imaging were analyzed using volumetric analysis software. Results Of the 376 PEH patients, 32 (8.5%) were emergent. Emergent patients had lower rates of preoperative heartburn (68.8%vs85.1%, p = 0.016) and regurgitation (21.9%vs40.2%, p = 0.04), with similar rates of other symptoms. Emergent patients more frequently had type IV PEHs (43.8%vs13.5%, p < 0.001). Volumetric analysis was performed on 201 patients, and emergent patients had a larger HSV (805.6 ± 483.5vs398.0 ± 353.1cm3, p < 0.001) and HDA (41.7 ± 19.5vs26.5 ± 14.7 cm2, p < 0.001). In multivariate analysis, HSV increase of 100cm3 (OR 1.17 CI 1.02–1.35, p = 0.022) was independently associated with greater likelihood of emergent repair. Post-operatively, emergent patients had increased length of stay, major complication rates, ICU utilization, reoperation, and mortality (all p < 0.05). Emergent group recurrence rates were higher and occurred faster secondary to increased use of gastropexy alone as treatment (p > 0.05). With a formal PEH repair, there was no difference in rate or timing of recurrence. Conclusions Emergent patients are more likely to suffer complications, require ICU care, have a higher mortality, and an increased likelihood of reoperation. A graduated increase in HSV increasingly predicts the need for an emergent operation. Those patients presenting electively with a large PEH may benefit from early elective surgery.
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Affiliation(s)
- Sharbel A Elhage
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA
| | - Angela M Kao
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA
| | - Michael Katzen
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA
| | - Jenny M Shao
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA
| | - Tanushree Prasad
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA
| | - Vedra A Augenstein
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA
| | - B Todd Heniford
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA
| | - Paul D Colavita
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA.
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Dubina ED, Moazzez A, Park H, Shover A, Kim DY, Simms ER. Predictors of Morbidity and Mortality in Complex Paraesophageal Hernia Repair: A NSQIP Analysis. Am Surg 2020. [DOI: 10.1177/000313481908501025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Paraesophageal hernia (PEH) repair is typically performed electively. Complex PEHs (obstructed or gangrenous) require more urgent repair and can have significant complications. Although elective repair is primarily laparoscopic, limited data are available on the use of laparoscopy for complex cases. Patients undergoing complex PEH repair were identified from the NSQIP database, and predictors of morbidity and mortality were compared for 2473 laparoscopic and 861 open repairs. Compared with the laparoscopic approach, emergent surgeries (36.7% vs 10.8%, P < 0.001) and preoperative sepsis (22.9% vs 7.4%, P < 0.001) were more common in the open group. Operative times were shorter for open repairs (152.6 vs 172.2 minutes, P = 0.03). However, open repair was associated with increased morbidity (28.2% vs 11%, P < 0.001) and mortality (5.2% vs 1.4%, P < 0.001), likely because of higher rates of preoperative comorbidities in the open group. On multivariable regression analysis, preoperative sepsis was associated with increased mortality and morbidity, whereas laparoscopic repair was associated with decreased morbidity. If laparoscopic repair can be safely completed, it is associated with decreased morbidity, despite longer operative times.
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Affiliation(s)
- Emily D. Dubina
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, California
| | - Ashkan Moazzez
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, California
| | - Hayoung Park
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, California
| | - Andrew Shover
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, California
| | - Dennis Y. Kim
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, California
| | - Eric R. Simms
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, California
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Kao AM, Ross SW, Otero J, Maloney SR, Prasad T, Augenstein VA, Heniford BT, Colavita PD. Use of computed tomography volumetric measurements to predict operative techniques in paraesophageal hernia repair. Surg Endosc 2019; 34:1785-1794. [DOI: 10.1007/s00464-019-06930-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 06/12/2019] [Indexed: 10/26/2022]
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Chernousov AF, Khorobrykh TV, Vetshev FP, Osminin SV, Korotkiy VI, Abdulkhakkimov NM, Chesarev AA, Salikhov R. [Treatment of reflux esophagitis in patients with cardiofundal, subtotal and total hiatal hernias]. Khirurgiia (Mosk) 2019:41-48. [PMID: 31317940 DOI: 10.17116/hirurgia201906141] [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: 06/10/2023]
Abstract
AIM To analyze treatment of patients with reflux esophagitis and large hiatal hernia. MATERIAL AND METHODS There were 85 patients with reflux esophagitis and large hiatal hernia. Laparoscopic repair was performed in 33 patients, laparotomy - in 52 cases. All patients underwent fundo- or gastroplication by A.F. Chernousov, correction of large defect of hiatal orifice by cruroraphy was applied in 55 (64.7%) patients. RESULTS Postoperative morbidity was near 10% after laparoscopic and conventional surgery despite more difficult video-assisted endoscopic technique. Complications Clavien-Dindo grade I-II were noted in 4 (12.1%) patients after laparoscopic treatment and in 6 (11.5%) patients after laparotomy. Medication was effective in all cases. Two patients with subtotal hernias had complications Clavien-Dindo grade IIIB after endoscopic surgery: recurrent hiatal hernia followed by severe reflux esophagitis and dysphagia. These complications required redo surgery. Repair of hiatal orifice is always possible without mesh reinforcement. Posterior cruroraphy is feasible and effective in all patients. Incidence of intraoperative and postoperative complications is comparable in both approaches (p<0.05). Mean hospital-stay after laparotomy was 7.3 days, after laparoscopy - 5.8 days. CONCLUSION Endoscopic formation of antireflux cuff by A.F. Chernousov is appropriate and effective in patients with reflux esophagitis and large/giant hiatal hernias.
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Affiliation(s)
- A F Chernousov
- Chair of Faculty-Based Surgery #1, Sechenov First Moscow State Medical University of Ministry of Health of the Russian Federation, Moscow, Russia, Burdenko Clinic of Faculty-Based Surgery, Moscow, Russia
| | - T V Khorobrykh
- Chair of Faculty-Based Surgery #1, Sechenov First Moscow State Medical University of Ministry of Health of the Russian Federation, Moscow, Russia, Burdenko Clinic of Faculty-Based Surgery, Moscow, Russia
| | - F P Vetshev
- Chair of Faculty-Based Surgery #1, Sechenov First Moscow State Medical University of Ministry of Health of the Russian Federation, Moscow, Russia, Burdenko Clinic of Faculty-Based Surgery, Moscow, Russia
| | - S V Osminin
- Chair of Faculty-Based Surgery #1, Sechenov First Moscow State Medical University of Ministry of Health of the Russian Federation, Moscow, Russia, Burdenko Clinic of Faculty-Based Surgery, Moscow, Russia
| | - V I Korotkiy
- Chair of Faculty-Based Surgery #1, Sechenov First Moscow State Medical University of Ministry of Health of the Russian Federation, Moscow, Russia, Burdenko Clinic of Faculty-Based Surgery, Moscow, Russia
| | - N M Abdulkhakkimov
- Chair of Faculty-Based Surgery #1, Sechenov First Moscow State Medical University of Ministry of Health of the Russian Federation, Moscow, Russia, Burdenko Clinic of Faculty-Based Surgery, Moscow, Russia
| | - A A Chesarev
- Chair of Faculty-Based Surgery #1, Sechenov First Moscow State Medical University of Ministry of Health of the Russian Federation, Moscow, Russia, Burdenko Clinic of Faculty-Based Surgery, Moscow, Russia
| | - R Salikhov
- Chair of Faculty-Based Surgery #1, Sechenov First Moscow State Medical University of Ministry of Health of the Russian Federation, Moscow, Russia, Burdenko Clinic of Faculty-Based Surgery, Moscow, Russia
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Mattioli S. Why consider a paraesophageal hernia giant and a long esophagus short? Definitions and results of surgery for paraesophageal hiatal hernias. J Thorac Cardiovasc Surg 2018; 155:1345. [DOI: 10.1016/j.jtcvs.2017.09.130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 09/29/2017] [Indexed: 01/25/2023]
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Kozower BD. Paraesophageal hernias: "You say potato, I say potato". J Thorac Cardiovasc Surg 2018; 155:1347. [PMID: 29452480 DOI: 10.1016/j.jtcvs.2017.10.094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Accepted: 10/26/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Benjamin D Kozower
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Mo
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Gorin SG, Khrupkin VI, Kustov AE, Andronov BA, Stradymov AA, Pisarevskaya AA, Verenok AM, Lyutov VD. [Perforated chronic gastric ulcer in sliding hiatus hernia]. Khirurgiia (Mosk) 2017:78-81. [PMID: 29286036 DOI: 10.17116/hirurgia20171278-81] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- S G Gorin
- War Veterans Hospital #2 of Moscow Healthcare Department
| | - V I Khrupkin
- War Veterans Hospital #2 of Moscow Healthcare Department; General Surgery Department of Sechenov First Moscow State Medical University, Moscow, Russia
| | - A E Kustov
- War Veterans Hospital #2 of Moscow Healthcare Department
| | - B A Andronov
- War Veterans Hospital #2 of Moscow Healthcare Department
| | - A A Stradymov
- War Veterans Hospital #2 of Moscow Healthcare Department
| | | | - A M Verenok
- War Veterans Hospital #2 of Moscow Healthcare Department
| | - V D Lyutov
- War Veterans Hospital #2 of Moscow Healthcare Department
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Modern diagnosis and treatment of hiatal hernias. Langenbecks Arch Surg 2017; 402:1145-1151. [PMID: 28828685 DOI: 10.1007/s00423-017-1606-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 07/18/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE Hiatal hernias are a common finding on radiographic or endoscopic studies. Hiatal hernias may become symptomatic or, less frequently, can incarcerate or become a volvulus leading to organ ischemia. This review examines latest evidence on the diagnostic workup and management of hiatal hernias. METHODS A literature review of contemporary and latest studies with highest quality of evidence was completed. This information was examined and compiled in review format. RESULTS Asymptomatic hiatal and paraesophageal hernias become symptomatic and necessitate repair at a rate of 1% per year. Watchful waiting is appropriate for asymptomatic hernias. Symptomatic hiatal hernias and those with confirmed reflux disease require operative repair with an anti-reflux procedure. Key operative steps include the following: reduction and excision of hernia sac, 3 cm of intraabdominal esophageal length, crural closure with mesh reinforcement, and an anti-reflux procedure. Repairs not amenable to key steps may undergo gastropexy and gastrostomy placement as an alternative procedure. CONCLUSIONS Hiatal hernias are commonly incidental findings. When hernias become symptomatic or have reflux disease, an operative repair is required. A minimally invasive approach is safe and has improved outcomes.
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Affiliation(s)
- A Duranceau
- Department of Surgery, Division of Thoracic Surgery, Université de Montréal, Montreal, Quebec, Canada
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Iqbal A, Naik R, Mohanan PK. Gastric Gangrene Due to a Strangulated Paraesophageal Hernia-a Case report. Indian J Surg 2015; 77:66-8. [PMID: 25972648 DOI: 10.1007/s12262-014-1135-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Accepted: 06/27/2014] [Indexed: 11/27/2022] Open
Abstract
Paraesophageal hernias are considered to be benign entities which are usually managed conservatively. We present a case of a middle-aged male with no previous history of esophageal hernia who presented with acute chest and abdominal pain. The patient was diagnosed to have a type 2 paraesophageal hernia with gastro-thorax. Laparotomy was performed during which it was found that herniated segment of the stomach had strangulated and gangrenous. Thoracotomy was performed and gangrenous stomach segment resected. A roux-en-Y esophago-jejunostomy was performed. Diaphragmatic defect was plicated. Patient recovered with adequate post operative support. A review of the literature revealed that paraesophageal hernias presenting as acute abdominal pain is a rare clinical entity and those with gastric gangrene is even rarer, with high mortality rates. We suggest that paraesophageal hernias require to be managed actively considering the seriousness of potential complications and the relative safety of newer elective surgical modalities. A high index of suspicion is needed in order to avoid missing this diagnosis in patients presenting with chest pain.
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Affiliation(s)
- Abid Iqbal
- Department of Surgery, Government Medical College Thrissur, Thrissur, Kerala India
| | - Rakesh Naik
- Department of Cardiovascular and Thoracic Surgery, Christian Medical College Vellore, Tamilnadu, Kerala India
| | - P K Mohanan
- Department of Surgery, Government Medical College Thrissur, Thrissur, Kerala India
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Marano L, Schettino M, Porfidia R, Grassia M, Petrillo M, Esposito G, Braccio B, Gallo P, Pezzella M, Cosenza A, Izzo G, Di Martino N. The laparoscopic hiatoplasty with antireflux surgery is a safe and effective procedure to repair giant hiatal hernia. BMC Surg 2014; 14:1. [PMID: 24401085 PMCID: PMC3898021 DOI: 10.1186/1471-2482-14-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2013] [Accepted: 01/02/2014] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Although minimally invasive repair of giant hiatal hernias is a very surgical challenge which requires advanced laparoscopic learning curve, several reports showed that is a safe and effective procedure, with lower morbidity than open approach. In the present study we show the outcomes of 13 patients who underwent a laparoscopic repair of giant hiatal hernia. METHODS A total of 13 patients underwent laparoscopic posterior hiatoplasty and Nissen fundoplication. Follow-up evaluation was done clinically at intervals of 3, 6 and 12 months after surgery using the Gastro-oesophageal Reflux Health-Related Quality of Life scale, a barium swallow study, an upper gastrointestinal endoscopy, an oesophageal manometry, a combined ambulatory 24-h multichannel impedance pH and bilirubin monitoring. Anatomic recurrence was defined as any evidence of gastric herniation above the diaphragmatic edge. RESULTS There were no intraoperative complications and no conversions to open technique. Symptomatic GORD-HQL outcomes demonstrated a statistical significant decrease of mean value equal to 3.2 compare to 37.4 of preoperative assessment (p < 0.0001). Combined 24-h multichannel impedance pH and bilirubin monitoring after 12 months did not show any evidence of pathological acid or non acid reflux. CONCLUSION All patients were satisfied of procedure and no hernia recurrence was recorded in the study group, treated respecting several crucial surgical principles, e.g., complete sac excision, appropriate crural closure, also with direct hiatal defect where possible, and routine use of antireflux procedure.
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Affiliation(s)
- Luigi Marano
- 8th General and Gastrointestinal Surgery - Department of Internal Medicine, Surgical, Neurological Metabolic Disease and Geriatric Medicine, Second University of Naples, Piazza Miraglia 2, Naples 80138, Italy
| | - Michele Schettino
- 8th General and Gastrointestinal Surgery - Department of Internal Medicine, Surgical, Neurological Metabolic Disease and Geriatric Medicine, Second University of Naples, Piazza Miraglia 2, Naples 80138, Italy
| | - Raffaele Porfidia
- 8th General and Gastrointestinal Surgery - Department of Internal Medicine, Surgical, Neurological Metabolic Disease and Geriatric Medicine, Second University of Naples, Piazza Miraglia 2, Naples 80138, Italy
| | - Michele Grassia
- 8th General and Gastrointestinal Surgery - Department of Internal Medicine, Surgical, Neurological Metabolic Disease and Geriatric Medicine, Second University of Naples, Piazza Miraglia 2, Naples 80138, Italy
| | - Marianna Petrillo
- 8th General and Gastrointestinal Surgery - Department of Internal Medicine, Surgical, Neurological Metabolic Disease and Geriatric Medicine, Second University of Naples, Piazza Miraglia 2, Naples 80138, Italy
| | - Giuseppe Esposito
- 8th General and Gastrointestinal Surgery - Department of Internal Medicine, Surgical, Neurological Metabolic Disease and Geriatric Medicine, Second University of Naples, Piazza Miraglia 2, Naples 80138, Italy
| | - Bartolomeo Braccio
- 8th General and Gastrointestinal Surgery - Department of Internal Medicine, Surgical, Neurological Metabolic Disease and Geriatric Medicine, Second University of Naples, Piazza Miraglia 2, Naples 80138, Italy
| | - PierLuigi Gallo
- 8th General and Gastrointestinal Surgery - Department of Internal Medicine, Surgical, Neurological Metabolic Disease and Geriatric Medicine, Second University of Naples, Piazza Miraglia 2, Naples 80138, Italy
| | - Modestino Pezzella
- 8th General and Gastrointestinal Surgery - Department of Internal Medicine, Surgical, Neurological Metabolic Disease and Geriatric Medicine, Second University of Naples, Piazza Miraglia 2, Naples 80138, Italy
| | - Angelo Cosenza
- 8th General and Gastrointestinal Surgery - Department of Internal Medicine, Surgical, Neurological Metabolic Disease and Geriatric Medicine, Second University of Naples, Piazza Miraglia 2, Naples 80138, Italy
| | - Giuseppe Izzo
- 8th General and Gastrointestinal Surgery - Department of Internal Medicine, Surgical, Neurological Metabolic Disease and Geriatric Medicine, Second University of Naples, Piazza Miraglia 2, Naples 80138, Italy
| | - Natale Di Martino
- 8th General and Gastrointestinal Surgery - Department of Internal Medicine, Surgical, Neurological Metabolic Disease and Geriatric Medicine, Second University of Naples, Piazza Miraglia 2, Naples 80138, Italy
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Fullum TM, Oyetunji TA, Ortega G, Tran DD, Woods IM, Obayomi-Davies O, Pessu O, Downing SR, Cornwell EE. Open versus laparoscopic hiatal hernia repair. JSLS 2013; 17:23-9. [PMID: 23743369 PMCID: PMC3662742 DOI: 10.4293/108680812x13517013316951] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Terrence M Fullum
- Department of Surgery, Howard University College of Medicine, Washington, DC 20060, USA.
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15
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Sandstrom CK, Stern EJ. Diaphragmatic hernias: a spectrum of radiographic appearances. Curr Probl Diagn Radiol 2011; 40:95-115. [PMID: 21440192 DOI: 10.1067/j.cpradiol.2009.11.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Diaphragmatic hernias are common, and although frequently incidental, recognition of both benign and life-threatening manifestations of diaphragmatic hernias is necessary to guide appropriate management. Congenital fetal diaphragmatic hernias, traumatic diaphragmatic rupture, and large symptomatic Bochdalek, Morgagni, and hiatal hernias are typically repaired surgically, while eventration, diaphragmatic slips, and small diaphragmatic hernias do not require intervention or imaging follow-up but should be recognized to avoid confusion with other diagnoses that require additional attention. This pictorial essay will explore the imaging findings and clinical characteristics of these entities.
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Affiliation(s)
- Claire K Sandstrom
- Division of Chest Imaging, Department of Radiology, University of Washington, Seattle, WA 98195-7115, USA.
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Gouvas N, Tsiaoussis J, Athanasakis E, Zervakis N, Pechlivanides G, Xynos E. Simple suture or prosthesis hiatal closure in laparoscopic repair of paraesophageal hernia: a retrospective cohort study. Dis Esophagus 2011; 24:69-78. [PMID: 20659144 DOI: 10.1111/j.1442-2050.2010.01094.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Laparoscopic repair of paraesophageal hernia (PEH) involves removal of the hernia sac, cruroplasty, and fundoplication. Mesh application to cruroplasty seems to reduce hernia recurrence rate, but may be associated with dysphagia. The aim of the study was to review the clinical and laboratory outcomes of a series of patients with PEH after laparoscopic repair. Patients with PEH, who had laparoscopic repair and 1-year postoperative follow-up, were included in the study. Pre- and postoperative testing included symptom questionnaires, barium esophagogram, pH-monitoring, barium swallow testing. In the first half cases, suturing of large hernia gaps was reinforced with prosthesis (PR), whereas in the second half only suture cruroplasty (SC) was performed. Sixty-eight patients (36 male) with PEH were included in the study. There were no conversions to open. Postoperatively, dysphagia grading was significantly correlated to esophageal transit time (P < 0.001). There were seven recurrences; one paraesophageal and six wrap migrations. Also, four cases with stenosis were identified all in the PR group. Dysphagia was more common (P= 0.05) and esophageal transit more delayed (P= 0.034) after PR than after SC. Two revisions, one for esophageal stenosis and one for recurrent PEH, derived from the SC group. Reflux was more common after Toupet fundoplication than after Nissen fundoplication (NF) (P= 0.031) in patients with impaired esophageal motility. Laparoscopic repair of PEH with SC is associated with satisfactory clinical outcomes and low rate of wrap migration, at least similar to PR hiatal repair. NF is effective as an antireflux procedure in all cases.
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Affiliation(s)
- N Gouvas
- 1st Department of General Surgery, Agia Olga Hospital of Athens, Greece.
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Schuchert MJ, Adusumilli PS, Cook CC, Colovos C, Kilic A, Nason KS, Landreneau JP, Zikos T, Jack R, Luketich JD, Landreneau RJ. The impact of scoliosis among patients with giant paraesophageal hernia. J Gastrointest Surg 2011; 15:23-28. [PMID: 20824386 DOI: 10.1007/s11605-010-1307-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2009] [Accepted: 08/09/2010] [Indexed: 01/31/2023]
Abstract
BACKGROUND Kyphoscoliosis is seen in approximately 1.4-15% of the octogenarian population of the US. We hypothesized that patients with kyphoscoliosis are affected with a reduced intra-abdominal volume and progressive laxity of the diaphragmatic hiatal sling musculature leading to an increased risk of hiatal hernia formation and progression over time. METHODS We retrospectively reviewed the clinical history and roentgenographic data of 320 paraesophageal hernia patients from 2003 to 2007. The prevalence of kyphoscoliosis among this patient cohort and the outcomes of surgical management were compared to paraesophageal hernia patients without kyphoscoliosis. RESULTS Ninety-three of the 320 patients (29.1%) were found to have significant K/S (mean age 74; 83% female). Laparoscopic repair of paraesophageal hernia with fundoplication was performed in 91% of these patients. There was one death (1.1%; aspiration pneumonia) and 17.2% major postoperative morbidity. Mean length of hospital stay was 8 days (median = 4; range 2-71). Prolonged stays were related mainly to marginal pulmonary status. Kyphoscoliosis was associated with increased peri-operative pulmonary morbidity (16.1%) compared to patients without kyphoscoliosis (7.0%, p = 0.02). CONCLUSION Kyphoscoliosis may contribute to the development and progression of paraesophageal hernias. Surgeons approaching paraesophageal hernia repair should be aware of the increased pulmonary morbidity and the postoperative care required in managing these patients.
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Affiliation(s)
- Matthew J Schuchert
- Division of Thoracic and Foregut Surgery, Heart, Lung and Esophageal Surgery Institute, UPMC Health System, Pittsburgh, PA, USA.
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18
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Khanna A, Finch G. Paraoesophageal herniation: a review. Surgeon 2010; 9:104-11. [PMID: 21342675 DOI: 10.1016/j.surge.2010.10.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2010] [Revised: 10/24/2010] [Accepted: 10/26/2010] [Indexed: 12/18/2022]
Abstract
BACKGROUND Paraoesophageal hiatus herniae repair can represent a formidable challenge. Afflicted patients tend to be elderly with multiple infirmities often with cardio-pulmonary dysfunction. They may present acutely with protracted vomiting and concurrent biochemical imbalances and it is a technically demanding procedure. There are several debated issues regarding operative technique. This paper will attempt to explain the nature of paraoesophageal hiatus herniae and reviews the recommended pre-operative investigations and operative strategies available. METHODS A literature search was performed from Pubmed and suitable clinical papers were selected for review. When attempting to address whether meshes should be included routinely, electronic searches were performed in PubMed, Embase and the Cochrane library. A systematic search was done with the following medical subject heading (MeSH) terms: 'paraoesophageal hernia repair' AND 'mesh'. In PubMed and Embase the search was carried out with the limits 'humans', 'English language', 'all adult: 19+ years' and 'published between 1990 and 2010'. A manual cross-reference search of the bibliographies of included papers was carried out to identify additional potentially relevant studies. RESULTS Firm conclusions are difficult to draw due to the diverse nature of both the disorder and the presentation however principals of management can be suggested. Similarly, there is no conclusive proof of the most effective operative technique and therefore the options are described. CONCLUSION Due to the relative lack of cases encountered at smaller institutions, there is a good argument for centralisation of these cases into regional centres to allow research and facilitate improvements in care.
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Affiliation(s)
- Achal Khanna
- Department of Surgery, Northampton General Hospital, UK.
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19
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Abstract
The management of paraesophageal hernia (PEH) has become one of the most widely debated and controversial areas in surgery. PEHs are relatively uncommon, often presenting in patients entering their seventh or eighth decades of life. Patients who have PEH often bear complicating medical comorbidities making them potentially poor operative candidates. Taking this into account makes surgical management of these patients all the more complex. Many considerations must be taken into account in formulating a management strategy for patients who have PEHs, and these considerations have led surgeons into ongoing debates in recent decades.
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Affiliation(s)
- S Scott Davis
- Emory Endosurgery Unit, Emory University, Emory Clinic Building A, 1365 Clifton Road, Suite H-124, Atlanta, GA 30322, USA.
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20
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Limsukon A, Barack BM, Soo Hoo GW. Images in radiology. Can't take a deep breath. Am J Med 2008; 121:1055-7. [PMID: 19028200 DOI: 10.1016/j.amjmed.2008.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2008] [Revised: 09/04/2008] [Accepted: 09/04/2008] [Indexed: 11/15/2022]
Affiliation(s)
- Atikun Limsukon
- Division of Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center, Los Angeles, Calif., USA.
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21
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Gockel I, Heintz A, Tong Trinh T, Domeyer M, Dahmen A, Junginger T. Laparoscopic Anterior Semifundoplication in Patients with Intrathoracic Stomach. Am Surg 2008. [DOI: 10.1177/000313480807400104] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The laparoscopic management of the intrathoracic stomach is still controversial. Laparoscopic semifundoplication in gastroesophageal reflux disease results in effective long-term reflux control and is, as compared with 360° Nissen fundoplication, associated with less frequent side effects such as dysphagia and gas bloat syndrome. The aim of our study was to evaluate the results of laparoscopic anterior semifundoplication in patients with intrathoracic stomach. Enrolled in this study are 19 patients (67.1 years of age; range, 37.5–83.7 years) with intrathoracic stomach undergoing laparoscopic anterior semifundoplication and a minimal follow up of 5 months postoperatively. The study covers the interval between August 1999 and March 2006. Including criterion was a minimum percentage of herniated intrathoracic stomach of 33 per cent. A standardized questionnaire was used for follow up and the modified symptomatic DeMeester score (0–9) was assessed. The median percentage of herniated stomach in the chest was 87.5 per cent (range, 33–100%). Seven patients revealed organo-axial volvulus of the stomach. Duration of preoperative symptoms was 24 months (range, 1–266 months) with a median follow up of 18 months (range, 5–76 months) postoperatively. The modified symptomatic DeMeester score was 0 (0–3). Thirteen of 19 patients were on no postoperative proton pump inhibitor medication. One patient had anatomic recurrence on late follow up at 27 months. The overall contentment with the surgical treatment on an analog scale from 0 to 10 was a median of 9. Although laparoscopic anterior semifundoplication yields satisfactory symptomatic results in patients with intrathoracic stomach, the incidence of failures and anatomical recurrences is higher than expected from subjective data. Prospective, randomized long-term studies are essential to gain further information about the “ideal” type of laparoscopic repair in large hiatal hernia with intrathoracic stomach.
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Affiliation(s)
- Ines Gockel
- Departments of General and Abdominal Surgery, Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Achim Heintz
- Departments of General and Abdominal Surgery, Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Tran Tong Trinh
- Departments of General and Abdominal Surgery, Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Mario Domeyer
- Departments of General and Abdominal Surgery, Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Anja Dahmen
- Departments of Diagnostic and Interventional Radiology, Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Theodor Junginger
- Departments of General and Abdominal Surgery, Johannes Gutenberg-University of Mainz, Mainz, Germany
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22
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Esophagus Benign Diseases of the Esophagus. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_44] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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23
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A review of laparoscopic paraesophageal hernia repair. Eur Surg 2007. [DOI: 10.1007/s10353-007-0325-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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24
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McLean TR, Haller CC, Lowry S. The need for flexibility in the operative management of type III paraesophageal hernias. Am J Surg 2006; 192:e32-6. [PMID: 17071178 DOI: 10.1016/j.amjsurg.2006.08.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2006] [Revised: 08/01/2006] [Accepted: 08/01/2006] [Indexed: 11/17/2022]
Abstract
BACKGROUND A myriad of operation exist to treat type III paraesophageal hernias (T3PH). How does one choose? METHODS A retrospective review of a consecutive series of resident-preformed T3PH repair. RESULTS Three patients with T3PH were operated on during a 6-year period. The presentation of each patient was unique. Three different surgical procedures were used to treat these patients depending on the patient's condition at presentation, the location of the gastroesophageal junction, and the documentation of reflux. Transabdominal hernia reduction and a modified Hill procedure was used in 1 patient; a transthoracic hernia reduction was supplemented with a either a Belsy-Mark IV fundoplication or a Collis-Nissen gastroplasty in the other 2 patients. Patients were discharged home 7 (3-13) days postoperatively, and at a mean follow-up of 23 (2-60) months, all patients are asymptomatic and without radiographic recurrence. CONCLUSION Operative selection for T3PH should be flexible depending on the (1) urgency of symptoms, (2) location of the gastroesophageal junction, and (3) evidence for gastroesophageal reflux.
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Affiliation(s)
- Thomas R McLean
- Dwight D. Eisenhower Veterans Administration Medical Center, 4101 South 4th Street Trafficway, Leavenworth, KS, USA.
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25
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Morino M, Giaccone C, Pellegrino L, Rebecchi F. Laparoscopic management of giant hiatal hernia: factors influencing long-term outcome. Surg Endosc 2006; 20:1011-6. [PMID: 16763927 DOI: 10.1007/s00464-005-0550-6] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2005] [Accepted: 01/20/2006] [Indexed: 11/25/2022]
Abstract
BACKGROUND The laparoscopic management of large hiatal hernias still is controversial. Recent studies have presented a high recurrence rate. METHODS In this study, 65 patients underwent elective laparoscopic repair of large hiatal hernia. A short esophagus was diagnosed in 13 cases. A primary closure of the hiatal defect was performed in 14 cases. "Tension-free" repair using a mesh was performed in 37 cases, and 14 patients underwent a Collis-Nissen gastroplasty. For the last 38 patients in the series, an intraoperative endoscopy was performed to identify the esophagogastric junction. RESULTS There was no mortality, no conversions to open surgery, and no intraoperative complications. A recurrent hernia was present in 23 of the 77 patients (30%). The recurrence rate was 77% when a direct suture was used and 35% when a mesh was used (p < 0.05). No recurrences were observed in the patients treated with the Collis-Nissen technique, but in one case, perforation of the distal esophagus developed 3 weeks after surgery. The multivariate analysis showed that recurrences are statistically correlated with the type of hiatal hernia and surgical technique. CONCLUSIONS To reduce recurrences after laparoscopic management of large hiatal hernias, it is essential to identify all cases of short esophagus using intraoperative endoscopy and to perform a Collis-Nissen procedure in such cases.
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Affiliation(s)
- M Morino
- Department of Surgery, Minimally Invasive Surgery Center, University of Turin, C.so A.M. Dogliotti, 14, 10126 Torino, Italy.
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26
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Kato H, Miyazaki T, Kimura H, Faried A, Sohda M, Nakajima M, Fukai Y, Masuda N, Fukuchi M, Manda R, Ojima H, Tsukada K, Kuwano H. A novel technique to facilitate laparoscopic repair of large paraesophageal hernias. Am J Surg 2006; 191:545-8. [PMID: 16531152 DOI: 10.1016/j.amjsurg.2006.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2004] [Revised: 10/17/2005] [Indexed: 11/20/2022]
Abstract
BACKGROUND Laparoscopic repair of large paraesophageal hernias (LPEH) is technically challenging, and requires advanced laparoscopic skills. We have developed a novel technique for facilitating laparoscopic repair of LPEHs safely and easily, using a Nelaton catheter. PATIENTS AND METHODS Seven patients with LPEHs were operated on through a laparoscopic approach. During surgery, the left lobe of the liver and right diaphragmatic crus were elevated using a suspended thread covered by a Nelaton catheter. RESULTS All patients were operated on laparoscopically using this technique. No patient required conversion to open method. The median operating time was 205 minutes and the range was from 155 to 295 minutes. No intraoperative or early complications occurred in any patient. Late complications occurred in 2 patients due to a small sliding hernia: a slipped fundoplication in 1 patient, and a gastric ulcer in the other. CONCLUSIONS In conclusion, laparoscopic repair of LPEH is a challenging procedure that requires wide experience in laparoscopic gastroesophageal surgery. Further refinement for this operation may be necessary.
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Affiliation(s)
- Hiroyuki Kato
- Department of General Surgical Science, Gunma University, Graduate School of Medicine, Maebashi, Gunma 371-8511, Japan
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27
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Abstract
Patients with iron deficiency anemia sometimes have a large paraesophageal hernia and no other explanation for their chronic blood loss. The management of these patients can be a dilemma, especially when the hernia is otherwise asymptomatic. We aimed to determine whether a laparoscopic repair of the hernia could cure the anemia. We reviewed a consecutive series of 11 cases of iron deficiency anemia associated with a large paraesophageal hernia, many without associated linear gastric erosions, managed by laparoscopic repair and fundoplication. There was one conversion in a patient with dense adhesions from previous upper abdominal surgery. Another patient required a laparoscopic reoperation for an early recurrence. Major morbidity occurred in three patients and there was no mortality. There was no recurrence of anemia after a median follow-up of more than 2 years. Iron deficiency anemia in association with a large paraesophageal hernia can be treated by laparoscopic repair with acceptable morbidity and minimal mortality. The complications of a large paraesophageal hernia are also prevented.
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Affiliation(s)
- J D Hayden
- Department of Surgery, University of Adelaide and Royal Adelaide Hospital, North Terrace, Adelaide, South Australia, Australia
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28
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Abstract
A tailored approach to the management of patients who have para-esophageal herniation appears to be the best policy. No one approach can universally apply to this patient population if optimal therapy, quality of life, and overall survival are to be optimized.
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Affiliation(s)
- Rodney J Landreneau
- Division of Thoracic and Foregut Surgery, University of Pittsburgh Medical Center, Shadyside Medical Center, 5200 Centre Avenue, Pittsburgh, PA 15232, USA.
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29
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Andujar JJ, Papasavas PK, Birdas T, Robke J, Raftopoulos Y, Gagné DJ, Caushaj PF, Landreneau RJ, Keenan RJ. Laparoscopic repair of large paraesophageal hernia is associated with a low incidence of recurrence and reoperation. Surg Endosc 2004; 18:444-7. [PMID: 14752653 DOI: 10.1007/s00464-003-8823-4] [Citation(s) in RCA: 114] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2003] [Accepted: 09/08/2003] [Indexed: 11/30/2022]
Abstract
BACKGROUND Laparoscopic repair of paraesophageal hernia (LRPEH) is a feasible and effective technique. There have been some recent concerns regarding possible high recurrence rates following laparoscopic repair. METHODS We reviewed our experience with LRPEH from 5/1996 to 8/2002. Large paraesophageal hernia (PEH) was defined by the presence of more than one-third of the stomach in the thoracic cavity. Principles of repair included reduction of the hernia, excision of the sac, approximation of the crura, and fundoplication. Pre- and postoperative symptoms were evaluated utilizing visual analogue scores (VAS) on a scale ranging from 0 to 10. Patients were followed with VAS and barium esophagram studies. Statistical analysis was performed using two-tailed Student's t-test. RESULTS A total of 166 patients with a mean age of 68 years underwent LRPEH. PEH were type II ( n = 43), type III ( n = 104), and type IV ( n = 19). Mean operative time was 160 min. Fundoplications were Nissen (127), Toupet (23), Dor (1), and Nissen-Collis (1). Fourteen patients underwent a gastropexy. One patient required early reoperation to repair an esophageal leak. Mean hospital stay was 3.9 days. At 24 months postoperatively there was statistically significant improvement in the mean symptom scores: heartburn from 6.8 to 0.5, regurgitation from 5.9 to 0.3, dysphagia from 4.0 to 0.5, chest pain from 3.7 to 0.3. Radiographic surveillance was obtained in 120 patients (72%) at a mean of 15 months postoperatively. Six patients (5%) had radiographic evidence of a recurrent paraesophageal hernia (two required surgery), 24 patients (20%) had a sliding hernia (two required surgery), and four patients (3.3%) had wrap failure (all four required surgery). Reoperation was required in 10 patients (6%); two for symptomatic recurrent PEH (1.2%), four for recurrent reflux symptoms (2.4%), and four for dysphagia (2.4%). Patients with abnormal postoperative barium esophagram studies who did not require reoperation have remained asymptomatic at a mean follow up of 14 months. CONCLUSION LPEHR is a safe and effective treatment for PEH. Postoperative radiographic abnormalities, such as a small sliding hernia, are often seen. The clinical importance of these findings is questionable, since only a small percentage of patients require reoperation. True PEH recurrences are uncommon and frequently asymptomatic.
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Affiliation(s)
- J J Andujar
- Minimally Invasive Surgical Program, West Penn Allegheny Health System, 4800 Friendship Ave., Pittsburgh, PA 15224, USA
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30
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Diaz S, Brunt LM, Klingensmith ME, Frisella PM, Soper NJ. Laparoscopic paraesophageal hernia repair, a challenging operation: medium-term outcome of 116 patients. J Gastrointest Surg 2003; 7:59-67. [PMID: 12559186 DOI: 10.1016/s1091-255x(02)00151-8] [Citation(s) in RCA: 119] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Laparoscopic paraesophageal hernia repairs performed in 116 patients between 1992 and 2001 were prospectively analyzed. Perioperative outcomes were assessed and follow-up was performed under protocol. There were 85 female and 31 male patients who had a mean (+/- SD) age of 65 +/- 13 years and an American Society of Anesthesiology score of 2.3 +/- 0.6. All but two patients underwent an antireflux procedure. Gastropexy was performed in 48 patients, an esophageal lengthening procedure in six patients, and prosthetic closure of the hiatus in six patients. Major complications occurred in five patients (4.3%) with two postoperative deaths (1.7%). Mean follow-up was 30 +/- 25 months; 96 patients (83%) have been followed for more than 6 months. Among these patients, 73 (76%) are asymptomatic, 11 (11%) have mild symptoms, and 12 (13%) take antacid medications. Protocol barium esophagograms were obtained in 69% of patients at 6 to 12 months' follow-up. Recurrence of hiatal hernia was documented in 21 patients (22% overall and in 32% of those undergoing contrast studies). Reoperation has been performed in three patients (3%). When only the patients with recurrent hiatal hernias are considered, 13 (62%) are symptomatic but only six (28%) require medication for symptoms. Laparoscopic paraesophageal hernia repair is generally safe, even in this high-risk group. This study confirms a relatively high incidence of recurrent hiatal abnormalities after paraesophageal hernia repair; however, most recurrent hiatal hernias are small and only 3% have required reoperation. Protocol esophagograms detect recurrences that are minimally symptomatic. Improved techniques must be devised to improve the long-term outcomes of laparoscopic paraesophageal hernia repair.
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Affiliation(s)
- Sergio Diaz
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - L Michael Brunt
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Mary E Klingensmith
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Peggy M Frisella
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Nathaniel J Soper
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri.
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31
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Scheidler MG, Keenan RJ, Maley RH, Wiechmann RJ, Fowler D, Landreneau RJ. "True" parahiatal hernia: a rare entity radiologic presentation and clinical management. Ann Thorac Surg 2002; 73:416-9. [PMID: 11845852 DOI: 10.1016/s0003-4975(01)03373-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND True parahiatal diaphragmatic hernias are rare entities that are sparsely accounted for in the literature. The current report is intended to depict the clinical profile and assess the feasibility of laparoscopic repair of parahiatal hernias. METHODS We conducted a retrospective review of all patients diagnosed and treated for parahiatal hernias. Clinical presentation and radiological assessment, as well as operative findings and repair, are discussed. RESULTS Of the 917 laparoscopic hiatal hernia repairs, 2 (0.2%) patients were identified with a parahiatal hernia. The presenting symptoms and preoperative testing were similar to those with more common paraesophageal hernias. Laparoscopic repair was successful in repairing the diaphragmatic defect and alleviating symptoms up to 4 years postoperatively. CONCLUSIONS Parahiatal hernias of the diaphragm appear to be rare primary diaphragmatic defects. The clinical presentation of parahiatal hernias is often indistinguishable from the more common paraesophageal pathology. Laparoscopic repair of this rare entity can be safely and successfully accomplished in conjunction with antireflux surgical interventions when indicated.
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Affiliation(s)
- Michael G Scheidler
- Divisions of General Thoracic and Minimally Invasive Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania 15213, USA
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32
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Wiechmann RJ, Ferguson MK, Naunheim KS, McKesey P, Hazelrigg SJ, Santucci TS, Macherey RS, Landreneau RJ. Laparoscopic management of giant paraesophageal herniation. Ann Thorac Surg 2001; 71:1080-6; discussion 1086-7. [PMID: 11308140 DOI: 10.1016/s0003-4975(00)01229-7] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Many surgeons have found laparoscopic fundoplication effective management of medically recalcitrant gastroesophageal reflux disease (GERD) associated with sliding type I hiatal hernias. The anatomic distortion and technical difficulty inherent with repair has limited the use of laparoscopy for repair of "giant" paraesophageal hernias (gPH). METHODS Since July 1993, we have accomplished laparoscopic repair of paraesophageal hiatal hernias in 54 of 60 (90%) patients. Five patients had classic type II hernias with total intrathoracic stomachs, and 53 patients had large sliding/paraesophageal type III herniation. Two patients had true parahiatal hernias. None had gastric incarceration. Median age was 53 years and 28 of 60 (47%) were women. Chest pain and dysphagia were primary complaints from 39 of 60 (65%). Heartburn with or without regurgitation was present in 52 of 60 (85%). Preoperative manometry and prolonged pH testing were obtained on 43 of 60 (72%) and 44 of 60 (73%) patients, respectively. Principles of repair included reduction of the hernia, excision of the sac, crural approximation, and fundoplication over a 54F bougie (Nissen, 41; Dor, 1; Toupet, 18) to "pexy" the stomach within the abdomen and to control postoperative reflux. RESULTS Mean operative time was 202+/-81 minutes. Conversion to "open" repair was required in 6 patients (iatrogenic esophageal injury in 2 patients and difficult hernia sac dissection in 4 patients). One postoperative mortality occurred as a result of sepsis and multiorgan failure after an intraoperative esophageal perforation. Follow-up barium swallow performed in 44 of 60 patients demonstrated recurrent hiatal hernias in 3 patients. Preoperative symptoms have been relieved in all but 3 patients. Reoperation for recurrent paraesophageal herniation has been required in these latter 3 patients. CONCLUSIONS Although technically challenging, laparoscopic repair of paraesophageal hiatal hernias is a viable alternative to "open" surgical approaches. Control of the herniation and the patient's symptoms are equivalent and hospitalization and return to full activity are shorter.
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Affiliation(s)
- R J Wiechmann
- Allegheny General Hospital Campus, Allegheny University of the Health Sciences, Pittsburgh, Pennsylvania, USA
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33
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Halpin VJ, Soper NJ. Paraesophageal Hernia. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2001; 4:83-88. [PMID: 11177685 DOI: 10.1007/s11938-001-0050-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The definitive management of paraesophageal hernia is surgical repair. The current standard of care is the laparoscopic paraesophageal hernia repair in patients who are medically fit for general anesthesia and operation. When patients are considered for operative repair, they should undergo diagnostic testing, including upper endoscopy, upper gastrointestinal series, and esophageal manometry.
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Affiliation(s)
- Valerie J. Halpin
- Department of Surgery, Washington University School of Medicine, 660 South Euclid Avenue, Box 8109, St. Louis, MO 63110-8109, USA
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34
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Esophagus. Surgery 2001. [DOI: 10.1007/978-3-642-57282-1_26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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35
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Abstract
Elective surgical repair of "giant" paraesophageal hernias is recommended to prevent the potential complications of gastric volvulus, obstruction, and ischemic perforation. We report the unusual complication of splenic capsular laceration and hemorrhagic shock following forceful retching by a patient with an incarcerated paraesophageal hernia.
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Affiliation(s)
- M F Szwerc
- Division of General Thoracic Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania 15212, USA
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36
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Abstract
The laparoscopic repair of paraesophageal hernia has proven to be safe and effective, with relatively low morbidity and mortality rates. The laparoscopic approach is feasible in patients with paraesophageal hernia because these patients are usually past middle age and commonly have multiple other medical problems. The procedure is technically demanding, but skilled laparoscopic surgeons should be able to perform the standard repair, that is, sac excision, crural closure, and fundoplication or gastropexy.
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Affiliation(s)
- M Oddsdóttir
- Department of Surgery, University Hospital-Landspitali Hringbraut, Reykjavik, Iceland.
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37
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Abstract
Herniation of a portion of the stomach through the esophageal hiatus into the posterior mediastinum is a common affliction of humans. The incidence of hiatal hernia is difficult to determine because of the absence of symptoms in a large number of patients. Upper gastrointestinal barium examinations in symptomatic patients identify some type of hiatal hernia in as many as 15% of patients.
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Affiliation(s)
- M Hashemi
- Department of Surgery, University of Southern California, Los Angeles, USA
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38
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Floch NR, DeVault KR, Smith SL, Hinder RA. Prolonged dysphagia after a paraesophageal hernia repair with Nissen fundoplication. J Clin Gastroenterol 1999; 28:224-7. [PMID: 10192607 DOI: 10.1097/00004836-199904000-00007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- N R Floch
- Department of Surgery, Mayo Clinic Jacksonville, Florida 32224, USA
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39
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Abstract
BACKGROUND Intrathoracic herniation of abdominal viscera is a potentially life-threatening condition, especially when diagnosis is delayed. The aim of this study was to estimate its incidence following oesophageal resection and to define contributing factors that might influence its occurrence. METHODS All radiographic studies of the chest that were made during follow-up in a series of 218 patients who underwent oesophagectomy between 1993 and 1997 were reviewed. RESULTS Herniation of bowel alongside the oesophageal substitute was detected in nine patients (4 per cent). Four hernias occurred within the first week after operation and five were detected at late follow-up. Surgical treatment was indicated in six patients. Analysis of predisposing factors revealed that extended incision and partial resection of the diaphragm were associated with an increased risk of postoperative hernia formation (four of 29 following extended enlargement versus five of 189 after routine opening of the oesophageal hiatus; P = 0.02). CONCLUSION Diaphragmatic herniation was found in 4 per cent of patients after oesophagectomy. After extended iatrogenic disruption of the normal hiatal anatomy, narrowing of the diaphragmatic opening may be indicated to avoid postoperative herniation of bowel into the chest. Awareness of its possible occurrence may help prevent the development of intestinal obstruction and strangulation.
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Affiliation(s)
- J W van Sandick
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
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40
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Maziak DE, Todd TR, Pearson FG. Massive hiatus hernia: evaluation and surgical management. J Thorac Cardiovasc Surg 1998; 115:53-60; discussion 61-2. [PMID: 9451045 DOI: 10.1016/s0022-5223(98)70442-8] [Citation(s) in RCA: 158] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Paraesophageal hernias represent advanced degrees of sliding hiatus hernia with intrathoracic displacement of the intraesophageal junction. Gastroesophageal reflux disease occurs in most cases, resulting in acquired short esophagus, which should influence the type of repair selected. METHODS Between 1960 and 1996, 94 patients with massive, incarcerated paraesophageal hiatus hernia were operated on at the Toronto General Hospital. The mean age was 64 years (39 to 85 years), with a female to male ratio of 1.8:1. Organoaxial volvulus was present in 50% of cases. Clinical presentation in these patients included postprandial pain in 56%, dysphagia in 48%, chronic iron deficiency anemia in 38%, and aspiration in 29%. Symptomatic reflux, either present or remote, was recorded in 83% of cases. All patients underwent endoscopy by the operating surgeon. In 91 of 94 patients, the esophagogastric junction was found to be above the diaphragmatic hiatus, denoting a sliding type of hiatus hernia. Gross, endoscopic peptic esophagitis was observed in 36% of patients: ulcerative esophagitis in 22% and peptic esophagitis with stricture in 14%. A complete preoperative esophageal motility study was obtained for 41 patients. The lower sphincter was hypotensive in 21 patients (51%), and the amplitude of peristalsis in the distal esophagus was diminished in 24 patients (59%). These abnormalities are both features of significant gastroesophageal reflux disease. In 13 recent, consecutive patients with paraesophageal hernia, the distance between the upper and lower esophageal sphincters was measured during manometry. The average distance was 15.4 +/- 2.33 cm (11 to 20 cm), which is consistent with acquired short esophagus. The normal distance is 20.4 cm +/- 1.9 (p < 0.0001). RESULTS All 94 patients were treated surgically: 97% had a transthoracic repair with fundoplication. A gastroplasty was added in 75 cases (80%) because of clearly defined or presumed short esophagus. There were two operative deaths, and two patients were never followed up. Among the 90 available patients, the mean follow-up was 94 months; median follow-up was 72 months. Seventy-two patients (80%) are free of symptoms (excellent result); 13 (13%) have inconsequential symptoms requiring no therapy (good result); and three patients (4%) are improved but have symptoms requiring medical therapy or interval dilatation (fair result). Two patients had poor results because of recurrent hernia and severe reflux. Both were successfully treated by reoperation with the addition of gastroplasty because of acquired shortening, which was not recognized at the first operation. CONCLUSIONS Most of these 94 patients had symptoms or endoscopic, manometric, and operative findings that were consistent with a sliding hiatus hernia. There was a high incidence of endoscopic reflux esophagitis and of acquired short esophagus. True paraesophageal hernia, with the esophagogastric junction in a normal abdominal location, appears rare. Our observations were supported by measurements obtained at preoperative endoscopy and manometry, and by findings at the time of surgical repair. These observations support the choice of a transthoracic approach for repair in most patients.
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Affiliation(s)
- D E Maziak
- University of Toronto, Department of Thoracic Surgery, Ontario, Canada
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41
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Zaninotto G, Costantini M, Anselmino M, Boccù C, Molena D, Rigotti P, Merigliano S, Ancona E. Oesophageal and cardia function in patients with paraoesophageal hiatus hernia. Br J Surg 1997. [DOI: 10.1046/j.1365-2168.1997.d01-1409.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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42
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Zaninotto G, Costantini M, Anselmino M, Boccù C, Molena D, Rigotti P, Merigliano S, Ancona E. Oesophageal and cardia function in patients with paraoesophageal hiatus hernia. Br J Surg 1997. [DOI: 10.1002/bjs.1800840835] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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43
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Abstract
OBJECTIVE The purpose of this report is to describe the authors' technique for the laparoscopic repair of paraesophageal hernias and the outcome in their series of patients. METHODS Thirty patients underwent elective laparoscopic repair of paraesophageal hernias. All were pure type II paraesophageal hernias as defined by upper gastrointestinal contrast studies. All operations were performed by a single surgeon (JKE) assisted by five different chief surgical residents. The authors have used various prototypes of a laparoscopic utility belt to reduce the physician requirement to the surgeon and a first assistant. The operative setup and specific techniques of the repair are described and illustrated. A concomitant anti-reflux procedure was performed in the last 23 patients. RESULTS Satisfactory repair using video-laparoscopic techniques was achieved in all cases. There were no deaths. Complications occurred in 8 of 30 patients. Postoperative gastroesophageal reflux developed in three of the first seven patients in whom fundoplication was not performed. Three consecutive patients had left lower lobe atelectasis believed to be related to endotracheal tube displacement during the passage of the bougie. One patient had postoperative dysphagia. There was one case of major deep venous thrombosis with pulmonary embolism. Twenty-eight of 30 patients were discharged home by postoperative day 3. Twenty-four of 30 patients had returned to normal activity by the time of their first postoperative office visit 1 week after surgery.
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Affiliation(s)
- C L Willekes
- Department of Surgery, Morristown Memorial Hospital, New Jersey, USA
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44
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Behrns KE, Schlinkert RT. Laparoscopic management of paraesophageal hernia: early results. JOURNAL OF LAPAROENDOSCOPIC SURGERY 1996; 6:311-7. [PMID: 8897241 DOI: 10.1089/lps.1996.6.311] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The objective was to review our early results with laparoscopic repair of paraesophageal hernias to determine the safety, technical feasibility, and short-term outcome of the operation. Twelve patients with a mean age of 75 +/- 1 years underwent laparoscopic repair of a paraesophageal hernia. Principles of open repair, including sac excision, primary crural repair, and pexy, were accomplished laparoscopically in 83%, 83%, and 100% of patients, respectively. In two patients the diaphragmatic defect was closed with mesh. Fundoplication was also performed in seven patients with symptoms of reflux disease. No laparoscopic procedure was converted to an open repair; however, one patient required a postoperative celiotomy to control hemorrhage. Short-term evaluation of all patients postoperatively detected gastroesophageal reflux disease (GERD) in five patients (42%), four of whom did not undergo fundoplication. Two major complications were esophageal perforation and bleeding. Minor complications included atrial fibrillation in two patients, meat impaction in one patient, and a small asymptomatic recurrence in a single patient. Overall patient satisfaction was high. Laparoscopic repair of paraesophageal hernias was safe and technically feasible and warrants further investigation. The incidence of postoperative esophageal reflux, however, is high if an antireflux procedure is not performed. Extensive preoperative evaluation for reflux should objectively identify patients requiring fundoplication and decrease the incidence of postoperative GERD.
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Affiliation(s)
- K E Behrns
- Department of Surgery, Mayo Clinic, Scottsdale, Arizona, USA
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45
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Oddsdottir M, Franco AL, Laycock WS, Waring JP, Hunter JG. Laparoscopic repair of paraesophageal hernia. New access, old technique. Surg Endosc 1995; 9:164-8. [PMID: 7597586 DOI: 10.1007/bf00191959] [Citation(s) in RCA: 55] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Large paraesophageal hernias are generally repaired by reduction of the stomach into the abdomen, sac excision, crural closure, and gastropexy or fundoplication. After gaining experience performing laparoscopic repair of sliding hiatal hernias and Nissen fundoplication we combined laparoscopic access with traditional surgical technique in treating patients with complex paraesophageal hernias. Ten adults, six males and four females, with type III paraesophageal hernias underwent laparoscopic repair between February 1993 and April 1994. The average age of the patients was 60.4 years (range 38-81). Using five ports (three 10 mm and two 5 mm), the stomach was reduced into the abdomen, the hernia sac was resected, and the defect was closed with pledgeted horizontal mattress sutures. In addition, nine patients had a Nissen fundoplication performed and one patient had a diaphragmatic gastropexy. The procedure was completed laparoscopically in all ten cases and the median operating time was 282 min (range 165-430). Two complications occurred, an intraoperative gastric laceration, and a postoperative mediastinal seroma. All patients were discharged on the 2nd or 3rd postoperative day. Eight of nine patients were asymptomatic at last follow-up (mean 8.9 months postop). One patient has mild dysphagia and heartburn from partial migration of the fundoplication into the chest. One patient died 3 months postoperatively of unrelated causes. Paraesophageal hernia can be reduced and repaired safely with laparoscopic access using standard surgical techniques.
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Affiliation(s)
- M Oddsdottir
- Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322, USA
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Rakić S, Pesko P, Dunjić MS, Gerzić Z. Paraoesophageal hernia repair with and without concomitant fundoplication. Br J Surg 1994; 81:1162-3. [PMID: 7953348 DOI: 10.1002/bjs.1800810826] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
There is currently no consensus as to whether an antireflux procedure should accompany surgical repair of paraoesophageal hernia. Forty consecutive patients with paraoesophageal hernia were studied. Surgery routinely included transabdominal hernia reduction, excision of the sac and crural repair. The addition of fundoplication was based on the presence of preoperative endoscopic evidence of oesophagitis. Twenty-three patients without endoscopic oesophagitis had no antireflux procedure whereas 17 with oesophagitis underwent concomitant antireflux surgery. Thirty-six patients were followed for 1-7 years. Patients without endoscopic oesophagitis had no postoperative reflux problems. All patients with oesophagitis who underwent fundoplication were improved or cured of reflux. The selection of patients for antireflux repair can satisfactorily be based on preoperative endoscopic findings.
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Affiliation(s)
- S Rakić
- Institute of Digestive Diseases, Belgrade University Clinical Centre, Serbia
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47
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Williamson WA, Ellis FH, Streitz JM, Shahian DM. Paraesophageal hiatal hernia: is an antireflux procedure necessary? Ann Thorac Surg 1993; 56:447-51; discussion 451-2. [PMID: 8379715 DOI: 10.1016/0003-4975(93)90878-l] [Citation(s) in RCA: 98] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Between January 1970 and October 1992, 119 patients underwent 126 repairs of a paraesophageal hiatal hernia at the Lahey Clinic. Seven patients with a recurrent hernia required reoperation. Of the procedures, 19 (15%) included an antireflux procedure because of severe reflux symptoms and objective evidence of reflux demonstrated by grade 2 esophagitis on endoscopy, manometric evidence of a hypotensive lower esophageal sphincter pressure (< or = 10 mm Hg), positive results on 24-hour pH monitoring, or all three methods. Follow-up ranged from 6 months to 18 years with a median of 61.5 months, and the results of 115 operations were analyzed. Symptomatic results were good to excellent after 96 (83.5%) of these 115 operations. Thirteen symptomatic paraesophageal hernias recurred in 12 patients (one recurrence per 58 patient-years of follow-up). Severe reflux symptoms accompanied by endoscopic evidence of esophagitis developed in 2 patients who had not undergone an antireflux procedure at the time of repair of the hernia. We conclude that an antireflux procedure is rarely required in patients undergoing repair of a paraesophageal hiatal hernia and should be employed only when objective evidence of reflux is seen preoperatively.
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Affiliation(s)
- W A Williamson
- Department of Thoracic and Cardiovascular Surgery, Lahey Clinic Medical Center, Burlington, MA 01805
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