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Pather K, Dowdall R, Mobley EM, Sacco J, Puri R. Definitive, urgent repair of acutely incarcerated paraesophageal hernias is comparable to an elective repair. Surg Endosc 2025:10.1007/s00464-025-11847-6. [PMID: 40490576 DOI: 10.1007/s00464-025-11847-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2025] [Accepted: 05/19/2025] [Indexed: 06/11/2025]
Abstract
BACKGROUND Emergent repair of paraesophageal hernias (PEHs) is rare. This study aimed to compare outcomes of elective and urgent PEH repairs in patients with type II-IV PEHs. METHODS This was a single-center retrospective review of type II-IV PEHs from February 2014 to April 2024. The operations were classified as elective or urgent. Indications for urgent repair included acute incarceration and/or gastric outlet obstruction, which required immediate NGT decompression and/or EGD followed by definitive repair during the same hospital admission. Outcomes were 90-day hernia recurrence, mortality, readmission, and reoperation. Significant associations between operative cohort and outcomes were evaluated using univariable logistic regression. RESULTS A total of 207 patients were included (female: 82%, median age: 64 years, ASA III: 57%). Type III PEH was most frequent (n = 116, 56%), followed by type IV (n = 64, 31%). There were 21 patients included in the urgent cohort. Of these, gastric decompression was performed via EGD in 16 patients (76%) and only NGT placement in two patients (10%). The median time to definitive repair was 6 [IQR 1.0-13.5] days. Laparoscopic (n = 126, 61%) and robotic (n = 75, 36%) approaches were similar between the elective and urgent cohorts (p = 0.70). Nissen fundoplication (n = 108, 52%) was the most common anti-reflux operation performed. The median length of stay (3 vs 4 days, p = 0.10) and hernia recurrence (n = 3 vs n = 1, p = 0.32) were comparable between the cohorts. There was one mortality in the urgent cohort secondary to a respiratory complication. Reoperations occurred in four patients, all in the elective cohort for gastric perforation, ischemic Roux limb, and early postoperative recurrence (n = 2). Readmissions included 18 (10%) and 3 patients (14%) from the elective and urgent cohorts, respectively (p = 0.55). CONCLUSION Acutely incarcerated PEHs are infrequent and require immediate gastric decompression. In stable patients, definitive urgent MIS repair can be performed safely during the same admission, with low risk of postoperative complications or recurrence, comparable to elective operations.
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Affiliation(s)
- Keouna Pather
- Department of Surgery, University of Florida College of Medicine-Jacksonville, 653 West 8th St, Jacksonville, FL, 32209, USA.
| | - Ryan Dowdall
- Department of Surgery, University of Florida College of Medicine-Jacksonville, 653 West 8th St, Jacksonville, FL, 32209, USA
| | - Erin M Mobley
- Department of Surgery, University of Florida College of Medicine-Jacksonville, 653 West 8th St, Jacksonville, FL, 32209, USA
| | - Jana Sacco
- Department of Surgery, University of Florida College of Medicine-Jacksonville, 653 West 8th St, Jacksonville, FL, 32209, USA
| | - Ruchir Puri
- Department of Surgery, University of Florida College of Medicine-Jacksonville, 653 West 8th St, Jacksonville, FL, 32209, USA
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Brandt A, Leslie Z, Rawson M, Ikramuddin S, Wise E. Morbidity of emergent versus elective hiatal hernia repair: an analysis of the NIS database. Surg Endosc 2025; 39:3979-3985. [PMID: 40346433 DOI: 10.1007/s00464-025-11773-7] [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] [Received: 03/15/2025] [Accepted: 04/27/2025] [Indexed: 05/11/2025]
Abstract
BACKGROUND Elective hiatal hernia repair (HHR) is associated with reduced morbidity compared to emergent HHR. However, few studies examine the specific factors contributing to morbidity in emergent HHR. This study uses the National Inpatient Sample (NIS) database to compare the morbidity of emergent versus non-emergent HHR and identify associated risk factors. METHODS Data from the NIS (2016-2021) were analyzed for all patients undergoing HHR. Health factors, including demographics, comorbidities, and operative details, were compared using chi-squared and T-tests. A multivariable logistic regression model was created to identify factors associated with morbidity, defined as postoperative complications such as sepsis, pneumonia, myocardial infarction, deep venous thrombosis (DVT), pulmonary embolism (PE), and others. RESULTS A total of 723,000 records existed with a hiatal hernia diagnosis code. Of these, 67,059 patients underwent HHR, with 61,586 (91.8%) undergoing non-emergent HHR. Emergent HHR was associated with increased morbidity (OR 3.95, 95% CI 1.0-1.05, p < 0.05). Risk factors for increased morbidity in both groups included hypertension and advanced age. Protective factors included female gender, GERD, and prior bariatric surgery. Diabetes increased morbidity in emergent HHR but not non-emergent HHR. Smoking, Medicare/Medicaid, mesh use, COPD, and history of DVT increased morbidity in elective HHR, but not emergent HHR. The robotic approach increased morbidity in non-emergent HHR but decreased it in emergent HHR. CONCLUSION Emergent HHR is associated with higher morbidity compared to non-emergent HHR. Risk factors like smoking, COPD, and DVT increase morbidity in non-emergent HHR, while female gender, GERD, and prior bariatric surgery are protective. The NIS database provides valuable insights into the morbidity associated with HHR and can guide surgical decision-making.
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Affiliation(s)
- Alyssa Brandt
- Department of Surgery, University of Minnesota Medical School, MMC 195, 420 Delaware Street SE, Minneapolis, MN, 55455, USA
| | | | - Mitch Rawson
- Department of Surgery, University of Minnesota Medical School, MMC 195, 420 Delaware Street SE, Minneapolis, MN, 55455, USA
| | - Sayeed Ikramuddin
- Department of Surgery, University of Minnesota Medical School, MMC 195, 420 Delaware Street SE, Minneapolis, MN, 55455, USA
| | - Eric Wise
- Department of Surgery, University of Minnesota Medical School, MMC 195, 420 Delaware Street SE, Minneapolis, MN, 55455, USA.
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Scagliola R, Fornaro R, Seitun S. Extracardiac Compression by Gastrointestinal Structures: A Comprehensive Anthology From the Literature. Cardiol Res Pract 2025; 2025:5871029. [PMID: 40313649 PMCID: PMC12043395 DOI: 10.1155/crp/5871029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 03/23/2025] [Accepted: 04/02/2025] [Indexed: 05/03/2025] Open
Abstract
Extrinsic heart compression by gastrointestinal (GI) structures is an often underrecognized finding in clinical practice. It is potentially related to unpredictable clinical conditions, ranging from incidental detection in asymptomatic subjects, to deranging and potentially life-threatening clinical manifestations. However, despite its potential clinical relevance, there is still no comprehensive analysis investigating the surrounding causes, clinical findings, and diagnostic imaging work-up for this patient population. A narrative review with an extensive bibliographic search of the literature was performed using PubMed (MEDLINE), Embase, and Cochrane Central Databases up to December 31, 2023. Despite the broad spectrum of GI etiologies, clinical manifestations, and cardiac chamber involvement scenarios, physicians must be aware of such an uncommon condition, in order to provide timely diagnosis through a comprehensive imaging approach, avoid misleading interpretations, and determine the most appropriate decision-making strategy.
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Affiliation(s)
| | - Rosario Fornaro
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Sara Seitun
- Radiology Division, San Martino Hospital, Genoa, Italy
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Ugliono E, Rebecchi F, Franco C, Morino M. Long-term durability and temporal pattern of revisional surgery of laparoscopic large hiatal hernia repair. Updates Surg 2025; 77:419-425. [PMID: 39847274 PMCID: PMC11961496 DOI: 10.1007/s13304-025-02070-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 01/07/2025] [Indexed: 01/24/2025]
Abstract
Laparoscopic repair is the preferred surgical treatment for symptomatic Large Hiatal Hernia (LHH). However, data on long-term outcomes are limited. This study aims to evaluate the 20-year follow-up results of laparoscopic LHH repair in a high-volume experienced tertiary center. Retrospective analysis of patients who underwent elective laparoscopic LHH repair between 1992 and 2008. Preoperative and perioperative data were collected. The primary endpoint was the long-term reoperation rate. Survival analyses were calculated according to the Kaplan-Meier method and compared with the log-rank test. A Cox proportional hazard model was used to investigate predictive factors of the need for revisional surgery. A total of 176 patients were included. All the procedures were performed laparoscopically, and in 5 cases (3.0%) with a robot-assisted approach. Mesh-augmented cruroplasty was performed in 26 patients (15.8%). A fundoplication was added in all patients: Nissen in 158 (89.8%), Toupet in 5 (2.8%), and Collis-Nissen in 13 (7.4%). Postoperative mean follow-up was 224.6 ± 83.3 months. Clinically significant hiatal hernia recurrence occurred in 27 (16.2%), and 18 patients (10.2%) underwent surgical revision. The median time-to-redo was 12 months (IQR 6-42 months). Overall durability without revisional surgery at 20-year follow-up was 90%. The rate of revisional surgery after LHH repair is low and is generally required within 12 months from primary surgery. Our results highlight the long-lasting effects of LHH repair at 20-year follow-up.
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Affiliation(s)
- Elettra Ugliono
- Department of Surgical Sciences, General Surgery and Center for Minimally Invasive Surgery, University of Torino, Corso A.M. Dogliotti 14, 10126, Turin, Italy.
- Department of Mechanical and Aerospacial Engineering, Politecnico of Turin, Corso Duca Degli Abruzzi 24, 10129, Turin, Italy.
| | - Fabrizio Rebecchi
- Department of Surgical Sciences, General Surgery and Center for Minimally Invasive Surgery, University of Torino, Corso A.M. Dogliotti 14, 10126, Turin, Italy
| | - Caterina Franco
- Department of Surgical Sciences, General Surgery and Center for Minimally Invasive Surgery, University of Torino, Corso A.M. Dogliotti 14, 10126, Turin, Italy
| | - Mario Morino
- Department of Surgical Sciences, General Surgery and Center for Minimally Invasive Surgery, University of Torino, Corso A.M. Dogliotti 14, 10126, Turin, Italy
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Aiolfi A, Bona D, Sozzi A, Bonavina L. PROsthetic MEsh Reinforcement in elective minimally invasive paraesophageal hernia repair (PROMER): an international survey. Updates Surg 2024; 76:2675-2682. [PMID: 39368031 DOI: 10.1007/s13304-024-02010-2] [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] [Received: 06/19/2024] [Accepted: 09/25/2024] [Indexed: 10/07/2024]
Abstract
The optimal treatment for paraesophageal hiatus hernia (PEH) is controversial. While crural buttressing with mesh shows promises in reducing recurrences, the decision to use mesh during minimally invasive PEH repair is largely subjective. Due to these uncertainties, we conducted a survey to examine current clinical practices among surgeons and to assess which are the most important determinants in the decision-making process for mesh placement. Thirty-five multiple-choice Google Form-based survey on work-up, surgical techniques, and issues are considered in the decision-making process for mesh augmentation during minimally invasive PEH repair. Responses were graded on a 5-point Likert scale and analyzed using descriptive statistics. Consensus was defined as > 70% of participants agreed (agree or strongly agree) on a specific statement. Overall, 292 surgeons (86% from Europe) participated in the survey. The median age of participants was 42 years (range 29-69). The median number of PEH procedures was 25/year/center (range 5-400), with 67% of participants coming from high-volume centers (> 20 procedures/year). Consensus on use of mesh was reached for intraoperative findings of large (> 50% of intrathoracic stomach) PEH (74.3%), crural gap with > 4 cm distance between right and left crus (77.1%), and/or crural atrophy with < 0.5 cm thickness of one or both pillars (73%), and for redo surgery (71.9%). Further, consensus was reached in defining recurrence as a combination of refractory symptoms and anatomical/radiological evidence of > 2 cm hernia. This survey shows that large PEH, wide crural transverse diameter, fragile crura, and redo surgery are the most influential issues driving the decision for mesh-reinforced cruroplasty.
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Affiliation(s)
- Alberto Aiolfi
- Division of General Surgery, Department of Biomedical Science for Health, I.R.C.C.S. Ospedale Galeazzi, Sant'Ambrogio, University of Milan, Via C. Belgioioso, 173, 20157, Milan, Italy.
| | - Davide Bona
- Division of General Surgery, Department of Biomedical Science for Health, I.R.C.C.S. Ospedale Galeazzi, Sant'Ambrogio, University of Milan, Via C. Belgioioso, 173, 20157, Milan, Italy
| | - Andrea Sozzi
- Division of General Surgery, Department of Biomedical Science for Health, I.R.C.C.S. Ospedale Galeazzi, Sant'Ambrogio, University of Milan, Via C. Belgioioso, 173, 20157, Milan, Italy
| | - Luigi Bonavina
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
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Corbett JM, Eriksson SE, Sarici IS, Jobe BA, Ayazi S. Complications After Paraesophageal Hernia Repair. Thorac Surg Clin 2024; 34:355-369. [PMID: 39332860 DOI: 10.1016/j.thorsurg.2024.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2024]
Abstract
Paraesophageal hernia repair (PEHR) is a challenging operation both technically and because the affected patient population is typically older with more comorbidities. As a result, PEHR is associated with substantial morbidity. Morbidity and mortality following PEHR vary significantly depending on the acuity of the operation and size of the hernia. In addition to a higher risk for general peri- and postoperative complications there are a variety of other foregut specific complications to consider including, acute perioperative, early, and late reherniation, mesh-related complications, perforation, gastroparesis, pulmonary and insufflation-related complications, among others. This review focuses on the complication-specific data on incidence, recognition etiology and management.
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Affiliation(s)
- Julie M Corbett
- Foregut Division, Surgical Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 454, Pittsburgh, PA 15224, USA
| | - Sven E Eriksson
- Foregut Division, Surgical Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 454, Pittsburgh, PA 15224, USA; Chevalier Jackson Research Foundation, Esophageal Institute, Western Pennsylvania Hospital, Pittsburgh, PA, USA
| | - Inanc Samil Sarici
- Foregut Division, Surgical Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 454, Pittsburgh, PA 15224, USA; Chevalier Jackson Research Foundation, Esophageal Institute, Western Pennsylvania Hospital, Pittsburgh, PA, USA
| | - Blair A Jobe
- Foregut Division, Surgical Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 454, Pittsburgh, PA 15224, USA; Chevalier Jackson Research Foundation, Esophageal Institute, Western Pennsylvania Hospital, Pittsburgh, PA, USA; Department of Surgery, Drexel University, Philadelphia, PA, USA
| | - Shahin Ayazi
- Foregut Division, Surgical Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 454, Pittsburgh, PA 15224, USA; Chevalier Jackson Research Foundation, Esophageal Institute, Western Pennsylvania Hospital, Pittsburgh, PA, USA; Department of Surgery, Drexel University, Philadelphia, PA, USA; 4815 Liberty Avenue, Suite 454, Pittsburgh, PA 15224, USA.
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Fuchs KH, Kafetzis I, Hann A, Meining A. Hiatal Hernias Revisited-A Systematic Review of Definitions, Classifications, and Applications. Life (Basel) 2024; 14:1145. [PMID: 39337928 PMCID: PMC11433396 DOI: 10.3390/life14091145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2024] [Revised: 08/15/2024] [Accepted: 08/19/2024] [Indexed: 09/30/2024] Open
Abstract
INTRODUCTION A hiatal hernia (HH) can be defined as a condition in which elements from the abdominal cavity herniate through the oesophageal hiatus in the mediastinum and, in the majority of cases, parts of the proximal stomach. Today, the role of HHs within the complex entity of gastroesophageal reflux disease (GERD) is very important with regard to its pathophysiology, severity, and therapeutic and prognostic options. Despite this, the application and stringent use of the worldwide accepted classification (Skinner and Belsey: Types I-IV) are lacking. The aim of this study was to carry out a systematic review of the clinical applications of HH classifications and scientific documentation over time, considering their value in diagnosis and treatment. METHODS Following the PRISMA concept, all abstracts published on pubmed.gov until 12/2023 (hiatal hernia) were reviewed, and those with a focus and clear description of the application of the current HH classification in the full-text version were analysed to determine the level of classification and its use within the therapeutic context. RESULTS In total, 9342 abstracts were screened. In 9199 of the abstracts, the reports had a different focus than HH, or the HH classification was not used or was incompletely applied. After further investigation, 60 papers were used for a detailed analysis, which included more than 12,000 patient datapoints. Among the 8904 patients, 83% had a Type I HH; 4% had Type II; 11% had Type III; and 1% had Type IV. Further subgroup analyses were performed. Overall, the precise application of the HH classification has been insufficient, considering that only 1% of all papers and only 54% of those with a special focus on HH have documented its use. CONCLUSIONS The application and documentation of a precise HH classification in clinical practice and scientific reports are decreasing, which should be rectified for the purpose of scientific comparability.
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Affiliation(s)
- Karl Hermann Fuchs
- Laboratory for Interventional and Experimental Endoscopy (InExEn), University of Würzburg, Grombühlstr. 12, 97080 Würzburg, Germany
| | - Ioannis Kafetzis
- Laboratory for Interventional and Experimental Endoscopy (InExEn), University of Würzburg, Grombühlstr. 12, 97080 Würzburg, Germany
| | - Alexander Hann
- Laboratory for Interventional and Experimental Endoscopy (InExEn), University of Würzburg, Grombühlstr. 12, 97080 Würzburg, Germany
- Head of Gastroenterology, Zentrum Innere Medizin, University of Würzburg, 97080 Würzburg, Germany
| | - Alexander Meining
- Laboratory for Interventional and Experimental Endoscopy (InExEn), University of Würzburg, Grombühlstr. 12, 97080 Würzburg, Germany
- Head of Gastroenterology, Zentrum Innere Medizin, University of Würzburg, 97080 Würzburg, Germany
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Kafetzis I, Fuchs KH, Sodmann P, Troya J, Zoller W, Meining A, Hann A. Efficient artificial intelligence-based assessment of the gastroesophageal valve with Hill classification through active learning. Sci Rep 2024; 14:18825. [PMID: 39138220 PMCID: PMC11322637 DOI: 10.1038/s41598-024-68866-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 07/29/2024] [Indexed: 08/15/2024] Open
Abstract
Standardized assessment of the gastroesophageal valve during endoscopy, attainable via the Hill classification, is important for clinical assessment and therapeutic decision making. The Hill classification is associated with the presence of hiatal hernia (HH), a common endoscopic finding connected to gastro-esophageal reflux disease. A novel efficient medical artificial intelligence (AI) training pipeline using active learning (AL) is designed. We identified 21,970 gastroscopic images as training data and used our AL to train a model for predicting the Hill classification and detecting HH. Performance of the AL and traditionally trained models were evaluated on an external expert-annotated image collection. The AL model achieved accuracy of 76%. A traditionally trained model with 125% more training data achieved 77% accuracy. Furthermore, the AL model achieved higher precision than the traditional one for rare classes, with 0.54 versus 0.39 (p < 0.05) for grade 3 and 0.72 versus 0.61 (p < 0.05) for grade 4. In detecting HH, the AL model achieved 94% accuracy, 0.72 precision and 0.74 recall. Our AL pipeline is more efficient than traditional methods in training AI for endoscopy.
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Affiliation(s)
- Ioannis Kafetzis
- Interventional and Experimental Endoscopy (InExEn), Department of Internal Medicine 2, University Hospital Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Germany.
| | - Karl-Hermann Fuchs
- Interventional and Experimental Endoscopy (InExEn), Department of Internal Medicine 2, University Hospital Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Germany
| | - Philipp Sodmann
- Interventional and Experimental Endoscopy (InExEn), Department of Internal Medicine 2, University Hospital Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Germany
| | - Joel Troya
- Interventional and Experimental Endoscopy (InExEn), Department of Internal Medicine 2, University Hospital Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Germany
| | - Wolfram Zoller
- Clinic for General Internal Medicine, Gastroenterology, Hepatology and Infectiology, Pneumology, Klinikum Stuttgart-Katharinenhospital, Kriegsbergstr. 60, 70174, Stuttgart, Germany
| | - Alexander Meining
- Interventional and Experimental Endoscopy (InExEn), Department of Internal Medicine 2, University Hospital Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Germany
| | - Alexander Hann
- Interventional and Experimental Endoscopy (InExEn), Department of Internal Medicine 2, University Hospital Würzburg, Oberdürrbacherstr. 6, 97080, Würzburg, Germany
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Kumar SS, Rama M, Koeneman S, Tannouri S, Tatarian T, Palazzo F. Morbidity and mortality following hiatal hernia repair in geriatric patients: a multicenter research network study. Surg Endosc 2024; 38:3999-4005. [PMID: 38858249 PMCID: PMC11219371 DOI: 10.1007/s00464-024-10956-y] [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] [Received: 04/22/2024] [Accepted: 05/23/2024] [Indexed: 06/12/2024]
Abstract
BACKGROUND Hiatal hernia is a common surgical pathology. Such hernias can be found incidentally and patients may opt for an initial nonoperative approach though many will pursue surgery after symptom progression. Data on the effects of age on the outcomes of hiatal hernia repair may help inform this decision-making process. METHODS The TriNetX database was queried for all adult patients undergoing hiatal hernia repair from 2000 to 2023. Patients were divided into elective and emergent cohorts on the basis of diagnosis codes indicating obstruction or gangrene. Patients aged 80-89 were compared against those aged 65-79 in unadjusted analysis. Logistic regression models controlling for additional health history covariates were created to calculate odds ratios for primary outcomes. RESULTS There were 2310 octogenarians and 15,295 seniors who underwent elective hiatal hernia repair, and 406 octogenarians and 1462 seniors who underwent emergent repair during the study period. The vast majority of patients in both groups underwent minimally invasive operations. In the elective cohort, octogenarians had higher rates of mortality, malnutrition, sepsis, respiratory failure, pneumonia, DVT, blood transfusion, and discharge to nursing facility. In the emergent cohort, octogenarians had higher rates of mortality, malnutrition, sepsis, and respiratory failure. The odds ratios for mortality in the elective and emergent cohorts were 3.9 (95% CI 3.1-5.0) and 3.5 (95% CI 2.1-5.6), respectively. CONCLUSION Octogenarians are at a meaningfully increased risk for mortality and morbidity after both elective and emergent hiatal hernia repair compared to senior-aged patients. Greater consideration should be given to surgical repair prior to the 8th decade of life.
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Affiliation(s)
- Sunjay S Kumar
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, 19107, USA
| | - Martina Rama
- Sidney Kimmel Medical College, Thomas Jefferson University, 1100 Walnut Street, 5th floor, Philadelphia, PA, 19107, USA
| | - Scott Koeneman
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, 19107, USA
| | - Sami Tannouri
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, 19107, USA
| | - Talar Tatarian
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, 19107, USA
| | - Francesco Palazzo
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, 19107, USA.
- Sidney Kimmel Medical College, Thomas Jefferson University, 1100 Walnut Street, 5th floor, Philadelphia, PA, 19107, USA.
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Marom G, Abu Salem S, Gefen R, Shweiki A, Pikarsky AJ, Fishman Y, Brodie R, Helou B, Mintz Y. Should We Operate Nonagenarians with Symptomatic Giant Paraesophageal Hernias? J Laparoendosc Adv Surg Tech A 2024; 34:479-483. [PMID: 38727556 DOI: 10.1089/lap.2024.0155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2024] Open
Abstract
Introduction: Hiatal hernia (HH) is a common disorder of the upper gastrointestinal (UGI) tract that general surgeons encounter. Giant paraesophageal is a subtype of HH in which more than 30% of the stomach is located in the chest. It can cause symptoms such as dysphagia, UGI bleeding, gastroesophageal reflux disease, and vomiting. As the life expectancy of the general population increases, the incidence of giant HH increases and can cause morbidity, including recurrent admissions and prolonged length of hospitalization. In this article, we describe a cohort of nonagenarian patients with HH who were admitted to our institution and were treated either surgically or medically. Methods: We retrospectively reviewed our prospectively maintained database of all nonagenarians who were admitted to our center between 2018 and 2022 with the diagnosis of HH. We compared the demographic data, clinical data, and outcomes between patients undergoing operative and nonoperative management. Results: Twenty patients of age over 90 years were hospitalized with HH-related symptoms. Six underwent surgery, whereas 14 received medical management. Surgical patients had fewer overall hospitalization days, shorter length of stay, and less blood product requirements. Notably two cases of in-hospital mortality occurred in the nonoperative group, whereas none occurred in the operative group. All surgical procedures were performed laparoscopically, with two minor perioperative complications. Conclusion: In selected nonagenarian patients, laparoscopic HH repair is safe and should be considered favorably. It can reduce hospitalization time and can mitigate morbidity.
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Affiliation(s)
- Gad Marom
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Samer Abu Salem
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Rachel Gefen
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Amir Shweiki
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Alon J Pikarsky
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yuri Fishman
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ronit Brodie
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Brigitte Helou
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Yoav Mintz
- Department of General Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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DeMeester SR, Bernard L, Schoppmann SF, McKay SC, Roth JS. Updated Markov Model to Determine Optimal Management Strategy for Patients with Paraesophageal Hernia and Symptoms, Cameron Ulcer, or Comorbid Conditions. J Am Coll Surg 2024; 238:1069-1082. [PMID: 38359322 DOI: 10.1097/xcs.0000000000001040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
BACKGROUND The current paradigm of watchful waiting (WW) in people 65 years or older with an asymptomatic paraesophageal hernia (PEH) is based on a now 20-year-old Markov analysis. Recently, we have shown that elective laparoscopic hernia repair (ELHR) provides an increase in life-years (L-Ys) compared with WW in most healthy patients aged 40 to 90 years. However, elderly patients often have comorbid conditions and may have complications from their PEH such as Cameron lesions. The aim of this study was to determine the optimal strategy, ELHR or WW, in these patients. STUDY DESIGN A Markov model with updated variables was used to compare L-Ys gained with ELHR vs WW in hypothetical people with any type of PEH and symptoms, Cameron lesions, and/or comorbid conditions. RESULTS In men and women aged 40 to 90 years with PEH-related symptoms and/or Cameron lesions, ELHR led to an increase in L-Ys over WW. The presence of comorbid conditions impacted life expectancy overall, but ELHR remained the preferred approach in all but 90-year-old patients with symptoms but no Cameron lesions. CONCLUSIONS Using a Markov model with updated values for key variables associated with management options for patients with a PEH, we showed that life expectancy was improved with ELHR in most men and women aged 40 to 90 years, particularly in the presence of symptoms and/or Cameron lesions. Comorbid conditions increase the risk for surgery, but ELHR remained the preferred strategy in the majority of symptomatic patients. This model can be used to provide individualized management guidance for patients with a PEH.
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Affiliation(s)
- Steven R DeMeester
- From the Center for Advanced Surgery, The Oregon Clinic, Portland, OR (DeMeester)
| | - Lisa Bernard
- Bernard Consulting, Selkirk, Ontario, Canada (Bernard)
| | | | | | - J Scott Roth
- Department of Surgery, The University of Kentucky, Lexington, KY (Roth)
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12
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Wong LY, Leipzig M, Elliott IA, Liou DZ, Backhus LM, Shrager JB, Berry MF. Outcomes of surgery for catastrophic hiatal hernia presentations. J Gastrointest Surg 2024; 28:285-286. [PMID: 38445922 DOI: 10.1016/j.gassur.2023.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 12/22/2023] [Indexed: 03/07/2024]
Affiliation(s)
- Lye-Yeng Wong
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, California, United States.
| | - Matthew Leipzig
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, California, United States
| | - Irmina A Elliott
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, California, United States; Department of Cardiothoracic Surgery, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, United States
| | - Douglas Z Liou
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, California, United States
| | - Leah M Backhus
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, California, United States; Department of Cardiothoracic Surgery, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, United States
| | - Joseph B Shrager
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, California, United States; Department of Cardiothoracic Surgery, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, United States
| | - Mark F Berry
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, California, United States; Department of Cardiothoracic Surgery, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, United States
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13
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DeMeester SR, Bernard L, Schoppmann SF, Kloosterman R, Roth JS. Elective Laparoscopic Paraesophageal Hernia Repair Leads to an Increase in Life Expectancy Over Watchful Waiting in Asymptomatic Patients: An Updated Markov Analysis. Ann Surg 2024; 279:267-275. [PMID: 37818675 DOI: 10.1097/sla.0000000000006119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2023]
Abstract
OBJECTIVE The aim of this study was to perform an updated Markov analysis to determine the optimal management strategy for patients with an asymptomatic paraesophageal hernia (PEH): elective laparoscopic hernia repair (ELHR) versus watchful waiting (WW). BACKGROUND Currently, it is recommended that patients with an asymptomatic PEH not undergo repair based on a 20-year-old Markov analysis. The current recommendation might lead to preventable hospitalizations for acute PEH-related complications and compromised survival. METHODS A Markov model with updated variables was used to compare life-years (L-Ys) gained with ELHR versus WW in patients with a PEH. One-way sensitivity analyses evaluated the robustness of the analysis to alternative data inputs, while probabilistic sensitivity analysis quantified the level of confidence in the results in relation to the uncertainty across all model inputs. RESULTS At age 40 to 90, ELHR led to greater life expectancy than WW, particularly in women. The gain in L-Ys (2.6) was greatest in a 40-year-old woman and diminished with increasing age. Sensitivity analysis showed that alternative values resulted in modest changes in the difference in L-Ys, but ELHR remained the preferred strategy. Probabilistic analysis showed that ELHR was the preferred strategy in 100% of 10,000 simulations for age 65, 98% for age 80, 90% for age 85, and 59% of simulations in 90-year-old women. CONCLUSIONS This updated analysis showed that ELHR leads to an increase in L-Ys over WW in healthy patients aged 40 to 90 years with an asymptomatic PEH. In this new paradigm, all patients with a PEH, regardless of symptoms, should be referred for the consideration of elective repair to maximize their life expectancy.
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Affiliation(s)
| | | | | | | | - J Scott Roth
- Department of Surgery, The University of Kentucky, Lexington, KY
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14
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Lou J, Kooragayala K, Williams J, Kalola A, Crudeli C, Sandilos G, Butchy MV, Shersher DD, Burg JM. Diagnostic Workup and Therapeutic Intervention of Hiatal Hernias Discovered as Incidental Findings on Computed Tomography. Am Surg 2024:31348241230096. [PMID: 38279933 DOI: 10.1177/00031348241230096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2024]
Abstract
BACKGROUND Computed tomography imaging routinely detects incidental findings; most research focuses on malignant findings. However, benign diseases such as hiatal hernia also require identification and follow-up. Natural language algorithms can help identify these non-malignant findings. METHODS Imaging of adult trauma patients from 2010 to 2020 who underwent CT chest/abdomen/pelvis was evaluated using an open-source natural language processor to query for hiatal hernias. Patients who underwent subsequent imaging, endoscopy, fluoroscopy, or operation were retrospectively reviewed. RESULTS 1087(10.6%) of 10 299 patients had incidental hiatal hernias: 812 small (74.7%) and 275 moderate/large (25.3%). 224 (20.7%) had subsequent imaging or endoscopic evaluation. Compared to those with small hernias, patients with moderate/large hernias were older (66.3 ± 19.4 vs 79.6 ± 12.6 years, P < .001) and predominantly female (403[49.6%] vs 199[72.4%], P < .001). Moderate/large hernias were not more likely to grow (small vs moderate/large: 13[7.6%] vs 8[15.1%], P = .102). Patients with moderate/large hernias were more likely to have an intervention or referral (small vs moderate/large: 6[3.5%] vs 7[13.2%], P = .008). No patients underwent elective or emergent hernia repair. Three patients had surgical referral; however, only one was seen by a surgeon. One patient death was associated with a large hiatal hernia. CONCLUSIONS We demonstrate a novel utilization of natural language processing to identify patients with incidental hiatal hernia in a large population, and found a 10.6% incidence with only 1.2%. (13/1087) of these receiving a referral for follow-up. While most incidental hiatal hernias are small, moderate/large and symptomatic hernias have high risk of loss-to-follow-up and need referral pipelines to improve patient outcomes.
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Affiliation(s)
- Johanna Lou
- Department of Surgery, Cooper University Hospital, Camden, NJ, USA
| | | | | | - Ami Kalola
- Cooper University Medical School of Rowan University, Camden, NJ, USA
| | - Connor Crudeli
- Cooper University Medical School of Rowan University, Camden, NJ, USA
| | | | | | - David D Shersher
- Department of Surgery, Cooper University Hospital, Camden, NJ, USA
| | - Jennifer M Burg
- Department of Surgery, Maine Medical Center, Portland, ME, USA
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15
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Pérez Lara FJ, Zubizarreta Jimenez R, Prieto-Puga Arjona T, Gutierrez Delgado P, Hernández Carmona JM, Hernández Gonzalez JM, Pitarch Martinez M. Determining the need for a thoracoscopic approach to treat a giant hiatal hernia when abdominal access is poor. World J Gastrointest Surg 2023; 15:2739-2746. [PMID: 38222019 PMCID: PMC10784824 DOI: 10.4240/wjgs.v15.i12.2739] [Citation(s) in RCA: 1] [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: 09/28/2023] [Revised: 11/09/2023] [Accepted: 12/06/2023] [Indexed: 12/27/2023] Open
Abstract
BACKGROUND Giant hernias present a significant challenge for digestive surgeons. The approach taken (laparoscopic vs thoracoscopic) depends largely on the preferences and skills of each surgeon, although in most cases today the laparoscopic approach is preferred. AIM To determine whether patients presenting inadequate laparoscopic access to the intrathoracic hernial sac obtain poorer postoperative results than those with no such problem, in order to assess the need for a thoracoscopic approach. METHODS For the retrospective series of patients treated in our hospital for hiatal hernia (n = 112), we calculated the laparoscopic field of view and the working area accessible to surgical instruments, by means of preoperative imaging tests, to assess the likely outcome for cases inaccessible to laparoscopy. RESULTS Patients with giant hiatal hernias for whom a preoperative calculation suggested that the laparoscopic route would not access all areas of the intrathoracic sac presented higher rates of perioperative complications and recurrence during follow-up than those for whom laparoscopy was unimpeded. The difference was statistically significant. Moreover, the insertion of mesh did not improve results for the non-accessible group. CONCLUSION For patients with giant hiatal hernias, it is essential to conduct a preoperative evaluation of the angle of vision and the working area for surgery. When parts of the intrathoracic sac are inaccessible laparoscopically, the thoracoscopic approach should be considered.
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Affiliation(s)
| | | | | | - Pilar Gutierrez Delgado
- Department of Surgery, HRU Carlos Haya, Unidad Cirugia Hepatobiliopancreat & Trasplantes, Malaga 29200, Spain
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16
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Ovaere S, Depypere L, Van Veer H, Moons J, Nafteux P, Coosemans W. The Belsey Mark IV procedure in the era of minimally invasive antireflux surgery. Dis Esophagus 2023; 36:doad042. [PMID: 37408470 DOI: 10.1093/dote/doad042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 05/08/2023] [Accepted: 06/12/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND Different surgical techniques exist in the treatment of giant and complex hiatal hernia. The aim of this study was to identify the role of the Belsey Mark IV (BMIV) antireflux procedure in the era of minimally invasive techniques. METHODS A single-center, retrospective cohort study was conducted. All patients who underwent an elective BMIV procedure aged 18 years or older, during a 15-year period (January 1, 2002 until December 31, 2016), were included. Demographics, pre-, per- and postoperative data were analyzed. Three groups were compared. Group A: BMIV as first procedure-group B: BMIV as a second procedure (first redo intervention)-group C: patients who had two or more previous antireflux interventions. RESULTS A total of 216 patients were included for analysis (group A n = 127; group B n = 51; group C n = 38). Median follow-up in groups A, B and C was 28, 48 and 56 months, respectively. Patients in group A were older and had a higher American Society of Anesthesiologists score compared to groups B and C. There was zero mortality in all groups. The severe complication rate of 7.9% in group A was higher compared with the 2.9% in group B and 3.9% in group C. Long-term outcome showed true recurrence, defined as both radiographic recurrence as well as associated symptoms, in 9.5% of cases in group A, 24.5% in group B and 44.7% in group C. CONCLUSIONS The BMIV procedure is a safe procedure with good results, moreover in the aging and comorbid patient with primary repair of a giant hiatal hernia.
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Affiliation(s)
- Sander Ovaere
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Lieven Depypere
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
- KU Leuven Department of Chronic Diseases, Metabolism and Ageing, Leuven, Belgium
| | - Hans Van Veer
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
- KU Leuven Department of Chronic Diseases, Metabolism and Ageing, Leuven, Belgium
| | - Johnny Moons
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
- KU Leuven Department of Chronic Diseases, Metabolism and Ageing, Leuven, Belgium
| | - Philippe Nafteux
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
- KU Leuven Department of Chronic Diseases, Metabolism and Ageing, Leuven, Belgium
| | - Willy Coosemans
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
- KU Leuven Department of Chronic Diseases, Metabolism and Ageing, Leuven, Belgium
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17
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Wilson HH, Ayuso SA, Rose M, Ku D, Scarola GT, Augenstein VA, Colavita PD, Heniford BT. Defining surgical risk in octogenarians undergoing paraesophageal hernia repair. Surg Endosc 2023; 37:8644-8654. [PMID: 37495845 DOI: 10.1007/s00464-023-10270-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 06/29/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND With an aging population, the utility of surgery in elderly patients, particularly octogenarians, is of increasing interest. The goal of this study was to analyze outcomes of octogenarians versus non-octogenarians undergoing paraesophageal hernia repair (PEHR). METHODS The Nationwide Readmission Database was queried for patients > 18 years old who underwent PEHR from 2016 to 2018. Exclusion criteria included a diagnosis of gastrointestinal malignancy or a concurrent bariatric procedure. Patients ≥ 80 were compared to those 18-79 years old using standard statistical methods, and subgroup analyses of elective and non-elective PEHRs were performed. RESULTS From 2016 to 2018, 46,450 patients were identified with 5425 (11.7%) octogenarians and 41,025 (88.3%) non-octogenarians. Octogenarians were more likely to have a non-elective operation (46.3% vs 18.2%, p < 0.001), and those undergoing non-elective PEHR had a higher mortality (5.5% vs 1.2%, p < 0.001). Outcomes were improved with elective PEHR, but octogenarians still had higher mortality (1.3% vs 0.2%, p < 0.001), longer LOS (3[2, 5] vs 2[1, 3] days, p < 0.001), and higher readmission rates within 30 days (11.1% vs 6.5%, p < 0.001) compared to non-octogenarian elective patients. Multivariable logistic regression showed that being an octogenarian was not independently predictive of mortality (odds ratio (OR) 1.373[95% confidence interval 0.962-1.959], p = 0.081), but a non-elective operation was (OR 3.180[2.492-4.057], p < 0.001). Being an octogenarian was a risk factor for readmission within 30 days (OR 1.512[1.348-1.697], p < 0.001). CONCLUSIONS Octogenarians represented a substantial proportion of patients undergoing PEHR and were more likely to undergo a non-elective operation. Being an octogenarian was not an independent predictor of perioperative mortality, but a non-elective operation was. Octogenarians' morbidity and mortality was reduced in elective procedures but was still higher than non-octogenarians. Elective PEHR in octogenarians is reasonable but should involve a thorough risk-benefit analysis.
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Affiliation(s)
- Hadley H Wilson
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - Sullivan A Ayuso
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - Mikayla Rose
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - Dau Ku
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive Suite 300, Charlotte, NC, 28204, USA
| | - Gregory T Scarola
- 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
| | - 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
| | - 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.
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18
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Lee Y, Huo B, McKechnie T, Agzarian J, Hong D. Impact of frailty on hiatal hernia repair: a nationwide analysis of in-hospital clinical and healthcare utilization outcomes. Dis Esophagus 2023; 36:doad038. [PMID: 37291973 DOI: 10.1093/dote/doad038] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 05/06/2023] [Accepted: 05/21/2023] [Indexed: 06/10/2023]
Abstract
Previous studies recommend a watch-and-wait approach to paraesophageal hernia (PEH) repair due to an increased risk for mortality. While contemporary studies suggest that elective surgery is safe and effective, many patients presenting with PEH are elderly. Therefore, we assessed the impact of frailty on in-hospital outcomes and healthcare utilization among patients receiving PEH repair. This retrospective population-based cohort study assessed patients from the National Inpatient Sample database who received PEH repair between October 2015 to December 2019. Demographic and perioperative data were gathered, and frailty was measured using the 11-item modified frailty index. The outcomes measured were in-hospital mortality, complications, discharge disposition, and healthcare utilization. Overall, 10,716 patients receiving PEH repair were identified, including 1442 frail patients. Frail patients were less often female and were more often in the lowest income quartile compared to robust patients. Frail patients were at greater odds for in-hospital mortality [odds ratio (OR) 2.83 (95% CI 1.65-4.83); P < 0.001], postoperative ICU admissions [OR 2.07 (95% CI 1.55-2.78); P < 0.001], any complications [OR 2.18 (95% CI 1.55-2.78); P < 0.001], hospital length of stay [mean difference (MD) 1.75 days (95% CI 1.30-2.210; P < 0.001], and total admission costs [MD $5631.65 (95% CI $3300.06-$7.963.24); P < 0.001] relative to their robust patients. While PEH repair in elderly patients is safe and effective, frail patients have an increased rate of in-hospital mortality, postoperative ICU admissions, complications, and total admission costs. Clinicians should consider patient frailty when identifying the most appropriate surgical candidates for PEH repair.
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Affiliation(s)
- Y Lee
- Division of General Surgery, McMaster University, Hamilton, Ontario, Canada
- Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - B Huo
- Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - T McKechnie
- Division of General Surgery, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - J Agzarian
- Division of Thoracic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - D Hong
- Division of General Surgery, McMaster University, Hamilton, Ontario, Canada
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19
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Wong LY, Parsons N, David EA, Burfeind W, Berry MF. The Impact of Age and Need for Emergent Surgery in Paraesophageal Hernia Repair Outcomes. Ann Thorac Surg 2023; 116:138-145. [PMID: 36702291 DOI: 10.1016/j.athoracsur.2023.01.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 01/08/2023] [Accepted: 01/14/2023] [Indexed: 01/24/2023]
Abstract
BACKGROUND Observation of paraesophageal hernias (PEHs) may lead to emergent surgery for hernia-related complications. This study evaluated urgent or emergent repair outcomes to quantify the possible sequelae of failed conservative PEH management. METHODS The impact of operative status (elective vs urgent or emergent) on perioperative mortality or major morbidity for patients who underwent hiatal hernia repair for a PEH diagnosis from 2012 to 2021 in the Society of Thoracic Surgery General Thoracic Surgery Database was evaluated with multivariable logistic regression models. RESULTS Overall, 2082 (10.9%) of 19,122 patients with PEHs underwent urgent or emergent repair. Patients undergoing nonelective surgery were significantly older than patients undergoing elective surgery (median age, 73 years [interquartile range, 63-82 years] vs 66 years [interquartile range, 58-74 years]) and had a lower preoperative performance score (P < .001). Nonelective surgical procedures were more likely to be performed through the chest or by laparotomy rather than by laparoscopy (20% vs 11.4%; P < .001), and they were associated with longer hospitalizations (4 days vs 2 days; P < .001), higher operative mortality (4.5% vs 0.6%; P < .001), and higher major morbidity (27% vs 5.5%; P < .001). Nonelective surgery was a significant independent predictor of major morbidity in multivariable analysis (odds ratio, 2.06; P < .001). Patients more than the age of 80 years had higher operative mortality (4.3% vs 0.6%; P < 0.001) and major morbidity (19% vs 6.1%; P < .001) than younger patients overall, and these older patients more often had nonelective surgery (26% vs 8.6%; P < .001) CONCLUSIONS: The operative morbidity of PEH repair is significantly increased when surgery is nonelective, particularly for older patients. These results can inform the potential consequences of choosing watchful waiting vs elective PEH repair.
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Affiliation(s)
- Lye-Yeng Wong
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California.
| | | | - Elizabeth A David
- Division of Cardiothoracic Surgery, University of Colorado, Aurora, Colorado
| | - William Burfeind
- Department of Cardiothoracic Surgery, St Luke's University Health Network, Bethlehem, Pennsylvania
| | - Mark F Berry
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California
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20
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Gerdes S, Schoppmann SF, Bonavina L, Boyle N, Müller-Stich BP, Gutschow CA. Management of paraesophageal hiatus hernia: recommendations following a European expert Delphi consensus. Surg Endosc 2023; 37:4555-4565. [PMID: 36849562 PMCID: PMC10234895 DOI: 10.1007/s00464-023-09933-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 02/05/2023] [Indexed: 03/01/2023]
Abstract
AIMS There is considerable controversy regarding optimal management of patients with paraesophageal hiatus hernia (pHH). This survey aims at identifying recommended strategies for work-up, surgical therapy, and postoperative follow-up using Delphi methodology. METHODS We conducted a 2-round, 33-question, web-based Delphi survey on perioperative management (preoperative work-up, surgical procedure and follow-up) of non-revisional, elective pHH among European surgeons with expertise in upper-GI. Responses were graded on a 5-point Likert scale and analyzed using descriptive statistics. Items from the questionnaire were defined as "recommended" or "discouraged" if positive or negative concordance among participants was > 75%. Items with lower concordance levels were labelled "acceptable" (neither recommended nor discouraged). RESULTS Seventy-two surgeons with a median (IQR) experience of 23 (14-30) years from 17 European countries participated (response rate 60%). The annual median (IQR) individual and institutional caseload was 25 (15-36) and 40 (28-60) pHH-surgeries, respectively. After Delphi round 2, "recommended" strategies were defined for preoperative work-up (endoscopy), indication for surgery (typical symptoms and/or chronic anemia), surgical dissection (hernia sac dissection and resection, preservation of the vagal nerves, crural fascia and pleura, resection of retrocardial lipoma) and reconstruction (posterior crurorrhaphy with single stitches, lower esophageal sphincter augmentation (Nissen or Toupet), and postoperative follow-up (contrast radiography). In addition, we identified "discouraged" strategies for preoperative work-up (endosonography), and surgical reconstruction (crurorrhaphy with running sutures, tension-free hiatus repair with mesh only). In contrast, many items from the questionnaire including most details of mesh augmentation (indication, material, shape, placement, and fixation technique) were "acceptable". CONCLUSIONS This multinational European Delphi survey represents the first expert-led process to identify recommended strategies for the management of pHH. Our work may be useful in clinical practice to guide the diagnostic process, increase procedural consistency and standardization, and to foster collaborative research.
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Affiliation(s)
- Stephan Gerdes
- Department of Surgery and Transplantation, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | | | - Luigi Bonavina
- Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | | | - Beat P Müller-Stich
- Department of General, Visceral and Transplant Surgery, University Hospital, Heidelberg, Germany
| | - Christian A Gutschow
- Department of Surgery and Transplantation, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland.
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21
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D'Urbano F, Tamburini N, Resta G, Maniscalco P, Marino S, Anania G. A Narrative Review on Treatment of Giant Hiatal Hernia. J Laparoendosc Adv Surg Tech A 2023; 33:381-388. [PMID: 36927045 DOI: 10.1089/lap.2023.0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
Abstract
Background: The current gold standard of treatment for giant hiatal hernias (GHHs) is laparoscopic surgery. Laparoscopic surgery was performed as a less invasive procedure for paraesophageal hernias more than 25 years ago. Its viability and safety have almost all been shown. Materials and Methods: A review of recent and current studies' literature was done. Prospective randomized trials, systematic reviews, clinical reviews, and original articles were all investigated. The data were gathered in the form of a narrative evaluation. We examine the state of laparoscopic GHH repair today and outline the GHH management strategy. Results: In this review, we clear up misunderstandings of GHH and address bad habits that may have contributed to poor results, and we have consequently performed a methodical evaluation of GHH. First, we address subcategorizing GHH and provide criteria to define them. The preoperative workup strategies are then discussed, with a focus on any pertinent and frequent atypical symptoms, indications for surgery, timing of surgery, and the importance of surgery. The approach to the techniques and the logic behind surgery are then presented along with some important dissection techniques. Finally, we debate the role of mesh reinforcement and evaluate the data in terms of recurrence, reoperation rate, complications, and delayed stomach emptying. Finally, we suggest a justification for common postoperative investigations. Conclusions: Surgery is the only effective treatment for GHH at the moment. If the right operational therapy principles are applied, this is generally successful. There is a growing interest in laparoscopic paraesophageal hiatal hernia repair as a result of the introduction of laparoscopic antireflux surgery. Today's less invasive procedures provide a better therapeutic choice with a lower risk.
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Affiliation(s)
- Francesco D'Urbano
- Department of Morphology, Experimental Medicine and Surgery, Section of Chirurgia 1, Sant'Anna Hospital, University of Ferrara, Ferrara, Italy
| | - Nicola Tamburini
- Department of Morphology, Experimental Medicine and Surgery, Section of Chirurgia 1, Sant'Anna Hospital, University of Ferrara, Ferrara, Italy
| | - Giuseppe Resta
- Department of Morphology, Experimental Medicine and Surgery, Section of Chirurgia 1, Sant'Anna Hospital, University of Ferrara, Ferrara, Italy
| | - Pio Maniscalco
- Department of Morphology, Experimental Medicine and Surgery, Section of Chirurgia 1, Sant'Anna Hospital, University of Ferrara, Ferrara, Italy
| | - Serafino Marino
- Department of Morphology, Experimental Medicine and Surgery, Section of Chirurgia 1, Sant'Anna Hospital, University of Ferrara, Ferrara, Italy
| | - Gabriele Anania
- Department of Morphology, Experimental Medicine and Surgery, Section of Chirurgia 1, Sant'Anna Hospital, University of Ferrara, Ferrara, Italy
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22
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Cocco AM, Chai V, Read M, Ward S, Johnson MA, Chong L, Gillespie C, Hii MW. Percentage of intrathoracic stomach predicts operative and post-operative morbidity, persistent reflux and PPI requirement following laparoscopic hiatus hernia repair and fundoplication. Surg Endosc 2023; 37:1994-2002. [PMID: 36278994 PMCID: PMC10017603 DOI: 10.1007/s00464-022-09701-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 10/02/2022] [Indexed: 10/31/2022]
Abstract
PURPOSE Large hiatus hernias are relatively common and can be associated with adverse symptoms and serious complications. Operative repair is indicated in this patient group for symptom management and the prevention of morbidity. This study aimed to identify predictors of poor outcomes following laparoscopic hiatus hernia repair and fundoplication (LHHRaF) to aid in counselling potential surgical candidates. METHODOLOGY A retrospective analysis was performed from a prospectively maintained, multicentre database of patients who underwent LHHRaF between 2014 and 2020. Revision procedures were excluded. Hernia size was defined as the intraoperative percentage of intrathoracic stomach, estimated by the surgeon to the nearest 10%. Predictors of outcomes were determined using a prespecified multivariate logistic regression model. RESULTS 625 patients underwent LHHRaF between 2014 and 2020 with 443 patients included. Median age was 65 years, 62.9% were female and 42.7% of patients had ≥ 50% intrathoracic stomach. In a multivariate regression model, intrathoracic stomach percentage was predictive of operative complications (P = 0.014, OR 1.05), post-operative complications (P = 0.026, OR 1.01) and higher comprehensive complication index score (P = 0.023, OR 1.04). At 12 months it was predictive of failure to improve symptomatic reflux (P = 0.008, OR 1.02) and persistent PPI requirement (P = 0.047, OR 1.02). Operative duration and blood loss were predicted by BMI (P = 0.004 and < 0.001), Type III/IV hernias (P = 0.045 and P = 0.005) and intrathoracic stomach percentage (P = 0.009 and P < 0.001). Post-operative length of stay was predicted by age (P < 0.001) and emergency presentation (P = 0.003). CONCLUSION In a multivariate regression model, intrathoracic stomach percentage was predictive of operative and post-operative morbidity, PPI use, and failure to improve reflux symptoms at 12 months.
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Affiliation(s)
- A M Cocco
- The Department of Surgery, The University of Melbourne, St Vincent's Hospital Melbourne, Melbourne, Australia.
- Upper GI and Hepatobiliary Surgical Unit, St Vincent's Hospital Melbourne, Melbourne, Australia.
| | - V Chai
- Upper GI and Hepatobiliary Surgical Unit, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - M Read
- The Department of Surgery, The University of Melbourne, St Vincent's Hospital Melbourne, Melbourne, Australia
- Upper GI and Hepatobiliary Surgical Unit, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - S Ward
- Upper GI and Hepatobiliary Surgical Unit, St Vincent's Hospital Melbourne, Melbourne, Australia
- Upper GI and Hepatobiliary Surgical Unit, Eastern Health, Melbourne, Australia
| | - M A Johnson
- The Department of Surgery, The University of Melbourne, St Vincent's Hospital Melbourne, Melbourne, Australia
- Upper GI and Hepatobiliary Surgical Unit, St Vincent's Hospital Melbourne, Melbourne, Australia
- Upper GI and Hepatobiliary Surgical Unit, Eastern Health, Melbourne, Australia
- Upper GI and Hepatobiliary Surgical Unit, The Royal Melbourne Hospital, Melbourne, Australia
| | - L Chong
- The Department of Surgery, The University of Melbourne, St Vincent's Hospital Melbourne, Melbourne, Australia
- Upper GI and Hepatobiliary Surgical Unit, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - C Gillespie
- Upper GI and Hepatobiliary Surgical Unit, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - M W Hii
- The Department of Surgery, The University of Melbourne, St Vincent's Hospital Melbourne, Melbourne, Australia
- Upper GI and Hepatobiliary Surgical Unit, St Vincent's Hospital Melbourne, Melbourne, Australia
- Upper GI and Hepatobiliary Surgical Unit, Eastern Health, Melbourne, Australia
- Upper GI and Hepatobiliary Surgical Unit, The Royal Melbourne Hospital, Melbourne, Australia
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23
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Tasoudis P, Vitkos E, Haithcock BE, Long JM. Transthoracic fundoplication using the Belsey Mark IV technique versus Nissen fundoplication: A systematic review and meta-analysis. Surg Endosc 2023:10.1007/s00464-023-09931-w. [PMID: 36754871 DOI: 10.1007/s00464-023-09931-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 01/28/2023] [Indexed: 02/10/2023]
Abstract
BACKGROUND Nissen fundoplication is considered the cornerstone surgical treatment for hiatal hernia repair. Belsey Mark IV (BMIV) transthoracic fundoplication is an alternative approach that is rarely utilized in today's minimally invasive era. This study aims to summarize the safety and efficacy of BMIV and to compare it with Nissen fundoplication. METHODS We searched MEDLINE, Scopus, and Cochrane Library databases for single arm and comparative studies published by March 31st, 2022, according to PRISMA statement. Inverse-variance weights were used to estimate the proportion of patients experiencing the studied outcome and random-effects meta-analyses were performed. RESULTS 17 studies were identified, incorporating 2136 and 638 patients that underwent Belsey Mark IV or Nissen fundoplication, respectively. A total of 13.8% (95% CI: 9.6-18.6) of the patients that underwent fundoplication with the BMIV technique had non-resolution of their symptoms and 3.5% (95% CI: 2.0-5.4) required a reoperation. Overall, 14.8% (95% CI: 9.5-20.1) of the BMIV arm patients experienced post-operative complications, 5.0% (95% CI: 2.0-9.0) experienced chronic postoperative pain and 6.9% (95% CI: 3.1-11.9) had a hernia recurrence. No statistically significant difference was observed between Belsey Mark IV and Nissen fundoplication in terms of post-interventional non-resolution of symptoms (odds ratio [OR]: 1.49 [95% Confidence Interval (95%CI):0.6-4.0]; p = 0.42), post-operative complications (OR:0.83, 95%CI: 0.5-1.5, p = 0.54) and in-hospital mortality (OR:0.69, 95%CI: 0.13-3.80, p = 0.67). Belsey Mark IV arm had significantly lower reoperation rates compared to Nissen arm (OR:0.28, 95%CI: 0.1-0.7, p = 0.01). CONCLUSIONS BMIV fundoplication is a safe and effective but technically challenging. The BMIV technique may offer benefits to patients compared to the laparoscopic Nissen fundoplication. These benefits, however, are challenged by the increased morbidity of a thoracotomy.
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Affiliation(s)
- Panagiotis Tasoudis
- Division of Cardiothoracic Surgery, Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA.
| | - Evangelos Vitkos
- Surgery Working Group, Society of Junior Doctors, Athens, Greece
| | - Benjamin E Haithcock
- Division of Cardiothoracic Surgery, Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Jason M Long
- Division of Cardiothoracic Surgery, Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
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24
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Reza JA, Bakhos C, Su S, Petrov R, Abbas AE. Robotic Belsey Mark IV Repair of the Paraesophageal Hernia. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2023; 18:84-89. [PMID: 36744735 DOI: 10.1177/15569845221150014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Surgical repair of paraesophageal hernias in patients with hostile abdomen is challenging. Despite its utility as an open procedure, the adoption of the minimally invasive Belsey Mark IV procedure has been limited because of the complexity of using traditional video-assisted thoracoscopic instrumentation. The robotic platform offers additional degrees of freedom, which enables minimally invasive transthoracic approach despite challenging anatomy. The purpose of this article is to describe a technique of robotic approach for the Belsey Mark IV operation. METHODS We retrospectively reviewed 5 cases of the robotic Belsey Mark IV procedure completed at a single institution between June 2018 and November 2021. Data were collected from a review of the medical records, including operative reports, anesthesia records, imaging, and clinical notes. The operative technique is described in the present article. There were 4 men and 1 woman. The average age of the patients was 64.4 ± 13.6 years, with an average body mass index of 24.5 kg/m2. Three patients had undergone previous transabdominal hiatal hernia repair, and 2 of them had 2 prior repairs. One patient underwent simultaneous pulmonary left lower lobectomy for cancer with the Belsey Mark IV procedure. RESULTS The average operative time was 209 ± 95 min (110 to 360 min). The average postoperative length of stay was 4.2 days, and 2 patients experienced complications including bleeding and persistent air leak (after lobectomy). The average blood loss was 67 ± 25 mL. CONCLUSIONS The robotic platform enables a transthoracic minimally invasive approach to the Belsey Mark IV operation.
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Affiliation(s)
- Joseph A Reza
- Department of Thoracic Medicine and Surgery, Division of Thoracic Surgery, Temple University Hospital, Philadelphia, PA, USA
| | - Charles Bakhos
- Department of Thoracic Medicine and Surgery, Division of Thoracic Surgery, Temple University Hospital, Philadelphia, PA, USA
| | - Stacey Su
- Department of Surgical Oncology, Division of Thoracic Surgery, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Roman Petrov
- Department of Thoracic Medicine and Surgery, Division of Thoracic Surgery, Temple University Hospital, Philadelphia, PA, USA
| | - Abbas E Abbas
- Department of Surgery, Division of Thoracic Surgery, Brown University, Providence, RI, USA
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25
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Siboni S, Bonavina L, Rogers BD, Egan C, Savarino E, Gyawali CP, DeMeester TR. Effect of Increased Intra-abdominal Pressure on the Esophagogastric Junction: A Systematic Review. J Clin Gastroenterol 2022; 56:821-830. [PMID: 36084164 PMCID: PMC9553247 DOI: 10.1097/mcg.0000000000001756] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
With the advent of high-resolution esophageal manometry, it is recognized that the antireflux barrier receives a contribution from both the lower esophageal sphincter (intrinsic sphincter) and the muscle of the crural diaphragm (extrinsic sphincter). Further, an increased intra-abdominal pressure is a major force responsible for an adaptive response of a competent sphincter or the disruption of the esophagogastric junction resulting in gastroesophageal reflux, especially in the presence of a hiatal hernia. This review describes how the pressure dynamics in the lower esophageal sphincter were discovered and measured over time and how this has influenced the development of antireflux surgery.
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Affiliation(s)
- Stefano Siboni
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milan, IRCCS Policlinico San Donato, San Donato Milanese
| | - Luigi Bonavina
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milan, IRCCS Policlinico San Donato, San Donato Milanese
| | | | - Ciara Egan
- Humanitas University, Humanitas Research Hospital, Rozzano, Milan
| | - Edoardo Savarino
- Gastroenterology Unit, Department of Surgery, Oncology, and Gastroenterology, University Hospital of Padova, Padova, Italy
| | | | - Tom R. DeMeester
- Emeritus, Keck School of Medicine, University of Southern California, Montague, MI
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26
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Varvoglis DN, Farrell TM. Poor Gastric Emptying in Patients with Paraesophageal Hernias: Pyloroplasty, Per-Oral Pyloromyotomy, BoTox, or Wait and See? J Laparoendosc Adv Surg Tech A 2022; 32:1134-1143. [PMID: 35939274 DOI: 10.1089/lap.2022.0342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
Abstract
Gastric emptying delay may be caused with both functional and anatomic derangements. Gastroparesis is suspected in patients presenting with certain foregut symptoms without anatomic obstruction. Data are still emerging regarding the best treatment of this condition. In cases where large paraesophageal hernias alter the upper gastrointestinal anatomy, it is difficult to know if gastroparesis also exists. Management of hiatal hernias is also still evolving, with various strategies to reduce recurrence being actively investigated. In this article, we present a systematic review of the existing literature around the management of gastroparesis and the management of paraesophageal hernias when they occur separately. In addition, since there are limited data to guide diagnosis and management of these conditions when they are suspected to coexist, we provide a rational strategy based on our own experience in patients with paraesophageal hernias who have symptoms or studies that raise suspicion for a coexisting functional disorder.
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Affiliation(s)
- Dimitrios N Varvoglis
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Timothy M Farrell
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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27
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Abstract
Background Laparoscopic large hiatal hernia (LHH) repair remains a challenge despite three decades of ongoing attempts at improving surgical outcome. Its rarity and complexity, coupled with suboptimal initial approach that is usually best suited for small symptomatic herniae have contributed to unacceptable higher failure rates. Results We have therefore undertaken a systematic appraisal of LHH with a view to clear out our misunderstandings of this entity and to address dogmatic practices that may have contributed to poor outcomes. Conclusions First, we propose strict criteria to define nomenclature in LHH and discuss ways of subcategorising them. Next, we discuss preoperative workup strategies, paying particular attention to any relevant often atypical symptoms, indications for surgery, timing of surgery, role of surgery in the elderly and emphasizing the key role of a preoperative CT imaging in evaluating the mediastinum. Some key dissection methods are then discussed with respect to approach to the mediastinal sac, techniques to avoid/deal with pleural breach and rationale to avoid Collis gastroplasty. The issues pertaining to the repair phase are also discussed by evaluating the merits of the cruroplasty, fundoplication types and gastropexy. We end up debating the role of mesh reinforcement and assess the evidence with regards to recurrence, reoperation rate, complications, esophageal dilatation, delayed gastric emptying and mortality. Lastly, we propose a rationale for routine postoperative investigations.
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28
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Braghetto I, Molina JC, Korn O, Lanzarini E, Musleh M, Figueroa M, Rojas J. Observational medical treatment or surgery for giant paraesophageal hiatal hernia in elderly patients. Dis Esophagus 2022; 35:6604852. [PMID: 35687053 DOI: 10.1093/dote/doac030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 04/30/2022] [Indexed: 12/11/2022]
Abstract
Giant paraesophageal hernias (GPHH) occur frequently in the elderly and account for about 5-10% of all hiatal hernias. Up to now controversy persists between expected medical treatment and surgical treatment. To assess if an indication for surgical repair of GPHH is possible in elderly patients. A prospective study that includes patients over 70 years of age hospitalized from January 2015 to December 2019 with GPHH. Patients were separated into Group A and Group B. Group A consisted of a cohort of 23 patients in whom observation and medical treatment were performed. Group B consisted of 44 patients submitted to elective laparoscopic hiatal hernia repair. Symptomatic patients were observed in both groups (20/23 in Group A and 38/44 in Group B). Charlson's score >6 and ASA II or III were more frequent in Group A. Patients in Group A presented symptoms many years before their hospitalization in comparison to Group B (21.8+7.8 vs. 6.2+3.5 years, respectively) (P=0.0001). Emergency hospitalization was observed exclusively in Group A. Acute complications were frequently observed and hospital stays were significantly longer in Group A, 14 patients were subjected to medical management and 6 to emergency surgery. In-hospital mortality occurred in 13/20 patients (65%) versus 1/38 patients (2.6%) in Group B (P=0.0001). Laparoscopic paraesophageal hiatal hernia repair can be done safely, effectively, and in a timely manner in elderly patients at specialized surgical teams. Advanced age alone should not be a limiting factor for the repair of paraesophageal hernias.
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Affiliation(s)
- Italo Braghetto
- Department of Surgery, University of Chile, Hospital "Dr. José J. Aguirre" Faculty of Medicine, Santos Dumont 999, Santiago 3830000, Chile
| | - Juan Carlos Molina
- Department of Surgery, University of Chile, Hospital "Dr. José J. Aguirre" Faculty of Medicine, Santos Dumont 999, Santiago 3830000, Chile
| | - Owen Korn
- Department of Surgery, University of Chile, Hospital "Dr. José J. Aguirre" Faculty of Medicine, Santos Dumont 999, Santiago 3830000, Chile
| | - Enrique Lanzarini
- Department of Surgery, University of Chile, Hospital "Dr. José J. Aguirre" Faculty of Medicine, Santos Dumont 999, Santiago 3830000, Chile
| | - Maher Musleh
- Department of Surgery, University of Chile, Hospital "Dr. José J. Aguirre" Faculty of Medicine, Santos Dumont 999, Santiago 3830000, Chile
| | - Manuel Figueroa
- Department of Surgery, University of Chile, Hospital "Dr. José J. Aguirre" Faculty of Medicine, Santos Dumont 999, Santiago 3830000, Chile
| | - Jorge Rojas
- Department of Surgery, University of Chile, Hospital "Dr. José J. Aguirre" Faculty of Medicine, Santos Dumont 999, Santiago 3830000, Chile
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29
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Impact of surgical repair on type IV paraesophageal hernias (PEHs). Surg Endosc 2021; 36:5467-5475. [PMID: 34796379 DOI: 10.1007/s00464-021-08828-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 10/19/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Paraesophageal hernias (PEHs; types II-III-IV) account for about 5% of all hiatal hernias (HHs). The peculiarity of PEHs is the presence of a herniated sac which contains a more or less important part of the stomach, along with other abdominal organs in type IV PEHs. Surgical treatment is more complex since it requires a reduction not only of the herniated content but also of the "container," namely the sac adherent to mediastinal structures. Since type III and IV PEHs are mostly grouped together as large PEHs, there is a lack of articles in the literature with regards to clear surgical outcomes, as well as management algorithms in type IV PEHs. This study aims to compare outcomes in type IV vs. type III PEHs after surgical repair. METHODS A retrospective study of patients who underwent laparoscopic PEH hernia repair (LPEHR) was conducted in a single institution between 2006 and 2020. Patient baseline characteristics and surgical outcomes were analyzed. RESULTS A total of 103 patients were included in the analysis. Patients presenting with type IV PEHs (12/103) were significantly older than patients with type III PEHs (91/104) (75.25 ± 7.15 vs. 66.91 ± 13.58 respectively (p = 0.039), and more fragile with a higher Charlson Comorbidity Index (CCI) (4.25 ± 1.48 vs. 2.96 ± 1.72, p = 0.016). Operative time was significantly longer (243 ± 101.73 vs. 133.38 ± 61.76, p = 0.002), and postoperative morbidity was significantly higher in type IV PEH repair (50% vs. 8.8% type III, p = 0.000). CONCLUSION Patients with type IV PEHs appear to be older and frailer. The higher incidence of postoperative complications in patients with type IV PEHs should advocate for a precise indication for surgical treatment, which should be performed in centers of expertise.
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30
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Velanovich V. Practice-Changing Milestones in Anti-reflux and Hiatal Hernia Surgery: a Single Surgeon Perspective over 27 years and 1200 Operations. J Gastrointest Surg 2021; 25:2757-2769. [PMID: 33532979 DOI: 10.1007/s11605-021-04940-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 01/18/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND There have been steady innovations in hiatal hernia and anti-reflux surgery. The purpose of this article is to provide a historical perspective on practice-changing innovations in the context a single surgeon experience's over a career. METHODS Patients undergoing anti-reflux surgery or hiatal hernia repair by a single surgeon from 12/1992 to 3/2020 were reviewed. DATA COLLECTED sex, age, hiatal hernia type, operation type, adjuncts used, and additional procedure performed during index operation. Superimposed on this experience are the practice-changing innovations that occurred over this timeframe. RESULTS During the time period, 1200 operations were performed. Distributions: Hernia type: I, 707 (58.9%); II-IV, 325 (27.1%); Recurrent/Failed, 168 (14.0%). Type of operation, including laparoscopic and open: Nissen fundoplication: 889 (74.1%); Toupet fundoplication: 162 (13.5%); Collis-Nissen/Toupet fundoplication: 44 (3.7%); hiatal hernia repair without fundoplication (laparoscopic and open): 38 (3.2%); endoluminal fundoplication: 35 (2.9%); hiatal hernia repair with Heller myotomy/ Dor fundoplication: 10 (0.8%); transthoracic Belsey Mark IV: 2 (0.2%); hiatal hernia repair with magnetic sphincter augmentation: 20 (1.7%). Mesh reinforcement: 185 (15.4%). Additional procedures, 210 (17.5%). During this time, these practice-changing innovations occurred: laparoscopic surgery, 48-h pH monitoring, high-resolution manometry, tailoring of fundoplication, energy sources for tissue division and hemostasis, pyloroplasty for symptomatic gastroparesis, the rise and fall of endoluminal therapies, mesh reinforcement, abandonment of short gastric vessel division, and magnetic sphincter augmentation. CONCLUSIONS Over the last 27 years, a number of practice-changing advances have been made. These have led to changes in technique and operation selection of anti-reflux and hiatal hernia surgery.
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Affiliation(s)
- Vic Velanovich
- Division of General Surgery, The University of South Florida Morsani College of Medicine, 5 Tampa General Circle, Suite 740, Tampa, FL, 33606, USA.
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31
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Sharma K, Sharma R, Tiwari T, Goyal S. Mixed type of hiatus hernia: incidental diagnosis of a potentially life-threatening condition. BMJ Case Rep 2021; 14:e245887. [PMID: 34580134 PMCID: PMC8477241 DOI: 10.1136/bcr-2021-245887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2021] [Indexed: 11/04/2022] Open
Affiliation(s)
- Kritika Sharma
- Department of Radiodiagnosis, Pacific Institute of Medical Sciences, Umarda, Udaipur, Rajasthan, India
| | - Rajaram Sharma
- Department of Radiology, Pacific Institute of Medical Sciences, Umarda, Udaipur, Rajasthan, India
| | - Tapendra Tiwari
- Department of Radiology, Pacific Institute of Medical Sciences, Umarda, Udaipur, Rajasthan, India
| | - Saurabh Goyal
- Department of Radiology, Pacific Institute of Medical Sciences, Umarda, Udaipur, Rajasthan, India
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32
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True Short Esophagus in Gastroesophageal Reflux Disease: Old Controversies With New Perspectives. Ann Surg 2021; 274:331-338. [PMID: 31490280 DOI: 10.1097/sla.0000000000003582] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To explore the true short esophagus (TSE) frequency and long-term results of patients undergoing gastroesophageal reflux disease (GERD) or hiatus hernia (HH) surgery. BACKGROUND The existence and treatment of TSE during GERD/HH surgery is controversial. Satisfactory long-term results have been achieved with and without surgical techniques dedicated to TSE. METHODS In 311 consecutive patients undergoing minimally invasive surgery for GERD/HH, the distance between the endoscopically-localized gastroesophageal junction (GEJ) and the apex of the diaphragmatic hiatus after maximal thoracic esophagus mobilization was measured. A standard Nissen fundoplication (SN) was performed in cases with an abdominal length >1.5 cm; in cases of TSE (abdominal length <1.5 cm), a Collis-Nissen (CN) or stomach around the stomach fundoplication (SASF) in elderly patients was performed. The fundoplication superior margin was fixed below the hiatus, but over the GEJ. The patients' symptoms, and radiological and endoscopic data were pre/postoperatively recorded. RESULTS After intrathoracic esophageal mobilization (median 9 cm), TSE was diagnosed in 31.8% of 311 cases. With a median follow-up of 96 months (309 patients), HH relapse was radiologically diagnosed in 3.2% of patients, with excellent, good, fair, and poor outcomes in 45.6%, 44.3%, 6.2%, and 3.9% of cases, respectively, and no significant differences among SN (68.5%), CN (26.4%), and SASF (5.2%). CONCLUSIONS TSE was present in 31.8% of patients routinely submitted to GERD/HH surgery. In the presence of TSE, CN and SASF performed according to determined surgical principles may achieve similar satisfactory results. This finding warrants confirmation with a prospective multicenter study.
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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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Affiliation(s)
- Laura Mazer
- Department of Surgery, Division of Minimally Invasive Surgery, University of Michigan, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, USA
| | - Dana A Telem
- Department of Surgery, Division of Minimally Invasive Surgery, University of Michigan, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, USA.
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Chen SW, Brody F, Lee KB, Walters J, Randall JA. Outcomes of Paraesophageal Hernia Repair: Analysis of the Veterans Affairs Surgical Quality Improvement Program Database. J Gastrointest Surg 2021; 25:593-602. [PMID: 32500419 PMCID: PMC7272139 DOI: 10.1007/s11605-020-04650-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 05/13/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND While there have been many outcome studies on paraesophageal hernia repair in the civilian population, there is sparse recent data on the veteran population. This study analyzes the mortality and morbidities of veterans who underwent paraesophageal hernia repair in the Veterans Affairs Surgical Quality Improvement Program database. METHODS Veterans who underwent paraesophageal hernia repair from 2010 to 2017 were identified using Current Procedural Terminology codes. Multivariable analysis was used to compare laparoscopic and open, including abdominal and thoracic approaches, groups. The outcomes were postoperative complications and mortality. RESULTS There were 1607 patients in the laparoscopic group and 366 in the open group, with 84.1% men and mean age of 61 years. Gender and body mass index did not influence the type of surgical approach. The mortality rates at 30 and 180 days were 0.5% and 0.7%, respectively. Postoperative complications, including reintubation (2.2%), pneumonia (2.0%), intubation > 48 h (2.0%), and sepsis (2.0%) were higher in the open group (15.9% versus 7.2%, p < 0.001). The laparoscopic group had a significantly shorter length of stay (4.3 versus 9.6 days, p < 0.001) and a lower percentage of return to surgery within 30 days (3.9% versus 8.2%, p < 0.001) than the open group. The ratio of open versus laparoscopic paraesophageal hernia repairs varied significantly by different Veterans Integrated Services Network regions. CONCLUSIONS Veterans undergoing laparoscopic paraesophageal hernia repair experience similar outcomes as patients in the private sector. Veterans who underwent laparoscopic paraesophageal hernia repair had significantly less complications compared to an open approach even after adjusting for patient comorbidities and demographics. The difference in open versus laparoscopic practices between various regions requires further investigation.
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Affiliation(s)
- Sheena W Chen
- Department of Surgery, Washington DC Veterans Affairs Medical Center, 50 Irving St NW, 2B-100, Washington, DC, 20422, USA
| | - Fred Brody
- Department of Surgery, Washington DC Veterans Affairs Medical Center, 50 Irving St NW, 2B-100, Washington, DC, 20422, USA.
| | - K Benjamin Lee
- Department of Surgery, Washington DC Veterans Affairs Medical Center, 50 Irving St NW, 2B-100, Washington, DC, 20422, USA
| | - Jarvis Walters
- Department of Surgery, Washington DC Veterans Affairs Medical Center, 50 Irving St NW, 2B-100, Washington, DC, 20422, USA
| | - James Alex Randall
- Department of Surgery, Washington DC Veterans Affairs Medical Center, 50 Irving St NW, 2B-100, Washington, DC, 20422, USA
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Adhikari S, Raja S. Commentary: A century of giant paraesophageal hernia (GPEH) repair: A century of controversy! JTCVS Tech 2020; 3:373-374. [PMID: 34317935 PMCID: PMC8305720 DOI: 10.1016/j.xjtc.2020.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 07/01/2020] [Accepted: 07/02/2020] [Indexed: 11/17/2022] Open
Affiliation(s)
- Saurav Adhikari
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Siva Raja
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
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Oude Nijhuis RAB, Hoek MVD, Schuitenmaker JM, Schijven MP, Draaisma WA, Smout AJPM, Bredenoord AJ. The natural course of giant paraesophageal hernia and long-term outcomes following conservative management. United European Gastroenterol J 2020; 8:1163-1173. [PMID: 32829676 PMCID: PMC7724529 DOI: 10.1177/2050640620953754] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Background Accurate information on the natural course of giant paraesophageal hernia is
scarce, challenging therapeutic decisions whether or not to operate. Objective We aimed to investigate the long-term outcomes, including hernia-related
deaths and complications (e.g. volvulus, gastrointestinal bleeding,
strangulation) of patients with giant paraesophageal hernia that were
conservatively managed, and to determine factors associated with clinical
outcome. Methods We retrospectively analysed charts of patients diagnosed with giant
paraesophageal hernia between January 1990 and August 2019, collected from a
university hospital in The Netherlands. Included patients were subdivided
into three groups based on primary therapeutic decision at diagnosis.
Radiological, clinical and surgical characteristics, along with long-term
outcomes at most recent follow-up, were collected. Results We included 293 patients (91 men, mean age 70.3 ± 12.4 years) with a mean
duration of follow-up of 64.0 ± 58.8 months. Of the 186 patients that were
conservatively treated, a total hernia-related mortality of 1.6% was
observed. Hernia-related complications, varying from uncomplicated volvulus
to strangulation, occurred in 8.1% of patients. Only 1.1% of patients
included in this study required emergency surgery. Logistic regression
analysis revealed the presence of symptoms (odds ratio (OR) 4.4, 95%
confidence interval (CI) 1.8–20.6), in particular obstructive symptoms
(vomiting, OR 15.7, 95% CI 4.6–53.6; epigastric pain, OR 4.4, 95% CI
1.2–15.8 and chest pain, OR 6.1, 95% CI 1.8–20.6) to be associated with the
occurrence of hernia-related complications. Conclusions Hernia-related death and morbidity is low in conservatively managed patients.
The presence of obstructive symptoms was found to be associated with the
occurrence of complications during follow-up. Conservative therapy is an
appropriate therapeutic strategy for asymptomatic patients.
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Affiliation(s)
- Renske A B Oude Nijhuis
- Amsterdam UMC, University of Amsterdam, Gastroenterology Endocrinology Metabolism, Meibergdreef 9, Amsterdam, the Netherlands
| | - Margot van der Hoek
- Amsterdam UMC, University of Amsterdam, Gastroenterology Endocrinology Metabolism, Meibergdreef 9, Amsterdam, the Netherlands
| | - Jeroen M Schuitenmaker
- Amsterdam UMC, University of Amsterdam, Gastroenterology Endocrinology Metabolism, Meibergdreef 9, Amsterdam, the Netherlands
| | - Marlies P Schijven
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Meibergdreef 9, Amsterdam, the Netherlands
| | - Werner A Draaisma
- Jeroen Bosch Hospital, Department of Surgery, den Bosch, The Netherlands
| | - Andreas J P M Smout
- Amsterdam UMC, University of Amsterdam, Gastroenterology Endocrinology Metabolism, Meibergdreef 9, Amsterdam, the Netherlands
| | - Albert J Bredenoord
- Amsterdam UMC, University of Amsterdam, Gastroenterology Endocrinology Metabolism, Meibergdreef 9, Amsterdam, the Netherlands
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Bhargava A, Andrade R. Giant paraesophageal hernia: What do we really know? JTCVS Tech 2020; 3:367-372. [PMID: 34317934 PMCID: PMC8305721 DOI: 10.1016/j.xjtc.2020.08.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 06/10/2020] [Accepted: 08/10/2020] [Indexed: 01/07/2023] Open
Affiliation(s)
- Amit Bhargava
- Division of Thoracic and Foregut Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minn
| | - Rafael Andrade
- Division of Thoracic and Foregut Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minn
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Dreifuss NH, Schlottmann F, Molena D. Management of paraesophageal hernia review of clinical studies: timing to surgery, mesh use, fundoplication, gastropexy and other controversies. Dis Esophagus 2020; 33:doaa045. [PMID: 32476002 PMCID: PMC8344298 DOI: 10.1093/dote/doaa045] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 04/14/2020] [Accepted: 05/02/2020] [Indexed: 12/11/2022]
Abstract
Despite paraesophageal hernias (PEH) being a common disorder, several aspects of their management remain elusive. Elective surgery in asymptomatic patients, management of acute presentation, and other technical aspects such as utilization of mesh, fundoplication or gastropexy are some of the debated issues. The aim of this study was to review the available evidence in an attempt to clarify current controversial topics. PEH repair in an asymptomatic patient may be reasonable in selected patients to avoid potential morbidity of an emergent operation. In acute presentation, gastric decompression and resuscitation could allow to improve the patient's condition and refer the repair to a more experienced surgical team. When surgical repair is decided, laparoscopy is the optimal approach in most of the cases. Mesh should be used in selected patients such as those with large PEH or redo operations. While a fundoplication is recommended in the majority of patients to prevent postoperative reflux, a gastropexy can be used in selected cases to facilitate postoperative care.
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Affiliation(s)
- Nicolás H Dreifuss
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | | | - Daniela Molena
- Division of Thoracic Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 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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Ihde GM. The evolution of TIF: transoral incisionless fundoplication. Therap Adv Gastroenterol 2020; 13:1756284820924206. [PMID: 32499834 PMCID: PMC7243382 DOI: 10.1177/1756284820924206] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 04/15/2020] [Indexed: 02/04/2023] Open
Abstract
Transoral incisionless fundoplication (TIF) was introduced in 2006 as a concerted effort to produce a natural orifice procedure for reflux. Since that time, the device, as well as the procedure technique, has evolved. Significant research has been published during each stage of the evolution, and this has led to considerable confusion and a co-mingling of outcomes, which obscures the results of the current device and procedure. This report is intended to review the identified stages and literature associated with each stage to date and to review the current state of treatment outcomes.
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Tartaglia N, Pavone G, Di Lascia A, Vovola F, Maddalena F, Fersini A, Pacilli M, Ambrosi A. Robotic voluminous paraesophageal hernia repair: a case report and review of the literature. J Med Case Rep 2020; 14:25. [PMID: 32019608 PMCID: PMC6998085 DOI: 10.1186/s13256-020-2347-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 01/06/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The treatment for sliding esophageal hernia with mild gastroesophageal reflux is usually conservative, but surgical treatment is recommended for refractory sliding esophageal hernia, paraesophageal hernia liable to prolapse, or paraesophageal hernia with ulceration and/or stenosis. Robotic surgery overcomes laparoscopic pitfalls by providing steady-state three-dimensional visualization, augmented dexterity with endo-wrist movements, and superior ergonomics for the surgeon. CASE PRESENTATION To investigate robotic paraesophageal hernia repair, a literature search was conducted using PubMed with the following key words: mini invasive surgery, robotic surgery, hiatal hernia, and Nissen fundoplication. We present the case of a 44-year-old Italian woman with a 20-year history of gastroesophageal reflux disease refractory to medical treatment, who underwent robotic Nissen fundoplication. In our center, we use the da Vinci® Xi™ Surgical System, which is an advanced tool for minimally invasive surgery. CONCLUSIONS Various reports published in the literature suggested that the robot-assisted approach was effective and was associated with very low postoperative morbidity and was accompanied by satisfactory symptomatic and anatomical radiological outcomes during a follow-up period. The robotic approach to paraesophageal repair is safe and effective with low complication rates. With increased experience, the operative time, length of stay, and complications decrease without compromising surgical principles.
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Affiliation(s)
- Nicola Tartaglia
- Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto, 71122, Foggia, Italy.
| | - Giovanna Pavone
- Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto, 71122, Foggia, Italy
| | - Alessandra Di Lascia
- Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto, 71122, Foggia, Italy
| | - Fernanda Vovola
- Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto, 71122, Foggia, Italy
| | - Francesca Maddalena
- Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto, 71122, Foggia, Italy
| | - Alberto Fersini
- Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto, 71122, Foggia, Italy
| | - Mario Pacilli
- Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto, 71122, Foggia, Italy
| | - Antonio Ambrosi
- Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto, 71122, Foggia, Italy
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Choi S, Tang A, Murthy S, Raja S. Preoperative Evaluation and Clinical Decision Making for Giant Paraesophageal Hernias: Who Gets an Operation? Thorac Surg Clin 2019; 29:415-419. [PMID: 31564398 DOI: 10.1016/j.thorsurg.2019.07.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Giant paraesophageal hernias can present as an asymptomatic incidentally detected paraesophageal hernia to an emergent gastric volvulus with concern for ischemia. In the acute setting, the preoperative evaluation aims to determine the extent of complications from gastric volvulus. In the elective setting, preoperative testing defines the gastroesophageal anatomy and function to select the optimal operation. Through thoughtful preoperative evaluation, the best operative approach can be tailored to each patient.
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Affiliation(s)
- Sarah Choi
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Andrew Tang
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Sudish Murthy
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Siva Raja
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Abstract
The transthoracic approach to PEH repair has been displaced by the laparoscopic methods of repair for valuable reasons. Despite the pressures of performing minimally invasive surgery, the experienced esophageal surgeon will appreciate the benefits of the transthoracic repair in select circumstances as outlined in this article. In this writing, we discussed our indications, the salient anatomy and important steps in performing a successful transthoracic PEH repair.
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Korwar V, Adjepong S, Pattar J, Sigurdsson A. Biological Mesh Repair of Paraesophageal Hernia: An Analysis of Our Outcomes. J Laparoendosc Adv Surg Tech A 2019; 29:1446-1450. [PMID: 31539310 DOI: 10.1089/lap.2019.0423] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Introduction: Symptomatic paraesophageal hernia (PEH) is an indication for surgical repair. Laparoscopic suture repair has high recurrence rates. Many surgeons prefer mesh repair to reduce PEH recurrence. Several types of mesh, synthetic and biological, are in use. Synthetic mesh has a risk of erosion and stricture, hence we preferred biological mesh repair. Our aim in this study is to assess medium-term outcomes of PEH repair with the use of biological mesh reinforcement over the cruroplasty. We also aimed to correlate clinical recurrences with radiological recurrences. Materials and Methods: This is a retrospective study of 154 consecutive patients from a single centre who underwent a standardized laparoscopic suture repair of the hiatus reinforced with an on-lay patch of Surgisis (porcine small intestine submucosa) and fundoplication. The mean age of the patients was 65 years. All patients were called for regular clinical follow-up and a barium study. Modified GERD-HRQL symptom severity instrument was used to assess postoperative symptoms and satisfaction. Results: The mean follow-up for barium swallow and clinical assessment were 28.42 ± 21.2 and 33.69 ± 23.46 months. The mean patient satisfaction score after surgery was 4.43 ± 1.09 (0-5). Follow-up barium swallow was performed in 122 (79.22%), 87 (56.49%) patients completed clinical follow-up questionnaire, and 77 (50%) had both. Symptomatic recurrence was noted in 25 (28.73%), recurrence on barium swallow 25(20.4%), and 10 (12.98%) had both. The reoperation rate was 3.25%. Mann-Whitney U test showed no statistical significance in reflux-related score between radiological recurrence group compared with no radiological recurrence (P = .06). Conclusions: Biological mesh repair of PEH is safe and well accepted by patients. There is significantly high PEH recurrence rate in long-term follow-up, even with mesh repair. Majority of these recurrences are small, asymptomatic, and the reoperation rate is very low.
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Affiliation(s)
- Vijay Korwar
- Department of Upper GI and Bariatric Surgery, Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, United Kingdom
| | - Samuel Adjepong
- Department of Upper GI and Bariatric Surgery, Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, United Kingdom
| | - Jayaprakash Pattar
- Department of Upper GI and Bariatric Surgery, Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, United Kingdom
| | - Audun Sigurdsson
- Department of Upper GI and Bariatric Surgery, Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, United Kingdom
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Pagel PS, Thorsen TN, Kugler NW, Haberman KM, Haasler GB, Otterson MF. Acute Onset of Nausea and Vomiting, Diffuse Abdominal Pain, and Profound Metabolic Acidosis 3 Years After Total Gastrectomy. J Cardiothorac Vasc Anesth 2019; 33:3214-3216. [PMID: 31101510 DOI: 10.1053/j.jvca.2019.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 04/16/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Paul S Pagel
- Anesthesia Service, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI.
| | - Thomas N Thorsen
- Anesthesia Service, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI
| | - Nathan W Kugler
- General Surgery Service, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI
| | - Kathryn M Haberman
- General Surgery Service, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI
| | - George B Haasler
- Cardiothoracic Surgery Service, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI
| | - Mary F Otterson
- General Surgery Service, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI
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Sorial RK, Ali M, Kaneva P, Fiore JF, Vassiliou M, Fried GM, Feldman LS, Ferri LE, Lee L, Mueller CL. Modern era surgical outcomes of elective and emergency giant paraesophageal hernia repair at a high-volume referral center. Surg Endosc 2019; 34:284-289. [DOI: 10.1007/s00464-019-06764-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 03/18/2019] [Indexed: 12/18/2022]
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Long-term efficacy of laparoscopic Nissen versus Toupet fundoplication for the management of types III and IV hiatal hernias. Surg Endosc 2018; 33:2895-2900. [DOI: 10.1007/s00464-018-6589-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 11/12/2018] [Indexed: 12/12/2022]
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Morrow EH, Chen J, Patel R, Bellows B, Nirula R, Glasgow R, Nelson RE. Watchful waiting versus elective repair for asymptomatic and minimally symptomatic paraesophageal hernias: A cost-effectiveness analysis. Am J Surg 2018; 216:760-763. [PMID: 30054004 DOI: 10.1016/j.amjsurg.2018.07.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 04/21/2018] [Accepted: 07/14/2018] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To evaluate the decision of watchful waiting (WW) versus elective laparoscopic hernia repair (ELHR) for minimally symptomatic paraesophageal hernias (PEH) with respect to cost-effectiveness. BACKGROUND The current recommendation for minimally symptomatic PEHs is watchful waiting. This standard is based on a decision analysis from 2002 that compared the two strategies on quality-adjusted life-years (QALYs). Since that time, the safety of ELHR has improved. A cost-effectiveness study for PEH repair has not been reported. METHODS A Markov decision model was developed to compare the strategies of WW and ELHR for minimally symptomatic PEH. Input variables were estimated from published studies. Cost data was obtained from Medicare. Outcomes for the two strategies were cost and QALY's. RESULTS ELHR was superior to the WW strategy in terms of quality of life, but it was more costly. The average cost for a patient in the ELHR arm was 11,771 dollars while for the WW arm it was 2207. CONCLUSION This study shows that WW and ELHR both have benefits in the management of minimally symptomatic paraesophageal hernias.
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Affiliation(s)
- Ellen H Morrow
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - Jennwood Chen
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Ravi Patel
- University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Brandon Bellows
- Department of Pharmacotherapy, University of Utah, Salt Lake City, UT, USA
| | - Raminder Nirula
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Robert Glasgow
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Richard E Nelson
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
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