Use of absorbable meshes in laparoscopic paraesophageal hernia repair

Paraesophageal hernia(PEH)repair is one of the most challenging upper gastrointestinal operations.Its high rate of recurrence is due mostly to the low quality of the crura and size of the hiatal defect.In an attempt to diminish the recurrence rates,some clinical investigators have begun performing meshreinforced cruroplasty with nonabsorbable meshes like polypropylene or polytetrafluoroethylene.The main problem with these materials is the occurrence,in some patients,of serious mesh-related morbidities,such as erosions into the stomach and the esophagus,some of which necessitate subsequent esophagectomy or gastrectomy.Absorbable meshes can be synthetic or biological and were introduced in recent years for PEH repair with the intent of diminishing the recurrence rates observed after primary repair alone but,theoretically,without the risks of morbidities presented by the nonabsorbable meshes.The current role of absorbable meshes in PEH repair is still under debate,since there are few data regarding their long-term efficacy,particularly in terms of recurrence rates,morbidity,need for revision,and quality of life.In this opinion review,we analyze all the presently available evidence of reinforced cruroplasty for PEH repair using nonabsorbable meshes(synthetic or biological),focusing particularly on recurrence rates,mesh-related morbidity,and long-term quality of life.

Terminal ileum gangrene secondary to a type Ⅳ paraesophageal hernia

Type Ⅳ paraesophageal hernia(PEH) is very rare, and is characterized by the intrathoracic herniation of the abdominal viscera other than the stomach into the chest. We describe a 78-year-old woman who presented at our emergency department because of epigastric pain that she had experienced over the past 24 h. On the day after admission, her pain became severe and was accompanied by right chest pain and dyspnea. Chest radiography revealed an intrathoracic intestinal gas bubble occupying the right lower lung field. Emergency explorative laparotomy identified a type Ⅳ PEH with herniation of only the terminal ileum through a hiatal defect into the right thoracic cavity. In this report, we also present a review of similar cases in the literature published between 1980 and 2015 in Pub Med. There were four published cases of small bowel herniation into the thoracic cavity during this period. Our patient represents a rare case of an individual diagnosed with type Ⅳ PEH with incarceration of only the terminal ileum.

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

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

Herniated pancreatic body within a paraesophageal hernia

A hiatal hernia can be classified as one of four types according to the position of the gastroesophageal (GE) junction and the extent of herniated stomach. Type Ⅰ, or sliding hernias, account for up to 95% of all hiatal hernias and occur when the GE junction migrates into the posterior mediastinum through the hiatus. Type Ⅱ occurs when the fundus herniates through the hiatus alongside a normally positioned GE junction. Type Ⅲ is a combination of types Ⅰ and Ⅱ hernias with a displaced GE junction as well as stomach protruding through the hiatus. Type Ⅳ paraesophageal hernias are the rarest of the hiatal hernias. Usually, colon or small bowel is herniated within the mediastinum along with the stomach. We present a case of a paraesophageal hernia with the mid-body of the pancreas as part of the hernia contents.

Intrathoracic major duodenal papilla with transhiatal herniation of the pancreas and duodenum:A case report and review of the literature

Transhiatal herniation of the pancreas is an extremely rare condition.In the published literature we found only eleven cases reported in the period of 1958 to 2011.A coincidental hiatal herniation of the duodenum is described in two cases only.To our knowledge,we report the first case with a hiatal herniation of the complete duodenum and proximal pancreas presenting an intrathoracic major duodenal papilla with consecutive intrahepatic and extrahepatic cholestasis.A 72-yearold Caucasian woman was admitted to our department with a hiatal hernia grade Ⅳ for further evaluation.According to our recommendation of surgical hernia repair soon after the diagnosis of a transhiatal herniation of the proximal pancreas and entire duodenum,we had to respect the declared intention of the patient for a conservative procedure.So we were forced to wait for surgical repair within an emergency situation complicated by a myocardial infarction and reduced general condition.We discuss the therapeutic decision making process and a complete literature review of this rare entity.

Laparoscopic repair of complete intrathoracic stomach with iron deficiency anemia:A case report

BACKGROUND Giant paraesophageal hiatal hernias(HH)are very infrequent,and their spectrum of clinical manifestations is large.Giant HH mainly occurs in elderly patients,and its relationship with anemia has been reported.For the surgical treatment of large HH,Nissen fundoplication is the most common antireflux procedure,and the reinforcement of HH repair with a patch(either synthetic or biologic)is still debatable.CASE SUMMARY We report on a case of giant paraesophageal HH in a middle-aged male patient with reflux symptoms and severe anemia.After performing a series of tests and diagnostic approaches,results showed a complete intrathoracic stomach associated with severe iron deficiency anemia.The patient underwent successful laparoscopic hernia repair with mesh reinforcement and Nissen fundoplication.Postoperatively,reflux symptoms were markedly relieved,and the imaging study showed complete reduction of the hernia sac.More importantly,anemia was resolved,and hemoglobin,serum iron and ferritin level were returned to the normal range.The patient kept regular follow-up appointments and remained in a satisfactory condition.CONCLUSION This case report highlights the relationship between large HH and iron deficiency anemia.For the surgical treatment of large HH,laparoscopic repair of large HH combined with antireflux procedure and mesh reinforcement is recommended.

An 81-year-old gentleman with symptomatic Bochdalek hernia

An 81-year-old gentleman with congenital polycystic kidney disease presented to his primary care physician with dysphagia, gastroesophageal reflux refractory to medical management, and 11.25 kg weight loss in a 6 mo-period. A barium swallow misdiagnosed a paraesophageal hernia for a Bochdalek hernia. Herein, we highlight how a Bochdalek hernia may be disregarded in the differential diagnosis and how providers can resort to a more common diagnosis, a paraesophageal hernia, which is more frequently encountered in old age and whose radiologic appearance might mimic a Bochdalek hernia.

Cardiovascular Complications of Large Hiatal Hernias: Expanding the Indications for Robotic Surgical Anatomic and Physiologic Repair: A Review

Background: Historically, the pathophysiology of Hiatal Hernias (HH) has not been fully understood. As a result, the surgical therapy of HH has focused primarily on gastrointestinal symptoms and Gastroesophageal Reflux (GERD). This treatment strategy has been associated with poor relief of symptoms and poor long-term outcomes. In fact, until recently, most patients with HH have been watched and referred for surgery as a last resort. Recent experience has shown that a large (giant) Hiatal Hernia (GHH) is a common problem known to impact adjacent organs such as the hearts and lungs. Those referred for surgical repair often complain of dyspnea, which is erroneously attributed to pulmonary compression or aspiration, but has been shown to be from tamponade caused from compression of the heart by herniated abdominal contents. This article reviews the present understanding of GHH, the cardiac complications which result from GHH, and the most advanced robotic minimally invasive surgical approach to the anatomic and physiologic repair of GHH. Methods: In a prospective cohort study, we evaluated patients undergoing RRHH with at least a 2-year follow-up. All patients undergoing elective (RRHH) were identified preoperatively and enrolled prospectively in this study. Preoperative characteristics, medical comorbidities, and clinical information were all recorded prospectively and recorded into a secure surgical outcomes database. All patients received the previously validated Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL) questionnaire preoperatively and at postoperative time points of 1 month, 1 year, and 2 years. Patients routinely had a barium swallow postoperatively before discharge but did not undergo a barium swallow, an endoscopy, or a CT scan study at the 1-month time point unless indicated by symptoms. At 6 months, 1 year, and yearly intervals thereafter, all patients received an endoscopy study to ascertain the presence of a recurrence, regardless of symptoms. Recurrence was defined as over 2 cm or 10% of the stomach above the diaphragm detected by CT, esophagogram or endoscopy. In addition, an extensive search was conducted using Pub Med in order to extract references to the cardiovascular complications of HH. Results: 423 patients underwent RRHH. With a long-term follow-up, there was a significant decrease in the Median Symptom Severity Score from 42.0 preoperatively, to 3.0 postoperatively. Recurrence was seen in 5 patients (5/423) for a recurrence rate of 1.1%. Conclusion: This experience has been the basis of two important realizations: 1) all patients with GHH have at least some degrees of clinically relevant compression of the inferior vena cava and the left atrium which causes tamponade and cardiogenic dyspnea which completely resolves after successful surgical repair;and 2) primary care providers and gastroenterologists who usually treat patients for GHH repair rarely recognize cardiac compression and tamponade as the cause of the shortness of breath and gradual increase in dyspnea on exertion and progressive fatigability in these patients. This article reviews the present understanding of GHH, the cardiac complications which result from GHH and the most advanced robotic minimally invasive surgical approach to the anatomic and physiologic repair of GHH.