Common signs, uncommon condition: A case report of a 41-year-old woman with a large left-sided esophageal hiatus hernia and a benign esophageal leiomyoma.

To determine if the severity of gastroesophageal reflux disease is dependent on the size of a hiatus hernia. Seventy-five patients with either a small (n = 25), medium (n = 25) or large (n = 25) hiatus hernia (assessed by high resolution esophageal manometry) were investigated using 24-h esophageal monitoring and a self-assessed symptom questionnaire. The questionnaire comprised the following items, each graded from 0 to 3 according to severity: heartburn; pharyngeal burning sensation; acid regurgitation; and chest pain. The percentage total reflux time was significantly longer in the group with hernia of 5 cm or more compared with the group with a hernia of < 3 cm (P < 0.002), and the group with a hernia of 3 to < 5 cm (P < 0.04). Pharyngeal burning sensation, heartburn and acid regurgitation were more common with large hernias than small hernias, but the frequency of chest pain was similar in all three hernia groups. Patients with a large hiatus hernia are more prone to have pathological gastroesophageal reflux and to have more acid symptoms than patients with a small hiatus hernia. However, it is unlikely that patients with an absence of acid symptoms will have pathological reflux regardless of hernia size.

Short esophagus is a disease of the past and the prevention of recurrent hiatal hernia is the challenge of the future

Anatomic changes induced by large hiatal hernia may alter esophageal pressure topography measurements made during high-resolution manometry. Retrospective study. Single-institution tertiary hospital. Ninety patients with large (>5 cm) hiatal hernias on endoscopy were compared with a control group of 46 patients without hernia selected from the same database of 2000 consecutive clinical high-resolution manometry studies. High-resolution manometry with at least 7 evaluable swallows for analysis. Esophageal pressure topography was analyzed for lower esophageal sphincter pressure, distal contractile integral, contraction amplitude, contractile front velocity, and distal latency time. Esophageal length was measured on esophageal pressure topography from the distal border of the upper esophageal sphincter to the proximal border of the lower esophageal sphincter. Esophageal pressure topography diagnosis was based on the Chicago Classification. The manometry catheter was coiled in the hernia and did not traverse the diaphragm in 44 patients (49%) with large hernia. Patients with large hernias had lower average lower esophageal sphincter pressures, a lower distal contractile integral, slower contractile front velocity, and shorter distal latency time than patients without hernia. They also exhibited a shorter mean esophageal length. However, the distribution of peristaltic abnormalities was not different in patients with and without large hernia. Patients with large hernias had an alteration of esophageal pressure topography measurements and a shortened esophagus. However, the distribution of peristaltic disorders was unaffected by the presence of hernia.

Aim. The article discusses the results of a study using a patented method of two-layer laparoscopic repair of large and giant hiatal hernias using a biocarbon implant in comparison with other surgical techniques. Materials and methods. 716 patients were divided into 3 study groups based on the area of the size of the esophageal hernia defect: group I (314 patients) – with small (less than 5 cm2) and medium (5–10 cm2) hiatal hernias, that is, up to 10 cm2, which hernioplasty was performed only by the method of posterior cruraphy; group II (323 patients) – with large hernias 10–20 cm2: subgroup 1 (92 patients) underwent posterior cruraphy, subgroup 2 (231 patients) – alloplasty. Depending on the alloplasty technique, subgroup 2, in turn, was divided: subgroup A (89 people) – hernioplasty with a polypropylene implant and subgroup B (142 people) – hernioplasty with a medical biocarbon construction. Study group III (79 patients) – patients with giant diaphragmatic hernias of more than 20 cm2 using alloplasty: subgroup A (29 people) – hernioplasty with a polypropylene implant and subgroup B (50 patients) – alloplasty with a medical biocarbon construction. Results. When comparing group I with subgroup 1 of group II, the following results were obtained. Statistically significant differences were found in the degrees and types of diaphragmatic hernias. The average age of patients and statistical differences for it were insignificant. When comparing subgroup 1 with subgroup 2 of group II, statistically insignificant differences were found in the degrees and types of hiatal hernias. The difference in the average age of patients was also statistically insignificant. The difference in the average age of patients was also statistically insignificant. When comparing subgroup A with subgroup B of group II, statistically insignificant differences were found among themselves in the degrees and types of hiatal hernias. When comparing subgroup 2 of group II with group III, the difference turned out to be statistically significant in the distribution of patients by types and degrees of diaphragmatic hernias. When comparing subgroup A with subgroup B of group III by degrees and types of hiatal hernias, statistically insignificant differences were revealed. Conclusion. Posterior cruraphia in small and medium diaphragmatic hernias had significant statistical differences in types and degrees compared to that in large hernias, as well as in the average area of the hernial defect. Posterior cruraphia with hernioplasty in large hiatal hernias did not differ statistically significantly according to any of the criteria. Plastic surgery with a polypropylene implant with alloplasty of a biocarbon implant for large hernias did not differ significantly according to any of the criteria. Hernioplasty for large hiatal hernias, when compared with giant hernias, differed significantly only in the degree and type, as well as in the area of the hernial defect. Onlay plastic surgery with a polypropylene implant with alloplasty of biocarbon structures for giant hernias did not differ significantly according to any of the criteria, except for gender distribution, which did not have significant fundamental significance, which made it possible to make a more correct comparison of the results of surgical interventions in these research subgroups.

Aim. The article discusses the results of a study using a patented method of two-layer laparoscopic repair of large and giant hiatal hernias using a biocarbon implant in comparison with other surgical techniques.Materials and methods. 716 patients were divided into 3 study groups based on the area of the size of the esophageal hernia defect: group I (314 patients) – with small (less than 5 cm2) and medium (5–10 cm2) hiatal hernias, that is, up to 10 cm2, which hernioplasty was performed only by the method of posterior cruraphy; group II (323 patients) – with large hernias 10–20 cm2: subgroup 1 (92 patients) underwent posterior cruraphy, subgroup 2 (231 patients) – alloplasty. Depending on the alloplasty technique, subgroup 2, in turn, was divided: subgroup A (89 people) – hernioplasty with a polypropylene implant and subgroup B (142 people) – hernioplasty with a medical biocarbon construction. Study group III (79 patients) – patients with giant diaphragmatic hernias of more than 20 cm2 using alloplasty: subgroup A (29 people) – hernioplasty with a polypropylene implant and subgroup B (50 patients) – alloplasty with a medical biocarbon construction.Results. When comparing group I with subgroup 1 of group II, the following results were obtained. Statistically significant differences were found in the degrees and types of diaphragmatic hernias. The average age of patients and statistical differences for it were insignificant. When comparing subgroup 1 with subgroup 2 of group II, statistically insignificant differences were found in the degrees and types of hiatal hernias. The difference in the average age of patients was also statistically insignificant. The difference in the average age of patients was also statistically insignificant. When comparing subgroup A with subgroup B of group II, statistically insignificant differences were found among themselves in the degrees and types of hiatal hernias. When comparing subgroup 2 of group II with group III, the difference turned out to be statistically significant in the distribution of patients by types and degrees of diaphragmatic hernias. When comparing subgroup A with subgroup B of group III by degrees and types of hiatal hernias, statistically insignificant differences were revealed.Conclusion. Posterior cruraphia in small and medium diaphragmatic hernias had significant statistical differences in types and degrees compared to that in large hernias, as well as in the average area of the hernial defect. Posterior cruraphia with hernioplasty in large hiatal hernias did not differ statistically significantly according to any of the criteria. Plastic surgery with a polypropylene implant with alloplasty of a biocarbon implant for large hernias did not differ significantly according to any of the criteria. Hernioplasty for large hiatal hernias, when compared with giant hernias, differed significantly only in the degree and type, as well as in the area of the hernial defect. «Onlay» plastic surgery with a polypropylene implant with alloplasty of biocarbon structures for giant hernias did not differ significantly according to any of the criteria, except for gender distribution, which did not have significant fundamental significance, which made it possible to make a more correct comparison of the results of surgical interventions in these research subgroups.

BackgroundStandard-of-care surgical treatments for gastroesophageal reflux disease (GERD), with large hiatal hernia (HH), result in a reoperation rate of up to 50% at 5 years. RefluxStop, acting as a mechanical stop without encircling the food passageway, offers a novel approach to treat large HH patients. This study assesses the safety and efficacy of RefluxStop surgery comparing large and small HH groups followed for up to 4 years.MethodsTwo cohorts were retrospectively analyzed in a combined investigator-initiated study evaluating safety outcomes of RefluxStop in severe GERD subjects, comparing concomitant small (≤3 cm) and large HH (4–10 cm) in Switzerland. Primary outcomes were procedure-related adverse events (AEs/ADEs). The secondary outcome was improvement in GERD-HRQL score.ResultsNinety-nine subjects underwent the RefluxStop surgical procedure, whereof 50 subjects had small (≤3 cm) and 49 subjects had large HH (4–10 cm). One surgeon at each site operated on both small and large hernia patients. No significant difference in AEs between patients with small and large HH was shown. At 1-year follow-up, subjects in both groups experienced statistically significant improvements in median (IQR) GERD-HRQL score of 93.8% (81.8%; 98.7%) for those with large HH and 85.7% (76.5%; 92.3%) for those with small HH.ConclusionRefluxStop surgery for GERD effectively treats patients with large HH that currently have no optimal treatment options, while showing significantly improved results for up to 4 years. Furthermore, RefluxStop provides equally favorable results and a robust low risk profile for subjects with either concomitant small (n = 49) and large (n = 50) HH.

Recurrent hiatus hernia is frequently found in patients undergoing reoperative antireflux surgery. The objective of this study is to report perioperative complications and subjective and objective outcomes for patients who underwent reoperative intervention for symptomatic large recurrent hiatus hernia. Retrospective review of a prospectively maintained database was performed to identify patients with large (≥ 5 cm gastric tissue above the crus) recurrent hiatus hernia who underwent reoperation after failed antireflux surgery. Data for preoperative workup, operative procedure, and postoperative 6-month follow-up were reviewed and analyzed. Two hundred twenty patients underwent reoperation over a 6-year period. Forty-four patients had large recurrent hiatus hernia; 21 underwent redo fundoplication, while 23 underwent Roux-en-Y (RNY) reconstruction as remedial procedure. Short esophagus was found in 16 cases (6 of 21 redo Collis fundoplications, 10 of 23 RNY reconstructions). There was significant symptom improvement and high degree of satisfaction reported in both groups. However, patients with short esophagus did better with RNY reconstruction compared with redo Collis gastroplasty. Repair of large recurrent hiatus hernia is a technically challenging procedure; however, there is high degree of symptom resolution and patient satisfaction. RNY reconstruction might be a better alternative in patients with short esophagus compared with redo Collis gastroplasty.

ABSTRACTBackgroundVery large hiatus hernias are often symptomatic, impact quality of life, and are increasingly encountered in aging populations. Laparoscopic repair offers excellent clinical outcomes. However, surgeons can be reluctant to offer surgery to the elderly due to concerns about morbidity and mortality. To determine safety, we evaluated outcomes following repair of very large hiatus hernias in patients aged 80 years and older and compared them to younger patients.MethodsData were extracted from a prospective database. Patients who underwent operative repair of a very large hiatus hernia (> 50% intrathoracic stomach) between 2000 and 2023 were included and categorized into groups based on age: young (< 70 years), older (70–79 years), and octogenarian (≥ 80 years). Perioperative and early postoperative clinical outcomes were determined and compared.Results1353 patients underwent surgery (< 70 years: 733 [54.2%], 70–79 years: 451 [33.3%], and ≥ 80 years: 169 [12.5%]). Rates of total intrathoracic stomach were commonest in octogenarians (11.6% vs. 20.4% vs. 32.5% and p < 0.001). Young and older patients were more likely to undergo elective surgery for heartburn (56.6% vs. 44.4% vs. 29.0% and p < 0.001), whereas octogenarians more likely underwent emergency surgery for gastric volvulus (5.4% vs. 6.6% vs. 14.5% and p = 0.019). Conversion to open surgery (1.1% vs. 1.1% vs. 5.0% and p = 0.002) and length of stay (2.69 vs. 3.19 vs. 4.62 days and p < 0.001) were greater in the octogenarian group. Major complications (4.2% vs. 5.1% vs. 8.1% and p = 0.120) and return to theater rates (2.6% vs. 2.9% vs. 2.7% and p = 0.925) were similar. Thirty‐day mortality rates were low for all groups but highest in octogenarians (0.3% vs. 0.4% vs. 1.8% and p = 0.048). Adverse outcomes were more likely with emergency presentations, which were more common in octogenarians.ConclusionDespite a higher rate of emergency surgery in octogenarians—major complications and overall mortality rates are still acceptably low. Repair of very large symptomatic hiatus hernia should not be withheld from patients aged over 80 who are otherwise fit.

Background The results of laparoscopic surgery for large symptomatic hiatus hernia were revieved prospectively. Methods This was a prospective review of large (greater than 10 cm) hiatus hernias treated by laparoscopic surgery at the Royal Adelaide Hospital from January 1994 to July 1997. Demographic data, preoperative investigations, operative findings, operating times, conversion rate, complications and follow-up were recorded prospectively. Results Some 48 patients with a large hiatus hernia were treated laparoscopically. All had repair of the hiatal pillars and 47 had a fundoplication. The median age was 58 (range 30–87) years and there were 25 women. There were 11 sliding, eight paraoesophageal and 29 mixed hiatus hernias, and 20 completely intrathoracic stomachs. Median operating time was 75 (range 48–195) min and there were 12 conversions to an open operation; four because of difficulty reducing the hernia, three for obesity, two for bleeding, two because it was not possible to define the anatomy and one for gastric perforation. The majority of conversions occurred earlier in this experience and a change in technique to dissecting the sac out of the thoracic cavity reduced the conversion rate (38 to 15 per cent; P = 0·03, Fisher's exact test). Complications occurred in eight patients and resulted in early reoperation in two (one open and one laparoscopic). There was no death. The median stay was 3 (range 2–10) days. At a median follow-up of 19 (range 3–46) months, eight patients had minor dysphagia and two patients had an incisional hernia (both converted to open operation). One patient had a recurrent paraoesphageal hernia at 6 months and required further surgery. Median satisfaction scores were 10 (range 7–10) of 10 and all patients said they would have the operation again. Conclusion Large hiatus hernias can be effectively treated laparoscopically. The initial high rate of conversion to open operation was reduced by a change in operative technique.

Management of intrathoracic stomach with polypropylene mesh prosthesis reinforced transabdominal hiatus hernia repair

Introduction: Cameron lesions are mucosal erosions or ulcers found at the level of the diaphragmatic hiatus within the hiatal hernia. Usually asymptomatic, Cameron lesions are found incidentally on upper endoscopy. However, they can be a source of obscure gastrointestinal bleeding. Cameron lesions have been reported to be associated mainly with large hiatus hernias and NSAIDs use. Here in, we present a unique case of gastrointestinal bleeding secondary to a Cameron ulcer associated with a small subcentimeter hiatus hernia. Case report: A 76-year-old woman with medical history of hypertension, sarcoidosis, prior cerebral vascular accidents, coronary artery disease presented with complaints of dark watery stools, multiple episodes of coffee ground emesis and mild epigastric abdominal pain. Physical examination revealed a soft abdomen with normal bowel sounds and mild tenderness in the epigastrium. Initial laboratory tests demonstrated hemoglobin of 10.3 g/dL, blood urea nitrogen and creatinine of 32 mg/dL and 1.5 mg/dL respectively. Esophagogastroduodenoscopy (EGD) revealed a small hiatal hernia with three linear clean based non-bleeding ulcers, consistent with Cameron ulcers (Figure 1&2). No gross lesions were noted in the remainder of the stomach or the duodenum.Figure: Small hiatal hernia (blue arrow) with three linear clean based non-bleeding ulcers (yellow arrow), consistent with Cameron ulcers.Figure: Small hiatal hernia (blue arrow) with three linear clean based non-bleeding ulcers (yellow arrow), consistent with Cameron ulcers.Discussion: Cameron lesions have a higher prevalence in cases of large hiatal hernias. An estimated 3.3-5% of individuals with hiatus hernias are said to have Cameron lesions. Prevalence however increases to 13.7% among patients with large (> 5cm) hiatus hernia. Cameron lesions are caused by a combination of various factors acting at the level of the diaphragmatic hiatus. Mechanical injury from the contractility of the respiratory diaphragm, mucosal damage from exposed esophageal mucosa to the caustic gastric acid and ischemia from mucosal erosions are thought to result in Cameron lesions. The treatment of Cameron lesions is mainly medical therapy with proton pump inhibitors. In patients with overt bleeding, there may be a need for endoscopic intervention with hemostasis clips coupled with medical therapy. Conclusion: Cameron lesions have a higher prevalence in large (>5cm) hiatus hernias. However, they can rarely be present in small sub-centimeter hiatus hernias and be a cause of an obscure GI bleeding. Therefore, a high index of suspicion for Cameron lesions is required at endoscopy- even in cases of small hiatus hernias in making a timely diagnosis and intervention.

To investigate two distinct clinical phenotypes of reflux esophagitis and intra-hernial ulcer (Cameron lesions) in patients with large hiatal hernias. A case series study was performed with 16 831 patients who underwent diagnostic esophagogastroduodenoscopy for 2 years at an academic referral center. A hiatus diameter ≥ 4 cm was defined as a large hernia. A sharp fold that surrounded the cardia was designated as an intact gastroesophageal flap valve (GEFV), and a loose fold or disappearance of the fold was classified as an impaired GEFV. We studied the associations between large hiatal hernias and the distinct clinical phenotypes (reflux esophagitis and Cameron lesions), and analyzed factors that distinguished the clinical phenotypes. Large hiatal hernias were found in 49 (0.3%) of 16,831 patients. Cameron lesions and reflux esophagitis were observed in 10% and 47% of these patients, and 0% and 8% of the patients without large hiatal hernias, which indicated significant associations between large hiatal hernias and these diseases. However, there was no coincidence of the two distinct disorders. Univariate analysis demonstrated significant associations between Cameron lesions and the clinico-endoscopic factors such as nonsteroidal anti-inflammatory drug (NSAID) intake (80% in Cameron lesion cases vs 18% in non-Cameron lesion cases, P = 0.015) and intact GEFV (100% in Cameron lesion cases vs 18% in non-Cameron lesion cases, P = 0.0007). In contrast, reflux esophagitis was linked with impaired GEFV (44% in reflux esophagitis cases vs 8% in non-reflux esophagitis cases, P = 0.01). Multivariate regression analysis confirmed these significant associations. GEFV status and NSAID intake distinguish clinical phenotypes of large hiatal hernias. Cameron lesions are associated with intact GEFV and NSAID intake.

Laparoscopy has become the standard surgical approach to surgery for gastrooesophageal reflux disease (GERD) and hiatal hernia repair with excellent long-term results and high patient satisfaction. However several studies have shown that hiatal hernia repair, especially large hiatus are associated with high recurrence rate. Mesh reinforcement has been proposed for repair of large hiatus hernia. The objective of this study was to evaluate the role of mesh cruroplasty in management of large hiatus hernia (> 5 cm). Between February 2002 to December 2007, 73 patients (28 men and 45 women) who underwent laparoscopic hiatal hernia repair with mesh cruroplasty were included in our study. Mesh reinforcement (cruroplasty) was used for repair of large hiatus hernia (>5 cms hernial defect). Mean age was 50.4 years (range 30-72 years). Follow up included barium swallow of patients at 3 months and yearly thereafter. Seventy-three patients underwent mesh cruroplasty for large hiatus hernia. We were able to adequately mobilise the oesophagus to achieve an intra-abdominal length of at least 3 cm in all patients. Intraoperative complication rate was 8.21% (6/73), intraoperative complications included pleural tear, bleeding from splenic capsule laceration and short gastric vessels. Postoperative complication rate was 4.1% (3/73), which included complete dyspahgia, atelactasis and pneumonia. Mean duration of hospitalisation was 3.5 days (range 3-9 days). Five patients (5/73) were lost to follow up. Four patients (5.8%) developed recurrence on routine follow up. No mesh related complications were noted on long-term follow up period. Mean follow up period was 3.2 years (range 5 months-6 years). Our data supports the use of mesh in hiatal hernia repair, especially in large hiatus hernia as it leads to low recurrence rates. Longer follow up and more randomised controlled trials are needed to establish laparoscopic mesh cruroplasty as standard technique for large hiatal hernia repair.

INTRODUCTION: Multiple studies have established a relationship between esophageal hiatal hernias (HH) and iron deficiency anemia (IDA), often attributed to presence of Cameron lesions. Small hernias are often detected incidentally, and most do not lead to anemia. This study is designed to evaluate if size of hernia directly correlates with degree of anemia, particularly in very large hernias, a finding that could provide insight into the management of these patients in the future. METHODS: Electronic medical records from 5/2016 to 5/2019 were retrospectively reviewed. Patients with a diagnosis of iron deficiency anemia with complete endoscopic workup including EGD, colonoscopy, and complete small bowel capsule were included. Exclusion criteria included an alternative source for anemia such as celiac disease, peptic ulcer, or significant small bowel AVMs. Collected information included standard demographics, size of hiatal hernia, nadir hemoglobin (Hgb) during visit, presence or absence of Cameron lesions, and other capsule endoscopy findings. Analysis of associations between hernia size at the time of capsule endoscopy and nadir Hgb was formulated using Pearson's correlation testing. Graphic representation of results was depicted via linear regression modeling. Two-score T testing was also utilized to examine whether significant differences in degree of anemia exist between small (&lt;5 cm) and large (≥5 cm) hiatal hernias. RESULTS: 45 patients were included in the final dataset (78% women, 22% men). Only 7% (3/45) had visible Cameron lesions on upper endoscopy. Overall, degree of anemia did not correlate to size of hiatal hernia as Pearson's correlation testing identified an r = -0.234 (P = 0.136). However, when controlling for hiatal hernias ≥5 cm, a statistically significant inverse relationship was noted between nadir hemoglobin levels and size of hiatal hernia, r = -0.362 (P = 0.041). Figure 1 summarizes these results. 2 score T-testing identified no significant difference in the mean nadir hemoglobin between small and large hiatal hernias, t = -0.029 (P = 0.488). CONCLUSION: A linear relationship between hernia size and degree of anemia appears to exist when esophageal hiatal hernias are 5 cm or larger, but even 3-4 cm hernias can result in significant iron loss. Clinicians should also be aware that Cameron lesions are not required to develop profound IDA. Our study is limited by sample size but offers some evidence that hernias larger than 5 cm should be considered for surgical repair.

LEFT VENTRICULAR DYSFUNCTION SECONDARY TO LARGE HIATAL HERNIA COMPLICATED BY GASTRIC OUTLET OBSTRUCTION