Correction Of Diaphragmatic Hernia Research Articles

Clinico-haematobiochemical Evaluation of Diaphragmatic Hernia and its Surgical Management in Cattle and Buffaloes- A Retrospective Study of 32 Cases

Background: Diaphragmatic hernia is an emerging threat in dairy animals due to accidental ingestion of potential foreign body via feed or fodder leads to traumatic reticulo pericarditis and net results into loss of milk production. Loss of milk production due to diaphragmatic hernia in dairy animals is worrying situation among the milkman and it needs to be addressed in early stage. Considering the livelihood of poor to marginal farmers on dairy animals, the present study aimed to evaluate the clinico-haematological changes and surgical management of diaphragmatic hernia in cattle and buffalo. Methods: The present retrospective study was carried in thirty two clinical cases of diaphragmatic hernia in cattle (17) and buffaloes (15) presented to teaching veterinary clinical complex from the rural area irrespective breeds, age and no. of lactation of animals. Result: The incidence was higher in recently parturited followed by advanced pregnant animals aged between 3.5-14 years (7.109±0.406) with duration of illness ranged between 4-35 days (16.563±1.627). All animals showed recurrent tympany, suspended rumination, constipation, neutrophilia, alkaline ruminal pH, lymphopenia and increased level of muscle enzymes and non-responsive to medicinal therapy. Plain radiography of thoraco-abdominal region showed break in continuity of diaphragmatic line and herniation of reticulum into thoracic cavity. All animals were subjected to surgical correction of diaphragmatic hernia under isoflurane general anaesthesia. Out of 32, 27 animals were recovered uneventfully and remaining five animals were succumbed during surgical repair of hernia due to cardiovascular failure. The present study concludes that, diaphragmatic hernia is common wasting disorders in dairy animals characterized by scanty faeces, recurrent tympany, neutrophilia, increased level of muscle enzymes due to chronic inflammatory changes and it can be treated successfully with herniorrhaphy under isoflurane general anaesthesia.

Electrical neuromodulation of the lower esophageal sphincter for the treatment of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a difficult to treat medical condition. Inadequate symptom control has been cited as one of the main reasons to drive to surgical therapies for GERD. This unmet medical need has led to new attempts at developing less-invasive therapies for the treatment of GERD. Lower esophageal sphincter (LES) electrical neuromodulation has been shown to improve outcomes in GERD, and may represent and alternative of treatment for special subgroups of patients, such as esophageal dysmotility patients, sleeve gastrectomy and lung transplant patients. A concise review of literature was performed through PubMed. We searched to identify published studies reporting on subjective and objective GERD after LES-electrical neuromodulation therapy (ENT). Data evaluated included GERD-health-related quality of life (HRQL), extra esophageal symptoms, PPI discontinuation and patient satisfaction rates, pH-study metrics, severe adverse effects (AEs), and treatment failures. The aim of the review is to summarize the safety and efficacy of LES-ENT in GERD patients reported up to date, including original data from the authors. Two clinical trials have shown safety and efficacy of LES-ENT with both short and long-term follow-up up to 3 years. Results were comparable in a prospective multi-center registry of LES-ENT for GERD with 223 patients from 16 sites in Europe and Latin America with an extended 5-year-follow up. LES-ENT has shown adequate efficacy in symptom control, medication use, acid exposure control, a solid safety profile and may represent an alternative treatment for patients that are not satisfied with PPI therapy, unable to receive a fundoplication or reluctant to undergo reported side effects. LES-ENT allows correction of hiatal hernia when needed, enhancing the effects of neuromodulation that can also be optimized after surgery. This can lead to an expanded indication of surgical therapies for those patients with unmet needs for GERD.

Long-Term Patient Outcomes After Laparoscopic Anti-Reflux Procedures

BackgroundLaparoscopic anti-reflux surgery with or without large hiatal hernia has been shown to have good short-term outcomes. However, limited data are available on long-term outcomes of greater than 5 years. The aim of this study is to review functional and symptomatic outcomes of anit-reflux surgery in a large tertiary referral medical center. MethodsTwo hundred ninety-seven patients who underwent anti-reflux surgery at the University of Nebraska Medical Center between 2002 and 2013 were included in this study. Patient data including pre- and post-operative studies and symptom questionnaires were prospectively collected and the database was used to analyze postoperative outcomes. ResultsA total of 297 Nissen fundoplications, 35 redo fundoplications and 22 Toupet procedures were performed. Mean BMI was 30.0 ± 6.2. The median follow-up was 70 (6–135) months. There were three reoperations (0.9 %) for recurrent symptoms. Mesh was used in 210 cases where hiatal hernia was larger than 2 cm. Median preoperative DeMeester score was 50.8 ± 46. There was a statistically significant improvement in composite heartburn score (83 % (CI 78.2, 87.7); p < 0.05), regurgitation (81.1 % (CI 76.1, 86.1); p < 0.05), and belching (63 % (CI 56.7, 69.3); p < 0.05). Atypical presentation such as pulmonary (e.g., aspiration (25.8 % (CI 20, 31.6), wheezing (20.3 % (CI 15, 25.6); p < 0.05), and throat symptoms (e.g., laryngitis 28 % (CI 22.1, 33.9); p < 0.05) also improved. Available radiographic studies for patients more than 3 years follow-up show an overall recurrence of 33.9 % (47.8 % in hiatal hernia > 5 cm repaired with mesh). Of those with recurrence, over 84 % were asymptomatic at follow-up. ConclusionsThis study shows that patients had excellent symptom control and low rates of complications and reoperations in long-term follow-up. We found that typical gastro intestinal symptoms responded better compared with atypical symptoms in spite of clear evidence of reflux on preoperative studies. Hiatal hernia was very commonly seen in our patient population and long-term radiographic follow-up suggest that asymptomatic recurrence may be high but rarely requires any surgical intervention. Anti-reflux surgery with correction of hiatal hernia if present is safe and effective in long-term follow-up.

Perspectives of operative endoscopy in fetal medicine

In this review the indications, techniques, results and perspectives of operative fetoscopy are described and discussed. Prenatal invasive therapy is indicated if postnatal therapy comes too late and fetal disease may lead to irreversible damage or death if it is left untreated. Potential candidates for intrauterine surgery are pregnancies with the following problems: diaphragmatic hernia, infravesical obstruction, sacrococcygeal teratoma, chorioangioma, neural tube defects, twin-twin transfusion syndrome and acardiac twin. The aim is to improve the intrauterine situation by minimally invasive surgery and to prevent irreversible damage. After delivery permanent repair is possible in cases with fetal malformations. Diaphragmatic hernia is the best example for the development from maximally invasive open fetal surgery to minimally invasive endoscopic surgery. There is still a lot of experimental work to be done, for example for the correction of diaphragmatic hernia and neural tube defects. However, in other areas such as severe second trimester twin-twin transfusion syndrome, endoscopic surgery is a well established technique in certain centres for fetal medicine. Endoscopic laser coagulation of the vascular placental anastomoses is a causal therapy and shows better results than serial amniodrainages. After 160 laser coagulations performed in our institution, the survival rates are as follows: overall 68 % of fetuses, with two survivors in 54 % and at least one survivor in 83 % of pregnancies.

Vascular changes with in utero correction of diaphragmatic hernia

In utero surgical correction of fetal diaphragmatic hernia is a new therapeutic alternative for selected prenatally diagnosed patients. With increasing experience, the authors have found that fetuses with herniation of the liver through the diaphragmatic defect have a high incidence of perioperative death. The hypothesis was that reduction of the liver during fetal diaphragmatic hernia repair caused distortion of fetal vascular anatomy resulting in fetal demise. To study this, the authors performed angiograms through the umbilical vein in fetal and neonatal cadavers, with and without diaphragmatic hernias, and simulated in utero repair. Large fetal congenital diaphragmatic hernias can be associated with dramatic changes in the vascular anatomy of the liver. The liver does not simply rotate up into the chest through a diaphragmatic defect; instead, the liver more likely develops in the chest, with its vascular anatomy situated accordingly. Attempts to reduce a herniated liver can result in significant distortion of the fetal vasculature, leading to fetal death. Techniques to prevent vascular compromise during hepatic manipulation may improve the outcome for fetuses during in utero repair of diaphragmatic hernias.

Lethal nonpulmonary anomalies associated with congenital diaphragmatic hernia: Implications for early intrauterine surgery

Recently, interest has been expressed in the correction of diaphragmatic hernia in utero as a solution to the problem of high mortality from this condition. Before such a procedure can be adopted in the human, studies aimed at establishing the contribution such advanced techniques would make in reducing mortality are required. Between 1973 and 1982, there were 36 cases of congenital diaphragmatic hernia among 75,512 births--an incidence of 1 in 2097 births. there were 11 (31%) stillbirths and 25 (69%) livebirths. the liveborn patients were divided into two groups: group A included 15 patients who died prior to transfer to the referral center; group B included ten neonates who arrived at the referral center and were operated upon. Twenty (56%) cases of diaphragmatic hernia (11 stillbirths and 9 liveborns who did not live long enough to be transferred to the referral center) were found to have lethal nonpulmonary associated anomalies at autopsy. In view of the high association of lethal anomalies it appears that fetal surgery would have a limited role in reducing mortality in congenital diaphragmatic hernia.

Reflections on the surgical management of achalasia of the esophagus

1. 1. Our experience has indicated that one can expect a good to excellent result from the treatment of achalasia by esophagocardiomyotomy in 85 per cent of the patients. 2. 2. The safety of the procedure, measured in terms of low morbidity and mortality, has caused us to consider this operation as initial therapy and to liberalize the indications for operation recently. 3. 3. Careful attention to technical details, the inclusion of pyloromyotomy or pyloroplasty, and the correction of hiatal hernia whether coexistent or surgically produced may well eliminate poor results from the Heller operation.