Gastric Fixation Research Articles

Fundoplication vs. gastric fixation for the management of emergency hiatal hernia repairs: aretrospective cohort study.

There is a paucity of literature comparing safety outcomes between formal fundoplication and gastric fixationproceduresfor hiatal hernia repairs, especially in the emergency setting. The objective of this study was to evaluate 30-day clinicaloutcomes between fundoplication and gastric fixation performed in emergency hiatal hernia repairs. A retrospective cohort study using the National Surgery Quality Improvement Program(NSQIP) database from 2011 to 2021 was conducted. The study population was determined usingICD9/10 codes describing diaphragmatic hernia without obstruction or gangrene, with obstruction,and with gangrene. Elective cases were excluded. CPT codes were used to group fundoplicationprocedures and gastric fixation procedures. The primary outcome was the 30-day complication rate. Secondary outcomes included 30-day readmission, reoperation and mortalityrates. A multivariablelogistic regression analysiswas used to adjust for clinically relevant confounding variables. A total of 971 and 346 were in the fundoplication and gastric fixation groups, respectively.Fundoplication was associated with a significantly lower (p < 0.05) 30-day complication, reoperation and mortality rates. There was no statistically significantdifference with respect to readmission. After adjustment, fundoplication was significantlyassociated with a decrease in odds of 30-day complications (OR 0.53,p < 0.001 95% CI0.40-0.71) and mortality (OR 0.55,p = 0.033 95% CI 0.32-0.95). However, there was nosignificant difference with respect to 30-day readmission (OR 0.86,p = 0.449 95%CI 0.59-1.27) and reoperation (OR 0.66,p = 0.063 95% CI 0.42-1.02). Patients with hiatal hernias that underwent emergent repair with fundoplication had asignificantly lower 30-day complication and mortality rates compared to those who underwent gastricfixation procedures. Fundoplication is a safe and feasible approach to manage hiatal hernias in the emergency setting for select patients.

Comment on "Sutured Versus Mesh-augmented Hiatus Hernia Repair: A Systematic Review and Meta-analysis of Randomized Controlled Trials".

Comment on "Sutured Versus Mesh-augmented Hiatus Hernia Repair: A Systematic Review and Meta-analysis of Randomized Controlled Trials".

Percutaneous endoscopic gastrostomy: a dislodgement complication due to a moving hiatal hernia

Objectives: Frail patients with malnourishment due to an esophageal condition and dysphagia are often unamenable to safe surgery. Thus, in high-risk patients, less invasive techniques such as percutaneous endoscopic gastrostomy (PEG) are regarded as a safer choice. Nevertheless, as described here, PEG insertion can have rare serious complications. Materials and methods: We report the case of a frail patient with dysphagia due to a large Zenker's diverticulum and concomitant giant hiatal hernia. To improve her nutrinitional status before surgery she received a PEG after endoscopic repositioning of the hernia. Results: Within 48 hours after hernia repositioning and PEG insertion, a severe adverse event ensued: dislodgement of the PEG due to stomach reherniation. Conclusions: This case challenges the use of PEG as an only means for gastric fixation for hiatal hernia.

Laparoscopic Paraesophageal Hernia Reduction with Two Point Fixation via Ponsky PEG Tube in a Patient in their early 90s

Paraesphageal hernia (PEH) repairs have been historically controversial due to widely variable clinician opinions. However, there is little research regarding the use of PEH reduction and gastropexy via a percutaneous endoscopic gastrostomy (PEG) tube. Guidelines by the Society of American Gastrointestinal and Endoscopic Surgeons do advise that the use of gastropexy alone is a valid option in patients with high risk of morbidity and mortality, but is associated with high hernia recurrence rates. A male in his early 90s presented with a six-week history of dysphagia, regurgitation and a 30- pound weight loss. Imaging revealed a large PEH and the entire stomach within the thoracic cavity. Despite the patient’s age and significant risk factors, it was determined that he required surgical intervention due to the severity of his symptoms. The safest course of action was reduction of PEH with two-point gastric fixation, rather than a prolonged repair of the hiatus or mesh implant. Due to the patient’s significant surgical risks, it was determined that the safest surgical approach would be laparoscopic reduction with dual gastropexy via PEG tube gastropexy. This approach was quick, without encroachment into the mediastinum and avoided any complications that mesh implantation could have posed. Gastropexy is a relatively simple technique with minimal tissue dissection that is tolerated well in elderly patients or those with decreased cardiac and pulmonary status. Regardless of the surgical PEH approach, there are inherent hernia recurrence rates

Atypical Presentation of Gastric Volvulus

Gastric volvulus has been reported in all age groups, however, it is typically diagnosed in the elderly. Organo-axial volvulus is the most common type, followed by the mesentero-axial and the combined types. Depending on the etiology, gastric volvulus can also be classified as primary (idiopathic) or secondary. Primary gastric volvulus occurs due to abnormalities of the gastric ligaments that lead to failed gastric fixation. Secondary gastric volvulus may be due to local anatomic abnormalities, including paraesophageal and diaphragmatic hernias, phrenic nerve paralysis, and atypical anatomy of adjacent organs. We report a 68-year-old female with a past medical history significant for gastric ulcer, who presented with fever and was admitted for sepsis of unknown etiology. Physical examination was noncontributory. Laboratory results demonstrated normal white blood cell count, hemoglobin of 8.5 g/dL, hematocrit 27%, and platelet count of 178,000 cells/L. Fecal occult blood test was positive. As part of the sepsis work-up, a computed tomography (CT) scan of the abdomen revealed rotation of the stomach along the long axis, suggestive of organo-axial volvulus. Upper gastrointestinal (GI) series demonstrated herniation of the entire stomach through the diaphragmatic esophageal hiatus. The stomach was rotated upon itself, which corroborated the CT findings of organo-axial volvulus. No associated obstruction, ulceration, malrotation, or masses were identified. Subsequent esophagogastroduodenoscopy (EGD) revealed esophagitis in the distal third of the esophagus with spiral rotation of the gastric mucosal folds, which confirmed the diagnosis of organo-axial volvulus. Surgical intervention was not indicated. Volvulus rarely involves the stomach. The range of presentations can vary from incidental radiographic findings to life-threatening emergencies, depending on the rate of progression and extent of gastric rotation. Acutely, patients can present with chest pain, abdominal pain, and vomiting. Abdominal distention, rigidity, and guarding can be noted on physical examination. Confirmatory studies include X-ray and CT. Treatment of acute gastric volvulus involves laparoscopic and/or endoscopic procedures/maneuvers, depending on the severity of symptoms and surgical eligibility of the patient. Chronic gastric volvulus can be managed conservatively or by laparoscopic and/or endoscopic interventions.Figure 1Figure 2Figure 3

Gastritis cystica profunda with a long stalk

Commentary Retrograde gastroesophageal intussusception is a rarely reported condition, in which a portion of the stomach invaginates into the esophagus. It must be distinguished from retrograde prolapse of the stomach, which is much more common and which may resemble at endoscopy its intussusceptive cousin. Gastroesophageal intussusception involves all layers of the stomach, whereas with retrograde prolapse, only the gastric mucosa passes into the esophagus. One predisposing factor involves poor fixation of the stomach, often a result of laxity or absence of gastrophrenic, gastrohepatic, gastrosplenic, and gastrocolic ligaments as well as the omental attachments. Other risk factors include increased abdominal pressure during retching or vomiting, physical exertion as with weight lifting, or ascites. Hiatus hernia with a lax phrenoesophageal ligament and various operations such as laparoscopic myotomy and fundoplication also have been cited as risk factors. Intussusception may cause intermittent dysphagia, nausea, and abdominal pain in patients with predisposing anatomy. If it is diagnosed in a nonemergent setting, it may be reasonable to attempt endoscopic reduction or even gastric fixation, but laparotomy and manual reduction are usually required. Lawrence J. Brandt, MD Associate Editor for Focal Points

Estratégia de fixação do sleeve gástrico na gastrectomia vertical laparoscópica

Initially conceived as the first of two stages in operations such as gastric bypass or duodenal switch in high-risk patients, laparoscopic vertical sleeve gastrectomy has increasingly become the definitive procedure for treating obesity and its comorbidities. Although it is associated with excellent results and postoperative quality of life, a number of complications related to improper position and/or gastric tube deformities, resulting from loss of natural fixation, may be associated to symptoms of persistent food intolerance and/or gastroesophageal reflux. To present the gastric fixation strategy in vertical sleeve gastrectomy for the treatment of obesity and related diseases. The gastric suture line along the "new greater curvature" is divided into two parts. Using non-absorbable 2.0 polyester thread, a continuous suture fixation is made in the proximal part attaching it to the free edge of the gastrocolic ligament with invagination. Separate sutures were applied to the distal part, including the transverse mesocolon near the lower edge of the pancreas. The stomach fixation strategy is easy to use, safe and can reduce complications arising from improper positioning and gastric tube alterations in laparoscopic vertical sleeve gastrectomy, particularly symptoms related to food intolerance and gastroesophageal reflux.

Percutaneous Push-Through Gastrostomy by Applying a CT-Guided Gastropexy

Purpose To evaluate the feasibility and complications of percutaneous push-through gastrostomy via a computed tomography (CT)–guided gastropexy. Materials and Methods From January 2005 to March 2008, 14 patients in whom an oropharyngeal passage with an endoscope was impossible received a gastrostomy using the push-through technique. To attach the stomach against the abdominal wall, a CT-guided gastropexy was performed in all patients before the gastrostomy. The initial gastric tube was replaced with a short, low-profile gastric tube 2 weeks after the gastrostomy procedure. Patients were monitored for complications and survival for 6 months. Results The CT-guided dual gastropexy and percutaneous push-through gastrostomy was successfully inserted in all patients. Six months follow-up of the patients revealed only minor complications: one gastrostomy leakage and two local wounds. Conclusions CT-guided dual gastropexy combined with the push-type gastrostomy technique is practical and safe in patients in whom an oropharyngeal passage with an endoscope is impossible and represents an alternative method of gastric fixation for radiologically placed gastrostomy tubes.

Alternative Techniques for Gastric Closure for NOTES

Objectives: Secure methods of gastric wall closure after NOTES procedures are still to be developed. Our institution developed a series of techniques allowing inexpensive and feasible gastric sealing. Methods: Using punctures of anterior abdomen prior to gastric opening, in a porcine model, the lumen was penetrated and needlescopic sutures are placed to allow posterior closure. Technical aspects included no use of disposable instruments or clips, and instalation of prefixated ties, with or without external endo-loops. Endoscopic gastric opening was also facilitated by technique of gastric wall fixation and external mobilization. Closure was performed using knot ligatures with non-absorbable yarn using techniques with or without gastric fixation. The methods utilized on the animals of the study conform to the July 2000 revision of Guiding Principles in the Care and Use of Animals (American Physiological Society), and animals were sacrificed at the end of the study. Results: In most cases, a secure gastric wall closure was obtained without use of clips or suture devices. In more difficult cases, fixation of the stomach to the anterior abdominal wall is also possible and recommended. Conclusions: Available technology is limited for gastric closure in natural orifice surgery. Alternative low-budget techniques are feasible, and available for any surgical institution. Further survival studies are necessary to evaluate the possibilities of the techniques.

Retrograde Gastric Intussusception After Myotomy for Achalasia

Retrograde gastroesophageal intussusception has been rarely reported in the literature. Risk factors include poor fixation of the stomach due to either long or loose mesenteric attachments; high intraabdominal pressure due to retching, physical exertion, or ascites; and hiatal hernia, which can lead to the development of a large gastroesophageal opening. An attempt at endoscopic reduction is reasonable, but laparotomy and manual reduction is usually required. We report a case of retrograde gastroesophageal intussusception in a patient with long-standing achalasia and two previous Heller myotomies.

First operative series that documented and used posterior gastric fixation for the surgical correction of hiatus hernia and gastroesophageal reflux.

First operative series that documented and used posterior gastric fixation for the surgical correction of hiatus hernia and gastroesophageal reflux.

A simplified method of gastropexy for transgastric enterostomy

Radiological placement of gastrostomy tubes was first described in 1983. Percutaneous gastropexy to facilitate gastrostomy placement was reported in 1986. Debate has continued to this day regarding the necessity of gastric fixation. We describe our technique of a simplified gastropexy to facilitate transgastric enterostomy and advocate its more widespread use.

‘IDIOPATHIC’ CHRONIC GASTRIC VOLVULUS

Gastric volvulus usually occurs secondary to another condition such as hiatal hernia. We report a case of so-called "idiopathic' gastric volvulus where the only abnormality was laxity of the gastric attachments. Upper gastrointestinal endoscopy was unhelpful in making the diagnosis, but a barium meal clearly demonstrated the abnormality. The patient underwent a Polya gastrectomy with a retrocolic gastroenterostomy, which was thought to be the best method of ensuring gastric fixation.

Percutaneous gastrostomy without gastropexy : O'Donovan NA, Heelan JA (Department of Diagnostic Radiology, McMaster University Medical Centre, 1200 Main Street W. Hamilton, Ontario L8N 3Z5, Canada). Can Assoc Radiol J 1995;46:194–195

To describe in detail the technique for percutaneous gastrostomy without gastropexy, to determine the overall success rate for this technique in providing access to the gastrointestinal tract for feeding and to determine if routine gastropexy is necessary.The authors reviewed all cases of percutaneous gastrostomy performed over a 14-month period. In total, 24 patients (12 males and 12 females) underwent insertion of gastrostomy tubes in the radiology department during this period. Eighteen of the patients had ear, nose and throat tumours and the other 6 had feeding difficulties as a result of neurologic disorders. All gastrostomy tubes were inserted under fluoroscopic guidance without sedation or administration of glucagon. Gastric fixation was not employed.All of the procedures were successful. No major complications occurred. One minor episode of chemical peritonitis did not require treatment.Percutaneous gastrostomy, performed in the radiology department, is safe and effective. On the basis of these findings and a literature review, the authors suggest that routine gastric fixation is not required. However, gastropexy may be appropriate in some circumstances, and its role in these situations has still to be confirmed.

Simplified percutaneous gastrostomy.

By using 16-F self-retaining feeding catheters, fluoroscopically guided percutaneous gastrostomy was performed in 68 consecutive adult patients without the use of gastric fixation devices. Short-term (2-week) follow-up of all patients was available, with 30-day follow-up obtained in 94% of the study group (n = 64). Thirty-day mortality was 12%, with no procedure-related deaths. Major and minor morbidity rates were 4.7% and 7.8%, respectively. The mean procedure time was 7 minutes. These data compared favorably with those of series employing smaller catheters placed with and without the use of gastropexy, as well as surgical gastrostomy and gastropexy procedures. Percutaneous placement of large-caliber (16-F) gastrostomy catheters is safe, effective, and rapid in the adult population and can be accomplished routinely without the use of prior gastropexy.

Gastric Volvulus in the Pediatric Population

Acute gastric volvulus in children is uncommon. Since 1899, only 77 cases have been documented in the world literature. In children, mesenteroaxial volvulus is the most common type and associated anatomic defects are the rule. Diagnostic delays result in gastric ischemia, perforation, and death. Nonoperative mortality is 80%. Early recognition, surgical reduction with gastric fixation, and repair of associated defects are the mainstays of therapy for acute gastric volvulus in the pediatric population.

Percutaneous drainage and feeding gastrostomies in 100 patients.

Percutaneous gastrostomy was performed in 100 cancer patients. In 67 patients with bowel obstruction, the procedure was performed for gastric drainage with 24-28-F Malecot catheters inserted in one sitting. The remaining 33 patients had supragastric obstructions or fistulas and required 10-14-F pigtail catheters for feeding purposes. Average postgastrostomy hospitalization was 3.6 days. Drainage gastrostomies were ready for use immediately after the procedure, whereas use of feeding gastrostomies started on average within 2 days of tube insertion. There were no major complications or deaths related to the procedure. Percutaneous gastrostomy is a simple and safe procedure even when large-caliber catheters are used, and it does not require gastric fixation to the abdominal wall to prevent spillage into the peritoneum.

Surgical Management of Gastric Torsion

Considerable investigation has been devoted to the gastric dilatation-torsion complex. An adequate explanation of its cause has yet to be made, or a means of prevention described. We do know of its highly lethal nature, especially if not aggressively treated, of the high incidence of recurrence, and of the associated pathophysiology. As surgeons, we must approach the patient in an aggressive systematic manner. Decompression and patient stabilization must be achieved prior to definitive surgical management. The surgery planned must correct the obvious pathologic state and include procedures designed to prevent recurrence of this condition. The tube gastrostomy technique promotes gastric fixation by dense adhesion bands exceeding that attainable by gastropexy alone. The procedure is easy to perform, requires little surgical time, and does not appear to be discomforting to the patient. In addition, the tube gastrostomy acts as a convenient decompressive pathway during the postoperative period, circumventing gastric intubation or pharyngostomy tube placement should distention occur.

Further experience with anterior gastric fixation in the management of hiatal hernia

Anterior gastropexy in properly selected patients is a simple, safe, and effective procedure for the surgical correction of symptomatic esophageal reflux in the presence of a sliding type of hiatal hernia not accompanied by fibrosis and secondary shortening of the esophagus. This technic is particularly useful in poor risk, elderly, and excessively obese patients and as an adjunct to other intraabdominal procedures.

Some problems in surgical Management of Children with Hiatus Hernia

Thirty-three cases of hiatus hernia treated by operation in an 8-year period are reviewed. It is suggested that less delay in surgical intervention when a child is not responding to medical management might reduce the number of children who develop strictures as a result of gastro-oesophageal reflux and might improve the development of the child. Gastric fixation with gastrostomy not only improves the nutrition of a child before a major corrective procedure, but in a few cases may avoid more drastic operation. Though maximal acid secretion tests do not help to identify those cases likely to develop a stricture, it is, however, a useful procedure in indicating whether or not vagotomy should be added to fundal plication.