Gastric Incarceration Research Articles

Gastric incarceration: A rare complication of parastomal hernia

Gastric incarceration: A rare complication of parastomal hernia

One-stage reconstructive jejunogastroplasty after previous multiple abdominal surgeries for left-sided diaphragm rupture complicated by gastric incarceration and necrosis

Acute gastric necrosis is a rare event requiring organ resection. Delayed reconstruction is advisable in patients with peritonitis and sepsis. The most common complication of gastrectomy with reconstruction is failure of esophagojejunostomy and duodenal stump. In case of severe esophagojejunostomy failure, appropriate surgical approach and timing of reconstructive stage should be analyzed. We report one-stage reconstructive surgery in a patient with multiple fistulas after previous gastrectomy. Surgery included reconstructive jejunogastroplasty with jejunal graft interposition. The patient underwent previous several unsuccessful reconstructive procedures complicated by failure of esophagojejunostomy and duodenal stump with external intestinal, duodenal and esophageal fistulas. Nutritional insufficiency, water and electrolyte disorders due to significant loss of proteins and intestinal juice through the drain tubes deteriorated clinical status. Surgical procedures finished reconstruction, provided closure of multiple fistulas and stomas and restored physiological duodenal passage.

S2978 Intrathoracic Gastric Incarceration Following Laparoscopic Nissen Fundoplication

INTRODUCTION: Nissen fundoplication is the most performed surgical treatment for GERD. Given the complex anatomy of the EG junction, structural complications occur in up to 30% of cases following fundoplication. Our case is that of post fundoplication paraesophageal hernia with intrathoracic gastric incarceration. CASE DESCRIPTION/METHODS: A 57yo F with PMHx of GERD and type III paraesophageal hiatal hernia who had undergone laparoscopic surgery with primary diaphragm repair and Nissen fundoplication 7mo prior presented with acute onset of dysphagia and epigastric pain. CT revealed superoposterior migration of the Nissen wrap above the diaphragm and a well-circumscribed pouchlike sac to the left of the Nissen fundoplication containing an air-fluid level, without evidence of perforation. GI was consulted and the patient underwent EGD revealing a tight Nissen wrap that was barely traversable. The gastric mucosa was congested, inflamed, and ulcerated from the GE junction to the gastric body concerning for acute incarceration and necrosis. Surgery was urgently consulted, and the patient underwent emergent exploratory laparoscopy which revealed incarcerated herniation of the previously performed fundoplication into the chest. The fundus and upper body of the stomach were necrotic. Laparoscopic subtotal linear gastrectomy with mediastinal abscess drainage and closure of the diaphragmatic defect was performed followed by intraoperative EGD. The patient was discharged a few days later and is currently doing well. DISCUSSION: Nissen fundoplication is a widely accepted and commonly performed anti reflux surgical procedure. The gastric fundus is wrapped around the intraabdominal esophagus, after mobilizing the esophagus and reducing the hiatal hernia, if present. The rate of serious complications has been documented as less than 5%. Incarceration post fundoplication is usually a late diagnosis as it presents with non-specific symptoms of abdominal pain, nausea, and vomiting. EGD with comprehensive retroflexed examination of the fundoplication and barium esophagram are the primary tests to assess for structural complications. Paraesophageal hernia is one of the complications reported after laparoscopic Nissen fundoplication, and it requires emergency operation when associated with incarceration, obstruction, or strangulation of the stomach. There should be high index of suspicion for complications in patients with history of Nissen fundoplication for early detection, prompt treatment, and satisfactory outcomes.Figure 1Figure 2Figure 3

371 LARGE HIATAL HERNIAS: WATCH AND WAIT, OR SURGICAL REPAIR?

Abstract Laparoscopic-assisted hiatal hernia (HH) repair has been reported to be safe and feasible. However, uncertainty exists regarding whether asymptomatic large HHs (L-HH) should be treated or if a watch-and-wait strategy should be used. The latter might expose the patient to the risk of progression and gastric incarceration. In this study, we investigated this issue by analyzing perioperative outcomes of patients who underwent HH repair at our high-volume center. Methods After obtaining approval from the Institutional Review Board, we queried a prospectively maintained database for data on patients who underwent primary minimally invasive HH repair between August 2016 and December 2019. All procedures were performed by a single surgeon (SKM). Hernias were classified in 4 groups: small (S-HH [sliding]), moderate (M-HH [<50% herniated stomach]), large (L-HH [50%–75% herniated stomach]) and giant (G-HH [≥75% herniated stomach]). Data on preoperative assessment, surgical procedure, and postoperative morbidity were analyzed and compared across groups. Complications were defined according to the Clavien-Dindo (CD) classification. Results In total, 170 patients met inclusion criteria. Mean age was 58.5 ± 11, 61.9 ± 11.3, 70.7 ± 10.3, and 72.6 ± 9.7 years for S-HH (n = 46), M-HH (n = 69), L-HH (n = 20), and G-HH (n = 35), respectively (p < 0.001). The mean operative time (minutes) increased by group as the HH size increased (69.6 ± 20.9, 83.5 ± 26.1, 99 ± 29.1, and 98.6 ± 24.9, respectively; p < 0.001). Eight of 35 patients with G-HH (22.9%) were treated urgently due to gastric incarceration. Postoperative complications were significantly more common after L-HH and G-HH repair (Figure 1). CD complications Grade II, IIIb, and IVa were observed only in patients with L-HH or G-HH. There was no mortality. Conclusion Patients with L-HH and G-HH are significantly older than those with S-HH or M-HH; this reflects the likely progressive nature of this pathology. Laparoscopic HH repair is associated with higher morbidity in patients with L-HH and G-HH. Furthermore, patients with G-HH are at risk of gastric incarceration, which requires emergency surgery. Our findings suggest that in patients with M-HH (even asymptomatic), a watch-and-wait strategy should be discouraged. Surgical repair, in experienced hands, is preferred.

Perforated Gastric Ulcer in an Incarcerated Hiatal Hernia

Clinical Imaging; An 81 year male came to our emergency department presenting with dyspnea and chest pain. The chest pain got worse on breathing and radiation to the epigastria. Past medical history included hiatus hernia and hypertension. His blood pressure was 88/63 mmHg, pulse rate 107 per minute. Abdominal examination revealed epigastria tenderness with voluntary guarding. Initial blood tests were all within normal limits. Chest X-ray revealed hiatal hernia with gas distension of the stomach (Figure 1A). Abdominal X-ray showed no diagnostic features. The abdomen CT reveals upper abdomen pneumoperitoneum in the periportal space and hernia sac (Figure 1B), moderate amount of ascites are also noted suspect gastric juice leakage (Figure 1C), indicating perforated gastric ulcer. He was taken for emergent exploratory laparotomy immediately .The right posterior wall fundus of gastric ulcer perforation 2 × 2 cm and upper gastric incarceration hiatal hernia were noted. The hiatal hernia repair and perforated ulcer repair were done. The patient recovered smoothly and was discharged 3 weeks later. Perforated gastric ulcer in an Incarcerated hiatal hernia is rare and the diagnosis is challenge. CT is the gold standard diagnostics and early surgery intervention reduces mortality and consequent complication.

Laparoscopic repair of secondary parahiatal hernia with incarceration of the stomach: a case report

IntroductionParahiatal hernia is an extremely rare subtype of hiatal hernia, which in turn is a type of diaphragmatic hernia in adults, and only a few cases have been reported to date. We report the case of a patient who suffered from gastric incarceration through an anatomically separate diaphragmatic defect, immediately lateral to a structurally normal esophageal hiatus, that developed after treatment of a malignant mesothelioma.Case presentationA 70-year-old Japanese man, who had undergone treatment for a left malignant pleural mesothelioma a year ago at another hospital, was referred to our institution following a 4-day history of epigastric pain. Esophagogastroscopy demonstrated a normal esophagogastric junction, with remarkable stenosis and active gastric ulcer of the gastric body. Histopathological examination of the gastric biopsy specimen confirmed a gastric ulcer. Furthermore, computed tomography revealed a large fluid-filled structure in the retrocardiac space. On the basis of preoperative data, we decided to attempt laparoscopic repair for the gastric volvulus. During surgery, gastric and omental herniation was observed within a peritoneal lined defect immediately lateral to the esophageal hiatus. Dissection near the esophageal hiatus revealed a discrete extrahiatal defect 3cm in diameter immediately adjacent to the left crus of the diaphragm. The parahiatal defect was closed using interrupted nonabsorbable heavy suture. The patient’s postoperative course was uneventful, and anastomotic leakage was not observed at postoperative barium swallowing.ConclusionsAlthough preoperative diagnosis of parahiatal hernia is difficult, a laparoscopic approach can be a useful therapeutic procedure not only for paraesophageal hernia but also for parahiatal hernia.

Late Gastric Incarceration 20 Years after Penetrating Chest Trauma

The diagnosis of diaphragmatic injury in trauma patients is a challenge for surgeons. Misdiagnosis is common and can only be corrected when patients present with symptoms of diaphragmatic hernia. We report a rare case of delayed traumatic diaphragmatic hernia masquerading as empyema 20 years after lower chest penetrating trauma. The herniated stomach was found intraoperatively. Delayed traumatic diaphragmatic hernia should always be suspected in patients with trauma that may have occurred many years ago.

Traumatic diaphragmatic rupture with delayed gastric incarceration

Traumatic diaphragmatic rupture with delayed gastric incarceration

Robotic Repair of Congenital Paraesophageal Hiatal Hernia

Congenital paraesophageal hiatal hernias are rare and can be associated with gastric incarceration, volvulus,mucosal ulceration, and anemia. Primary repair of the hernia and fundoplication are recommended. In this paper,we report a case of a 3-year-old child with abdominal pain who was noted to have a paraesophageal hiatal hernia with partial gastric volvulus. A 5 mm robot platform was utilized to facilitate hernia sac dissection,hiatal repair, and fundoplication.

Delayed presentation of a patient with a ruptured diaphragm complicated by gastric incarceration and perforation after apparently minor blunt trauma

Rupture of the diaphragm is almost always due to major trauma and is most commonly associated with road-traffic accidents. We report a case of delayed presentation of a 35-year-old woman with a ruptured diaphragm, 11 days following apparent minor blunt trauma. This case illustrates how the diagnosis of ruptured diaphragm can be missed and demonstrates the importance of considering this diagnosis in all cases of blunt trauma to the trunk. It also demonstrates the potential pitfall of misinterpreting the chest radiograph, and the value of repeat imaging after insertion of a nasogastric tube.

Minimally invasive management of paraesophageal herniation in the high-risk surgical patient

Background: Traditional management of symptomatic paraesophageal herniation involves hernia reduction, hiatal closure, and an antireflux procedure or gastropexy. Patients with significant comorbidities may not tolerate operative repair. A new technique, laparoscopic-assisted endoscopic reduction and fixation of the stomach, may provide a minimally invasive treatment alternative. Methods: Eleven elderly patients with symptomatic paraesophageal herniation were managed with flexible endoscopy and double percutaneous endoscopic gastrostomy (PEG) tube insertion with or without laparoscopic assistance. Results: All patients presented with a symptomatic paraesophageal hernia. Mean age was 78.3 years (range 72 to 84). Each was deemed at high risk for definitive repair due to preexisting coronary artery disease as well as at least two other serious comorbidities. Hernia reduction and intra-abdominal fixation of the stomach was achieved in each case using flexible endoscopy and double PEG insertion. Laparoscopic assistance for reduction and gastropexy was utilized in 9 cases. Mean operative time was 61 minutes (range 28 to 104). Average length of stay was 2.8 days (range 0 to 12). One minor and three major postoperative complications occurred. Over a mean follow-up of 4.1 months (range 2 to 7), all patients have resumed oral intake and achieved weight gain. Conclusions: Patients with symptomatic paraesophageal herniation require intervention to alleviate symptoms and avoid the complications of gastric incarceration. For the high-risk patient, endoscopic reduction and PEG with laparoscopic assistance appears to provide effective treatment.

Gastric Incarceration and Perforation following Posttraumatic Diaphragmatic Hernia

We report the case of a 36-year-old male patient who developed gastric incarceration and perforation in a diaphragmatic hernia 8 months after an automobile accident.During emergency surgery, protrusion of the stomach into the thoracic cavity and perforation on the anterior aspect of the stomach were noted.The gastric perforation and the diaphragmatic defect were closed. During the postoperative course, the patient developed sepsis and coagulopathy that subsided following medical therapy. In order to prevent severe complications, surgery is indicated as soon as conclusive diagnosis is made.

Laparoscopic management of giant paraesophageal herniation

Background. Many surgeons have found laparoscopic fundoplication effective management of medically recalcitrant gastroesophageal reflux disease (GERD) associated with sliding type I hiatal hernias. The anatomic distortion and technical difficulty inherent with repair has limited the use of laparoscopy for repair of “giant” paraesophageal hernias (gPH). Methods. Since July 1993, we have accomplished laparoscopic repair of paraesophageal hiatal hernias in 54 of 60 (90%) patients. Five patients had classic type II hernias with total intrathoracic stomachs, and 53 patients had large sliding/paraesophageal type III herniation. Two patients had true parahiatal hernias. None had gastric incarceration. Median age was 53 years and 28 of 60 (47%) were women. Chest pain and dysphagia were primary complaints from 39 of 60 (65%). Heartburn with or without regurgitation was present in 52 of 60 (85%). Preoperative manometry and prolonged pH testing were obtained on 43 of 60 (72%) and 44 of 60 (73%) patients, respectively. Principles of repair included reduction of the hernia, excision of the sac, crural approximation, and fundoplication over a 54F bougie (Nissen, 41; Dor, 1; Toupet, 18) to “pexy” the stomach within the abdomen and to control postoperative reflux. Results. Mean operative time was 202 ± 81 minutes. Conversion to “open” repair was required in 6 patients (iatrogenic esophageal injury in 2 patients and difficult hernia sac dissection in 4 patients). One postoperative mortality occurred as a result of sepsis and multiorgan failure after an intraoperative esophageal perforation. Follow-up barium swallow performed in 44 of 60 patients demonstrated recurrent hiatal hernias in 3 patients. Preoperative symptoms have been relieved in all but 3 patients. Reoperation for recurrent paraesophageal herniation has been required in these latter 3 patients. Conclusions. Although technically challenging, laparoscopic repair of paraesophageal hiatal hernias is a viable alternative to “open” surgical approaches. Control of the herniation and the patient’s symptoms are equivalent and hospitalization and return to full activity are shorter.