Hiatal Hernia Repair Research Articles

Reconstruction of the phreno-esophageal ligament (R-PEL) prevents the intrathoracic migration (ITM) after concomitant sleeve gastrectomy and hiatal hernia repair

BackgroundLaparoscopic Sleeve Gastrectomy (LSG) is the most attractive bariatric procedure, but the postoperative intrathoracic gastric migration (ITM) and “de novo” GERD are major concerns.The main objective of our study was to evaluate the efficiency of the concomitant HHR with or without partial reconstruction of phreno-esophageal ligament (R-PEL) to prevent ITM after LSG. The secondary objectives focused on procedure’s metabolic and GERD-related outcomes.Patients and methodConsecutive patients who underwent primary LSG and concomitant HHR were included in a single-center prospective study. According to the HHR surgical technique, two groups were analyzed and compared: Group A included patients receiving crura approximation only and Group B patients with R-PEL. The patients’ evolution of co-morbidities, GERD symptoms, radiologic, and endoscopic details were prospectively analyzed.ResultsTwo hundred seventy-three patients undergoing concurrent HHR and LSG were included in the study (Group A and B, 146 and 127 patients) The mean age and BMI were 42.6 ± 11.3 and 43.4 ± 6.8 kg/m2. The 12-month postoperative ITM was radiologically found in more than half of the patients in Group A, while in group B, the GEJ’s position appeared normal in 91.3% of the patients, meaning that R-PEL reduced 7 times the rate of ITM. The percentage of no-improvement and “de novo” severe esophagitis (Los Angeles C) was 4 times higher in group A 3.4% vs. 0.8% with statistical significance, and correlated to ITM. The GERD symptoms were less frequent in Group B vs Group A, 21.3% vs 37%, with statistical significance. No Barrett’s esophagus and no complication were recorded in any of the patients.ConclusionConcurrent LSG and HHR by crura approximation only has a very high rate of ITM in the first postoperative year (over 50%). R-PEL is an innovative technique which proved to be very efficient in preventing the ITM after HHR.

Evaluation of a biodegradable polyurethane patch for repair of diaphragmatic hernia in a rat model: A pilot study

IntroductionCongenital diaphragmatic hernia (CDH) repair is an area of active research. Large defects requiring patches have a hernia recurrence rate of up to 50%. We designed a biodegradable polyurethane (PU)-based elastic patch that matches the mechanical properties of native diaphragm muscle. We compared the PU patch to a non-biodegradable Gore-Tex™ (polytetrafluoroethylene) patch. MethodsThe biodegradable polyurethane was synthesized from polycaprolactone, hexadiisocyanate and putrescine, and then processed into fibrous PU patches by electrospinning. Rats underwent 4 mm diaphragmatic hernia (DH) creation via laparotomy followed by immediate repair with Gore-Tex™ (n = 6) or PU (n = 6) patches. Six rats underwent sham laparotomy without DH creation/repair. Diaphragm function was evaluated by fluoroscopy at 1 and 4 weeks. At 4 weeks, animals underwent gross inspection for recurrence and histologic evaluation for inflammatory reaction to the patch materials. ResultsThere were no hernia recurrences in either cohort. Gore-Tex™ had limited diaphragm rise compared to sham at 4 weeks (1.3 mm vs 2.9 mm, p = 0.003), but no difference was found between PU and sham (1.7 mm vs 2.9 mm, p = 0.09). There were no differences between PU and Gore-Tex™ at any time point. Both patches formed an inflammatory capsule, with similar thicknesses between cohorts on the abdominal (Gore-Tex™ 0.07 mm vs. PU 0.13 mm, p = 0.39) and thoracic (Gore-Tex™ 0.3 mm vs. PU 0.6 mm, p = 0.09) sides. ConclusionThe biodegradable PU patch allowed for similar diaphragmatic excursion compared to control animals. There were similar inflammatory responses to both patches. Further work is needed to evaluate long-term functional outcomes and further optimize the properties of the novel PU patch in vitro and in vivo. Level of evidenceLevel II, Prospective Comparative Study.

More research needed in mesh hiatal hernia repair? Comment on Analatos et al. and trial sequential analysis.

More research needed in mesh hiatal hernia repair? Comment on Analatos et al. and trial sequential analysis.

Sleeve gastrectomy morphology and long-term weight-loss and gastroesophageal reflux disease outcomes.

The relationship between sleeve gastrectomy (SG) morphology and long-term weight-loss and gastroesophageal reflux disease (GERD) outcomes is unknown. All patients (n = 268) undergoing SG performed by 3 surgeons at a single academic institution from January 1, 2010 to December 31, 2012 were included. Long-term weight-loss and GERD outcomes were available for 90 patients which were incorporated in analyses. SG morphology was determined from postoperative day 1 upper gastrointestinal series (UGIS) available from 50 patients. Images were independently categorized using previously published methodology as Dumbbell (38%), Lower Pouch (22%), Tubular (26%), or Upper Pouch (14%) by Radiologist and Surgeon. Radiologist categorization was used when disagreement occurred (8%). Univariable analyses were conducted to explore potential associations between SG morphology, weight loss, and GERD outcomes. Follow-up was 8.2 ± 0.9years. Population characteristics included age of 45.1 ± 10.8years, female sex in 83.3%, and hiatal hernia repair (HHR) performed at index SG in 17.8%. Surgeons did not preferentially achieve a specific SG morphology. Changes from preoperative obesity and associated diseases comprised body mass index (BMI) (49.5 ± 7.6 vs. 39.2 ± 9.4kg/m2; p < 0.0001), diabetes mellitus (30.0 vs. 12.2%; p = 0.0006), hypertension (70.0 vs. 54.4%; p = 0.0028), hyperlipidemia (42.2 vs. 24.2%;p = 0.0017), obstructive sleep apnea (41.1 vs. 15.6%; p < 0.0001), osteoarthritis (48.9 vs. 13.3%; p < 0.0001), back pain (46.5 vs. 28.9%; p = 0.0035), and medications (4.8 ± 3.3 vs. 3.7 ± 3.5; p < 0.0001). Dumbbell SG morphology was associated with lesser reduction in BMI at follow-up (--6.8 ± 7.2 vs. -12.4 ± 8.3kg/m2; p = 0.0196) while greater BMI change was appreciated with Lower Pouch SG shape (-16.9 ± 9.9 vs. -8.4 ± 6.8kg/m2; p = 0.0017). GERD was more prevalent at follow-up than baseline (67.8 vs. 47.8%; p < 0.0001). GERD-specific outcomes included de novo (51.1%), persistent (27.9%), worsened (58.1%), and resolved (14.0%) disease. Ten patients underwent reoperation for refractory GERD with SG morphology corresponding to Dumbbell (n = 5) and Upper Pouch (n = 1) for those with available UGIS. Univariable analyses showed that patients with GERD experienced a larger reduction in BMI compared with patients without GERD (-11.8 ± 7.7 vs. -7.0 ± 5.1kg/m2; p = 0.0007). Patient age, surgeon, morphology category, and whether a HHR was done at index SG were not associated with the presence of any, de novo, or worsened GERD. Female sex was associated with worsened GERD (96.0 vs. 4.0%; p = 0.0455). Type of calibration device, distance from staple line to pylorus, and whether staple line reinforcement was used were not associated with SG morphology classification. This is the first study assessing the impact of SG morphology on long-term weight loss and GERD. Our data suggest an association between SG morphology and long-term weight loss but not with GERD outcomes. Current technical standards may be limited in reproducing the same SG morphology. This information may help guide the technical optimization and standardization of SG. Surgeons did not favor a specific SG morphology (1). Our results signal to a relationship between radiographic assessment of SG morphology and long-term weight-loss outcomes with Dumbbell classification correlated with lesser reduction in BMI (2a) and Lower Pouch morphology associated with superior weight loss (2b). SG, sleeve gastrectomy; BMI, body mass index.

Thoracoscopic vs open repair of congenital diaphragmatic hernia after extracorporeal membrane oxygenation: a comparison of intra-operative data

PurposeECMO is an escalation treatment for hypoxic respiratory failure in patients with CDH. Open repair has been advocated after ECMO indicating that physiological changes associated to thoracoscopic repair were not well tolerated.MethodsWe have performed a retrospective review of all patients who underwent ECMO prior CDH repair over a 7 year period (2015–2021). Outcome measures were intra-operative Ph, PCO2, PO2 and FiO2 at 30 min, 1 h 30 min, and 2 h 30 min of surgery, operative time and recurrence rate. Data are shown in median (range).ResultsEleven patients required ECMO prior CDH repair. Six of eleven (55%) were done thoracoscopically (Group A) and five of eleven (45%) via laparotomy (Group B). Two of six (33%) patients (Group A) were converted to a laparotomy, one of six (16%) patient developed a recurrence, and there was no recurrence in Group B. Two of five (40%) patients died within the first 60 days of life, whilst there was no death in Group A. Intra-operative values are shown below.ConclusionWhilst this is a preliminary report of a limited number of patients, there is no obvious difference of intra-operative blood gas parameters during surgical repair in patients after ECMO. Thoracoscopic CDH repair may be considered in patients after ECMO.

A new type of retropancreatic fascia hernia in the supramesocolic space preoperatively misdiagnosed as a diaphragmatic hernia: report of two cases

BackgroundWe encountered two cases of a new type of retroperitoneal hernia. We herein report the unique features of these cases.Case presentationCase 1: A Japanese girl was born at a gestational age of 37 weeks, weighing 2550 g. She underwent laparotomic left diaphragmatic hernia repair for a left Bochdalek hernia at the age of one day. The postoperative course was uneventful; however, chest radiography at the age of 35 days revealed bowel gas in the mediastinum, while computed tomography exhibited intestinal prolapses from the medial side of the mesh into the thoracic cavity. Reoperation was performed at the age of 77 days, showing that the defect hole was not at the diaphragm but in the absence of retropancreatic fascia, which was connected to the posterior mediastinum from the supramesocolic space. The mediastinum space was closed with a suturing spine and artificial mesh, and the defect hole in the pancreatic body was sutured. Case 2: A Japanese boy was born at a gestational age of 40 weeks, weighing 3502 g. He was diagnosed with a left diaphragmatic hernia at birth and underwent laparotomy at the age of two days. Operative findings showed no defect hole in the diaphragm, and no intestine was observed in the abdominal cavity. After close observation of the abdominal cavity, the intestine was found around the pancreatic body, and manual reduction of the intestine was performed. The defect hole existed in the absence of the retropancreatic fascia, which was connected to the extra-pleural space. The defect hole in the pancreatic body was sutured and closed with a non-absorbable thread.ConclusionsWe assumed that our cases were a new type of retroperitoneal hernia, which we named “retropancreatic fascia hernia”.

Defining risk factors for mortality after emergent hiatal hernia repair in the era of minimally invasive surgery

BackgroundRisk factors for mortality following emergent hiatal hernia (HH) repair in the era of minimally invasive surgery remain poorly defined. MethodsData was obtained from the National Inpatient Sample (NIS), National Readmissions Database, and National Emergency Department Sample for patients undergoing HH repair between 2010 and 2018. Univariate and multivariate logistic regression analyses reported with odds ratio (OR) and 95% confidence intervals (CI) were performed to identify factors associated mortality. ResultsVia the NIS, mortality rate was 2.2% (147 patients). Via the NEDS, the mortality rate was 3.6% (303 patients). On multivariate analysis, predictors of mortality included age (OR 1.05, CI: 1.04,1.07), male sex (OR 1.49, CI: 1.06,2.11), frailty (OR 2.49, CI: 1.65,3.75), open repair (OR 3.59, CI: 2.50,5.17), and congestive heart failure (OR 2.71, CI: 1.81,4.06). ConclusionsThere are multiple risk factors for mortality after hiatal hernia repair. There is merit to a laparoscopic approach even in emergent settings.

Accuracy of Surgeon and Patient Estimated Cost and Reimbursement for Common General Surgical Operations and Benefit of Centers for Medicare and Medicaid Services Price Transparency Rules.

On January 1, 2021, the Centers for Medicare and Medicaid Services implemented a hospital price transparency rule. Consumerism as a means of reducing healthcare expenditure is predicated on informed consumers making discrete choices. For 10 months, immediately after a preoperative clinic visit at an academic medical center, patients and their surgeons were surveyed regarding their estimation of hospital cost and hospital reimbursement for the upcoming operation. Responses were compared to average institutional cost (fiscal year 2019) for Medicare patients undergoing a laparoscopic approach for each operation. We calculated the difference between actual reimbursement and cost with patients' estimates and actual reimbursement and cost with surgeons' estimates. Sixty-six questionnaires were collected from patients who underwent laparoscopic operations, that included cholecystectomy (n = 20), inguinal hernia (n = 17), umbilical hernia repair (n = 6), ventral hernia repair (n = 6), incisional hernia (n = 6), hiatal hernia repair (n = 1), and lipoma or cyst excision (n = 10). Patients' estimates of hospital cost exceeded actual hospital cost by a median of $4,502 and were less than hospital reimbursement by a median of $1,834. Surgeon estimates for direct cost were $825 less than hospital direct cost and $1,659 less than hospital reimbursement. Patients as well as their surgeons do not estimate healthcare cost or remuneration accurately and therefore will be ineffective change agents in reducing surgical spending based on price transparency without further education of both parties. Patients consistently overestimated surgical cost while surgeons consistently underestimated surgical cost and reimbursement. It is likely that better-informed surgeons and patients are necessary prerequisites for Centers for Medicare and Medicaid Services price transparency rules to be effective in reducing Medicare expenditures in surgery.

Is systematic formal crural repair mandatory at the time of magnetic sphincter augmentation implantation?

Laparoscopic placement of the LINX Magnetic Sphincter Augmentation (MSA) device has become an accepted alternative to fundoplication in appropriate patients. Initial studies of MSA targeted to patients with 'early' disease allowed for the most minimal dissection of the esophagus to place the device, without hiatal dissection or repair (NoHHR), in patients with no or minimal hernia findings at surgery. Subsequent studies have compared systematic formal hiatal dissection and repair (Formal HHR) with the original minimal dissection technique. Review of published literature on MSA includes discussion on treatment of hiatal hernia at the time of implantation, accompanying the review of the physiology of the crural diaphragm. Formal hiatal hernia repair at the time of MSA implantation results in better control of reflux with less dysphagia and risk of postoperative hernia than NoHHR, regardless of the presence or size of hiatal hernia. Systematic crural repair should accompany any MSA implantation regardless of the presence or size of hiatal hernia.

Hiatal hernia repair with transoral incisionless fundoplication versus Nissen fundoplication for gastroesophageal reflux disease: A retrospective study.

Background and study aims Concomitant hiatal hernia (HH) repair with transoral incisionless fundoplication (TIF) is a therapeutic option for patients with HH > 2 cm and gastroesophageal reflux disease (GERD). Data comparing this approach with laparoscopic Nissen fundoplication (LNF) are lacking. We performed an exploratory analysis to compare these two approaches' adverse events (AEs) and clinical outcomes. Patients and methods This was a multicenter retrospective cohort study of HH repair followed by LNF versus HH repair followed by TIF in patients with GERD and moderate HH (2-5 cm). AEs were assessed using the Clavien-Dindo classification. Symptoms (heartburn/regurgitation, bloating, and dysphagia) were compared at 6 and 12 months. Results A total of 125 patients with HH repair with TIF and 70 with HH repair with LNF were compared. There was no difference in rates of discontinuing or decreasing proton pump inhibitor use, dysphagia, esophagitis, disrupted wrap, and HH recurrence between the two groups ( P > 0.05). The length of hospital stay (1 day vs. 2 days), 30-day readmission rate (0 vs. 4.3 %), early AE rate (0 vs. 18.6 %), and early serious AE rate (0 vs. 4.3 %) favored TIF (all P < 0.05). The rate of new or worse than baseline bloating was lower in the TIF group at 6 months (13.8 % vs. 30.0 %, P = 0.009). Conclusions Concomitant HH repair with TIF is feasible and associated with lower early and serious AEs compared to LNF. Further comparative efficacy studies are warranted.

Post-laparoscopic sleeve gastrectomy, intrathoracic sleeve migration and its management: A case series and review of literature.

De novo or persistent gastro-oesophageal reflux disease which may or may not be associated with injury of the oesophageal mucosa is now a known complication in post-sleeve gastrectomy patients. Repair of hiatal hernias to avoid such circumstances has been commonly performed, although recurrences may occur resulting in migration of gastric sleeve into the thorax, which is now a well-known complication. We report four cases of post-sleeve gastrectomy patients who presented with reflux symptoms, with their contrast-enhanced computed tomography abdomen showing intrathoracic sleeve migration and had hypotensive lower oesophageal sphincter with normal body motility on their oesophageal manometry. A laparoscopic revision Roux-en-Y gastric bypass surgery with hiatal hernia repair was performed for all four of them. No post-operative complications were seen at 1-year follow-up. Laparoscopic reduction of migrated sleeve with posterior cruroplasty and conversion to Roux-en-Y gastric bypass surgery can be safely performed for patients presenting with reflux symptoms in cases of intra-thoracic sleeve migration with good short-term outcomes.

Mounier-Kuhn With Multiple Diverticula

A male in his 60s, nonsmoker, with history of gastroesophageal reflux disease, hiatal hernia repair, and recurrent bronchitis presented to an otolaryngology subspecialty clinic with 1 month of mild dyspnea. Office bronchoscopy identified a paratracheal diverticulum and abnormal scar tissue in the mainstem bronchi bilaterally. The trachea demonstrated posterior scar bands with intermittent dilations (Figure 1). Computed tomography (CT) imaging revealed a 44×18–mm cystic, extrapulmonary lesion along the right side of the trachea, as well as tracheobronchomegaly (Figure 2).

Massive chest tube output after congenital diaphragmatic hernia repair on extracorporeal membrane oxygenation

Peripherally inserted central catheter (PICC) lines are used routinely in neonates requiring prolonged drugs and parenteral nutrition and complications are usually infectious, mechanical, or thrombotic in nature. Spontaneous extravascular migration is extremely rare, and presentation with large volume chest tube output even rarer. We present a case involving a neonate on extracorporeal membrane oxygenation (ECMO) after congenital diaphragmatic hernia (CDH) repair and discuss management strategies.

Robot-assisted repair of hiatal hernia: Advantages and disadvantages in comparison to conventional laparoscopic repair: A literature review

Abstract The laparoscopic fundoplication has proven to be the standard technique of antireflux surgery and hiatal hernia (HH) repair over the last decade. However, robot-assisted surgery is more and more implemented in daily practice. Several studies have proven the feasibility and safety of robot-assisted HH repair and antireflux surgery. Both approaches seem to be similar regarding perioperative and postoperative complications, length of hospital stay, postoperative symptoms, and quality of life, as well as objective assessment of gastric acid exposure. Nevertheless, high total costs as well as a considerably longer total operating time of robot-assisted surgery need to be considered. The role of robot-assisted surgery in complex cases is promising but needs to be evaluated. Eventually, the decision regarding the technique used should be based on the surgeon’s discretion and experience.

Laparoscopic Surgical Repair of a Giant Hiatal Hernia with Prothesis: How We Do It (with Video)

Laparoscopic Surgical Repair of a Giant Hiatal Hernia with Prothesis: How We Do It (with Video)

Factors affecting the treatment success of sleeve gastrectomy with concomitant hiatal hernia repair on gastroesophageal reflux disease in patients with obesity

Factors affecting the treatment success of sleeve gastrectomy with concomitant hiatal hernia repair on gastroesophageal reflux disease in patients with obesity

Xanthogranulomatous Cholecystitis: A Distinctive Subtype of Importance.

A 53-year-old female with a history of hiatal hernia repair presented with right upper quadrant pain and jaundice. Physical examination revealed tenderness of the right upper quadrant. Laboratory tests showed elevated C-reactive protein of 109 mg/L (normal <10) and total bilirubin of 181 μmol/L (normal 0–21). Abdominal computed tomography highlighted a gallstone within the main bile duct and an enlarged gallbladder with heterogenous enhancement and intramural hypoattenuating nodules (Figure A). These radiological features established the diagnosis of xanthogranulomatous cholecystitis (XC).

Robot-assisted laparoscopic repair in hiatal hernia with kyphosis: A case report with meta-analysis

Abstract BACKGROUND: Hiatal hernia is a high incidence disease, of which, partial patients requiring surgery have gastroesophageal reflux or dysphagia. Although minimally invasive surgery has been widely utilized in recent years, the optimal surgical therapy still remains controversial. In this study, we reported a kyphosis patient undergoing robot-assisted laparoscopic hiatal hernia repair and launched a meta-analysis aiming to evaluate the advantages of this surgery strategy. MATERIALS AND METHODS: Six databases (Cochrane Central Register of Controlled Trials, PubMed, MEDLINE, EMBASE, ClincialTrials.gov database and Web of Science) were searched from inception to September 20, 2022. All studies describing the patients undergoing robotic hiatal hernia or laparoscopic hiatal hernia were included. And the meta-analysis was performed using R package meta (v6.0.0). RESULTS: We reported a 75-year-old female patient of short stature and with severe kyphosis was diagnosed with hiatal hernia and underwent a robotic surgery. For meta-analysis, 1,128 articles were identified in the initial database search, and among them, 6 articles were included in the final analysis. The results showed that robotic surgery had no advantage in operation time and intraoperative complications rate compared with traditional laparoscopic surgery (both P &lt; 0.01). Regardless of the statistical significance, robotic surgery tended to have a lower conversion and postoperative complication rate, as well as the length of hospital stay. CONCLUSIONS: Robotics have some advantages in the surgical treatment of hiatal hernia compared with the conventional laparoscopic surgery, the use of which can facilitate the treatment for some challenging cases.

The outcome of hiatal hernia repair and factors associated with surgical outcome in the pediatric population: a single-center experience

The outcome of hiatal hernia repair and factors associated with surgical outcome in the pediatric population: a single-center experience

Complications and outcome of traumatic diaphragmatic hernia repair without post-operative chest drain: Retrospective study in 90 cats.

Diaphragmatic herniorraphy is the treatment of choice for traumatic diaphragmatic hernia (TDH). Several methods have been described for the removal of residual air and fluid during and after surgery, such as the insertion of chest drains, intercostal thoracentesis, and transdiaphragmatic thoracentesis. However, there are no indications regarding the most useful technique and the impact that choice of technique could have in the immediate postoperative period. To evaluate the development of complications and outcomes associated with the use of intraoperative transdiaphragmatic thoracentesis in cats undergoing diaphragmatic herniorrhaphy for TDH. Medical records of cats treated for acute and chronic TDH between 2010 and 2019 were reviewed. Cats were included if intraoperative pneumothorax was treated with transdiaphragmatic thoracentesis, without the use of intercostal chest drain. Outcome, intra- and post-operative complications were recorded. Intraoperative and postoperative complication rates were 3.3% and 12.4%, respectively. Development of postoperative pneumothorax was associated with the presence of comorbidities (p = 0.046). The overall survival rate was 93.3%. Long-term survival had a significant association with the presence of comorbidities (p = 0.045), if the procedure was performed as an emergency (p = 0.041) or in older cats (p = 0.011). Intraoperative transdiaphragmatic thoracentesis could be considered an effective method for the removal of residual air after surgery for TDH, because it ensures a good outcome for the patient, with low development of complications, especially for uncomplicated cases. The presence of comorbidities, the need to perform a surgical procedure in emergency, and the age of the patient can be considered factors influencing the development of complications. Critical patient selection, based on assessment of potential risk factors for complications is warranted to understand which patient will benefit from thoracostomy tube placement.