Large Hiatal Hernia Research Articles

Recidiva paraesofágica de hernia hiatal. Diagnóstico radiológico y resolución quirúrgica laparoscópica

La tasa de recidiva radiológica luego de la cirugía de las hernias hiatales grandes tipo IV es cercana al 50%. La mayoría de las veces la recidiva supone un ascenso parcial de la funduplicatura al tórax (telescopaje), y si no tiene expresión clínica puede optarse por un manejo conservador (solo 3-6% requieren cirugía de revisión). Sin embargo, en ocasiones hay otro tipo de recidivas (paraesofágicas) que deben valorarse mediante estudios funcionales, endoscópicos y radiológicos, que dan disfagia con mayor frecuencia.
 Un tránsito contrastado digestivo superior permite en este caso identificar el tipo de recidiva herniaria, con migración parcial del fundus gástrico hacia el tórax paraesofágico izquierdo, y una funduplicatura continente pero realizada técnicamente en por debajo de lo deseable (cuerpo alto) (figura).
 La resolución del cuadro implica la reducción de la hernia a la cavidad abdominal, con cierre del defecto diafragmático, desmontar la funduplicatura anterior anatomizando la zona y la reconfección de una nueva funduplicatura.

Current surgical concepts for type III hiatal hernia: a survey among members of the Swiss Society of Visceral Surgery.

Surgery for large hiatal hernias has greatly evolved over the last decade, but there is an ongoing controversy regarding many technical aspects, such as the use of meshes or the necessity to add a fundoplication. The purpose of this survey was to assess the current spectrum of surgical care for mixed axial and paraoesophageal hiatal hernias (type III hiatal hernia) in Switzerland. In April 2020, we conducted a web-based survey comprising 25 questions on surgical management of type III hiatal hernia among members of the Swiss Society for Visceral Surgery. The survey focused exclusively on primary hernias in an elective setting. Responses were graded on a five-point Likert scale and analysed using descriptive statistics. Consensus was defined as agreement (agree or strongly agree) ≥75%. Forty-seven visceral surgeons with a median annual institutional caseload of 15 (interquartile range 10-30) type III hiatal hernia participated in the survey (response rate 15%). Agreement ≥75% was found for several basic technical steps (access via laparoscopy, hernia sac resection, preservation of vagus nerves, preservation of aberrant left hepatic artery, single-stitch posterior suture repair of hiatus with braided, non-resorbable material, complementary antireflux procedure). In contrast, consensus was not achieved for several important surgical details (mesh hiatoplasty, type of antireflux procedure, gastropexy, management of short oesophagus). A high percentage of participating surgeons experienced mesh related complications in their own or assigned patients: erosions (15% and 36%, respectively), stenoses (26% and 24%, respectively) and pericardial tamponades (9% and 15%, respectively). Nevertheless, hiatal reinforcement with mesh (in all or in selected cases) was reported by 91% of participants without consensus regarding mesh type, shape, placement and fixation technique. Apart from a few generally accepted technical steps, surgical management of type III hiatal hernia is highly variable amongst visceral surgeons in Switzerland. Although mesh-related complications appear to be common, most Swiss surgeons report routine mesh use for hiatal reinforcement.

Complications of gastroesophageal reflux disease: 10-year experience

Purpose: Gastroesophageal reflux disease (GERD) is a common condition of modern times resulting from chronic reflux of gastric contents into the esophagus. The cause underlying GERD involves an imbalance between noxious and protective factors of the esophageal mucosa and a functional disorder of the lower esophageal sphincter (LES). The transitional release of the LES appearing more frequently and longer than physiologically normal is the main cause for the development of GERD. The negative effects of reflux can increase by disturbed esophageal motility, which is unable to regularly clear the esophagus in esophageal motility disorders and disturbed gastric emptying in large hiatal hernias and peptic ulcers. Typical GERD symptoms include a burning sensation or pain behind the sternum, return of bitter or acidic gastric content into the esophagus, rare odynophagia and extraesophageal signs, such as non-cardiac chest pain, chronic cough, and hoarseness
 Methods: A literature revue and a review of clinical cases over a 10-year span in the Department for Thoracic Surgery University Medical Centre Maribor.
 Results: The study was also drawn from 10 years of experience with surgical treatment of GERD and its complications. The treatment of reflux esophagitis and asthma as a GERD complication is not the domain of a surgeon. Surgical treatment is indicated in passage-blocking conditions and in cases in which GERD cannot be managed with medical therapy. In the period from 2006–2015 we performed 928 surgeries to remove and prevent GERD complications.
 Conclusion: Several possible complications of GERD are known, among which the development of Barret’s esophagus as a pre-malignant condition of the esophageal mucosa and the development of glandular carcinoma of distal esophagus are especially dangerous. Therefore, a precise diagnostic treatment is necessary when treating the underlying disease of patients as the clinical picture of GERD often resembles problems related to other thoracic pathologies.

Resuscitation and organ reduction in large traumatic diaphragmatic hernia

Diaphragmatic injury is a rare entity and clinically difficult to be diagnosed as symptoms are often masked due to associated injury in a poly trauma case. There are no specific signs and symptoms for diagnosing diaphragmatic rupture. High degree of clinical suspicion is needed in all cases of thoraco-abdominal injury to diagnose a case of diaphragmatic rupture. Cardiovascular and Thoracic compromise secondary to Large Diaphragmatic hernia can be significant and needs consideration and immediate intervention

OV07 LAPAROSCOPIC HIATAL HERNIA MESH-SUTURE REPAIR

Abstract Aim “A new original laparoscopic operative technique was used to suture paraesophageal hernia (PEH) with the strips of mesh. Material and Methods The Mercilen (MercilenTM) mesh suture was used to close large hiatal hernia. The strips of mesh, instead of normal thread, were applied to close the gap between diaphragm’s crura in 12 patients with hernia defect more than 5 cm. Mesh suture were tighten as a simple laparoscopic intracorporeal knot. The surgical technique and surgical outcomes are presented. Results 12 patients underwent a laparoscopic PEH suturing with Mercilen strips of mesh. We recorded no recurrence or dysphagia at 6 and 12 months follow-up. Conclusions Mesh-sutured repairs of diaphragm’s hernia support the concepts of force distribution and resistance to suture pull through. The new original technique avoids using the sheet of mesh and enables to reduce the amount of dangerous complications connected with mesh and its fixation. Mesh-sutured closures of hiatal hernias seem to be safe and effective in tension closure of large hiatal defects. Further investigations are needed to evaluate the results. Using the mesh suture technique for the closure of large PEH, we protect the cruras from being cutting through. Besides, the mesh stripes and its knots produce tissue scarring around the esophagus making the suture line stronger.

A possible endoscopic therapy for large hiatal hernia complicated with refractory gastroesophageal reflux disease.

A possible endoscopic therapy for large hiatal hernia complicated with refractory gastroesophageal reflux disease.

Plastic for diaphragmal 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.

Imperfect high-resolution manometry studies: Prevalence and predictive factors.

Imperfect high-resolution manometry (HRM) studies can impact clinical management of patients with esophageal symptoms. Esophageal high-resolution manometry (HRM) studies attempted and/or performed by trained motility operators at a tertiary care center over a 2-year period were identified. When studies were attempted but not completed, reasons for an imperfect study (critically imperfect=LES not adequately traversed; non-critically imperfect=diaphragm not traversed), and point of identification (identified by motility nurse vs. identified on physician review) were recorded. Prevalence and clinical predictors of critically and non-critically imperfect studies were determined. Of 962 HRM studies attempted in 951 patients, 33 (3.4%) were critically imperfect (17 curled catheters), and 125 (13.0%) were non-critically imperfect. A third of critically imperfect studies, and 64.7% of curled catheters had achalasia, while 99.2% of non-critically imperfect studies had large hiatus hernias. Motility nurses detected 90.9% of critically imperfect and 55.8% of non-critically imperfect studies in real-time (p<0.001). Achalasia independently predicted curled catheters; large hiatus hernias predicted non-critically imperfect studies (p<0.001 for each). Compared to technically perfect studies, catheter curling was encountered more often in older patients, catheter intolerance in younger patients, and non-critically imperfect studies in females (p<0.001 for each). No critical motor disorder was identified in intolerant patients. Achalasia should be suspected when a curled catheter is encountered especially in older patients, while intolerant patients do not have critical motor disorders. Critically imperfect HRM studies are rare when performed by trained motility operators, which are identified in real time and aborted.

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

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: A hiatal hernia is an anatomical abnormality in which abdominal contents displace into the thoracic cavity through a diaphragmatic defect and can result in GERD, bronchiectasis, and rarely cardiac compression. We describe a case of a large hiatal hernia in an advanced age female in whom the hernia compressed the left ventricle resulting in significant cardiac dysfunction. CASE PRESENTATION: An advanced age female with a past history of diabetes, hypertension, hypothyroidism, and large hiatal hernia repaired in 2017 presented with nausea and bloody/bilious vomiting with food intolerance and was found to have a gastric outlet obstruction. The patient's case was complicated by aspiration pneumonia and cardiac sequelae. Patient exhibited soft pressures and sinus tachycardia in the 120 to 140 range with frequent atrial and ventricular ectopy and a left bundle branch block. Echocardiogram noted that her left ventricle was small and compressed secondary to bowel from the hiatal hernia. Given patient's advanced age, the plan was to treat conservatively with beta blockers. Patient then had rhythmic change to new atrial fibrillation with rapid ventricular response. Ultimately patient had cardiorespiratory compromise secondary to decreased preload from cardiac compression from her large hiatal hernia and expired. DISCUSSION: There are a few case reports of cardiac sequelae such as ST elevation and decreased preload from left atrial and ventricular compression due to large hiatal hernias, especially in the post prandial state in which the mass effect increases. In this patient's case, the patient's mass effect of her large hiatal hernia was exacerbated by her gastric outlet obstruction. She had recurrence of her hiatal hernia despite two repair procedures in the past and given her advanced age, she was a poor surgical candidate for surgery of her hernia. She had conservative management with beta blockers and NG tube placement for gastric decompression, but she ultimately had complicated course with increased ectopy, new arrhythmia, and left ventricular compression caused by mass effect of the massive hernia. CONCLUSIONS: The patient's mass effect of her large hiatal hernia was exacerbated by her gastric outlet obstruction which led to increased ectopy, new arrhythmia, and decreased preload from left ventricular compression. In an advanced age patient with gastric outlet obstruction and a history of large hiatal hernia, the treatment options were limited. In cases of patients who are able to undergo more aggressive management, it is advisable to closely monitor and intervene on large hiatal hernias and relieve the cause of gastric outlet obstructions as they can have significant cardiopulmonary effects secondary to their mass effect as seen in this case. REFERENCE #1: Umemura, A. et al. Cardiopulmonary Impairments Caused by a Large Hiatal Hernia with Organoaxial Gastric Volvulus Showing Upside-Down Stomach: A Case Report. The American journal of case reports, [s. l.], v. 20, p. 1530–1535, 2019. DOI 10.12659/AJCR.918191 REFERENCE #2: Gnanenthiran, S. et al. Feeding Inducses Left Atrial Compression and Impedes Cardiac Filling in Patients with Large Haital Hernia. Journal of the American Society of Echocardiography. V.32, iss. 3, p. 375-384, 2019. DOI 10.1016/j.echo.2018.09.017 REFERENCE #3: Harada, K. et al. Left ventricular obstruction caused by a large hiatal hernia. Echocardiography (Mount Kisco, N.Y.), [s. l.], v. 34, n. 8, p. 1254–1256, 2017. DOI 10.1111/echo.13563. Disponível em: https://search-ebscohost-com.ezproxy.libraries.wright.edu/login.aspx?direct=true&db=mnh&AN=28497506&site=eds-live. Acesso em: 11 set. 2020. DISCLOSURES: No relevant relationships by Anas Ahmed, source=Web Response No relevant relationships by Amie Kim, source=Web Response No relevant relationships by Steven Young, source=Web Response

S2177 Ibuprofen Impaction: No Pill Is Too Small

Introduction: Acute esophageal necrosis (AEN) is an emerging cause of gastrointestinal bleeding with an increasing incidence over the past two decades. It appears as a circumferential necrotic lesion encircling the distal esophagus with various proximal extensions. It is most commonly associated with exacerbations of medical co-morbidities such as diabetes, renal failure, coronary disease;however cases of AEN due to mechanical alteration in gut anatomy are exceedingly rare and its prognosis is less defined. We present a unique constellation of AEN, Cameron ulcers (CU), and gastric volvulus from a large paraesophageal hiatal hernia. Case Description/Methods: A 77-year-old female began experiencing abdominal pain and repeated emesis. She had a history of COPD, GERD, episodes of bleeding ulcers, hiatal hernia, malnutrition, and recently COVID-19. She was hemodynamically stable, ill-appearing with tenderness to abdominal palpation and a negative stool guaiac. BP 106/48 mm/Hg, HR 107, requiring oxygen. Investigations revealed WBC 18.5 k/uL, Hgb 9.8 g/dL, and acute renal failure. A CT abdomen revealed complete herniation of the stomach into the posterior mediastinum, dilated esophagus, organoaxial gastric volvulus, and gastric distension [Figure 1 - Pane A-C]. IV fluids, pantoprazole 80 mg, and ondansetron 4 mg were given. An EGD revealed a large hiatal hernia, Cameron ulcers (CU), and necrotic ulceration along the mid-to-lower third of the esophagus. The patient deferred surgical intervention and was discharged home on hospice. Discussion: These constellations represent a common underlying pathophysiologic mechanism that stems from large hiatal hernias and their effect on surrounding structures in our case, precipitated by a paraesophageal hiatal hernia that became too large causing acute gastric volvulus. In severe presentations, the stomach may herniate into the posterior mediastinum known as an upside-down stomach requiring surgery while CU represents trauma to the mucosa from the hernia sliding. In our patient, lower esophagus blood flow traversing through the lesser gastric curvature may have been compromised during gastric necrosis. Simultaneously, sudden gastric stunning from acute outlet obstruction can lead to prolonged acidic bathing of the esophageal mucosa. Often the esophagus can compensate for this by increasing blood flow, however, this is compromised in low-flow states. Limitations of our study include lack of follow-up. A systematic review of all cases of AEN and gastric volvulus are in Table 1.

S3592 Cameron Lesions Resulting in Occult GI Bleeding and Anemia

Introduction: Cameron lesions are ulcerations which develop in the sac of hiatal hernias at the diaphragmatic hiatus. They occur in about 3-12% of patients with hiatal hernias. The overall prevalence of Cameron lesions in all patients is less than 1%. Nonsteroidal anti-inflammatory drugs (NSAIDs) are also associated with the development of Cameron lesions. These lesions can present with either occult or overt gastrointestinal bleeding. They are often missed on routine endoscopy given their diminutive size and inconspicuous location which requires thorough antegrade and retrograde examination. We describe a case of a woman with a large hiatal hernia and Cameron lesions with resulting symptomatic iron deficiency anemia. Case Description/Methods: A 50-year-old woman with obstructive sleep apnea, chronic lymphedema, and major depressive disorder underwent routine esophagogastroduodenoscopy (EGD) due to several months of dysphagia and odynophagia. She was found to have grade B esophagitis and a large hiatal hernia with multiple Cameron lesions. Proton pump inhibitor was prescribed. A few months later, patient presented to clinic with orthostatic dizziness and weakness; Hemoglobin (Hgb) was 6.0 mg/dL (previously normal two years prior). She was admitted to the hospital and received red blood cell transfusions with an appropriate response in Hgb and oral iron supplementation; anti-reflux medications were continued on discharge. After one year of strict adherence to anti-reflux regimen and iron supplementation, her hemoglobin levels normalized. Repeat EGD was obtained eighteen months later due to continued dysphagia and odynophagia and showed resolution of Cameron lesions and esophagitis but progression in the size of the hiatal hernia. She was referred to a general surgeon and underwent laparascopic para-esophageal repair and partial fundoplication with resolution of her symptoms. Discussion: Cameron lesions may cause overt and occult gastrointestinal bleeding with resulting iron deficiency anemia. These lesions have been mostly described in association with large hiatal hernias and routine NSAID use. Medical treatment with a proton pump inhibitor and discontinuation of NSAIDs is usually sufficient to treat these ulcerations but some patients may require endoscopic or surgical management in severe cases. Gastroenterologists should give special attention to the mucosa of the diaphragmatic hiatus in patients with a hiatal hernia and suspicion for gastrointestinal bleeding to evaluate for Cameron lesions.Figure 1.: Cameron lesions seen on retrograde view during endoscopy.

S3567 No Barrett's, No Way! A Case of De novo Esophageal Adenocarcinoma

Introduction: Instances of esophageal adenocarcinoma have been increasing at a more drastic rate in the United States and Western Europe in recent years. This calls for more aggressive and comprehensive screening processes for patients with chronic reflux and for those found to have Barrett’s esophagus. Barrett’s esophagus is widely accepted as a precursor to adenocarcinoma of the esophagus, but this case provides a caveat to this rule of thumb. Case Description/Methods: This is a case of a 63-year-old woman who initially presented with severe GERD and was complaining of reflux and regurgitation, as well as nocturnal coughing and wheezing. An endoscopy was conducted revealing LA class 3 esophagitis, a large hiatal hernia, and a distal esophageal inflammatory nodule. The patient was treated aggressively with a combination of a daily PPI and a nightly H2RA. A three-month follow-up endoscopy revealed improvement of her esophagitis, which was downgraded to LA class 1. There was no evidence of Barrett’s esophagus, and the esophageal nodule had healed. Despite this treatment plan the patient was still complaining of regurgitation. An upper GI series revealed a 5 cm hiatal hernia with reflux on water siphon test and valsalva maneuver. Subsequently, a laparoscopic partial fundoplication was performed with complete resolution of all symptoms and successful discontinuance of all acid suppression medications. 2 and ½ years later the patient presented with new onset dysphasia. An upper endoscopy was subsequently performed which revealed a large adenocarcinoma of the distal esophagus and 2 satellite lesions above the adenocarcinoma. Discussion: This case highlights an infrequent presentation of de novo adenocarcinoma with no evidence of Barrett’s esophagus in a conservative time interval. In the chance that the endoscopist may have missed a short segment Barrett’s because of sampling error, the standard of care would have been a 3-year interval surveillance endoscopy. A repeat endoscopy was performed in 2.5 years regardless of no evidence of Barrett’s; the standard of care was not sufficient in this case. This patient exhibited LA class 3-4 distal esophagitis and despite healing, still developed an advanced adenocarcinoma. This may indicate that there is an alternative pathway to esophageal adenocarcinoma in patients with such severe reflux. This case should provide support to potentially screen patients more aggressively who present with severe reflux.Figure 1.: Row 1: initial endoscopy Row 2: second endoscopy Row 3: third endoscopy

Mycobacterium avium Pulmonary Infection Disguised as a Urinary Tract Infection

In the United States, Mycobacterium avium complex (MAC) has been found to be the most common isolate in non-tuberculous disease, and pulmonary infection is the most frequent presentation. It is ubiquitous in the environment, particularly in soil and manufactured water supply sources. Worldwide, M. avium infections, both pulmonary and disseminated, are steadily increasing. Due to MAC’s ability to cause non-specific symptoms and its pervasiveness within the environment, it is paramount to incorporate this diagnosis in the differential, especially in those most susceptible. We report a case of a Mycobacterium avium complex pulmonary infection in 72-year-old Caucasian male with history of chronic immunosuppression and large hiatal hernia, highlight the imaging features, and discuss the importance of maintaining awareness in immunocompromised hosts.

THORACOSTOMY, PLEASE? MASSIVE DIAPHRAGMATIC HERNIA MASQUERADING AS COMPLEX PLEURAL EFFUSION

TOPIC: Imaging TYPE: Medical Student/Resident Case Reports INTRODUCTION: Dyspnea is defined as a patient's experience of his or her own breathlessness and is a powerful clue of an underlying pathology that may not be confined to the cardiopulmonary system. Gastrointestinal pathology is often an overlooked etiology of intrathoracic pathology and an unusual cause of respiratory symptoms (1). Hiatal hernias rarely present as dyspnea and are usually seen on plain chest radiograph as a retrocardiac opacity with an air fluid level (2,3). We report a case of left hemithorax opacification suspicious for a large loculated pleural effusion that in fact represented diaphragmatic herniation of abdominal contents. CASE PRESENTATION: A 97-year-old female with history of hiatal hernia and gastroesophageal reflux disease (GERD) presented to the hospital from an assisted living facility with dyspnea and confusion. As part of her evaluation, a chest X-ray (CXR) was obtained which showed a large left pleural effusion with associated incomplete collapse of the left lung (Figure 1). This was further investigated with computed tomography (CT) of her chest which showed a large, complex left-sided pleural effusion with associated collapse (Figure 2A) for which pulmonary service was asked to evaluate the patient. On review of previous studies, an oral-contrast abdominal and chest CT was done which showed abdominal contents above the diaphragm in the left thoracic cavity - confirming the presence of a large paraesophageal hiatal hernia (Figure 2B). No surgical intervention was offered nor was additional work-up needed for the abnormality observed on CT. DISCUSSION: Although hiatal hernias are common, with studies suggesting a prevalence of 50% of people 50 years or older (3), it rarely results in dyspnea, becoming symptomatic only in the presence of significant hernia size resulting in left atrial compression and/or decreased pulmonary compliance (3). This case highlights the importance of independent evaluation and review of imaging, especially if the "official" read does not seem to fit the clinical scenario. Likewise, longitudinal comparison with previous imaging is paramount to establishing the chronicity and nature of encountered pathology and should be done consistently to avoid incorrect diagnoses and potentially unnecessary procedures. CONCLUSIONS: Herniation of abdominal contents in the form of hiatal hernia is common in adults but rarely manifests as dyspnea. Diagnosis is established on the basis of specific symptoms in combination with radiographic findings. If imaging is misinterpreted, as was done initially in this case, appropriate treatment may be delayed and unwarranted procedures may be performed. Clinicians must interpret imaging independently accounting for clinical context and perform longitudinal assessment of prior studies to arrive at the correct diagnosis. REFERENCE #1: Prevalence of Dyspnea Among Hospitalized Patients at the Time of Admission. Jennifer P. Stevens, MD, MS, Tenzin Dechen, MS, Richard Schwartzstein, MD, Carl O'Donnell, ScD, Kathy Baker, RN, MSN, Michael D. Howell, MD, MPH, and Robert B. Banzett, PhD. Journal of Pain and Symptom Management. 2018 July; Vol. 56 No. 1: 15-22. REFERENCE #2: Hiatal Hernia: An unusual presentation of dyspnea. Seied Ahmad Mirdamadi, MD, Mahfar Arasteh, MD. N Am J Med Sci. 2010 Aug; 2(8): 395-396. REFERENCE #3: When the Stomach Rules the Heart: Dyspnea as a Neglected Complication of a Large Hiatal Hernia. Thomas H. Marwick, MBBS, PhD. Journal of the Americal College of Cardiology. 2011 October 58 (15): 1635-1636. DISCLOSURES: No relevant relationships by Christine Girard, source=Web Response No relevant relationships by Daniel Kotok, source=Web Response

Hiatal hernia, lower esophageal sphincter and their combined effect on the natural history of gastroesophageal reflux disease: implications for surgical therapy

: The modern surgical therapy of gastroesophageal reflux disease (GERD) is based upon the concept that the antireflux barrier has two components that form a “double-sphincter” and work synergistically to protect from reflux of gastroduodenal contents: the lower esophageal sphincter (LES) and the crural diaphragm. Factors implicated in the pathogenesis of hiatal hernia (HH) are the thoraco-abdominal pressure gradient, the esophageal shortening secondary to reflux-induced fibrosis, and the hiatal enlargement due to peri-esophageal tissue deterioration. Genetic and biologic factors can predispose to HH formation through alterations in extracellular matrix protein metabolism, and through structural changes of the muscular crura, central tendon, and phreno-esophageal ligament. This will eventually result in loss of tensile strength and/or loss of recoil ability of elastic fibers. Failure of LES or the crural diaphragm or both contribute to progression of GERD and development of complications such as Barrett’s esophagus and esophageal adenocarcinoma. Patients’ selection for antireflux surgery is critical for optimal outcomes. While laparoscopic cruroplasty and Toupet or Nissen fundoplication remain the current gold standard in antireflux surgery, the high rates of anatomical and clinical recurrence in patients with large hiatus hernia still represent a matter of concern. To reduce recurrence rates after surgical repair, it is clear that both axial and radial tension at the esophago-gastric junction (EGJ) must be minimized. This has led to an increasing interest for the use of prosthetic mesh to reinforce the esophageal hiatus. Recognition of anatomical and functional abnormalities at an early disease-stage is critical to prevent complications and to provide the most appropriate surgical therapy and the best clinical outcomes.

S1620 A Symptomatic Posterior Mediastinal Space Pseudocyst Managed by Cystgastrostomy Through a Hiatal Hernia

Introduction: Pseudocysts are seen after acute pancreatitis (AP) and consist of collections of pancreatic secretions surrounded by a fibrous wall. Mediastinal extension of pseudocysts is a rare complication of AP. Here we describe the unique case of a large pseudocyst that extended along a hiatal hernia sac resulting in chest pain and dysphagia, requiring cystgastrostomy in the posterior mediastinal space. Case Description/Methods: A 64-year-old female with a history of a large hiatal hernia (HH) presented to the emergency room (ER) with gradual onset retrosternal pain and associated dysphagia of 1 week duration. She had a recent hospitalization for AP two months earlier. In the ER, vital signs were within normal limits. Cardiac evaluation, complete blood count, and comprehensive metabolic panel were unremarkable. Abdominal computed tomography revealed a 7 x 6.2 cm peripancreatic fluid collection extending through the diaphragm in the posterior mediastinal space, resulting in mass effect on the distal esophagus and HH sac (Figure 1A-C). Upper endoscopy revealed extrinsic-appearing narrowing in the distal esophagus immediately proximal to a 5 cm Hill grade IV HH. Endosonography (EUS) guided cystgastrostomy was successfully performed using a 10 mm x 10 mm electrocautery enhanced lumen apposing metal stent (LAMS). Post-procedure the patient reported symptomatic relief and was admitted for overnight observation. Repeat cross sectional imaging revealed significant reduction in the size of the pseudocyst (Figure 1D). EUS two weeks later revealed complete pseudocyst resolution and the LAMS was removed. Discussion: Mediastinal extension of a pseudocyst is a rare complication of acute pancreatitis. In prior reports, mediastinal pseudocysts have been managed by endoscopic aspiration, placement of plastic stents, or surgical drainage. To our knowledge, this is the first case of a cystgastrostomy performed through a hiatal hernia to drain a pseudocyst in the posterior mediastinum.Figure 1.: Axial (A) and coronal (B and C) views of the CT scan revealed a large pseudocyst extending into the posterior mediastinal space. The sagittal view (D) showed the lumen-apposing metal stent draining the pseudocyst into the hiatal hernia sac.

S2557 Endoscopic Treatment of Gastric Perforation Resulting From Slipped Nissen Fundoplication

Introduction: Nissen fundoplication is used to treat gastroesophageal reflux disease and gastric hernias. Herein, we present a rare case of slipped fundoplication induced by physical strain, which was complicated by gastric perforation resulting in a pneumomediastinum and pleural effusion. Due to his herniated stomach, initial esophagram failed to demonstrate the diagnosis. Perforation was closed via endoscopy and resulting empyema was managed with antibiotics and chest tube drainage. Clinical resolution was achieved. Case Description/Methods: A 66 yo male with history of compensated cirrhosis and polycystic kidney disease, who had previously undergone Nissen fundoplication in 1995 for hiatal hernia presented with sudden onset of sharp epigastric pain in association with neck swelling and dyspnea after lifting a heavy wheelbarrow. Vitals were stable. Physical exam was notable for subcutaneous emphysema. Initial laboratory data was only significant for leukocytosis (19 bil/L). CT scan demonstrated pneumomediastinum and collapsed right lung. Initial esophagram showed no extra-luminal contrast leakage, but CT chest performed the following day discovered a contrast collection above the diaphragm suggestive of esophageal perforation. Upper endoscopy findings included a recurrent large hiatal hernia with a small perforation noted near the dome of the fundus. Pustular drainage was seen and contrast injection detected the same fluid collection as noted on imaging. Closure was achieved with argon plasma coagulation ablation and an 11 mm over-the-scope-clip (OTSC) deployed in retroflexed position. Subsequent serial imaging with upper GI series and CT scans confirmed lack of contrast leakage and resolution of pneumomediastinum. Empyema was managed with chest tube drainage and antibiotics. Discussion: We demonstrate a rare case of gastric fundus perforation likely resulting from acute slippage of fundoplication from his initial surgery 26 years ago caused by physical strain. Upon presentation, patient lacked typical peritoneal signs due to recurrent herniation of his stomach above the diaphragm. Thus, instead, patient was found to have mediastinal air and a pleural effusion. Lastly, due to altered anatomy, the esophagram did not detect the perforation, necessitating endoscopic evaluation. With the development of OTSCs, gastroenterologists now can safely and effectively treat gastrointestinal perforations.

Large Hiatal Hernia Associated with Cameron Ulcers and Consecutive Sideropenic Anemia: Case Presentation

BACKGROUND: Cameron lesions are seen in 5.2% of patients with hiatal hernia who undergo esophagogastroduodenoscopic examinations. The prevalence of Cameron lesions seems to be dependent on the size of the hernial sac, with an increased prevalence in the larger-sized sac. In about two-thirds of the cases, multiple Cameron lesions are noted rather than a solitary erosion or ulcer. AIM: The aim of this case report is to present the patient with Cameron ulcers associated with hiatal hernia. CASE PRESENTATION: Our patient presented with postprandial retrosternal pain, especially immediately after eating, vomiting, dyspnea, weight loss, fatigue, signs, and symptoms of severe hypochromic microcytic anemia without signs of acute gastrointestinal bleeding. No history of gastroesophageal disease. Colonoscopy was done and eliminate colic cause of anemia. The endoscopy showed a large hiatal hernia and linear erosions and ulcerations at the level of gastrodiaphragmatic contact (Cameron ulcers) and one non-sanguinant subcardial elipsoid ulceration. After conservative and operative treatment, there was significant clinically and laboratory improvement definitively, after 6 months. Cameron lesion is a rare cause of refractory sideropenic anemia. Diagnosis is very difficult in developing countries, where iron deficiency anemia is more common. A history of disease, clinical course, and laboratory findings are the important facts for diagnosis. CONCLUSION: Endoscopy is the gold standard for diagnosis, although it is not uncommon to overlook these lesions due to their unique location. There are two modalities for the treatment of Cameron lesions: Medical or surgical, which should be individualized for each patient. By severe refractory anemia and large hiatal hernia, associated with clinical signs, surgical approach is very important.

Repair of Large Hiatal Hernias With the Use of Mesh and Autologous Platelet-Rich Plasma.

According to recent studies, large hiatal hernias (HH) can be associated with a lower content of type-I and type-III collagen in the phrenoesophageal ligament (POL). We therefore hypothesize that the use of a mesh implant with autologous platelet-rich plasma (PRP) for repair of large HH would have a positive effect on long-term outcome.The purpose of our study was to determine the level of type-I and type-III collagens in the POL of patients with large HH with the aim of improving the technique of HH repair. During the first phase of the study, the collagen content within the POL was assessed in 18 patients with HH and 14 cadaveric specimens without HH. During the second phase, 54 patients with large HH (defined as 10 to 20 cm2), that required surgery were recruited. Laparoscopic repair involved use of a nonabsorbable self-fixating ProGrip mesh infiltrated with 2 to 4 mL of autologous PRP was used for reinforcement of crural repair. Results were assessed using endoscopy, barium swallow, 24-hour impedance-pH monitoring and a quality of life gastroesophageal reflux disease-health related quality of life questionnaire. The content of collagen within POL in patients with HH was significantly lower than in the cadaveric specimens without HH. Of the 54 patients undergoing HH repair, all procedures were performed laparoscopically and there were no mortalities in this group. At 48 months, only 2 HH recurrences (3.7%) were detected. During this period, the mean gastroesophageal reflux disease-health related quality of life score decreased from 15.7±5.5 to 5.9±0.6 (P<0.05). Our study has shown that the collagen content is reduced in patients with large HH; thus, it is advisable to use mesh for HH repair in such patients. Use of mesh infiltrated in PRP is safe and can have positive impact on results of HH repair.

634 ROBOTIC-ASSISTED HIATAL HERNIA AND GASTROESOPHAGEAL DISEASE SURGERY: INITIAL RESULTS AND EXPERIENCE IN A SINGLE INSTITUTION

Abstract Gastroesophageal reflux disease, associated with sliding or large paraesophageal hiatal hernia, represents a common disease that frequently needs a surgical solution. The repair of large paraesophageal hiatal hernias is still a challenge in minimally invasive surgery but the robotic approach seems to gain widespread acceptance because offers enhanced visualization, dexterity and reach, which may facilitate the hiatal reconstruction and mediastinal dissection. Methods Between June 2019 and February 2021, 23 patients (5 male, 18 female) underwent robotic approach fundoplication (19 sliding hernia, 3 paraesophageal and 2 gastroesophagic reflux) after being pre operative diagnosed. All surgeries were elective. Biosynthetic tissue absorbable mesh was applied in one patient with double time recurrence hernia. Sixteen patients underwent total fundoplication (Nissen), 6 patients had Toupet fundoplication, and one patient had hiatus repair without fundoplication. Results The mean age of the patients was 61 years. Biosynthetic mesh was used in one patient. The mean operative time was 127 minutes (80-240) and no intraoperative complications were described. There were no conversions to open or laparoscopic procedures. Nine of the twenty-three patients underwent redo hiatal hernia repairs and the mean hospital stay was 2 days. Only one patient had a major complication (Clavien Dindo 3b) requiring urgent surgery. The early and 30 day mortality rate was 0%. Conclusion In our experience, robotic approach to paraesophageal repair seems safe and effective with low complication rates even in high-risk patients and those with redo surgery. Subjectively, the robotic approach provides the surgeon better vision and maneuverability during the intervention. We hope to progressively increase the number of robotic cases to analyse long-term clinical outcomes such as hiatal hernia recurrences, need of medical therapy and quality of life.