Large Paraesophageal Hiatal Hernia Research Articles

Risk factors associated with radiological and clinical recurrences after laparoscopic repair of large hiatal hernia with TiO2Mesh™ reinforcement.

Laparoscopic repair of large para-esophageal hiatal hernias (LPHH) remains controversial. Several meta-analyses suggest hiatus reinforcement with mesh has better outcomes over cruroplasty in terms of less recurrence. The aim of this study was to evaluate the medium-term results of treating LPHH with a biosynthetic monofilament polypropylene mesh coated with titanium dioxide to enhance biocompatibility (TiO2Mesh™). A retrospective observational study, using data extracted from a prospectively collected database was performed at XXX from December 2014 to June 2023. Included participants were all patients who underwent laparoscopic repair of large (> 5cm) type III hiatal hernia in which a TiO2Mesh™ was used. The results of the study, including clinical and radiological recurrences as well as mesh-related morbidity, were analyzed. Sixty-seven patients were finally analyzed. Laparoscopic approach was attempted in all but conversion was needed in one patient because of bleeding in the lesser curvature. With a median follow-up of 41months (and 10 losses to follow-up), 22% of radiological recurrences and 19.3% of clinical recurrences were described. Regarding complications, one patient presented morbidity associated with the mesh (mesh erosion requiring endoscopic extraction). Recurrent hernia repair was an independent factor of clinical recurrence (OR 4.57 95% CI (1.28-16.31)). LPHH with TiO2Mesh™ is safe and feasible with a satisfactory medium-term recurrence and a low complication rate. Prospective randomized studies are needed to establish the standard repair of LPHH.

V-029 TRANSABDOMINAL LAPAROSCOPIC MANAGEMENT OF RECURRENT LUMBAR HERNIA (GRYNFELT)

Abstract Aims Lumbar hernias are very rare defects of the posterior abdominal wall.They can be classified as Grynfelt in the upper lumbar space(it is the most frequent) and Petit in the lower lumbar triangle. Its treatment can be performed by open approach, or by laparoscopic approach(TAPP or TEP), observing a lower incidence of recurrences and postoperative pain by laparoscopy. Methods Video-case. Results 78-year-old female who attended the clinic presenting a lump that had been increasing in size and was causing pain in the left upper lumbar region. Surgical histories: open lumbar hernioplasty(2018). Physical examination: recurrent left-lumbar hernia(Grynfelt).CT-scan: left-lumbar hernia(defect:45mm) with colon into the hernial sac and a large paraesophageal hiatal hernia. Since the hiatal hernia also needs to be treated, we decided to perform a laparoscopic TAPP-approach to treat the lumbar hernia.The patient was placed in the right lateral decubitus. We use 3 ports(1×12mm,2×5mm) to perform the surgery and place a 10×15cm PVDF mesh fixed with Tisseel and closed the peritoneum with V-Lock 3-0.The patient presented a satisfactory evolution without complications and was discharged in 1°POD. No recurrence. Conclusion Lumbar hernias are a disease with a very low incidence, so there is no clear consensus on the best surgical treatment.Our group think the laparoscopic approach in this type of hernia, whether through the transabdominal(TAPP) or extraperitoneal(TEP) approach, is the most appropriate, since it offers the advantages of minimally invasive surgery(less postoperative pain, shorter LOS) and <postoperative complications related to the surgical site and a lower incidence of hernia recurrence have been reported.

V-055 LAPAROSCOPIC FUNDOPLICATION WITH HANDXTM HOOK AND NEEDLE HOLDER

Abstract Aim HandX™ is a handheld, powered laparoscopic device with interchanging single-patient fully articulating instruments. It is electromechanically controlled, and, as the manual interface is handled by the surgeon, beside the patient's bed, the movements of the surgeon's wrist and fingers are translated to the instrument-articulating tip.This report is to show the feasibility and safety of this technology implemented with a monopolar dissecting hook in a complex abdominal procedure. Materials and Methods We report the case of the laparoscopic repair of a large hiatal hernia using HandXTM instruments. Results The index case was a 69-year-old female with symptomatic large paraesophageal hiatal hernia. Three 5 mm trocars were used: 1 in the left midclavicular line, 1 in on the right of the midline close to the costal arch and 1 assistant on the right midclavicular line, one 11 mm umbilical. The sac was dissected with the HandXTM monopolar hook and the stomach was fully reduced into the abdomen with the hernia sac. The hiatus was closed with three separated stiches handled with the articulating needle holder. A Nissen funduplication was performed. Three separated stiches were used to secure the wrap, using the HandX needle holder. At the end of the operation a mesh was used to reinforce the hiatus. The operative time was 80 minutes, no blood loss nor intraoperative or post-operative complications were recorded Conclusions The report showed how the HandX technology could be safely adopted to obtain both a safe dissection and an ergonomically advantageous suture in laparoscopic Nissen fundoplication.

Paraesophageal hernia repair with laparoscopic Toupet fundoplication: impact on pulmonary function, respiratory symptoms and quality of life.

Paraesophageal hiatal hernia (PEH) is characterized by protrusion of intra-abdominal organs into the posterior mediastinum. Respiratory symptoms and reduced pulmonary function have been described as possibly related to lung compression. To assess the effect of laparoscopic Toupet fundoplication (LTF) for PEH repair on pulmonary function, measured with pulmonary function tests (PFTs), and respiratory symptoms. Retrospective, single-center, cohort study (November 2015-2020). All patients that completed pre- and postoperative (12months) PFTs assessment were included. The gastroesophageal reflux disease health-related quality of life (GERD-HRQL), reflux symptom index (RSI) and short form-36 (SF-36) were used. Overall, 71 patients were included. The median age was 67.1years and the majority were females (78.8%). Baseline PFTs were within normal limits in 91% of patients. At 12month follow-up, total lung capacity (TLC) (4.77 vs. 5.07 L; p = 0.0251), vital capacity (VC) (2.97 vs. 3.31 L; p = 0.0065), forced expiratory volume in one second (FEV1) (2.07 vs. 2.44 L; p < 0.001) and forced vital capacity (FVC) (2.78 vs. 3.19 L; p < 0.001) were significantly improved. No significant differences were found for diffusing capacity of lung for carbon monoxide (DLCO) (17.09 vs. 17.24; p = 0.734), and FEV1/FVC (0.77 vs. 0.77; p = 0.967). Interestingly, improvements were more pronounced in patients with large PEH (type IIIb and IV). At 12month follow-up, both gastrointestinal and respiratory symptoms were significantly improved and 94% of patients were satisfied with the operation. The GERD-HRQL (18.1 ± 7.9 vs. 4.01 ± 2.4; p = 0.001), RSI (37.8 ± 9.7 vs. 10.6 ± 8.9; p < 0.001) and all SF-36 items were improved. LTF for the treatment of PEH is safe and seems to be effective up to 12month follow-up with improved lung volumes, spirometry values, quality of life, gastrointestinal and respiratory symptoms.

Successful laparoscopic repair for large paraesophageal hiatal hernia presenting cardiopulmonary problems: Two case reports

Large paraesophageal hiatal hernia, which is a type III hiatal hernia, involves the combined herniation of both the esophagogastric junction and fundus. Different symptoms are noted in patient with hiatal hernia, the most common being gastroesophageal reflux disease-related symptoms. Herein, we present two cases of large paraesophageal hiatal hernia with symptoms mimicking cardiopulmonary disease, which were successfully treated by laparoscopic hernia repair.

Robotic Laparoscopic Transdiaphragmatic Repair of Large Hiatal Hernias

Introduction: Although laparoscopic Nissen fundoplication is the most common procedure for the repair for hiatal hernia (HH) repair, HH recurrence due to breakdown of the hiatoplasty has been reported as a common mechanism of failure after primary repair. Left transthoracic anatomic and physiologic repair (AFR) of HH is associated with lower incidence of leak and reoperation but greater morbidity. Adopting the transthoracic approach to a robotic laparoscopic platform may represent the ideal approach to the repair of HH. This study reviews the results of this technique. Methods: A retrospective review was performed on patients who had robotic AFR (RAFR) of large HH. All patients received the previously validated Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL) questionnaire preoperatively and postoperatively. Objectively, symptoms were graded using the Visick Scale. Recurrence was defined as greater than 2 cm or 10% of the stomach above the diaphragm detected by either CT, esophagogram or endoscopy. The preoperative data was compared to the results at 2 years. Results: 396 patients underwent RAPR. The Median GERD-HRQL score was 42 (range 38 - 45) preoperatively and 6 (range 0 - 14) at two years (p Conclusion: RAFR of HH is associated with excellent symptom relief and low recurrence rate. RAFR should be considered when deciding on what operation to perform in patients with large paraesophageal hiatal hernias.

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.

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

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.

S3041 Primary Gastric Synovial Sarcoma: A Rarity Tucked Within

INTRODUCTION: Synovial sarcoma (SS) is a rare tumor, accounting for about 10% of soft tissue sarcomas. The most common sites are the extremities. GI tract involvement is uncommon. We present a rare case of Primary Gastric SS. Based on our literature review, there are less than 20 reported cases. CASE DESCRIPTION/METHODS: 77 y.o. Female with hx of Hiatal Hernia and Chronic GERD presented with upper abdominal discomfort, loss of appetite and 12 lb unintentional weight loss. She denied melena or vomiting. Physical exam was unremarkable. Labs revealed new anemia with Hgb 9.8 g/dl from baseline 13 g/dl. CT abdomen showed a large paraesophageal hiatal hernia that had increased in size from imaging 8 yrs ago. EGD showed a very large hiatal hernia containing the fundus, cardia and body of the stomach. A large, polypoid, ulcerated, partially circumferential mass with no bleeding was seen in the gastric body within the hiatal hernia. Multiple biopsies were taken with cold forceps. Biopsy showed malignant spindle cell neoplasm. Immunohistochemical staining was highly suspicious for synovial sarcoma. FISH study was positive for SS18 (SYT) gene rearrangement, which was consistent with a diagnosis of Synovial Sarcoma. Staging scans showed no evidence of metastatic disease. She underwent near total gastrectomy and primary hiatal hernia repair. Surgical pathology showed a 9.5 cm spindle cell, histologic grade 3, synovial sarcoma. Resection margins were negative for tumor and there was no lymphovascular or omental involvement. She received no adjuvant therapy, and there has been no evidence of local recurrence or distant metastasis for 5 months after surgery. Oncology recommends serial surveillance imaging and EGD at 1 year. DISCUSSION: Primary gastric SS is rare and difficult to diagnose. It is important to distinguish from other common GI mesenchymal tumors, such as GIST, leiomyoma, leiomyosarcoma and schwannoma. Immunohistochemical staining and molecular analysis are useful tools. Much of the management is guided by case reports. The mainstay of treatment for gastric SS is surgical resection. Data on the role of adjuvant radiation or chemotherapy is sparse. Based on the available data, size greater than 5cm have a high rate of recurrence. However, given the small number of cases, prognosis of gastric SS remains unclear. The rare diagnosis of primary gastric SS makes our case unique. Currently, very few cases of gastric SS exist in the literature and more data is necessary to understand the natural history of this disease.Figure 1.: Gastric Mass seen on EGD.Figure 2.: H&E: Momomorphic cellular spindle cell neoplasm infiltrating the stomach wall extending into mucosa. Arrows point to the residual gastric foveolar glands. There is background acute inflammation caused by erosion of the lesion in the stomach.Figure 3.: Immunohistochemical stain : Tumor cells display strong patchy CK7 and diffuse TLE1 positivity. A FISH study demonstrates SS18 gene rearrangement supporting synovial sarcoma diagnosis (not shown).

S2918 Giant Paraesophageal Hernia and Gastric Volvulus: An Uncommon Etiology of Vomiting and Upper Gastrointestinal Bleeding

INTRODUCTION: Paraesophageal hiatal hernia is a rare type of hiatal hernia, which occurs mostly in the elderly population after the age of 70, and accounts for less than 5% of all hiatal hernias. Here we report a rare case of a large paraesophageal hiatal hernia and gastric volvulus as an uncommon cause of vomiting and upper gastrointestinal bleeding. CASE DESCRIPTION/METHODS: A 46-year-old female with a past medical history of anemia and GERD presents with one day history of coffee ground emesis and melena. She has no history of previous gastrointestinal bleeding and denies NSAID use. She has been off PPI agents for one year due to the improvement of acid reflux disease after weight loss of 40 lbs. Etiology of anemia was not found during the previous GI workup including an upper endoscopy completed locally. Upon presentation, her hemoglobin was checked low at 9.3 g/dl from her baseline of 11.0 g/dl. She underwent a repeat upper endoscopy which revealed a large paraesophageal hernia (7 cm) with multiple linear erosions/ulcerations, suggestive of Cameron's lesions. The insufflation of the stomach was abnormal, with a distorted antrum located at an eccentric angle concerning for gastric volvulus. Further workup with computerized tomography (CT) scan of the chest and abdomen showed findings of a large type 3 hiatal hernia with organoaxial volvulus, and no evidence of ischemia or obstruction. She subsequently underwent laparoscopic repair of her paraesophageal hernia and Nissen fundoplication with resolution of anemia after the surgery. DISCUSSION: Paraesophageal hernia with gastric volvulus is a rare entity that can manifest with vomiting due to partial or complete gastric outlet obstruction, and gastrointestinal bleeding due to mucosal ischemia or Cameron's lesions. It is critical for gastroenterologists to recognize paraesophageal hiatal hernias during upper endoscopy evaluation, due to its association with gastric volvulus leading to incarceration and life-threatening strangulation. Emergency surgery is required for acute ischemic gastric volvulus. Otherwise, elective surgery can be offered to symptomatic patients and laparoscopic surgery is the mainstay of treatment approaches.Figure 1.: Giant Paraesophageal hiatal hernia: Retroflexion (A) and forward view (B) revealed giant hiatal hernia with Cameron lesions. C: Chest/abdominal CT confirmed large type 3 paraesophageal hernia with gastric volvulus.

Robotic Fundoplication for Large Paraesophageal Hiatal Hernias.

Purpose:Laparoscopic fundoplication is now a cornerstone in the treatment of gastro-esophageal reflux disease (GERD) with sliding hernia. The best outcomes are achieved in those patients who have some response to medical treatment compared to those who do not. Robotic fundoplication is considered a novel approach in treating GERD with large paraesophageal hiatal hernias. Our goal was to examine the feasibility of this technique.Methods:Seventy patients (23 males and 47 females) with mean age 64 y old (22–92), preoperatively diagnosed with a large paraesophageal hiatal hernia, were treated with a robotic approach. Biosynthetic tissue absorbable mesh was applied for hiatal closure reinforcement. Fifty-eight patients underwent total fundoplication, 11 patients had partial fundoplication, and one patient had a Collis-Nissen fundoplication for acquired short esophagus.Results:All procedures were completed robotically, without laparoscopic or open conversion. Mean operative time was 223 min (180–360). Mean length of stay was 38 h (24–96). Median follow-up was 29 mo (7–51). Moderate postoperative dysphagia was noted in eight patients, all of which resolved after 3 mo without esophageal dilation. No mesh-related complications were detected. There were six hernia recurrences. Four patients were treated with redo-robotic fundoplication, and two were treated medically.Conclusions:The success of robotic fundoplication depends on adhering to a few important technical principles. In our experience, the robotic surgical treatment of gastroesophageal reflux disease with large paraesophageal hernias may afford the surgeon increased dexterity and is feasible with comparable outcomes compared with traditional laparoscopic approaches.

Laparoscopic gastric fundus tamponade: a novel adaptation of the Toupet fundoplication for large paraesophageal hernia repair.

Laparoscopic repair of large paraesophageal hiatal hernia with defects too large to close primarily or greater than 8cm is technically challenging. The ideal repair remains unclear and is often debated. Utilizing the gastric fundus as an autologous patch to obliterate and tamponade large hiatal defects may offer a new solution. The aim of this study was to evaluate the short-term outcomes following partial posterior fundoplication with gastric fundus tamponade. Retrospective chart review and prospective patient follow up was conducted on patients who underwent laparoscopic hiatal hernia repair between 2015 and 2019 by a single surgeon. Basic demographics, pre-operative diagnoses, operative technique, and clinical outcomes were recorded. Fifteen patients underwent the described technique for repair of large paraesophageal hiatal hernia. All procedures were completed laparoscopically with a short post-operative length of stay (mean of 3days) and no 30-day readmissions. The majority of patients reported resolution of their pre-operative symptoms. Only one patient required surgery for emergent indications and the same patient was the only mortality in the study, which was secondary to respiratory failure, necrotizing pneumonia, and sepsis as a result of gastric volvulus and obstruction. Utilizing the gastric fundus as an autologous patch to repair large hiatal hernia may be a safe and efficacious solution with good short-term outcomes. However, further studies should be conducted to elucidate long-term results.

Assessment of short-term outcome with TiO2 mesh in laparoscopic repair of large paraesophageal hiatal hernias

BackgroundLaparoscopic large para-oesophageal hiatal hernia (LPHH) repair using mesh reinforcement significantly reduces postoperative recurrence rates compared to conventional suture repair, especially within short follow-up times. However, the ideal strategy for repairing LPHH remains disputable because no clear guidelines are given regarding indications, mesh type, shape or position. The aim of this study was to survey our short-term results of LPHH management with a biosynthetic monofilament polypropylene mesh coated with titanium dioxide to enhance biocompatibility (TiO2Mesh™).MethodsA retrospective study was performed at Ramon y Cajal University Hospital, Spain from December 2014 to October 2018. Data were collected on 27 consecutive patients with extensive hiatal hernia defects greater than 5 cm for which a laparoscopic repair was performed by primary suture and additional reinforcement with a TiO2Mesh™. Study outcomes were investigated, including clinical and radiological recurrences, dysphagia and mesh-related drawbacks.ResultsTwenty-seven patients were included in our analysis; 10 patients were male, and 17 were female. The mean age was 73 years (range, 63–79 years). All operations were performed laparoscopically. The median postoperative hospital stay was 3 days. After a mean follow-up of 18 months (range, 8-29 months), only 3 patients developed clinical recurrence of reflux symptoms (11%), and 2 had radiological recurrences (7%). No mesh-related complications occurred.ConclusionsTiO2Mesh™ was found to be safe for laparoscopic repair of LPHH with a fairly low recurrence rate in this short-term study. Long-term studies conducted over a period of years with large sample sizes will be essential for confirming whether this mesh is suitable as a standard method of care with few drawbacks.

Robotic Fundoplication for Gastroesophageal Reflux Disease and Hiatal Hernia: Initial Experience and Outcome

Gastroesophageal reflux disease, associated with sliding or large paraesophageal hiatal hernia, represents a common clinical presentation. The repair of large paraesophageal hiatal hernias is still a challenge in minimally invasive surgery. Between March 2014 and August 2016, 50 patients (18 males and 32 females) underwent robotic fundoplication (17 sliding and 33 paraesophageal hernias). The mean age of the patients was 58 years. Biosynthetic mesh was used in 28 patients with paraesophageal hernia. The mean operative time was 115 minutes (90-132) in the sliding hiatal hernia group, whereas it was 200 minutes (180-210) in the paraesophageal hiatal hernia group. The mean hospital stay was 36 hours (24-96). Eight patients experienced mild dysphagia which resolved after four weeks. No postoperative dysphagia was recorded at 30-month median follow-up. We experienced one recurrence in the sliding hernia group and two recurrences in the paraesophageal hernia group, with two patients treated robotically. Robotic fundoplication in treating sliding hiatal hernia is feasible and safe but is more challenging in the large paraesophageal group. Improved patient outcomes hinge on the operative technique used and increasing surgeon experience. The increased dexterity that robotic surgery affords enables the esophageal surgeon to more adeptly apply the traditional principles of laparoscopic fundoplication.

Cardiac Tamponade as a Complication of Hiatal Hernia

Hiatal hernia is frequently encountered by gastroenterologists, typically as an incidental finding. Associated gastroesophageal reflux disease may be managed with proton pump inhibitor therapy, although resistant cases may require fundoplication repair of the hernia. We present an unusual case of a patient with paraesophageal hiatal hernia presenting with recurrent NSTEMI and cardiac tamponade secondary to extrinsic cardiac compression by the hernia. Following comprehensive clinical and radiologic evaluation, she underwent nasogastric tube (NGT) decompression of the stomach, which resolved the tamponade. The hernia was subsequently surgically repaired. An 87-year-old female with a history of paraesophageal hiatal hernia, gastroesophageal reflux disease, and coronary artery disease presented to our hospital with severe substernal chest pain. Two years previously, she was hospitalized with an episode of chest pain and elevated troponin caused by cardiac compression secondary to a large paraesophageal hiatal hernia. Vitals were within normal limits on admission. Examination showed a soft, non-distended, non-tender abdomen, with active bowel sounds. A systolic murmur was auscultated throughout the precordium, loudest at the right upper sternal border. Chest computed tomography revealed a large hiatal hernia containing nearly the entire stomach with mass effect on the heart. Echocardiography revealed a large hernia partially effacing the left atrium and left ventricular free wall, compressing the heart, and causing tamponade physiology. Electrocardiogram showed ST segment depression in leads V5 and V6. Relevant initial labs included troponin 2 ng/mL. Shortly after admission, the patient underwent NGT placement with two days of continuous wall suction, which resolved her troponin elevation and ST segment depression, and alleviated her symptoms. She was referred to general surgery and, three days later, underwent a paraesophageal hernia repair with mesh and Toupet fundoplication. She was discharged with cardiology follow up two days later. There are few prior reports of hiatal hernia causing tamponade post coronary bypass surgery or failed hernia repair. To our knowledge, this is the first case reported without preceding surgery. We recommend that extrapericardial pathology be considered in tamponade patients with coexistent hiatal hernia, and that cardiac risk be accounted for in the decision whether or not to surgically repair a large or expanding hiatal hernia. 2636 Figure 1. Chest CT scan obtained prior to nasogastric tube decompression shows dilation of the stomach with compression of the heart.2636 Figure 1. Chest CT scan obtained prior to nasogastric tube decompression shows dilation of the stomach with compression of the heart.

Para-Esophageal Hiatal Hernia with entire Stomach within the Chest

Clinical Image: Roemheld syndrome (RS), also known as gastric-cardia, is a syndrome where abnormalities in the gastrointestinal tract are found to be associated with cardiac symptoms like arrhythmias and palpitations, in the context of a normal cardiac workup. The underlying mechanism is that the mechanical pressure from GI organs on the heart reduces the cardiac filling, as well as causes compression of the vagus nerve leading to rhythm abnormalities. This case is regarding a 49 years old female with a large para-esophageal hiatal hernia (Figure 1 and 2) who developed paroxysmal atrial fibrillation. Patient was treated temporarily with rate control medications and anticoagulation and finally underwent hernia repair with complete resolution of atrial fibrillation

Long-term results and complications related to Crurasoft® mesh repair for paraesophageal hiatal hernias.

The application of mesh-reinforced hiatal closure has resulted in a significant reduction in recurrence rates in comparison with primary suture repair. However, the use of meshes has not completely extended in all the cases of large paraesophageal hiatal hernias (LPHH) due to the complications related to them. The aim of this study is to present our long-term results and complications related to Crurasoft® mesh (Bard) for the treatment of LPHH. From January 2004 to December 2014, 536 consecutive patients underwent open or laparoscopic fundoplication for gastroesophageal reflux disease or LPHH at Ramón y Cajal University Hospital. Primary simple suture of the crura and additional reinforcement with a Crurasoft® mesh (Bard) was performed in 93 patients (17.35%). Radiologic hiatal hernia recurrence and mesh-related complications were investigated. Of the 93 patients undergoing mesh repair, there were 28 male and 65 female with a mean age of 67.27years (range 22-87years). Laparoscopic surgery was attended in 88.2% of the cases, and open surgery in the rest 11.8%. Mean operative time was 167.05min (range 90-370min). Median postoperative stay was 4.79days (range 1-41days). Conversion rate was 8.53% (7 patients). Intraoperative complications were described in 10.75% (10 patients), but all of them, except in one case, could be managed laparoscopically. Overall postoperative complications rate was 28%. Early postoperative complications occurred in 11 patients (12%), respectively, for grades 2 (6 cases), 3b (1 case) and 5 (4 cases) according to the Clavien-Dindo classification. Late postoperative complications occurred in 15 patients (16%), respectively, for grades 1 (7 cases), 2 (2 cases), 3b (5 cases) and 5 (1 case) according to the Clavien-Dindo classification. Thirty day-mortality rate was 4.3%. Mortality rate specific associated with the mesh was 1%. Reoperation rate was 5.4%. After a median follow-up of 76.33months (range 3-130months), 8 patients (9%) developed a recurrent hiatal hernia. Mesh was removed in three cases (3.22%). In our experience, the recurrence rate in patients with a Crurasoft® (Bard) is acceptable. However, the rate of postoperative complications and mortality is excessive. The use of meshes in the hiatus keeps on being controversial due to the severe complications related to them. It would be advisable to compare our results in the non-mesh group in terms of recurrences and complications, to determine if meshes in the hiatus should be given in these patients due to its high rate of complications.

Case report: Type IV paraesophageal hernia

This case report is about a 43 year old man, who presented with a large paraesophageal hiatal hernia. Hiatal hernias are common and often asymptomatic. However, this patient’s hernia was caused by a large defect in his diaphragm, into which his stomach, multiple loops of small bowel and even part of his colon had herniated, causing recurrent gastric obstruction. While this is a condition that develops slowly, over time in most patients, this case of hiatal hernia likely results from a congenital defect, given his relatively young age, the size of the defect and his associated anatomical abnormalities. This report details his presentation and surgical repair, complemented with corresponding images.

Short-term results for laparoscopic repair of large paraesophageal hiatal hernias with Gore Bio A® mesh

BackgroundThe application of mesh-reinforced hiatal closure has resulted in a significant reduction in recurrence rates in comparison with primary suture repair. One of the most debated issues is the risk of complications related to the use of the prosthesis, such as esophageal erosion and postoperative dysphagia. The aim of this study is to present our short-terms results in the treatment of laparoscopic paraesophageal hiatal hernia (LPHH) with a synthetic polyglycolic acid:trimethylene carbonate mesh (Gore Bio A®). MethodsFrom January 2011 to December 2012, 10 patients with large paraesophageal hiatal hernias and hiatal defect over 5 cm were included. Primary simple suture of the crura and additional reinforcement with a Gore Bio A® mesh was performed. Hiatal hernia or gastroesophageal reflux disease (GERD) symptoms recurrence, dysphagia and mesh-related complications were investigated. ResultsOf the 10 patients undergoing mesh repair, there were 7 women and 3 men with a mean age of 65.5 years. All operations were completed laparoscopically. Median postoperative stay was 3 days. After a median follow-up of 20.3 months, one patient developed a recurrent hiatal hernia (10%). There were no mesh-related complications. ConclusionsThe use of Gore Bio A® mesh for the laparoscopic repair of large paraesophageal hiatal hernias is safe and with a reasonably low recurrence rate in this short-term study. Additional long-term studies with ample numbers carried out for years will be necessary to see if this synthetic mesh is not only safe but also successful in the prevention of recurrences.