Diaphragmatic Crura Research Articles

Prediction of high-flow nasal cannula failure in patients with acute respiratory failure by measuring the cross-sectional area of the diaphragmatic crus and ROX index

The delayed prediction of high-flow nasal cannula (HFNC) failure is associated with poor prognosis in patients with acute respiratory failure (ARF) treated with HFNCs. This study aimed to identify the early predictors for requiring mechanical ventilation (MV) in ARF patients treated with HFNCs. This was a single-center retrospective observational study based on ARF patients older than 18 years, treated with HFNC, and had chest computed tomography (CT) scans performed in the emergency department (ED) of a tertiary hospital between July 2018 and June 2020. The demographic and laboratory data were collected, and the cross-sectional area (CSA) of the diaphragmatic crus was measured on the chest CT scan. Two hundred and twenty-nine patients with ARF (92 females and 137 males) were treated with HFNCs during the study period and included in this study. Twenty-five female patients (27.17%) and 32 male patients (23.36%) required subsequent intubation and MV and were categorized as HFNC failures. Their respiratory rate-oxygenation (ROX) indexes were acquired at two hours, and the average CSA of the diaphragmatic crura was integrated to analyze the predictive power, which showed good predictive accuracy in both gender groups (area under the receiver operating characteristic curves (AUROC) for females, 0.778, and males, 0.782). The optimal ROC curve cutoff point for the average CSA of the diaphragmatic crus was estimated to be 1.48 cm2 in female patients and 1.64 cm2 in male patients. Altogether, these results indicated that the CSA measurement of the diaphragmatic crus on CT in ARF patients might help predict the risk of HFNC failure.

EGS P26 Audit of outcomes of Hiatus hernia repairs done as an emergency procedure in a tertiary care center

Abstract Background Hiatus hernia is the abnormal protrusion of stomach and /or intra-abdominal contents into the chest via a widened space between the diaphragmatic crura. Patients with hiatus hernias can present with a wide spectrum of symptoms ranging from a mild dyspepsia to acute presentations such as obstruction and strangulation. The recurrence rate, morbidity and mortality in patients requiring emergency surgeries in such acute presentations has been reported to be significantly high compared to that of elective hernia repair. We aim to assess the outcomes of hiatus hernia repairs done as an emergency surgery in a tertiary care center. Methods A retrospective study of all emergency hiatus hernia repairs done over a span of 10 years was done. Demographic details, BMI, smoking status, past medical history, method of diagnosis and management, duration of inpatient stay and the follow up was collected. The primary outcome of the study was 30 day mortality rate. Secondary outcomes were further surgeries during the same admission and recurrence rate. Results A total of 25 patients were identified to undergo an emergency hiatus hernia repair. 1 patient was excluded due to transfer to a different health board. 62.5%(n=15) of the patient were females. Duration of stay as inpatient ranged between 3 and 138 days. Of note, there were no deaths during the stay or recorded mortality by 30 days in the cohort. Conclusions The mortality rate in our unit is low in comparision with reported studies in literature.

OGC P49 Case report: Ivor Lewis oesophagectomy requiring one lung ventilation in a patient with a previous laryngectomy

Abstract Background A 68 year old patient with squamous cell carcinoma (SCC) of lower oesophagus (T3N0M0) presented for Ivor Lewis oesopphagectomy (ILO) following neoadjuvant chemoradiotherapy. Four years previously the patient had undergone total laryngectomy, radical right neck dissection with right pectoralis major flap and bilateral adjuvant radiotherapy for hypopharyngeal SCC (pT3N2bM0). A tracheal stoma was present with speaking valve in-situ. An ILO was planned requiring one lung ventilation (OLV) to facilitate surgical access. In our institution, OLV is routinely achieved via double lumen endotracheal tube (DLT), although endobronchial blocker through single lumen endotracheal tube or laryngeal mask airway and endobronchial intubation with a single lumen tube are potential options. Post laryngectomy the method used for lung isolation is limited and care must be taken not to traumatise the stoma site or surrounding tissue. Additionally, the angulation formed by the trachea and stoma mean a DLT is often not suitable while specific double lumen tracheostomy tubes may have too great a diameter for a small stoma. Surgically, close relations of the tumour to gastro-oesophageal junction, left diaphragmatic crus and descending thoracic aorta made suitability for resection uncertain, despite two negative staging laparoscopies. We describe the anaesthetic and surgical management of this interesting case. Methods General anaesthesia was delivered via an intravenous induction and maintenance was with sevoflurane. Airway management included bag mask ventilation with a neonatal facemask followed by placement of an 8mm reinforced endotracheal tube through the tracheal stoma. Prior to right thoracotomy a right sided 9Fr VivaSight endobronchial blocker (Ambu) was placed under direct vision using a single use Ambu aScope™ 4 Broncho Slim fibreoptic bronchoscope. OLV was successful using this method; SpO2 ≥96% (FiO2 0.6) and peak inspiratory pressure 18–20cmH2O-1. Analgesia comprised intrathecal morphine, right erector spinae plane local anaesthetic block and infusion catheter and morphine PCA. Abdominal phase was undertaken laparoscopically. The hiatus was noted to be fibrotic following chemoradiotherapy and a small capsular breach of the left lobe of liver occurred, controlled with Surgiflo (Ethicon). A right thoracotomy was performed through the 6th intercostal space. Right lung was deflated and surgical access was adequate. OrVil (Covidien – Medtronic) anastomosis was attempted but the anvil was unable to pass through the pharynx, therefore a purse string applicator was applied and OrVil staple used. The left pleura was also breached during dissection. One left and two right chest drains were placed. Results Postoperatively, analgesia was adequate and the patient did not require any cardiovascular or respiratory support. However, on first postoperative day it was noted that the speaking valve was not functioning causing significantly hoarse voice. A valve leak was detected and though hard to know the precise cause, it was assumed that it had become dislodged via either anaesthetic procedures, surgical handling or a combination. Despite some improvement in the symptoms over the first post-operative week, the patient also experienced airway soiling on commencing oral intake and after review by ENT a new valve was successfully sited and all symptoms resolved. Although a minor and easily rectifiable complication, the ‘loss of voice’ was very distressing for the patient. The patient had an otherwise uneventful postoperative course and was discharged home on day-11. Clinic review at six weeks revealed the patient had made a complete recovery and had resumed all normal activities. Histology showed scattered small foci of moderately differentiated SCC infiltrating the muscularis propria (stage ypT2). Longitudinal margins were clear of both dysplasia and malignancy. There was no evidence of lymphatic, venous or perineural invasion. One of 12 lymph nodes showed metastatic SCC. Adjuvant course of Nivolumab immunotherapy is currently planned. Conclusions We have presented an unusual case of previous laryngectomy plus requirement for OLV for ILO. The use of an endobronchial blocker via a reinforced endotracheal tube has been shown to be a successful airway management strategy. Speaking valve displacement and/or malfunction is a potential complication in such cases and should form part of preoperative counselling. Close liaison between surgical, anaesthetic and ENT teams is essential in the management of complex and unusual cases and, as we have demonstrated, strong teamwork leads to successful outcomes for patients.

Minimally invasive fundoplication for gastroesophageal reflux disease

: Gastroesophageal reflux disease (GERD), is one of the most common gastrointestinal diseases treated by physicians, with most patients being successfully managed medically. Patients with refractory or persistent disease may be treated using minimally invasive surgical techniques. Patients may also elect for surgical treatment of GERD to avoid the potentially deleterious effects of long term antisecretory [proton pump inhibitor (PPI)] use. Preoperative workup is critical to establish the presence of GERD, to rule out concomitant or alternative pathology, and to document the presence or absence of coexisting esophageal motility disorders. When the technical tenants are respected, laparoscopic fundoplication is a safe and effective treatment of GERD. The general principles involve adequate mobilization of the gastroesophageal junction and gastric fundus, high mediastinal dissection, and demonstration of adequate intraabdominal esophageal length. This is followed by secure closure of the diaphragmatic crura, as well as creation of a fundoplication to reinforce the typically hypotonic lower esophageal sphincter. The type of fundoplication used is typically influenced by preoperative manometry, presence of dysphagia, and patient age. Long term symptomatic relief, without the need for antisecretory medications, is achievable for the majority of properly selected patients. Postoperative morbidity and mortality are uncommon following laparoscopic treatment of GERD. The following manuscript describes our method for performance of both laparoscopic complete and partial fundoplication.

Comparative Outcomes of Anti-Reflux Surgery in Obese Patients with Gastroesophageal Reflux Disease1

IntroductionRoux-en-Y gastric bypass (RYGB) has been the preferred operation for obese patients with gastroesophageal reflux disease (GERD); however, some patients are hesitant to undergo bypass. Obese patients have a multifactorial predisposition to GERD, including lower esophageal sphincter (LES) dysfunction and aberrant pressure gradients across their diaphragmatic crura. Among non-obese patients, anti-reflux surgery (ARS) with hiatal hernia (HH) repair and LES augmentation has shown excellent long-term results. We aimed to determine whether patient satisfaction and GERD recurrence differed between obese and non-obese patients who underwent ARS. MethodsReview of patients who underwent ARS between January 2012 and June 2021 was performed. Perioperative and postoperative characteristics were compared across three BMI groups: BMI < 30 kg/m2, 30 kg/m2 ≤ BMI < 35 kg/m2, and BMI ≥ 35 kg/m2. ResultsFour-hundred thirteen patients were identified, of which 294 (71.1%) had BMI < 30 kg/m2, 87 (21.1%) were 30 kg/m2 ≤ BMI < 35 kg/m2, and 32 (7.7%) had a BMI ≥ 35 kg/m2. Patients with BMI ≥ 35 kg/m2 had higher preoperative manometric and EndoFLIP™ intra-balloon pressure at the LES than those with lower BMIs. This value was increased to a similar level throughout ARS across the three cohorts. Post-operative GERD-specific satisfaction was similar across the three cohorts, as were rates of postoperative reflux and hiatal hernia recurrence on barium swallow; rates of reoperation were low. ConclusionsARS with HH repair and LES augmentation may be appropriate for select patients across a range of BMIs, including those with a BMI ≥ 35 kg/m2 who are hesitant to undergo RYGB.

V-046 LAPAROSCOPIC SURGICAL MANAGEMENT OF AN HUGE DIAPHRAGMATIC HERNIA

Abstract Introduction Diaphragmatic hernias (DH) in most cases are the consequence of a diaphragmatic trauma causing a missed injury. Less frequently, DHs are congenital. Case Presentation A 52 years old patient came to our attention due to a worsening severe dyspnea. A chest CT scan were performed, showing an extensive left-side DH. We present the video of the surgical procedure. The patient mentioned a severe left hemithorax trauma occurred almost twenty years before due to a motorbike accident. Possibly, a diaphragmatic injury was not diagnosed at the time. Subsequently, a Covid-19-related chronic cough resulting in a persistently increased intra abdominal pressure may have caused the herniation of abdominal viscera. The surgical procedure was laparoscopic. The whole greater omentum and most of the transverse colon were herniated and, after a thorough adhesiolysis between the herniated tissues and the left diaphragmatic crus, the DH was reduced. It was confirmed the presence of a 8 cm defect of the left hemidiaphragm, it was repaired with a absorbable continuous suture. A 08×10 cm Bio-A patch was positioned over. The herniated tissues were meticulously examined and showed no signs of damage. Conclusions Diaphragm's injuries are unfortunately difficult to diagnose in an acute setting, thus remaining often unbeknownst to the surgeon. Some patients never develop any symptoms because of such missed diaphragmatic injuries. Some others instead, due to an increase in the intra abdominal pressure, may develop symptomatic DHs. In the latter case, surgical management becomes mandatory.

GASTROESOPHAGEAL REFLUX DISEASE AND PHRENIC NERVE INJURY: A RETROSPECTIVE ANALYSIS OF 518 PATIENTS WITH CLINICALLY SIGNIFICANT DIAPHRAGM PARALYSIS

GASTROESOPHAGEAL REFLUX DISEASE AND PHRENIC NERVE INJURY: A RETROSPECTIVE ANALYSIS OF 518 PATIENTS WITH CLINICALLY SIGNIFICANT DIAPHRAGM PARALYSIS

Normal Adrenal Gland Thickness on Computed Tomography in Nepalese Adults Presenting to Tertiary Referral Hospital

Introduction: Various benign and malignant conditions may alter the morphology and dimensions of adrenal gland. There is limited data on normal dimensions of adrenal gland in Nepalese population. Our study aimed to find out the normal adrenal gland thickness measurement. Methods: It is a descriptive cross-sectional study conducted in a tertiary referral hospital over a period of one year. Ethical approval was taken from the institutional review committee. All the patients referred to Radiology Department for abdominal Computed Tomography evaluation unrelated to adrenal pathology were included. We measured maximum thickness of adrenal limb and body along with diaphragmatic crus on either side. Results: Mean adrenal gland thickness of right medial limb, right lateral limb and body was 3.57 ± 0.87 mm, 3.33 ± 0.79 mm, 5.69 ± 1.19 mm respectively. Similarly, mean adrenal gland thickness of left medial limb, left lateral limb and body was 4.16 ± 0.9 mm, 3.84 ± 0.85 mm, 6.07 ± 1.35 mm respectively. On comparison of medial and lateral limbs to ipsilateral diaphragmatic crus thickness, 298 (99.3%) and 296 (98.6 %) cases had ratio less than one on right side and 280 (93.3%) and 268 (89.3 %) cases had ratio less than one on left side. Conclusions: Our study has established the reference measurement of normal adrenal gland thickness in Nepalese adult population. Similarly, the ratio of adrenal limb thickness to ipsilateral diaphragmatic crus thickness can also be a helpful parameter for predicting the normality.

Dunbar Syndrome Treated by Laparoscopic Surgery

Median arcuate ligament syndrome (MALS) or Dunbar syndrome is a rare condition resulting from compression of the celiac trunk by the median ligament at the level of the diaphragmatic crus. Abdominal tomography contributes to the diagnosis by demonstrating the level of obstruction and the presence of collateral arterial circulation in the gastroduodenal region, typical of the disease in chronic cases. The therapeutic options, although few, find in the laparoscopic surgical treatment the best option for releasing the muscle fibers in the arcuate ligament region. We report a rare case of a 38-year-old woman diagnosed with MALS successfully treated laparoscopically.

536. PREVENTING ESOPHAGO-GASTRIC ANASTOMOTIC LEAKS; THE ROLE OF LOAD-BEARING SUTURES

Abstract The leak rate of esophago-gastric anastomosis remains at 10 to 30% despite technological advances and robotic techniques. From the moment of recovery from anaesthesia, the anastomosis is subjected to incessant distraction by the diaphragm with each inspiratory effort. It was hypothesized that eliminating all possible tension on the anastomosis during the vulnerable healing phase, by employing tension-bearing sutures between conduit and pleura, would provide the greatest opportunity for success. This study evaluated such a strategy. A prospectively maintained database of all esophagectomies performed over a 21-year period, was interrogated for the anastomotic leak rate following the introduction of a tension-elimination anastomotic technique. This consisted of securing the gastric conduit to the mediastinal pleura using load-bearing sutures inserted obliquely. When these were secured, the anastomosis became floppy, and remaining so throughout the vulnerable phase of healing, when collagenase digestion reduces anastomotic tensile strength by two-thirds. All patients had a contrast study performed between day 5 to 7 and all intra-hospital mortalities underwent autopsy to determine the cause of death. Clinical, radiological and autopsy leaks were recorded. There were 145 intra-thoracic esophago-gastric anastomoses created in 143 patients (two patients required salvage re-resection for tumour recurrence); of which 77% were male, and 65.3% were for adenocarcinoma. Fifty-five percent were stapled and 45% were hand-sewn. There was only 1 confirmed leak during the study period and 1 patient died from a mediastinal haemorrhage, which at autopsy was considered to possibly be the result of sepsis as a result of an occult anastomotic leak. The low anastomotic leak-rate is attributed to the protective effect of the load-bearing sutures; preventing any traction on the anastomosis, the most incessant source of which is the piston-like action of the diaphragm and the gripping of the diaphragmatic crura. It is intuitive that eliminating all tension during the most vulnerable phase of healing would also reduce any risk posed by minor impairments of blood supply or technical imperfections of anastomotic technique, facilitating anastomotic success.

Renal Artery Stenosis due to Entrapment

Common etiologies of renovascular occlusive disease include atherosclerosis disease, developmental fibrotic conditions such as fibromuscular dysplasia, and vasculitis. Extrinsic compression of the renal artery is a rarely reported phenomenon but can lead to similar clinical manifestations. We report recent experience with 2 patients who presented with extrinsic renal artery compression due to entrapment. Diagnosis was made with a constellation of findings on computed tomography angiography, dynamic duplex sonography, and catheter angiography. Both patients had hypertension and 1 had downstream subsegmental renal infarcts. The patients, both with right-sided renal artery entrapment, were treated with open surgical decompression. Exposure was achieved via extended Kocher maneuver followed by mobilization of the right kidney and, in 1 patient, detachment of the right lobe of liver to allow circumferential exposure of the proximal right renal artery to the aorta. All entrapping tissue was circumferentially released. Both operations were uncomplicated. Intraoperative sonography was used to confirm luminal patency of the released segments. Follow-up of renal artery duplex in both patients demonstrated resolution of dynamic compression. Renal artery peak systolic velocity and accelerations indices were all within normal limits. In both patients, improvement in blood pressure control was noted and discontinuation of anticoagulation was possible in the patient who had recurrent episodes of renal infarct. Extrinsic compression of renal artery by diaphragmatic crura is rare but should be considered in younger patients or otherwise any patients with no vascular risk factors when renovascular hypertension workup yields no demonstrable intrinsic disease. A high index of suspicion should be raised when an anomalously high origin of the renal artery or proximity to the diaphragmatic crura is seen on cross-sectional imaging. Work-up should include dynamic imaging to assess compression of renal arteries during expiration. Open surgical or laparoscopic decompression of the involved renal arteries can be curative.

Comparing anterior gastropexy to no anterior gastropexy for paraesophageal hernia repair: a study protocol for a randomized control trial

BackgroundMore than half of patients undergoing paraesophageal hernia repair (PEHR) will have radiographic hernia recurrence at 5 years after surgery. Gastropexy is a relatively low-risk intervention that may decrease recurrence rates, but it has not been studied in a prospective manner. Our study aims to evaluate the effect of anterior gastropexy on recurrence rates after PEHR, compared to no anterior gastropexy.MethodsThis is a two-armed, single-blinded, registry-based, randomized controlled trial comparing anterior gastropexy to no anterior gastropexy in PEHR. Adult patients (≥18 years) with a symptomatic paraesophageal hernia measuring at least 5 cm in height on computed tomography, upper gastrointestinal series, or endoscopy undergoing elective minimally invasive repair are eligible for recruitment. Patients will be blinded to their arm of the trial. All patients will undergo laparoscopic or robotic PEHR, where some operative techniques (crural closure techniques and fundoplication use or avoidance) are left to the discretion of the operating surgeon. During the operation, after closure of the diaphragmatic crura, participants are randomized to receive either no anterior gastropexy (control arm) or anterior gastropexy (treatment arm). Two hundred forty participants will be recruited and followed for 1 year after surgery. The primary outcome is radiographic PEH recurrence at 1 year. Secondary outcomes are symptoms of gastroesophageal reflux disease, dysphagia, odynophagia, gas bloat, regurgitation, chest pain, abdominal pain, nausea, vomiting, postprandial pain, cardiovascular, and pulmonary symptoms as well as patient satisfaction in the immediate postoperative period and at 1-year follow-up. Outcome assessors will be blinded to the patients’ intervention.DiscussionThis randomized controlled trial will examine the effect of anterior gastropexy on radiographic PEH recurrence and patient-reported outcomes. Anterior gastropexy has a theoretical benefit of decreasing PEH recurrence; however, this has not been proven beyond a suggestion of effectiveness in retrospective series. If anterior gastropexy reduces recurrence rates, it would likely become a routine component of surgical PEH management. If it does not reduce PEH recurrence, it will likely be abandoned.Trial registrationClinicalTrials.gov NCT04007952. Registered on July 5, 2019.

Effect of laparoscopic angle of His reconstruction in the treatment of patients with gastroesophageal reflux disease and hiatal hernia.

Effect of laparoscopic angle of His reconstruction in the treatment of patients with gastroesophageal reflux disease and hiatal hernia.

Inspiratory and expiratory CT analyses of the diaphragmatic crus in chronic obstructive pulmonary disease

PurposeThis study aimed to investigate the association between the results of pulmonary function tests (PFTs) in patients with chronic obstructive pulmonary disease (COPD) and the size of their diaphragmatic crus (DC) using inspiratory and expiratory CT.Materials and methodsThirty-three patients who underwent inspiratory and expiratory CT and PFTs between July and December 2019 were studied retrospectively. The short axis, long axis, and cross-sectional area (CSA) of the bilateral DC were measured, and the percentage change of the DC after expiration (% change of DC) in the size was calculated. The correlation between the results of the PFTs (forced expiratory volume in 1 s [FEV1], FEV1/forced vital capacity [FVC], and percent predicted FEV1 [%FEV1]) and the size and % change of DC was statistically analyzed.ResultsSignificant correlations were observed between the short axis of the right and left DC at expiration and PFTs (FEV1, r = –0.35, –0.48, p = 0.04, .007; FEV1/FVC, r = –0.52, –0.65, p = 0.002, < .001; %FEV1, r = –0.56, –0.60, p < 0.001, < 0.001; respectively), between the CSA of the right DC at expiration and PFTs (FEV1/FVC, r = –0.42, p = 0.01; %FEV1, r = –0.41, p = 0.017; respectively), and between the % change of the short axis of the left DC and the CSA of the left DC and PFTs (FEV1, r = 0.64, 0.56, p < 0.001, .001; %FEV1, r = 0.52, 0.51, p = 0.004, 0.004; respectively). The smaller the short axis of the DC and CSA at expiration and the larger the % change in DC of the CSA, the lower the airflow limitation.ConclusionThere were significant correlations between airflow limitation and the short axis of the bilateral DC at expiration, and the % change in the DC of the CSA. Certain CT measurements of the DC may reflect airflow limitation in patients with COPD.

Extragonadal germ cell tumor presenting with spinal cord compression: a case report and literature review

BackgroundYolk sac tumor or endodermal sinus tumor is an uncommon malignant germ cell neoplasm. This tumor usually presents in childhood or young adulthood as a testicular or ovarian mass. Extragonadal sites such as mediastinal, intracranial, and sacrococcygeal have been described. A review of the literature revealed limited related cases. The clinical presentation, radiographic characteristics, operative findings, and patient outcomes are discussed.Case presentationWe report the occurrence of a primary paraspinal germ cell tumor in a 28-month-old boy who presented with thoracic spinal cord compression. The patient presented with pain, weakness, paraplegia, and bowel and bladder disturbances.MRI was done and showed a retroperitoneal and paravertebral mass invading the left diaphragmatic crus, the lateral neural foramen, and the posterior paravertebral muscles. Morphologic and immunohistochemical features were consistent with a germ cell tumor, namely an endodermal sinus tumor (yolk sac) of the epidural area. The final diagnosis was determined to be stage IV extragonadal germ cell tumor. The patient underwent emergency surgery consisting of T10–12 laminectomy and epidural mass resection with the release of the spinal cord compression and received chemotherapy consisting of cisplatin, bleomycin, and etoposide. After six cycles of chemotherapy, follow-up MRI showed complete resolution of the tumor. The patient has been in complete remission 16 years from his initial diagnosis. He still, however, has mild residual weakness in both lower extremities and some detrusor-sphincter dyssynergia.ConclusionExtragonadal germ cell tumors presenting with spinal cord compression are rare; however, they should be included in the differential diagnosis of every child younger than 3 years old who does not present with the typical features. Germ cell tumors are sensitive to platinum-based chemotherapy, and surgery should only be performed for spinal cord compression and for obtaining tissue biopsy for a definitive diagnosis. The sooner the decompression is done, the better neurological outcome is achieved. Long-term remission, and possibly cure, can be achieved with a multidisciplinary treatment strategy.

A comprehensive study of the abdominal ganglia part 1: Celiac, phrenic and superior mesenteric ganglia.

Patients with pancreatic cancer, chronic pancreatitis and other abdominal pain syndromes may develop debilitating pain throughout the course of their illness with little to no relief by most conventional methods. While some form of relief is experienced by patients, not all benefit from these procedures and side effects, while transitory in most cases are severe and often not expected. Our aim was therefore to investigate the anatomy surrounding the abdominal sympathetic ganglia, the target for the invasive procedures in an attempt to understand the variations in results. The abdominal cavities of nine individuals were dissected and the ganglia investigated, harvested and histologically and immunochemical stained. The phrenic ganglion was found inconsistently and more often in the left than the right. If present it was located in association with the inferior phrenic artery and often connected to the celiac ganglion. The celiac ganglion was located anterior to the diaphragmatic crus on both sides and specifically posteromedial to the suprarenal gland and superior to the renal artery on the left. On the right it was located posterior to the suprarenal gland and inferior vena cava also superior to the renal vessels. The superior mesenteric ganglion was only positively identified in one individual and was located on the left lateral aspect of the superior mesenteric artery. The blockade procedures for treatment of pain are developed to target the area around the celiac artery where the ganglion is commonly described to be located. However, based on our results of its location and interconnections the ganglion is not located in the targeted area.

Impacts of sleeve gastrectomy on gastroesophageal reflux disease in severely obese Korean patients

Laparoscopic sleeve gastrectomy (LSG) has established popularity as a bariatric and metabolic surgery. However, the incidence of gastroesophageal reflux disease (GERD) following LSG is controversial. This study aims to describe the prevalence of de novo GERD after LSG. A retrospective chart review was performed for 130 patients who underwent a routine endoscopic surveillance before and after LSG between January 2013 and October 2018. The diagnosis of GERD was determined by presence of symptoms, history of PPI treatment, and endoscopic findings. The esophagogastroduodenoscopy (EGD) was performed annually after LSG and/or when the patients complained of severe reflux symptoms. The prevalence of GERD before surgery was 18.5%. At 1 year after LSG, GERD was present in 70 (53.8%) of the 130 patients. GERD consisted of 55 patients with newly developed GERD, and 15 with preexisting GERD. 9 (37.5%) out of pre-existing GERD patients were free of symptoms and abnormal finding at EGD following LSG. During the LSG, 66 (50.8%) patients with hiatal hernia underwent re-approximation of the diaphragmatic crura. There was no significant relationship between hiatal hernia repair and postoperative GERD (p=0.39). Number of patients taking PPI medication before and after LSG were 34 (26.2%) and 49 (37.7%). Out of 56 (43.1%) patients with endoscopic lesions, LA grade A was 31 (23.9%), B=15 (11.5%), C=4 (3.1%), and D=6 (4.6%). In this study, 42.3% (n=55) of total patients developed newly developed GERD, and 7.7% (n=10) had LA grade C or D esophagitis.

Renal Artery Stenosis Due To Entrapment

INTRODUCTION Entrapment of the celiac artery by the median arcuate ligament and diaphragmatic crura is a known clinical entity. There have been rare reports of extrinsic compression of the renal arteries by the diaphragmatic crura leading to secondary renal pathology. METHODS RESULTS Both operations were uncomplicated. At 1month follow-up, renal doppler of both patients demonstrated resolution of dynamic compression of the renal artery. PSV and accelerations indices were all within normal limits. In both patients, improvement in blood pressure control was noted. Discontinuation of anticoagulation was possible in the patient who had recurrent embolic episodes. CONCLUSION Extrinsic compression of renal artery by diaphragmatic crura is rare, but a definite anatomic and clinical entity. Work-up should include dynamic imaging to assess for compression of renal arteries during expiration. Surgical decompression of renal arteries is a viable option. Renal artery entrapment should be included in the differential diagnosis in younger patients with hypertension without demonstrable intrinsic disease, especially when anomalous origin of the renal artery or proximity to the diaphragmatic crura are seen on cross sectional imaging. Entrapment of the celiac artery by the median arcuate ligament and diaphragmatic crura is a known clinical entity. There have been rare reports of extrinsic compression of the renal arteries by the diaphragmatic crura leading to secondary renal pathology. Both operations were uncomplicated. At 1month follow-up, renal doppler of both patients demonstrated resolution of dynamic compression of the renal artery. PSV and accelerations indices were all within normal limits. In both patients, improvement in blood pressure control was noted. Discontinuation of anticoagulation was possible in the patient who had recurrent embolic episodes. Extrinsic compression of renal artery by diaphragmatic crura is rare, but a definite anatomic and clinical entity. Work-up should include dynamic imaging to assess for compression of renal arteries during expiration. Surgical decompression of renal arteries is a viable option. Renal artery entrapment should be included in the differential diagnosis in younger patients with hypertension without demonstrable intrinsic disease, especially when anomalous origin of the renal artery or proximity to the diaphragmatic crura are seen on cross sectional imaging.

Modified side overlap esophagogastrostomy after laparoscopic proximal gastrectomy.

We report a new method of esophagogastrostomy after proximal gastrectomy, side overlap with fundoplication by Yamashita (SOFY) in 2017. Recently, even better treatment results can be obtained by modifying the SOFY method. We describe the technical details of the modified SOFY (mSOFY) after laparoscopic proximal gastrectomy. The stomach was dissected in the short axis direction and the esophagus was dissected in the left and right direction. After the proximal gastrectomy, the bilateral diaphragmatic crus were dissected to enhance gastric elevation. After confirming that the esophagus overlapped more than 5 cm at the center of the remnant stomach (we call it SOFY check), the remnant stomach was suture‐fixed to the dissected diaphragmatic crus. The right wall of the esophageal stump and the remnant stomach were anastomosed using the full length of a 45 mm‐linear stapler. The entry hole was closed in a direction that did not widen the anastomotic hole. Both sides of the esophagus, remnant stomach, and diaphragmatic crus were suture‐fixed on the cranial side 1–2 cm away from the anastomosis. Moreover, the left wall and lower end of the esophagus was suture‐fixed to the remnant stomach. The preserved dorsal esophageal wall is pressed and flattened by pressure from the pseudofornix, which is the reflux prevention mechanism. The mSOFY method had favorable treatment outcomes. In conclusion, mSOFY can be one of the safe and feasible reconstruction methods after laparoscopic proximal gastrectomy.

Modern aspects of diagnosis and surgical treatment of hiatal hernias: Literature Review

Laparoscopic correction is the main method of treating hiatal hernias. However, despite more than thirty years of experience, many issues remain controversial and require compilation and standardization. The authors have analyzed the latest scientific studies and recommendations on the treatment of hiatal hernias with a high level of evidence, which is presented in the form of a review with a comparison of their own experience in surgical treatment of 171 patients operated on for hiatal hernias. The risk of transition of an asymptomatic hiatal hernia to a clinically significant one is 1% per year, while observation, rather than active surgical tactics, is indicated. Only symptomatic hernias are subject to surgical treatment. Surgical intervention should include the following mandatory steps: dissection of the esophagealdiaphragmatic ligament with excision of the hernial sac while protecting the branches of the vagus nerve; dissection of both crura of diaphragm, transhiatal mobilization of the esophagus in the mediastinum to achieve the length of its intraabdominal segment of 2–3 cm; if a short esophagus is suspected, a mandatory step is to perform Collis gastroplasty; mobilization of the gastric fundus by dividing gastrointestinal ligament and short gastric arteries; creation of a fundoplication cuff on a calibration probe of at least 30–36 Fr. The choice of the fundoplication and cruroraphia methods did not significantly affect the long-term results of treatment. Laparoscopic interventions are the most effective way to treat patients with hiatal hernias, due to their safety, low trauma, low complication rate and the possibility of rapid rehabilitation of patients. The technique of surgical intervention needs a clarified standardization.