Small Hiatal Hernia Research Articles

An adult case of large defect of small mesenteric hiatal hernia causing small bowel obstruction

BackgroundSmall mesenteric hiatal hernias (SMHHs) are defined as a small group of internal hernias (IHs) that frequently diagnosed in children. However, SMHHs are relatively rare in adults. Bowel loop herniation via an abnormal mesenteric defect can lead to strangulated intestinal obstruction. Congenital SMHHs are commonly observed in pediatric patients, with some cases involving neonatal death.Case presentationA 24-year-old healthy male patient visited our hospital with a 2-day history of a sudden onset lower abdominal pain. He was initially diagnosed with enteritis. However, his symptoms worsened, and he was brought to our hospital. Contrast-enhanced computed tomography (CT) scan showed formation of a closed loop in the small intestine within the pelvis and signs of ischemia. As the patient was diagnosed with small bowel obstruction (SBO) caused by IH, emergency laparoscopic surgery was performed to loosen the obstruction. The patient was found to have ascites and small-bowel necrosis. A part of the small intestine that measured 30 cm was strangulated via a large-diameter defect (17 × 11 cm) in the ileal mesentery. Via a small abdominal incision, the necrotic bowel was resected, and the mesenteric defect was repaired.ConclusionSMHHs are rare in adults, and they should be considered as potential causes of strangulated intestinal obstruction in adults without a history of laparotomy or trauma.

537. ASSESSING THE EFFECT OF HIATAL HERNIA SIZE ON PERIOPERATIVE OUTCOMES AND HOSPITAL READMISSION RATES AFTER PRIMARY REPAIR

Abstract Background Minimally invasive hiatal hernia (HH) repair remains the gold standard for correcting mechanical defects due to its safety and favorable clinical outcomes (i.e., relief of patient symptoms). However, several operative factors, including the HH size, may negatively impact the postoperative course. We aimed to determine if an increase in HH size was related to an increased risk of perioperative complications or hospital readmissions. Methods After IRB approval, we performed a retrospective analysis using a prospectively maintained database containing demographic, perioperative, and clinical data from all patients who underwent HH repair by a single experienced foregut surgeon between September 2016 and July 2023. Four groups were defined based on the proportion of stomach at the thoracic cavity determined during the surgery: A (small HH: <25%), B (moderate HH: 25-49%), C (large HH: 50-74%), and D (intrathoracic stomach [ITS]: ≥75%). Non-parametric tests were used to assess differences between the groups, and logistic regressions were used to determine the relevant odds ratios (OR). Results A total of 391 patients who underwent primary HH repair met the inclusion criteria (73.7% women; mean age 64.4±12.5 years; mean BMI 28.9±4.9 kg/m2). The distribution of groups was: A (n=160, 40.9%), B (n=63, 16.1%), C (n=64, 16.4%), and D (n=104, 26.6%). Patients presenting with ITS (group D) were older, had longer operative duration, greater blood loss (p<.001), and a significantly increased risk of presenting with early postoperative complications (OR 2.78 [CI95: 1.52-5.06]) and being admitted to the ICU (OR 12.35 [CI95: 3.41-44.71]). Conclusion The HH size, defined by the proportion of the stomach at the thoracic cavity, is associated with an increased risk of early postoperative complications and ICU admission; moreover, a trend toward higher 30- and 90-day hospital readmission rates was noted. This factor may be a consequence of the progressive nature of the disease; hence, it should be considered when choosing between continued medical observation and surgical treatment of patients presenting with asymptomatic HH. An early intervention may reduce the risk of postoperative comorbidity.

Comprehensive Assessment of Esophageal Disorders Associated with Hiatus Hernia: Insights from Big Data Analysis.

Hiatus hernia (HH) is a prevalent endoscopic finding in clinical practice, frequently co-occurring with esophageal disorders, yet the prevalence and degree of association remain uncertain. We aim to investigate HH's frequency and its suspected association with esophageal disorders. We reviewed endoscopic reports of over 75,000 consecutive patients who underwent gastroscopy over 12 years in two referral centers. HH was endoscopically diagnosed. We derived data on clinical presentation and a comprehensive assessment of benign and malignant esophageal pathologies. We performed multiple regression models to identify esophageal sequela associated with HH. The overall frequency of HH was (16.8%); the majority (89.5%) had small HHs (<3 cm). Female predominance was documented in HH patients, who were significantly older than controls (61.1±16.5 vs. 52.7±20.0; P < 0.001). The outcome analysis of esophageal pathology revealed an independent association between HH, regardless of its size, and erosive reflux esophagitis (25.7% vs. 6.2%; OR = 3.8; P < 0.001) and Barrett's esophagus (3.8% vs. 0.7%; OR = 4.7, P < 0.001). Furthermore, following rigorous age and sex matching, in conjunction with additional multivariable analyses, large HHs were associated with higher rates of benign esophageal strictures (3.6% vs. 0.3%; P < 0.001), Mallory Weiss syndrome (3.6% vs. 2.1%; P = 0.01), and incidents of food impactions (0.9% vs. 0.2%; P = 0.014). In contrast, a lower rate of achalasia was noted among this cohort (0.55% vs. 0%; P = 0.046). Besides reflux-related esophageal disorders, we outlined an association with multiple benign esophageal disorders, particularly in patients with large HHs.

Hiatal hernia: risk factors, and clinical and endoscopic aspects in gastroscopy.

Hiatal hernia (HH) is a common finding in gastroscopy. The aim of the present study was to investigate the frequency rate of HH among patients who underwent esophagogastroduodenoscopy (EGD) according to their age, gender, and procedural indication. A multicenter, retrospective study including all EGDs was conducted across seven endoscopy departments between 2016 and 2021. Demographic information, procedural indications, and findings from the initial EGD were collected. Of the 162,608 EGDs examined, 96,369 (59.3%) involved female patients. HH was identified in 39,619 (24.4%) of all EGDs performed, comprising small HH in 31,562 (79.6%) and large HH in 3,547 (9.0%). The frequency of HH was 16.5% in the age group of ≤50 years and 37.3% in those aged ≥81 years. HH was diagnosed in 38.7% (11,370) of patients with heartburn/reflux symptoms, 31.5% of those with dysphagia, 28.5% of those with positive fecal occult blood tests, and 24.3% of those who would undergo bariatric surgery. Age (odds ratio 1.030), female gender (odds ratio 1.309), reflux symptoms (odds ratio 2.314), and dysphagia (odds ratio 1.470) were identified as predictors for HH. Risk factors for HH diagnosed by EGD in symptomatic patients were shown to be advanced age, female gender, and the presence of heartburn or dysphagia.

THU387 Euglycemic Diabetic Ketoacidosis And SGLT-2 Inhibitor Use

Abstract Disclosure: N. Abrahimi: None. A. Abrahimi: None. N. Terrigno: None. Background: Diabetic ketoacidosis (DKA) is a known adverse effect of SGLT-2 inhibitors. (1) Incidences of euglycemic diabetic ketoacidosis in patients on SGLT-2 inhibitors are reported on less. Clinical Case: A 39-year-old male past medical history of uncontrolled, non-insulin dependent diabetes mellitus and pancreatitis who presented with abdominal pain, nausea and coffee ground emesis. On initial work up, basic metabolic panel showed blood glucose level of 175 mg/dL with an elevated anion gap of 22 mmol/L. Initial differentials included suspicion for euglycemic diabetic ketoacidosis or acute intraabdominal pathology. Venous blood gas showed metabolic acidosis, with a pH of 7.21 and bicarbonate of 9.7 mmol/L, beta hydroxybutyrate was elevated at 7.83 mmol/L. CT abdomen pelvis found a small hiatal hernia, gastric wall thickening, likely gastritis, and was negative for other intraabdominal pathology. Home medications of the patient included dapagliflozin, semaglutide, metformin, gabapentin, and pantoprazole. Patient was admitted with the diagnosis of suspected euglycemic diabetic ketoacidosis and was started on an insulin drip along with D5 0.45 normal saline. Patient’s anion gap was monitored with basic metabolic panel orders every two hours. The insulin drip was discontinued once the patient had two consecutive normal anion gaps and the patient was subsequently started on a subcutaneous insulin regimen. Conclusion: SGLT-2 inhibitors may cause euglycemic diabetic ketoacidosis based on the physiology of the SGLT-2 transporter and the pharmacology of the SGLT-2 inhibitors. (2) Clinical importance of this case report is to consider euglycemic diabetic ketoacidosis in patients on SGLT-2 inhibitors presenting with nausea, vomiting with normal blood glucose to not delay in the diagnosis and treatment of this life-threatening condition.

483. INTRAOPERATIVE EVALUATION OF HIATAL HERNIA SIZE AND CANDIDACY IN TIF ELIGIBLE PATIENTS

Abstract Background Transoral incisionless fundoplication (TIF) is gaining prominence in treatment of gastroesophageal reflux disease (GERD) for patients with absent or small hiatal hernia. As TIF gains popularity, appropriate patient evaluation and selection is paramount in establishing anatomical candidacy hence successful outcome. We evaluated patients who were intended to be treated with TIF and underwent a standard evaluation but instead underwent robotic hiatal hernia repair. We compared their preoperative evaluation of hernia size with intraoperative findings. Methods A cohort of seventy-six patients from a single-center database from January 2020 to March 2023 were retrospectively analyzed. All were deemed candidates for TIF based on our inclusion criteria (pH confirmation of GERD, hiatal hernia &amp;lt;2 cm) and underwent preoperative testing with endoscopy, esophagram, pH and manometry. Twenty-seven of these patients either were denied TIF by their insurance company or had personal preference for surgery (daVHH) over endoscopic intervention and underwent robotic assisted paraesophageal hernia repair. We examined intraoperative measurements of hiatal hernia size and EG junction anatomy and compared them to standard preoperative evaluation. Results On pre-operative endoscopy 23 patients were found to have no hiatal hernia, 20 were found to have a small hernia, 3 a medium hernia, and 1 a large hernia. Esophagram evaluation demonstrated no hiatal hernia in 17 patients and a small hernia in 23 patients. The average hiatal hernia size seen during manometry was 0.54 cm (0–2 cm) while the average hernia seen intra-operatively was 3.26 cm (1.5–4.8 cm). There was a significant difference between preoperative hernia size evaluated by manometry and intraoperative hernia size (p-value 0.04). Conclusion Standard preoperative evaluation of patients intended to be treated with TIF appears to have a tendency to underestimate the size of hiatal hernia and omits evaluation of paraesophageal anatomy. This can lead to poor patient selection of failure of this treatment modality. Addition of cross-sectional imaging to the evaluation of patients with small hiatal hernias can facilitate a more meaningful therapeutic decision making for endoscopic, surgical, and combination treatment options.

Role of Transoral Incisionless Fundoplication in Salvage Therapy for Recurrent Reflux

Background: Gastroesophageal reflux (GERD) occurs when anatomic barriers fail to prevent retrograde movement of stomach contents into the esophagus. When lifestyle and medications fail to relieve patients’ symptoms, anti-reflux procedures can be safe and effective options for addressing the mechanical deficits (such as reduced lower-esophageal sphincter pressure, hiatal hernia, and/or patulous diaphragmatic hiatus) contributing to GERD. When laparoscopic fundoplication treatment of GERD fails, repeat surgical treatment is an option—but comes with risk of increased morbidity when compared to the primary fundoplication. Transoral incisionless fundoplication (TIF) is an endoscopic anti-reflux procedure that may be an alternative option for salvage therapy in patients with recurrent GERD. Methods: This review will explore fundoplication failure, the theoretical role for TIF in this setting, and the literature to support TIF as endoscopic rescue at this time. Literature review of studies reporting TIF for salvage therapy outcomes was performed, revealing 2 published papers. Results: TIF as salvage therapy has been shown in patients with minimal recurrent hiatal hernia but a loose fundoplication to be feasible, safe, and effective with improvement of GERD symptom scores and acid exposure time. However, this has only been shown in small, retrospective studies at this time. Conclusion: TIF may be a reasonable alternative to repeat laparoscopic fundoplication in patients with a small hiatal hernia.

A novel modified method for treating patients with refractory gastro-esophageal disease and moderate hiatus hernia.

Endoscopic anti-reflux mucosectomy (ARMS) is effective for patients with refractory gastroesophageal reflux disease (rGERD) with small hiatus hernia. However, evidence of its applicability on larger lesions is lacking. This study aimed to evaluate the efficiency and safety of ARMS for patients with rGERD with moderate hiatus hernia (3-5 cm) and determine the appropriate resection range (either 2/3 or 3/4 circumference). Thirty-six patients with rGERD with moderate hiatus hernia were enrolled. They were divided into the 2/3 and 3/4 circumferential mucosal resection groups. The patients received modified ARMS. The gastroesophageal reflux disease questionnaire (GERD-Q) and DeMeeter scores, endoscopy, 24-h pH monitoring results, and lower esophageal sphincter (LES) resting pressure were compared pre and post procedure. The therapeutic effects and complications of the two mucosal resection ranges were analyzed. Thirty-six patients were enrolled in this study, all of whom had undergone ARMS operation with at least 6 months of follow-up. In the 2/3 circumferential mucosal resection group, the GERD-Q score, acid exposure time (AET), and DeMeester score improved significantly compared with those before operation (P<0.001). In the 3/4 circumferential mucosal resection group, the GERD-Q score, AET, and DeMeeter score worsened after six months (P<0.001), but there was no difference between the two groups (P>0.05). In both groups, there was no significant improvement in the ratio of esophagitis grade C/D and LES resting pressure after treatment compared with the baseline values (P>0.05) and no postoperative bleeding or perforation. The incidence of postoperative esophageal stenosis in the 2/3 circumferential mucosal resection group was lower than those in the 3/4 circumferential mucosal resection group (P=0.041). Modified ARMS is effective for patients with rGERD with moderate hiatus hernia, but it cannot significantly increase the postoperative resting pressure of LES. The 2/3 circumferential mucosal resection can reduce the incidence of postoperative esophageal stenosis.

Small hiatal hernias: clinical manifestations, sleep disorders and quality of life

Purpose of the study : to identify the features of clinical manifestation, sleep disorders and quality of life in patients with small hiatal hernias in gastroesophageal (GER) and duodenogastroesophageal refl ux (DGER). Materials and methods . 120 patients with small (1–2 degrees) hiatal hernias and grade I–III refl ux esophagitis on the basis of predominantly GER (35 people) and DGER (85 people) refl ux were examined. Sleep disorders were assessed using the Yu. A. Aleksandrovsky scale, violations of the quality of life — the KSC RAMS questionnaire. Results. Small hiatal hernias in all cases occur with a pronounced refl ux syndrome in the form of combination of esophageal and extraesophageal manifestations, developing both on the basis of GER and DGER. Esophageal manifestations of refl ux syndrome predominate in the presence of DHER and are combined with biliary dyspepsia. Extraesophageal manifestations do not depend on the type of refl ux. Dyssomnia was noted in every second patient with hiatal hernia, primarily presomnic and intrasomnic disorders, which were most pronounced in patients with GER. In the majority of patients with small hiatal hernias, the main reasons for the decrease in the quality of life, regardless of the type of refl ux into the esophagus, were the need for treatment, adherence to a diet, instrumental studies, and restriction of physical activity.

Advanced Endoscopic Imaging and Interventions in GERD: An Update and Future Directions

Gastroesophageal reflux disease (GERD) is one of the most common gastrointestinal diseases encountered in primary care and gastroenterology clinics. Most cases of GERD can be diagnosed based on clinical presentation and risk factors; however, some patients present with atypical symptoms, which can make diagnosis difficult. An esophagogastroduodenoscopy can be used to assist in diagnosis of GERD, though only half of these patients have visible endoscopic findings on standard white light endoscopy. This led to the development of new advanced endoscopic techniques that enhanced the diagnosis of GERD and related complications like squamous cell dysplasia, Barrett's esophagus, and early esophageal adenocarcinoma. This is conducted by improved detection of subtle irregularities in the mucosa and vascular structures through optical biopsies in real-time. Management of GERD includes lifestyle modifications, pharmacological therapy, endoscopic and surgical intervention. Minimally invasive endoscopic intervention can be an option in selected patients with small hiatal hernia and without complications of GERD. These endoscopic interventions include endoscopic fundoplication, endoscopic mucosal resection techniques, ablative techniques, creating mechanical barriers, and suturing and stapling devices. As these new advanced endoscopic techniques are emerging, data surrounding the indications, advantages and disadvantages of these techniques need a thorough understanding.

Endoscopic management of gastroesophageal reflux disease: Panacea for proton pump inhibitors dependent/refractory patients.

Endoscopic therapies in proton pump inhibitors (PPI) dependent/refractory gastroesophageal reflux disease (GERD) are increasingly indicated in patients who are not suitable or willing for chronic medical therapy and surgical fundoplication. Currently available endoluminal anti-reflux procedures include radiofrequency therapy (Stretta), suturing/plication and mucosal ablation/resection techniques at the gastroesophageal junction. Meticulous work up and patient selection results in a favorable outcome with these endoscopic therapies, especially the quality of life and partially the PPI independence. Stretta can be considered in patients with PPI refractory GERD and might have a role in patients with reflux hypersensitivity and functional heartburn. Endoscopic fundoplication using the Esophyx device and the GERD-X device have strong evidence (multiple randomized controlled trials) in patients with small hiatus hernia and high volume reflux episodes. Mucosal resection/ablation techniques like anti-reflux mucosectomy and anti-reflux mucosal ablation have shown promising results but need long term follow-up studies to prove their efficacy. The subset of PPI dependent GERD population will benefit from endoscopic therapies and the future of endoscopic management of GERD looks promising.

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.

OH MY GERD! ILD AND RECURRENT ASPIRATION PNEUMONIA IN THE SETTING OF SEVERE GERD

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Heartburn is notorious for causing a chronic cough that produces a negative pulmonary workup. In severe gastroesophageal reflux disease (GERD) the stakes are higher, with complications causing aspiration pneumonia and chemical pneumonitis leading to interstitial lung disease (ILD). We present a case with a reversed clinical picture - clinically significant pulmonary findings suggesting severe GERD without being able to confirm aspiration. CASE PRESENTATION: A 61 year old gentleman with refractory GERD and restrictive lung disease requiring home oxygen was admitted to the hospital for dyspnea and hypoxia. The patient was hypoxic on presentation, oxygen saturation in the 60s on 2L, only improving to 85% with non-invasive ventilation, thus leading to intubation. Chest x-ray revealed bibasilar hazy infiltrates, right greater than left. Tracheal aspirate culture grew E. coli, diagnosing the patient with aspiration pneumonia, which was then treated appropriately. This was the patient's ninth episode of aspiration pneumonia in the last twelve months, several of these requiring hospitalization. Past medical history included laparoscopic sleeve gastrectomy for peptic ulcer disease ten years ago with symptoms persisting and failing proton pump inhibitor therapy and H2 therapy. On a recent hospitalization for his recurrent pneumonias, workup included multiple speech evaluations and modified barium swallow concerning for but not confirming aspiration. Esophagogastroduodenoscopy discovered a four centimeter hiatal hernia and was negative for Barrett's esophagus. pH monitoring revealed elevated acid exposure time (29.5% vs normal <4.5%). Patient was referred to surgery for further treatment options. He was cautioned that his lung problems would not resolve until the acid reflux was controlled. DISCUSSION: This case exemplifies multiple lung complications of severe, uncontrolled GERD. While multiple swallow evaluations could not reveal aspiration, it is reasonable to conclude the patient nevertheless was aspirating frequently, particularly at night. These symptoms were likely exacerbated by sedating medications he was taking, like quetiapine. Additionally, while GERD is not uncommon after gastric modification, there are only a few cases described in the literature that present severely enough to cause aspiration pneumonia. A small hiatal hernia together with the gastric sleeve, both innocent enough on their own, caused a synergy leading to the severe symptoms this patient experienced. Without surgical intervention, it is unlikely the pneumonitis and pneumonia will improve. CONCLUSIONS: In patients with recurrent pneumonia, acid reflux should be high on the differential, even in the absence of evidence of aspiration. REFERENCE #1: Taylor JK, Fleming GB, Singanayagam A, Hill AT, Chalmers JD. Risk factors for aspiration in community-acquired pneumonia: analysis of a hospitalized UK cohort. Am J Med. 2013 Nov;126(11):995-1001. DISCLOSURES: No relevant relationships by Samapon Duangkham, source=Web Response No relevant relationships by Ricardo Franco, source=Web Response No relevant relationships Added 12/03/2020 by Ebtesam Islam, source=Web Response, value=Consulting fee Removed 04/30/2021 by Ebtesam Islam, source=Web Response No relevant relationships by Haitem Mezughi, source=Web Response No relevant relationships by Alexandra Wichmann, source=Web Response

Early case of dysphagia aortica

A 72-year-old man with a history of idiopathic pulmonary fibrosis, aortic valve replacement, and pulmonary hypertension underwent an esophageal work-up during evaluation for a potential lung transplant. High-resolution manometry showed intact peristalsis with a cardiovascular pressure artifact across the middle to distal parts of the esophagus (A). The patient did not describe any history of dysphagia. Upper endoscopy showed a small hiatal hernia and grade B esophagitis. A barium esophagram showed slightly delayed esophagus emptying, which resolved with multiple swallows, and an impression of vascular compression (B).

Рефлюкс-ассоциированные особенности диссомний и нарушений в эмоционально-личностной сфере больных с малыми грыжами пищеводного отверстия диафрагмы

Рефлюкс-ассоциированные особенности диссомний и нарушений в эмоционально-личностной сфере больных с малыми грыжами пищеводного отверстия диафрагмы

Small hiatal hernia as a risk factor of atrial fibrillation.

PurposeHiatal hernia (HH) is considered a risk factor of atrial fibrillation (AF). The aim of this study was to evaluate HH in computed tomography (CT) images in patients awaiting ablation due to atrial fibrillation, and to look for a correlation between HH in patients without AF and with AF.Material and methodsThis study included 441 patients divided in two groups: 207 patients subjected to computed tomography before ablation procedure due to atrial fibrillation and 234 patients as the control group, who underwent CT scans to rule out coronary disease (no AF in history).ResultsSmall HH, e.g. under or equal to 2 cm, are associated with a higher risk of AF compared to the control group, which was not observed for bigger HH.ConclusionsThe presence of small HH may be a risk factor of AF.

High-resolution manometry findings with hiatus hernia

: The esophagogastric junction (EGJ) is comprised of both the intrinsic lower esophageal sphincter (LES) and extrinsic crural diaphragm (CD) such that intraluminal pressure represents a composite of the two. With type I hiatal hernias there is weakening of the pharyngoesophageal ligament attaching the esophagus to the CD such that the distal esophagus, including the LES, becomes displaced cephalad. High-resolution manometry (HRM), can accurately detect an axial hiatal hernia as confirmed by studies comparing HRM to barium esophagram, upper endoscopy, or intraoperative findings. In HRM studies, hiatus hernia becomes evident by a spatial separation between the pressure signature of the LES and that of the CD; the operative confirmation of hiatus hernia correlates with this separation exceeding 1 cm. With LES-CD separation of <2 cm the HRM pressure signatures of the two overlap, but as the LES-CD separation increases beyond that the two become completely separate. The other progression noted in HRM studies is in the location of the respiratory inversion point (RIP), the axial location at which the inspiratory change in pressure transitions from an inspiratory increase, characteristic of intra-abdominal recordings to an inspiratory decrease, characteristic of intrathoracic recordings. In the normal state and with small hiatal hernias, the location of the RIP correlates with where the CD impinges on the esophagus at inspiration. However, with larger hernias the RIP can localize with either the CD or the LES reflective of whether or not the CD has become incompetent, presumably a result of hiatal dilatation. Consequently, there are three distinct EGJ pressure morphologies in HRM: (I) normal with minimal LES-CD separation, (II) hiatus hernia with LES-CD separation >1 cm and the RIP localized at the CD, and (III) hiatus hernia with LES-CD separation >1 cm and the RIP localized at the LES.

Пластика и крурорафия при хиатальных грыжах

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.

Small hiatal hernia and postprandial reflux after vertical sleeve gastrectomy: A multiethnic Asian cohort.

Laparoscopic vertical sleeve gastrectomy (LSG) is a popular bariatric procedure performed in Asia, as obesity continues to be on the rise in our population. A major problem faced is the development of de novo gastroesophageal reflux disease (GERD) after LSG, which can be chronic and debilitating. In this study, we aim to assess the relationship between the presence of small hiatal hernia (HH) and the development of postoperative GERD, as well as to explore the correlation between GERD symptoms after LSG and timing of meals. In doing so, we hope to gain a better understanding about the type of reflux that occurs after LSG and take a step closer towards effectively managing this difficult to treat condition. We retrospectively reviewed data collected from patients who underwent LSG in our hospital from Dec 2008 to Dec 2016. All patients underwent preoperative upper GI endoscopy, during which the identification of hiatal hernia takes place. Patients' information and reflux symptoms are recorded using standardized questionnaires, which are administered preoperatively, and again during postoperative follow up visits. Of the 255 patients, 125 patients (74%) developed de novo GERD within 6 months post-sleeve gastrectomy. The rate of de novo GERD was 57.1% in the group with HH, and 76.4% in the group without HH. Adjusted analysis showed no significant association between HH and GERD (RR = 0.682; 95% CI 0.419 to 1.111; P = 0.125). 88% of the patients who developed postoperative GERD reported postprandial symptoms occurring only after meals, and the remaining 12% of patients reported no correlation between the timing of GERD symptoms and meals. There is no direct correlation between the presence of small hiatal hernia and GERD symptoms after LSG. Hence, the presence of a small sliding hiatal hernia should not be exclusion for sleeve gastrectomy. Electing not to perform concomitant hiatal hernia repair also does not appear to result in higher rates of postoperative or de novo GERD.

S2031 Esophageal Polyps Associated With Barrett’s Esophagus: Is This an Adenocarcinoma or Not?

INTRODUCTION: Barrett’s esophagus (BE) appears usually as a flat salmon-colored lesion. Esophageal adenocarcinomas associated with BE, traditionally appearing as an ulcer or a mass, seem to originate via the BE-dysplasia-carcinoma sequence. There is only a handful of reported cases of polypoid esophageal adenocarcinomas associated with BE. We describe a compelling case of incidental finding of BE with multiple esophageal polyps that turned out to be invasive adenocarcinoma. CASE DESCRIPTION/METHODS: A 60-year-old male with a past medical history of coronary artery disease and atrial fibrillation underwent laparoscopic cholecystectomy for chronic abdominal discomfort. His postoperative course was complicated by biliary leak; hence ERCP was performed and successful biliary stent placement was achieved. Two months later, an upper endoscopy was being performed for biliary stent removal when multiple 4 to 15 mm pedunculated and sessile polyps were identified in the distal esophagus (Figure 1). The upper endoscopy also revealed mucosal changes consistent with long-segment BE, C8-M10 per Prague criteria, a small hiatal hernia and multiple small gastric polyps. All large esophageal polyps were successfully resected with cold snare, after Eleview injection. The exception was a 10 mm polyp that was not liftable. Pathology reading of the resected polyps demonstrated low- and high-grade dysplasia along with intramucosal carcinoma (Figure 2). While the unresectable polyp revealed a moderately to poorly differentiated adenocarcinoma with HER2 positivity on FISH analysis. This was followed by an endoscopic ultrasound, which showed a 2 cm mass with irregular borders infiltrating the submucosa plus peritumoral lymph node involvement (Figure 3). The patient was referred to a multidisciplinary team of GI oncologists as well as a foregut surgeon for further management. DISCUSSION: Polypoid lesions of the esophagus are considered rare. To this date, there is no clear consensus on their management. We did a literature review, and we found 27 reported cases of polypoid dysplasia of the esophagus, 10 of them were having multiple lesions. The table is showing their characteristics and outcome. Through this case, we emphasize the association between these polypoid lesions and the adenocarcinoma of the esophagus. Hence, when esophageal polyps associated with BE are encountered, we are recommending their resection associated to multiple biopsies.Figure 1.: Upper Gastrointestinal endoscopy: Multiple polypoid lesions in the lower third of the esophagus, no signs of bleeding.Figure 2.: Image A, Esophageal Biopsy, High Magnification: Intestinal metaplasia with nuclear enlargement, loss of nuclear polarization, occasional prominent nucleoli, and increased apoptosis, as well as crypt fusion and cribriforming; changes consistent with high-grade dysplasia. Image B: Sheets of infiltrating malignant cells at medium magnification infiltrating the lamina propria.Figure 3.: Upper Endoscopic Ultrasonography: Hypoechoic mass in the lower third of the esophagus, the lesion is non circumferential, the borders are irregular, 5 mm in thickness with submucosal invasion.