Small Hiatal Hernia Research Articles

Should Small Sliding Hiatal Hernias Be Reported at CT Colonography?

The objective of our study was to determine whether colonic distention at CT colonography (CTC) induces small incidental sliding hiatal hernias. This study evaluated for the presence and, if present, the size (small, moderate, or large) of sliding (type 1) hiatal hernias in 3126 consecutive asymptomatic adults (mean age ± SD, 57.0 ± 7.4 years) undergoing screening CTC. Colonic distention was achieved with automated continuous CO(2) delivery. As an internal control, standard CT studies (i.e., without colonography technique) were available for comparison in 123 individuals with a hernia present at CTC. In addition, the prevalence of hiatal hernia was assessed in an external control group of 488 adults (mean age, 60.8 years) undergoing abdominal CT without colonic distention. The Fisher exact test was used to test for statistical significance. Hiatal hernias were present in 47.8% (1495/3126) of adults at screening CTC (86% small, 13% moderate, 1% large). Abdominal CT of the 123 internal control subjects showed resolution of the hernia in 64.2% (79/123) of cases and was smaller in an additional 12 cases. The prevalence of sliding hiatal hernias in the external control group was 23.8% (116/488), significantly lower than in the CTC screening cohort (p < 0.0001). After applying an empiric correction factor based on results from the internal control group to account for technique-induced hernias, the estimated prevalence for the CTC cohort more closely matched that for the external control subjects. Our findings suggest that small sliding hiatal hernias are commonly induced by colonic distention at CTC and should probably not be reported to avoid inappropriate diagnosis, workup, or treatment.

En mann i 30-årene med residiverende oppkast og magesmerter lindret av varm dusj

A man in his 30s was admitted to the medical ward with nausea, retching, vomiting and abdominal pain. Seven years previously he had been admitted with stabbing retrosternal pain that worsened with intake of food and drink. At that time a small hiatus hernia of 1 – 2 cm and a small protrusion down towards the Z line were demonstrated. Over the following years the patient was admitted several times with corresponding symptoms. During the last admission it appeared that he smoked marijuana once a week. On examination on admission the patient had epigastric pain, he was sweating, felt nauseated and vomited green fluid. He had a lean stature. His blood pressure was 140/ 90 mm Hg, pulse 48 and the temperature measured in his ear was 35.4 °C. There was slight tenderness on light palpation in the epigastrium. There was no diarrhoea, he had had a normal bowel movement the same morning. His medication was pantoprazole 40 mg  1. He had smoked marijuana on the day before admission. Pantoprazole infusion was started. He had metabolic acidosis with base excess (BE) – 9.0 mmol/l (–3 – 3 mmol/l) and lactate 5.1 mmol/l (0.5 – 2.2 mmol/l) but the circulation was not affected. Blood tests showed a haemoglobin of 17.7 g/100 ml (13.4 – 17.0 g/100 ml), leukocytes 12.9  109/l (3.7 – 10.0  109/l), potassium 4.9 mmol/l (3.5 – 4.4 mmol/l) and glucose 8.4 mmol/l (4.2 – 6.3 mmol/l). The serum ethanol was negative.

Pancreatic Acinar Metaplasia (PAM) in the Distal Esophagus - Is it a Variant of Pancreatic Heterotopia or an Under Reported Histological Finding?

Purpose: Introduction: PAM consists of nests or lobules of pancreatic acinar cells which are characterized by the presence of fine acidophilic granules in the apical cytoplasm and prominent basophilia of the basal portion of the cells. They contain exocrine pancreatic markers such as lipase, trypsinogen, and pancreatic alpha-amylase. Pancreatic heterotopia (PH) (pancreatic rest) is distinguished from PAM by the presence of ductal elements, pancreatic stroma or well defined islets. We report a case of PAM above the gastro esophageal junction (GEJ) and present a brief review of the literature. Case: A 77 year old woman with known GERD for more than 10 years underwent a follow up EGD for refractory symptoms. Patient had a known history of acoustic neuroma treated with resection and radiotherapy, and hyper plastic colon polyps. The current EGD showed a small hiatus hernia and irregular Z line, a fundic gland polyp, and erythematous gastropathy. Biopsies of the distal esophagus showed gastric mucosa with ectopic pancreatic tissue and adjacent inflammation. There was no evidence of BE or H. Pylori gastritis. Discussion: Out of 644 patients who underwent EGD Johansson et al identified PAM above GEJ in 40 (6%), below GEJ in 67 (10%) and both above and below GEJ in 14 (2%). Female gender, H. Pylori infection and GERD were associated with PAM above the GEJ. Focal PAM was found in 11 of 350 (3.14%) biopsies of Barrett's mucosa from 120 patients with BE enrolled in a clinical efficacy trial of omeprazole versus ranitidine for treatment of GERD. Another study by Popiolek et al examined GEJ specimens from 69 young adults and children and found that PAM was present in 16% of the study population and was not associated with BE. The data suggested that PAM at the GEJ develops independently of inflammation and was felt to be a congenital. In contrast, anecdotal reports of heterotopic pancreas (commonly recognized as pancreatic rest) causing abdominal pain, acute pancreatititis, GI bleeding, gastric perforation, gastric outlet obstruction, obstructive jaundice, intussuception, pseudocyst formation, and rarely adenocarcinoma have been described. The presence of PAM above GEJ is likely congenital and may have no clinical relevance or malignant potential. However it remains a distinct and common histological finding and may be underreported in clinical practice.

Endoscopic, endoluminal fundoplication for gastroesophageal reflux disease: Initial experience and lessons learned

Several devices have been developed to create an antireflux barrier endoscopically for the treatment of gastroesophageal reflux disease. All have failed to provide long-term symptom relief, were associated with clinically important complications, or were otherwise removed from the market. A new device, the Esophyx (Endogastric Solutions, Redmond, WA), provides the closest approximation experimentally to a standard Belsy fundoplication. This report describes an initial experience with this device. Patients considered candidates for endoscopic fundoplication include those with symptomatic gastroesophageal reflux disease, a small (<2 cm) hiatal hernia, objective pathologic evidence of gastroesophageal reflux disease, and an absence of other esophageal motility disorders. The procedure was conducted under general anesthesia with a surgeon operating the device and an endoscopist operating the gastroscope. H-fasteners were placed from the esophagus to the gastric cardia with the goal of creating an approximately 270-300° fundoplication approximately 3-4 cm in length. Symptom severity was measured with the GERD-HRQL instrument (best possible score 0, worst possible score 50). The patients were followed-up for complications and symptom improvement. In all, 26 patients underwent an attempted endoscopic fundoplication. Two patients could not be completed because of the inability to pass the device. Of the 24 patients who underwent endoscopic fundoplication, 20 had the typical symptoms of gastroesophageal reflux disease, 4 had symptoms of laryngopharyngeal reflux, and 4 had recurrent symptoms after a Nissen fundoplication. There was 1 major complication of a gastric mucosal tear that led to bleeding and the need for a blood transfusion. Nineteen (79%) patients reported satisfaction with their symptom relief. Of those dissatisfied, 2 had symptoms of laryngopharyngeal reflux, 1 had functional heartburn, 1 had associated gastroparesis, and 1 had clear failure with gastroesophageal reflux disease. The median GERD-HRQL score improved from 25 (interquartile range, 19.5-28.5) to 5 (interquartile range, 3-9; P = .0004). Endoscopic fundoplication with the Esophyx device is feasible with satisfactory initial results. Endoscopic fundoplication seems to be best suited for patients with small hiatal hernias and mild-to-moderate typical symptoms; however, subsequent trials are needed to assess the long-term effectiveness of the technique.

Short Segment Hiatal Hernia - The Long and the Short of It

The role of hiatal hernias (HH) has traveled through the full swing of the pendulum. Initially thought to be necessary for gastro-esophageal reflux, subsequently HH as a pathologic entity fell out of favour and was considered an incidental finding of no real consequence. In the last decade, HH have found favour again and are now established risk factors for the development of gastro-esophageal reflux disease (GERD), non-erosive reflux disease (NERD), Barrett's oesophagus, and oesophageal adenocarcinoma. Moreover HH have now been demonstrated impair the effect of proton pump inhibitors (PPI).1-9 To date most authors would consider a hiatus hernia, referred to Hyun et al. as long segment hiatus hernia (LSHH), to be present if the diaphragmatic indentation (diaphragmatic crus) is seen 2 cm or more distal to the Z-line and the top of the stomach mucosal folds.10,11 The manuscript by Hyun et al. is the first to suggest that hiatal hernias between 0.5-2 cm are significantly associated with columnar lined epithelium (CLE) and Los Angeles grade A reflux oesophagitis. Here the rates of CLE and grade A oesophagitis was greater or on par with patients who had LSHH. Moreover the study found that HH was present in 9.3% of patients with SSHH comprising the majority (5.6%) dwarfing the rate of LSHH (3.8%). HH can be of three types, with type 1 (sliding) HH the type in question in this study which accounts for about 90% of all HH.12 Type I (sliding) HH results from laxity and loss of elasticity of the phreno-oesophageal ligament. Currently HH is regarded as present if greater than 2 cm difference is detected because of the inherent margin of error, as the gastro-oesophageal junction (GOJ, recognized as the Z line) moves physiologically proximally during swallowing in relation to the diaphragmatic crus.2,13 The GOJ moves in relation to the diaphragmatic crus in a number of situations including respiration, oesophageal insufflation, and gastric insufflation, moving from the supine to the upright position.2,13 Moreover conditions including Barrett's epithelium or a patulous hernial orifice can make determination of the GOJ and diaphragmatic crus respectively, difficult to accurately determine. While large HH are easily identified in radiological, endoscopic and manometric studies, the diagnosis of a small hiatus hernia is not well-standardized. The current practice of diagnosing a hiatus hernia and measuring its size using the centimetre markings on the endoscope is inaccurate. There is no standardization regarding the degree of air insufflation or which phase of respiration the measurement is made at.11 It is also difficult to be certain that the tip of the endoscope is precisely at the Z-line or diaphragmatic crus, and the distance to the incisors is often obscured by the bite block. Presently the margin of error related to the above factors is considered to be 2 cm, hence the entity of short segment HH has not been considered in previously published papers. Recently developments in oesophageal manometry have suggested a method by which SSHH could be diagnosed with accuracy given the inherent inaccuracy of endoscopy, barium studies and traditional manometry in the sub group of HH under 2 cm in length. High resolution endoclip manometry studies although not practical for routine clinical assessment can be used to confirm the presence or absence of endoscopically determined SSHH. It is beyond the scope of this editorial to describe the method in detail, suffice to say that a major limitation of Hyun et al.'s study is the absence of reproducibility of the demonstration of SSHH, and this method may be a means by which this criticisms of the study may be circumvented. This is especially importantly as the published data relating to reproducibility of 'standard' or LSHH is scant, and the reproducibility of SSHH would be even more controversial. There are few published data on the correlation between different diagnostic modalities in the diagnosis of HH. One study demonstrated significant disagreement between the two diagnostic modalities for the diagnosis of HH when using both upper GI endoscopy and barium studies.14 In summary, the study by Hyun et al. raises the intriguing concept of SSHH. It is tempting to postulate that by detecting even mild grades of HH we may be able to manage a risk factor for diseases including reflux oesophagitis, Barrett's oesophagus and oesophageal adenocarcinoma or at the very least prognosticate for our patients. However the long of it is, more work needs to be done, the reproducibility of the measurements needs to verified, a protocol developed for measuring HH length which may possibly include the use of other diagnostic modalities and the short of it is, if SSHH is indeed an entity, it clearly deserves more attention given its association with CLE and reflux oesophagitis, and it's relative prevalence to LSHH as demonstrated in this paper.

Short Segment Hiatal Hernia: Is It a Clinically Significant Entity?

IntroductionHiatal hernia (HH) is a well-known contributory factor of gastroesophageal reflux disease (GERD). However, studies on the clinical significance of simple small HH are lacking. We conducted a study to clarify the clinical significance of short segment HH (SSHH) in relation to GERD.Methods4,592 consecutive cases (male/female: 2,076/2,516, median age: 49 years) examined with diagnostic esophagogastroduodenoscopy for the first time were enrolled. During the insertion of endoscope, presence of HH was determined and the length was measured, if present. The relationships between gender, age, presence of erosive esophagitis, and columnar-lined esophagus (CLE) and the lengths of HH were analyzed.ResultsAmong 4,592 cases, HH was present in 428 cases (9.3%); SSHH was found in 255 cases (5.6%) and long segment HH (LSHH) in 173 cases (3.8%). HH was more frequent among males and patients with LSHH tended to be older. Erosive esophagitis was observed in 4.8%, 22.0%, and 37.0% of no HH, SSHH, and LSHH group, respectively (p <0.05). CLE was observed in 14.4%, 36.5%, and 24.3% of no HH, SSHH, and LSHH group, respectively (p <0.05).ConclusionsSSHH is not a clinically silent and "innocent entity," but rather a condition with a significant pathologic significance similar to LSHH in regard to GERD.

Mediastinal Thoracic Duct Cyst

Thoracic duct cysts of the mediastinum are rare. This case report describes a 68-year-old woman who was successfully treated with surgical resection. The clinical and radiographic presentation and pathology are discussed, and the pertinent literature is reviewed.

Transoral incisionless fundoplication for gastroesophageal reflux disease in an unselected patient population

EsophyX is an endolumenal approach to the treatment of gastroesophageal reflux disease (GERD). This report describes one of the earliest and largest North American experiences with this device. Prospective data were gathered on consecutive patients undergoing EsophyX fundoplication for a 1-year period between September 2007 and March 2009. During this time, the procedure evolved to the current technique. A P value less than 0.05 was considered significant. The study enrolled 26 patients with a mean age of 45 years. The patients included 16 women (62%) with a mean body mass index (BMI) of 28 and an American Society Anesthesiology (ASA) classification of 2. These patients included 11 with associated small hiatal hernias, 3 with Barrett's esophagus, and 5 with esophageal dysmotility. The procedure time was 65 min (range, 29-137 min), and the length of hospital stay was 1 day (range, 0-6 days). The postoperative valve circumference was 217 degrees, and the valve length was 2.7 cm. Two complications of postoperative bleed occurred, requiring transfusion. The mean follow-up period was 10 months. Comparison of pre- and postoperative Anvari scores (34-17; P = 0.002) and Velanovich scores (22-10; P = 0.0007) showed significant decreases. Although 68% of the patients were still taking antireflux medications, 21% had reduced their dose by half. Three patients had persistent symptoms requiring Nissen fundoplication, and there was one late death unrelated to the procedure. This study represents an initial single-institution experience with EsophyX. According to the findings, 53% of the patients had either discontinued their antireflux medication (32%) or had decreased their dose by half (21%). Both symptoms and health-related quality-of-life (HRQL) scores significantly improved after treatment. Further follow-up evaluation and objective testing are required.

Two-year results of a feasibility study on antireflux transoral incisionless fundoplication using EsophyX

A feasibility study (n = 19) evaluated the safety and initial efficacy of transoral incisionless fundoplication (TIF) for the treatment of gastroesophageal disease (GERD). The results at 1 year (n = 17) indicated that TIF was safe and had a significant effect on reducing GERD symptoms, proton pump inhibitor (PPI) usage, acid exposure, and small hiatal hernia. This study was designed to evaluate the long-term safety and durability of TIF. Fourteen patients (50% female; median age, 34 years) completed the 2-year follow-up assessment tests. Three patients were excluded from the study after 1 year because two of them underwent retreatment and one was lost to follow-up. At 2 years, no adverse events related to TIF were reported. A >or=50% improvement in GERD-HRQL scores compared with those at baseline on PPIs was sustained by 64% of patients. TIF was effective in eliminating heartburn in 93% of patients and daily PPI therapy in 71% of patients. Significantly (p < 0.05) more patients were able to consume reflux-causing foods and maintain lifestyle activities without GERD symptoms compared with baseline on PPIs. Fundoplications were durable and maintained their geometric dimensions. TIF was effective in eliminating hiatal hernia in 60% of patients and esophagitis in 55% of patients. Global assessment of all outcomes in each patient revealed that 79% of patients experienced complete cure (29%) or remission (50%) of GERD at 2 years after TIF. The results at 2 years supported the long-term safety and durability of TIF and its sustained effect on the elimination of heartburn, esophagitis, <or=2 cm hiatal hernia, and daily dependence on PPIs.

Successful Use of Octreotide to Treat Ménétrier’s Disease: A Rare Cause of Abdominal Pain, Weight Loss, Edema, and Hypoalbuminemia

A 75-year-old man presented with steadily increasing upper abdominal pain, worse after meals, over 6 weeks. He also described anorexia, early satiety, intermittent postprandial nausea and bilious vomiting, as well as bilateral ankle edema and an unintentional 10-lb weight loss, despite daily use of lansoprazole and furosemide. He described no heartburn, dysphagia, melena, hematemesis, diarrhea, fevers, night sweats, or other cardiopulmonary or urinary symptoms. His past medical history was notable for mild gastroesophageal reflux, hypertension, depression, and benign prostatic hyperplasia. Current medications included lansoprazole, valsartan, furosemide, and escitalopram. He had a negative family history and did not smoke or drink alcohol. Physical examination was normal except for 2? bilateral pitting edema to the knees. Laboratory studies were notable mainly for an albumin level of 1.5 g/dl. His white blood cell count was 10,800/ mm (54% neutrophils, 22% lymphocytes, 22% eosinophils), hematocrit 42%, and platelets 338,000/mm. Other liver function tests and serum chemistries were normal except for calcium of 6.9 mg/dl. Urinalysis was normal. Chest X-ray was normal, as was his electrocardiogram. IgA and IgG for Helicobacter pylori were positive. Abdominal computed tomography (CT) after intravenous and oral contrast showed significant thickening of the proximal gastric body and fundus with associated engorgement of the perigastric vessels and no mass (Fig. 1). The distal stomach wall was normal. Endoscopy revealed markedly thickened gastric folds with nodularity, erythema, and exudate involving the proximal stomach (Fig. 2a, b), but sparing the antrum and pylorus. The stomach was poorly distensible, and a small hiatal hernia was seen. Multiple superficial cold forceps biopsies revealed no evidence for active H. pylori infection and failed to show eosinophilia, viral inclusions, epithelial malignancy, or lymphoma. Interestingly, there were elongated gastric foveolae, many of which exhibited a corkscrew-like appearance. These hyperplastic foveolae were lined by gastric epithelium without regenerative features or mucin depletion. Atrophy of the parietal cell layer and mild lamina propria chronic inflammation were also noted. The patient was treated empirically for H. pylori with a 14day course of amoxicillin, clarithromycin, and lansoprazole based on the positive H. pylori serologies. After treatment, he continued taking a proton pump inhibitor twice daily but his symptoms did not change. He was also prescribed a brief course of prednisone that improved his peripheral eosinophilia; however, his symptoms continued to worsen. Full-thickness gastric biopsies, obtained using a jumbo forceps during a repeat endoscopy, showed foveolar hyperplasia with tortuous, corkscrew shapes and dilated mucin-filled gastric pits, atrophy of the parietal cell layer, and mild chronic inflammation of the lamina propria (Fig. 3). Some foveolar cells exhibited mucin depletion. There were no H. pylori organisms or cytomegalovirus M. Rothenberg (&) Division of Gastroenterology and Hepatology, Stanford University Medical Center, 300 Pasteur Drive, MC: 5187, Stanford, CA 94305-5187, USA e-mail: rothenbergmike@gmail.com

Esophageal sebaceous glands diagnosed after endoscopic mucosal resection

A 57-year-old man without any symptoms or signs of illness underwent upper-GI endoscopy for a routine health evaluation. Esophagoscopy revealed a small hiatal hernia and multiple 0.5-mm to 5-mm diameter yellow-whitish granular nodules scattered throughout the middle and lower esophagus, resembling xanthomata (A). These lesions stained slightly with Lugol iodine solution, and enhanced-magnification endoscopy with narrow-band image system revealed that they were encircled by slightly stretched microvessels (B). When autofluorescence image system was used, the intervening esophageal mucosa was green, whereas the granular lesions were pink or violet (C). To obtain sufficient tissue for a histopathologic diagnosis, we performed EMR with a ligating device (EMRL). We successfully resected the lesion without any complications. His clinical course after EMRL was uneventful and he was discharged. Histology revealed the lesions to be esophageal ectopic sebaceous glands without hair follicle (D, H&E, orig. mag. 20). The glands consisted of units of large polyhedral cells with clear vacuolated cytoplasm, accompanied by an excretory duct.

205: A Case of Endoscopy-Related Peritonitis in a Peritoneal Dialysis Patient

A CASE OF ENDOSCOPY-RELATED PERITONITIS IN A PERITONEAL DIALYSIS PATIENT Minesh Pathak, Tibor Fulop. University of Mississippi Medical Center, Jackson, Mississippi. We present a case of a 54 year-old female with end-stage renal disease on continuous ambulatory peritoneal dialysis (PD) and history of systemic lupus erythematosus and hypertension. She presented with two days history of generalized abdominal pain, associated with nausea and vomiting. She reported no fever, hematemesis, melena, hematochezia, diarrhea or cloudy PD effluent. Her symptoms started shortly after an upper gastrointestinal (GI) endoscopy with biopsies, revealing only “inflammation and a small hiatal hernia. Vitals on admission: heart rate of 145/min, blood pressure 135/66 mmHg, respiratory rate 35/min. She was in moderate distress and looked clinically ill. Physical exam revealed moderately diffuse tenderness, lack of bowel sounds and involuntary guarding. Laboratory results: ABG with pH of 7.48, pCO2 28 mmHg, PO2 85; serum HCO3 18 mMol/L, potassium of 7.7 mMol/L, lactic acid 7.2 mMol/L, WBC count 15,100 /mm3. Acute peritonitis with sepsis was entertained and surgery was immediately consulted. Subsequent exploratory laparotomy revealed copious murky fluid, without evidence for bowel perforation or obstruction. Peritoneal dialysis (PD) catheter was removed. Peritoneal fluid Gram stain showed both gram positive and gram negative flora. Blood cultures grew S. pneumoniae. She received also appropriate treatment with broad antibiotic coverage and hemodialysis was started for renal replacement therapy. Discussion: Peritonitis occurs commonly in patients undergoing peritoneal dialysis, either due to direct contamination of the fluid bag connector, or due to tunnel infection of PD catheter. This case report likely represented a transmural route of infection resulting from biopsy with upper GI endoscopy. When evaluating patients with PD peritonitis, focused history should specifically query recent GI procedures. Early surgical exploration and broad spectrum coverage, including empiric anaerobic coverage may be appropriate for these patients.

Challenging the Limits of Esophageal Manometry

After steady improvement until about 1980, the technology behind esophageal manometry saw little change until recent years. A variety of sensor technologies existed including solid-state strain gauge transducers, circumferentially sensitive transducers, multilumen perfused catheters with external pressure transducers, and the Dentsleeve device. However, irrespective of transducer design, the basic format of manometric studies was of multiple line-tracings representing pressure change versus time at several discrete esophageal loci. Furthermore, of the sensor designs available, only the Dentsleeve device provided a validated method for assessing sphincter relaxation. However, the Dentsleeve accomplished this at the expense of pressure response rate and spatial resolution leading some experts to focus instead on these limitations. In brief, little standardization existed in methodology among centers and there was no agreement regarding optimal assembly design or study interpretation.

A Prospective Randomized Study Comparing Two Different Techniques for Laparoscopic Sleeve Gastrectomy

Laparoscopic sleeve gastrectomy (LSG) represents a relatively new restrictive operation for obesity. We report a prospective randomized study comparing two different techniques of performing this procedure. Between January and August 2006, 20 patients (group A) and 20 patients (group B) were prospectively and randomly submitted to LSG. The characteristics of the patients in the two groups were similar for age and sex. The median preoperative weight was of 120 kg (95-180) (A) and 133 kg (83-175) (B) (NS). The median preoperative BMI was of 42.5 kg/m2 (35-58) (A) and 47 kg/m2 (37-58) (B) (NS). The two techniques differ in that in A, stapling is performed after full devascularization and mobilization of the gastric curve, whereas in B stapling is performed as soon as the lesser sac is entered and the greater curve is devascularized after full completion of the sleeve. The staple-line is reinforced at the end of stapling in both techniques. Median operative time was 34 min (12-54) (A) and 25 min (9-51) (B) (P = 0.06). Median peroperative bleeding was 5 mL (0-450) (A) and 5 mL (0-100) (B) (P = 0.37). Median number of staple cartridges used was 6 (5-7) (A) and 6 (4-7) (B) (P = 0.63). Peroperative complications were a small hiatal hernia requiring repair and a bleeding in two patients of A. Postoperative leak occurred in 1 patient of A, and minor early complications affected 2 patients of A and 1 patient of B. Peroperative and postoperative mortality was 0. Median hospital stay was 3 days (1-10) (A) and 3 days (2-7) (B) (P = 0.59). One stenosis as a late complication appeared in a patient of B. %EWL at 6 months and 1 year was respectively 43.4% (A), 42.2% (B) and 48.3% (A) 49.5% (B) (P = 0.82). LSG can be performed by two different techniques. The technique B (section of the stomach followed by its mobilization) appears familiar to surgeons usually performing laparoscopic RYGBP. No observed differences are significant, but the technique B when looking at observed distributions, seems to be better than the technique A (mobilization of the stomach followed by its section) in terms of operative time, peroperative bleeding and hospital stay.

Laparoscopic Clam Shell Partial Fundoplication Achieves Effective Reflux Control With Reduced Postoperative Dysphagia and Gas Bloating

We describe a novel laparoscopic "clam shell" partial fundoplication, incorporating a modified Toupet with an anterior fundic flap for the management of medically recalcitrant gastroesophageal reflux disease. We hypothesize that this clam-shell-like mechanism allows a dynamic rather than rigid circumferential antireflux barrier allowing effective reflux control (compared with partial fundoplication) with reduced occurrence of postoperative dysphagia, gas bloating and vagal nerve injury (compared with Nissen fundoplication). Between November 2002 and May 2006, 140 patients (82 female; mean age, 53 years) underwent this laparoscopic clam shell fundoplication procedure for medically recalcitrant gastroesophageal reflux disease (n = 94) or large paraesophageal hernias (n = 46). Preoperative invasive studies (endoscopy, manometry, pH monitoring) and noninvasive studies (barium swallow and radionuclide gastroesophageal motility) revealed esophageal dysmotility in 26 patients. Routine barium swallow and radionuclide studies were performed 6 months postoperatively and then at yearly intervals. There was no mortality or conversions to open procedures. Mean operative time was 45 minutes; median hospital stay was 1 day (range, 1 to 4). Overall control of reflux symptoms was seen in 95% of patients. Postoperative gas bloating and significant dysphagia occurred in only 11% and 6% of patients, respectively. Three patients (2%) experienced postoperative complications (pneumonia, 2; pleural effusion requiring drainage, 1). Postoperative studies demonstrated reflux in 8 patients (5%) and the presence of small hiatal hernias in 5 patients (4%) during a mean follow-up 19 months (range, 7 to 42). Twenty five patients (17%) underwent postoperative esophageal dilation (median dilations, 1; range, 1 to 3) for dysphagia (11 of these patients had preoperative esophageal dysmotility). Five patients underwent repeat fundoplication (recurrent reflux, 2; gas bloating, 1; dysphagia, 2). Clam shell near-circumferential fundoplication may be considered as an attractive alternative antireflux approach to Nissen fundoplication, particularly among patients at risk for postoperative dysphagia or gas bloating.

Reflux-assoziierter Nussknacker-Ösophagus bei 49-jähriger Patientin mit nicht kardialem Thoraxschmerz (NCCP)

A 49-year-old woman was admitted to our department because of intermittent left-sided chest pain for the past 2 years. The patient reported an increasing frequency and duration of the symptoms which were independent from food intake, medication or physical exercises. A cardiac cause of the chest pain was excluded before admittance to our hospital. The initially performed upper endoscopy revealed a small oesophageal hiatal hernia but no signs of acute or chronic inflammation. Basal oesophageal manometry and pH monitoring confirmed the presence of a nutcracker oesophagus, defined by high-amplitude contractions of the distal oesophagus, in combination with a gastro-oesophageal reflux disease. The patient was treated with high-dose pantoprazole for 8 weeks before re-examination. Interestingly, the symptoms completely disappeared upon medication and the relief of the chest pain was accompanied by normalisation of the nutcracker oesophagus pattern. Thus, our observation provides evidence for a causative role of acid reflux in the pathophysiology of the nutcracker oesophagus and, in addition, suggests that effective acid suppression might be a useful therapeutic tool to deal with this painful motility disorder of the oesophagus.

ENDOLUMINAL GASTROPLICATION FOR GASTROESOPHAGEAL REFLUX APPEARING AFTER GASTRIC SURGERY

Endoluminal gastroplication (ELGP) is a new endoscopic treatment for gastroesophageal reflux disease (GERD). However, its efficacy has been reported only for primary GERD but not for postoperative GERD. Here we report the first two cases of GERD that appeared after gastric surgery and were successfully treated by ELGP. Both patients developed GERD after gastric surgery. Esophagogastrofiberscopy showed esophagitis and small hiatal hernia. The symptoms failed to disappear after medical therapy and ELGP was performed. ELGP involved the use of the BARD (EndoCinchTM) endoscopic suturing system, where two to three plications were placed at the esophagogastric junction. Procedure time, start of soft diet and hospital stay were 55 min, the first postoperative day (POD), 5 days and 60 min, 1 POD and 5 days, for patients 1 and 2, respectively. No adverse events were noted apart from mild and transient epigastric pain. The GERD‐related symptoms markedly improved after ELGP. Improvements were also noted in acid exposure time and bile reflux time after the procedure. ELGP is safe and effective for GERD that develops after surgery although this needs to be confirmed in long‐term follow‐up studies. ELGP is potentially suitable for GERD after Billroth‐I distal gastrectomy with lymph node dissection for gastric cancer.

Prosthetic mesh repair of large and recurrent diaphragmatic hernias

Laparoscopic repair of large paraesophageal hernias (PEH) is associated with significant recurrence rates. Use of prosthetic mesh to complete tension-free repair of the hiatus has been suggested to decrease the recurrence rate. Fifty-nine patients with large (n = 44) or recurrent (n = 15) PEH were operated on via the laparoscopic approach with the use of prosthetic mesh. Patients were followed with office visits and phone interviews. All patients were referred for barium studies. Data analysis included all patients, including conversions, on an intention-to-treat basis. Followup was completed in 56 (95%) patients. Mean followup time was 28.4 months. Forty patients (74%) had significant relief of all symptoms. Barium studies were performed in 45 patients (80.3%), including all symptomatic patients. Fifteen patients (33%) had a small sliding hernia, six (13.3%) had recurrent PEH, and four (8.8%) had narrowing of the gastroesophageal junction. Most patients with small hiatal hernias were symptomatic (60%). All responded to medical treatment. Laparoscopic repair of large PEH with reinforcement mesh is feasible and safe with excellent short-term results. Long-term followup shows a low PEH recurrence requiring reoperation, but a significant number of patients develop symptomatic recurrent small hiatal hernias that can be managed nonoperatively.

Hiatal hernia recurrence after laparoscopic fundoplication

To determine the influence of hiatal hernia size and the laparoscopic fundoplication technique on the rate of hernia recurrence. The preoperative, operative, and postoperative observational data of 381 patients operated on at the Department of Surgery of Kaunas University of Medicine during the period of 1998-2004 for hiatal hernia complicated with gastroesophageal reflux were analyzed. The surgery technique (Nissen or Toupet operation) was chosen independently of the hernia size. The radiological investigation of the esophagus-stomach using barium contrast as well as esophagogastroduodenoscopy and biopsy was performed for all patients before the surgery. The subjective and objective assessment of the patients' health status was investigated before and no less than 12 months after surgery. If the disease symptoms remained or new ones (i.e. pain behind the sternum, dysphagia, etc.) occurred after surgery, the hernia recurrence was suspected. The radiological investigation of the esophagus-stomach using barium contrast, as well as esophagogastroduodenoscopy and biopsy were performed at the consultative outpatient clinic. The hernia recurrence was confirmed after performing these two investigations. When analyzing the results, the patients were divided into two groups: Group 1--patients with small hiatal hernia (grade 1 and 2 hernia according to radiological classification), Group 2--patients with large hiatal hernia (grade 3 and 4 hernia according to radiological classification). A total of 272 (71.4%) patients had small hiatal hernia, and 109 (28.6%) patients had large ones. Hernia recurrence was diagnosed in 7 (2.58%) patients in Group 1, while in Group 2, 11 (10.1%) patients had hernia recurrence (P<0.05). Laparoscopic Nissen fundoplication was performed in 287 (75.4%) patients, after which 14 (4.98%) patients had hernia recurrence, while Toupet fundoplication was performed in 94 (24.6%) patients, after which 4 (4.3%) patients had hernia recurrence (P>0.05). The recurrence rate of hiatal hernia after laparoscopic fundoplications is significantly higher in patients with large hernias (grade 3 and 4 according to radiological classification). The surgery technique (Nissen or Toupet fundoplication) was not a significant factor affecting the recurrence rate of hiatal hernia.

Anisakiasis en un paciente portadora de una pequeña hernia hiatal: Caso clínico

We describe the presence of anisakiasis in a patient who had a small hiatal hernia. A 60 year-old women presented general malaise, burning pain, flatulence, persistent nausea and abdominal distension during five days before consulting. She referred that she ate a dish of marinated raw fish with lemon and pepper ("cebiche") and after a few hours the symptoms began. An esophagogastroscopy showed a white colour larva of approximately three cm with the cephalic end partially adhered and localized in the mucosa of the hiatal hernia. During the procedure the worm was easily extracted. The morphologic study of the specimen identified it as a stage IV larva of Pseudoterranova sp. The clinical condition of the patient improved after the extraction of the parasite.