Subacute Small Bowel Obstruction Research Articles

#6795 DISSEMINATED STRONGYLOIDES INFECTION IN A PATIENT WITH IGA NEPHROPATHY ON IMMUNOSUPPRESSIVE MEDICATIONS

Abstract Background and Aims Immunosuppressive medications such as high dose steroids and antimetabolites are frequently used in glomerulonephritis. However, use of these medications is usually associated with various adverse effects. Among the drawbacks of immunosuppressive therapy, the risk of reactivation of latent infections, including parasitic infestations, is to be considered. Method Case report. Results Our case is a 28 year old male patient who was diagnosed as a case of IgA nephropathy 7 months back with M1E1S1T1C0 lesions with a serum creatinine of 1.7 mg/dL and eGFR of 56 ml/min/1.73 m2. He was started on prednisolone (40mg daily) and mycophenolate mofetil (1000mg twice daily) for 1 month. He presented with us with diarrhea. He was treated with IV fluids and mycophenolate mofetil was stopped. After two weeks, he was readmitted with a 4-day history of fever, vomiting, and epigastric pain. On examination, he showed mild epigastric tenderness, normal vitals. The laboratory investigations on admission showed hemoglobin-15 g/dL, total leucocyte count-8600, eosinophilia with absolute eosinophil count 1900/ mm3, urea-92 mg/dL, creatinine-2 mg/dL. ECG showed sinus tachycardia, and HRCT chest revealed bilateral ground glass opacities and a calcified nodule in the left upper lobe. Liver function test was normal with normal amylase and calcium level. Blood culture was sterile. Ultrasound abdomen showed a bilateral raised Eco pattern in kidneys rest were normal. Upper GI endoscopy revealed diffuse edema, erythema, and superficial ulceration in duodenum and biopsy was taken. The duodenal biopsy showed features of strongyloidiasis stercoralis (Figure 1). Bronchoesophageal lavage was done which revealed strongyloidiasis stercoralis larvae. Meanwhile, the patient developed subacute small bowel obstruction with abdominal x ray showing multiple air fluid levels and CT scan showed features of small bowel obstruction with transition at mid-ileal level secondary to short segment thickening. Small bowel obstruction was relived with conservative mangement with ryles tube decompression and enemas. He was diagnosed with disseminated strongyloidiasis and treated with ivermectin for 14 days with full recovery Conclusion Our case signifies need of awareness among clinicians of the risk of disseminated strongyloidiasis as a complication of the treatment with immunosuppressive medications even in non-endemic areas.

CASE REPORT: GOSSYPIBOMA IN A 30 YEAR OLD FEMALE

Surgical materials are sometimes inadvertently left in the body after surgeries,Cotton materials are the commonest objects forgotten[1]. The implications for the patient and the surgeon are serious . A signicant complication of surgical practice is gossypiboma [2]. Despite signicant interest and numerous guidelines, there are few known incidents because of a multitude of variables , including possible legal repercussions .[2] Gossypiboma, also called textiloma or cottonoid , refers to a foreign object , such as cotton matrix or a sponge , inadvertently left in the body cavity at the end of a surgical operation[3]. Here we describe a rare instance of transluminal surgical sponge migration in a 30 year old female who underwent low transverse cesarean section 3 months ago and presents with abdominal distention, anorexia , constipation and weight loss. She was thoroughly evaluated with imaging and suspected features of subacute small bowel obstruction . Patient underwent diagnostic laparoscopy with bowel resection and anastomoses , Patient eventually got better and was discharged .

AMYAND'S HERNIA – A CONTINUUM OF CLINICAL PRESENTATION AND LITERATURE REVIEW

Introduction: Amyand's hernia is dened as an inguinal hernia containing a vermiform appendix within its sac. The incidence of this rare entity ranges from 0.9% to 1.7%. It poses a diagnostic challenge due to its low incidence, indistinct clinical presentation, and ambiguous appearance on imaging. Therefore, surgery is often performed for diagnosis as well as for treatment. Here we report different presentations of Amyand's hernia as case scenarios. A 67-year-old male and a 65-year-old-male presented to the emergency room with an irreducible rightCase Presentations: inguinal hernia and subacute small bowel obstruction. A 77-old-male was electively admitted for right inguinal hernia repair. Normal Appendix was encountered in all three patients when the hernial sac was explored. Hence, they were treated with inguinal hernia repair alone while preserving the appendix. The rst patient had an appendix, cecum, and part of ascending colon in a viable state with some infected peritoneal uid in the hernial sac and was treated with Desarda's hernia repair without mesh. The second patient had appendix, cecum, distal ileum, and part of ascending colon in the hernial sac with no evidence of infection and the third patient had only an appendix in a healthy state in the hernial sac. Both patients were treated with Amid's modication of Lichtenstein's tension-free hernioplasty with polypropylene mesh. All patients had uneventful postoperative period and follow-up visits. Surgeons worldwide agree with the fact that, since the appendix may be non-inamedConclusion: when found within the inguinal hernia sac, removal is not always compulsory. By the rarity, and the wide divergence of its presentation, each case series and review article bring valuable information regarding its diagnosis and treatment.

Primary Sclerosing Encapsulating Peritonitis in an Adult Male: A Case Report

Introduction: Primary sclerosing encapsulating peritonitis (PSEP), also referred to as “cocoon abdomen”, is a rare but potentially devastating disease. It is defined as the encapsulation of a segment of the small bowel by a fibro-collagenous membrane leading to acute or sub-acute small bowel obstruction. Though the exact etiology and pathophysiology of this debilitating medical condition are still controversial, PSEP has been reported to be associated with multiple congenital developmental abnormalities. Diagnosis of PSEP is usually delayed as the disease is relatively rare and commonly present with non-specific symptoms associated with non-specific laboratory findings and non-conclusive radiologic features. Patient Concerns: We present a 42-year-old male patient presenting for elective abdominal laparoscopy for his four-year recurrent abdominal pain. Diagnosis: Preoperative diagnosis of PSEP as the cause of his chronic abdominal pain was not made until at laparotomy where a thick fibrotic peritoneal sac encasing the entire small bowel was found. Interventions: Excision of the fibrotic sac with extensive adhesiolysis were done by the general surgeon. Outcomes: The patient experienced a ten-day period of post op ileus after which he had a complete recovery. Conclusion: With the increasing number of cases suffering from this condition being reported in literature, surgeons must be aware of this debilitating disease in the differential diagnosis of abdominal obstruction.

91 Intestinal Malrotation Identified on Diagnostic Laparoscopy in a 79-Year-Old Male Presenting With Symptoms of Sub-Acute Bowel Obstruction

Abstract Congenital malrotation of the midgut in the adult population is most likely to present with non-specific abdominal symptoms that can pose a diagnostic dilemma. If left untreated the symptoms of malrotation can have a significant impact on patients’ quality of life and the condition can lead to significant morbidity and mortality. We report a case of malrotation identified in a 79-year-old male who presented with a chronic picture suggestive of sub-acute small bowel obstruction. The patient underwent thorough clinical review including CT and MRI scan which showed evidence of dilated small bowel but failed to show an underlying cause. The absence of findings with initial tests prompted the team to consider surgical investigation. Diagnostic laparoscopy identified evidence of congenital malrotation, and this was successfully treated with a Ladd’s procedure. This case adds to the evidence that malrotation is a more common finding in adults than previously thought and emphasises the importance of pursuing a definitive diagnosis when routine tests do not demonstrate sufficient cause for a patient’s symptoms.

An unusual case of subacute small bowel obstruction - Gallstone ileus.

Introduction and importanceGallstone ileus is caused by an impaction of one or more gallstones within the gastrointestinal tract, leading to mechanical intestinal obstruction. It is a rare complication of cholelithiasis leading to the formation of a cholecystoenteric fistula and is associated with high mortality rates. We report a case of atypical subacute small bowel obstruction due to gallstone ileus.Presentation of caseAn 82-year-old man, with previously diagnosed cholelithiasis, presented with abdominal pain and vomiting for nine days. The contracted gallbladder with distended bowel loops was visualized on abdominal ultrasound. Computed tomography of the abdomen and pelvis revealed dilated loops of the small intestine with a gallstone in the proximal ileum, causing intestinal obstruction with pneumobilia, suggesting gallstone ileus with cholecystoduodenal fistula. The patient underwent an emergency laparotomy and enterolithotomy to remove the impacting gallstone. The cholecystoduodenal fistula was left undisturbed due to the significant risk of duodenal injury. The patient had an uneventful postoperative recovery.ConclusionGallstone ileus almost always requires surgical management. However, performing an interval biliary surgery is based on the clinical judgment of the surgeon. In our case, the patient's clinical status determined the treatment in which an enterotomy with stone extraction alone was largely sufficient, and has supported the literature. Gallstone ileus is an important differential diagnosis in elderly patients with gallstone disease, untreated or undiagnosed, presenting with features of small bowel obstruction.

A rare case of idiopathic multiple small bowel strictures in Indian subcontinent: a case report

Small bowel ulcers and strictures are uncommon but when they occur they can be an important cause of morbidity. We reported a case of a multiple strictures in small bowel that was treated surgically pain for 15 years. She also had hypoalbuminemia and iron deficiency anemia. A diagnosis of small bowel stricture was made on CT and surgery was advised. Resection of the 100 cm long segment of small bowel was done. Approximately 10 smooth strictures were identified in the resected segment. Histology did not identify any specific cause. A 43 year old Indian female was diagnosed with subacute small bowel obstruction. She had a history of chronic abdominal pain for 15 years. She also had hypoalbuminemia and iron deficiency anemia. A diagnosis of small bowel stricture was made on CT and surgery was advised. Resection of the 100 cm long segment of small bowel was done. Approximately 10 smooth strictures were identified in the resected segment. Histology did not identify any specific cause. Subacute small bowel obstruction can be associated with various factors. Multiple idiopathic small bowel strictures can be considered as one of the causes. In present case no cause of ulcers and strictures could be found. Idiopathic multiple bowel strictures with fecalith is rare. Histopathology and other investigations revealed no specific cause. We recorded no postoperative complications 2 months after surgery by resection and anastomosis.

78 A Lockdown Dilemma; Ingestion of Magnetic Beads Presenting as Right Iliac Fossa Pain and Sub-Acute Small Bowel Obstruction

Abstract A 13-year-old girl presented with a three-day history of migratory right iliac fossa pain. Observations and inflammatory markers were normal, and an ultrasound scan was inconclusive. A provisional diagnosis of non-specific abdominal pain or early appendicitis was made, and she was discharged with safety netting advice. She represented six days later with ongoing abdominal pain now associated with multiple episodes of vomiting; hence, the decision was made to proceed to diagnostic laparoscopy rather than a magnetic resonance scan for further assessment as recommended by the radiology department. Intra-operative findings revealed 200mls of serous fluid in the pelvis, normal-looking appendix, dilated stomach, and a tangle of small bowel loops. Blunt and careful dissection revealed fistulous tracts that magnetized the laparoscopic instruments. A mini-laparotomy was performed with the extraction of fourteen magnetic beads and the repair of nine enterotomies. Foreign body ingestion is a known cause of abdominal pain, which in some cases might mimic or even be the cause of acute appendicitis. This case highlights the importance of careful history taking in children presenting with acute abdominal pain of doubtful aetiology.

Adhesive subacute small bowel obstruction presenting with gross rectal bleeding

Abstract The pathogenesis of massive lower gastrointestinal bleed (LGIB) due to angio-dysplasia and ulceration is rare and not well understood. We discuss an unusual presentation of a child with painless massive LGIB arising from chronic intestinal adhesions causing subacute small bowel obstruction and angio-dysplastic ulceration but without any clinical or radiological evidence of bowel obstruction.

Phytobezoar induced small bowel obstruction: an uncommon cause of intestinal occlusion

A case of a 42-year-old female patient with a two-days diffuse colicky abdominal pain, nausea and three episodes of vomiting is presented. Furthermore, patient complained for inability to eat for almost a week. In addition, patient had a history of subtotal gastrectomy Billroth II-type, due to gastric ulcer six years ago. There were no other known co-morbidities. Except for a distended, somewhat painful abdomen and sluggish bowel sounds, the rest clinical examination was unremarkable. Plain abdominal X-ray and ultrasound findings agreed with the clinical suspicion of sub-acute small bowel obstruction probably due to post-operative adhesions. A conservative management was decided. However, the patient after an initial clinical improvement, had a relapse of symptoms with the first feeding attempt. A followed computed tomography of the abdomen revealed a well define, oval, mass-like containing mostly air bubbles lesion, occupying for approximately six centimeters long the jejunum lumen. The diagnosis of jejunal phytobezoar was set. In accordance of computed tomography diagnosis were the intra-operative findings and the post-operative histopathology.

An unusual case of phytobezoar-induced small bowel obstruction

Bezoars, and to lesser extent phytobezoars, are among the rare causes of small bowel obstruction. A bezoar generally describes retained concretions of indigestible foreign material that accumulate and conglomerate in the gastrointestinal tract, most commonly in the stomach. We present an unusual case of phytobezoar-induced sub-acute small bowel obstruction originating from unfamiliar plant material in a 74-year-old woman. The past history was insignificant regarding comorbidities other than depression. Presenting complaints were history of abdominal pain and vomiting. Imaging studies and physical examination suggested small bowel obstruction. The patient underwent exploratory laparotomy after 1 day of conservative treatment. We found a 4.5 cm obstructing phytobezoar intraoperatively. The undigested plant material caused the obstruction. Postoperatively, the plant was identified as Scorzonera papposa. The patient was discharged uneventfully. The elderly patients should avoid semi-cooked vegetables, plants of unknown origin and high-fibre diet.

Excision of Ovarian Remnant Causing Chronic Pelvic Pain

Video Objective To demonstrate effective excision of ovarian remnant in chronic pelvic pain following hysterectomy and bilateral salpingoophrectomy for endometriosis. Setting A 38year-old G0 was diagnosed with endometriosis aged 17, subsequently undergoing 37 laparoscopies for pelvic pain. Total laparoscopic hysterectomy and bilateral salpingoophrectomy was performed aged 32, reported as technically difficult due to deep infiltrating endometriosis and adhesions. She continued to suffer with pelvic pain, with multiple admissions with subacute small bowel obstruction. A trial of progesterone and GNRH was unsuccessful. In 2017 ultrasound showed a cystic structure in the right pelvis, suggesting ovarian remnant confirmed by FSH and oestradiol levels. Interventions Laparoscopic adhesiolysis and excision of ovarian remnant was scheduled and Clomiphene 50mg prescribed 2 weeks preoperatively to stimulate the ovarian tissue, allowing easier identification and excision. Intraoperative ultrasound demonstrated increased ovarian volume. On entry there were dense adhesions and the pelvis obliterated. Methodical adhesiolysis was achieved with a mixture of blunt dissection and monopolar diathermy. The ovarian remnant was seen on the right side surrounded by thickened peritoneum. The ureter was identified and unexpectedly found pulled medially by adhesions. Ureterolysis was performed down to the ovarian remnant, which was dissected to allow the ureter to fall laterally. The ovarian remnant was safely excised with the cystic elements aspirated to facilitate removal in a retrieval bag via the 5mm right iliac fossa port incision. The ovarian tissue was excised in its entirety and at the end of the procedure the bowel was mobile, lying in its anatomical position. Conclusion Consider remnant ovarian tissue in endometriosis patients who have had previous difficult hysterectomy and bilateral salpingoophrectomy with continued pain. Clomiphene enlarges remnant ovarian tissue to aid identification and excision. Before excising pathology it is important to identify normal structures when presented with distorted anatomy to ensure a safe approach.

Perforated Jejunal Pseudoiverticulum in a Child A Case Report with Review of Literature

Background: Jejunal diverticula are rare and majority of them are asymptomatic. However rarely, they may present with perforation as an acute abdominal emergency. Hence this condition should be considered in the differential diagnosis and management of small bowel diverticular disease. Case summary: A 6-year-old child presented with sudden onset of abdominal pain, with vomiting and diarrhea. Clinical Examination showed features of acute abdomen. CT scan showed distended bowel loops with features suggestive of subacute small bowel obstruction. Emergency laparotomy was done, during which jejunal diverticulum with perforation was seen with pus and adhesions. Resection of small segment of bowel with perforated diverticulum and anastomosis was performed. Histopathology showed features of Pseudo diverticulum with perforation. 4 months post-surgery, the child is doing well. Conclusion: Jejunal diverticula are rare, however perforated diverticula may present as an acute abdominal emergency and could necessitate surgical repair.

Superior mesenteric artery syndrome – a rare diagnosis for common upper gastrointestinal symptoms

Superior mesenteric artery (SMA) syndrome is a rare acquired vascular compression disorder in which acute angulation of the SMA results in compression of the third part of the duodenum, leading to intestinal obstruction. This is typically caused by an angle of 6 – 25° between the abdominal aorta and the SMA, in comparison with the normal range of 38 – 56°, as a result of a lack of retroperitoneal visceral fat (mesenteric fat). In addition, the aortomesenteric distance is 2 – 8mm as opposed to the typical 10 – 20mm. Here we report the case of an 11-year-old girl who presented with frequent attacks of non-specific abdominal pain over a few years, who had been treated symptomatically without a clear diagnosis. However, in the last admission, she presented to our hospital with symptoms of subacute small bowel obstruction including bilious vomiting and epigastric pain that prompted extensive investigations including multislice abdominal computerized tomography with oral and intravenous contrast. This scan confirmed the diagnosis of SMA syndrome.

Late metastatic colon cancer masquerading as primary jejunal carcinoma

Metastasis to the small bowel from a previously resected colorectal cancer is rare and may erroneously be diagnosed as a primary small bowel carcinoma. It usually occurs several years after the primary resection. We present the case of a 67-year-old man who had undergone left hemicolectomy for colon cancer 3 years earlier and returned with subacute small bowel obstruction. This was initially thought, based on preoperative radiological findings and normal colonoscopic examination, to be due a primary jejunal cancer. Even at surgery, the lesion convincingly appeared as an obstructing primary small bowel carcinoma. However, the histology of the resected small bowel revealed metastatic colon cancer. This rare and an unusual metastatic occurrence some years after the primary resection is described and reviewed.

Sub acute intestinal obstruction- A Vanek s tumor induced ileoileal intussuception

Vanek's tumor is a rare benign inflammatory fibroid polyp like localized lesions originating in the submucosa of the gastrointestinal tract. Intussusceptions due to inflammatory fibroid polyps are uncommon; moreover, ileo-ileal Intussusception presenting as subacute small bowel obstruction has rarely been reported. We report a 49-year-old man who came with complaints of indigestion, flatulence, altered bowel habits with abdominal distension for the past 1½ year that aggravated since a week. Abdominal examination revealed distension, signs of intestinal obstruction. The patient underwent laparoscopic assisted resection of intussuscepted ileal segment and four-layer side to side anastomosis. Histopathological analysis showed an ulcerative lesion with variable cellularity, formed by spindle cells with small number of mitosis and an abundant inflammatory infiltrate comprising mainly eosinophils. Immunohistochemistry confirmed the diagnosis of ileal Vanek's tumor. Although inflammatory fibroid polyps are seen very rarely in adults, they are among the probable diagnoses that should be considered in obstructive tumors of the small bowel causing Intussusceptions.

MR Enterography Is a Useful Test in the Investigation of Small Bowel Disease

Purpose: MR Enterography (MRE) aids assessment of Crohn's disease (CD) but may also be indicated in the investigation of other SB pathology. We studied the frequency and clinical impact of incidental findings detected by MRE in patients with suspected or known CD. Methods: We conducted a retrospective review of 1022 MRE studies performed between June, 2009 and February, 2013 at our institution. Clinical data (demographics, disease characteristics and therapy) were obtained from electronic patient records. Incidental findings were defined as unexpected lesions in or outside the small intestine, unknown at the time of referral and unrelated to inflammatory bowel disease (IBD). Results: Of 1,022 MRE studies 500 patients had a diagnosis of IBD, 418 had CD, 61 had ulcerative colitis (UC) and 21 had IBD unclassified (IBDU). Of 418 CD patients, 243 were female, mean age 36. Abnormalities were noted in 306 MRE scans, 170 active non-stricturing, 121 active stricturing and 13-fibrostenotic disease. Within active groups were 35 fistulae and 12 abscesses. Incidental findings included colonic inflammation (10), gallstones (17), ovarian cysts (22), jejunal intussusception (1), sacroileitis (1), renal cysts (11), hepatic cysts (12), splenic haemangioma (1), mesenteric abscess (1), adrenal nodule (2), uterine fibroid (5), chronic pancreatitis (1) and splenomegaly (2). Eighty-two studies were performed in UC or IBDU; 48 were female, mean age 33. Seventeen patients had small bowel thickening with signs of active inflammation in 12/17. Incidental findings included a right ischio-anal fossa collection, pancreatic divisum, gallstones, liver and ovarian cysts, diverticular disease, large bowel abnormalities in 6 patients, colitis (5) and colonic polyps (1). MRE was performed in 522 patients without IBD. Indications included iron deficiency anaemia, abdominal pain, weight loss, diarrhoea, rectal bleeding, vomiting and abnormal colonoscopy. Findings included small bowel thickening (4), sub-acute small bowel obstruction (2), small bowel stricture (1), small bowel malignancies (2) and small bowel intussusception (1). Incidental findings included ovarian, hepatic and renal cysts, adrenal adenoma, splenic and liver haemangioma, PUJ obstruction, AAA, liver metastases, gallstones, pelvic abscess, uterine fibroids, large bowel stricture, diverticular disease, cirrhosis, lymphadenopathy, horseshoe kidney, atrophic pancreas and acute appendicitis. Conclusion: A small but significant proportion of patients have important incidental findings at MRE. MRE can add meaningfully to the investigation of SB pathology. A careful selection of patients can be achieved through a collaborative multi-disciplinary approach.

PWE-200 Mr Enterography is a Useful test in the Investigation of Small Bowel Disease

IntroductionMR enterography (MRE) aids assessment of small bowel (SB) inflammatory bowel disease (IBD). We aimed to determine the frequency and clinical impact of incidental findings detected by MRE in patients...

Levofloxacin induced hypoglycemia in a non-diabetic patient

Fluoroquinolones are generally regarded as safe antimicrobial agents with relatively few adverse effects or drug interactions. Because of their recognized safety profile and potent in vitro activity, fluoroquinolones have been widely used for the treatment of community- and hospital-acquired infections. Although uncommon, both hypoglycemia and hyperglycemia (dysglycemia) appear to occur with all the fluoroquinolones. It is usually reported in conjunction with impaired creatinine clearance and elderly diabetics receiving concomitant treatment with antidiabetic agents (especially sulfonylureas) or insulin. The exact mechanism of this effect is unknown but is postulated to be a result of blockage of adenosine 5\'-triphosphate-sensitive potassium channels in pancreatic β-cell membranes. Here we report a case of hypoglycemia in a hospitalized nondiabetic elderly patient in whom this life-threatening adverse effect was related in a temporal fashion to the administration of intravenous levofloxacin meant to cover pulmonary infection in a setting of subacute small bowel obstruction and septicaemia. This case emphasizes the occurrence of profound and prolonged hypoglycemia consequent upon levofloxacin use, an adverse reaction that has been described with almost all members of the quinolone family of antibiotics. Taking into consideration the frequency of fluoroquinolone use in the hospital and ambulatory setting, clinicians should be cognizant of this potential adverse effect in non-diabetic patients treated with levofloxacin, and they should look out for symptoms of hypoglycemia and monitor blood glucose levels more frequently, especially early in the course of therapy.

Laparoscopic repair of giant hiatus hernia: prosthesis is not required for successful outcome

Giant hiatus hernia (GHH) are difficult to manage effectively. This study reports a laparoscopic, prosthesis-free technique to repair of GHH. Retrospective analysis of a prospectively populated database of a single surgeon's experience of GHH (>30 % intrathoracic stomach) repair using a novel, uniform technique was performed. Routine postoperative endoscopy, quality of life (QOL), and Visick scoring was conducted. Surgery was conducted in 100 patients (70F, 30 M). Mean (standard deviation [SD]) age was 69.1 (±11.4), median (interquartile range) ASA was 2 (range, 2-3), and mean (SD) body mass index (BMI) was 29.1 (±4.5). Mean follow-up was 574.1 (±240.5) days. One (1 %) patient was converted to an open procedure due to technical issues. Median stay was 2.5 days (range, 2-4). One postoperative death occurred secondary to respiratory sepsis. Eight (8 %) patients had perioperative complications: 4 major (PE, non-ST elevation MI, postoperative bleed managed conservatively, infected mediastinal fluid collection); and 4 minor (pneumothorax, asymptomatic troponin leak, subacute small bowel obstruction, and urinary retention). Ninety-nine (99 %) patients had objective screening for recurrence at 3-6 months. Two (2 %) patients have had symptomatic recurrence of their hiatus hernia; both involved a recurrent fundal herniation. Another seven (7 %) had small (<2 cm), asymptomatic recurrences diagnosed only on routine follow-up. Seven (7 %) patients have required reintervention for dysphagia with endoscopic dilatation conducted to good effect in all cases. Two (2 %) patients have required revisional surgery: one for a symptomatic recurrence at 3 months and a second for recurrent mediastinal collection. The Visick score fell from a mean (SD) of 3 (±1.1) to 1.7 (±0.8) postoperatively (p < 0.0001). The mean (SD) QOL preoperatively was 87.8 (±24) versus 109.1 (±22.3) postoperatively (p < 0.0001). GHH can be managed safely and effectively laparoscopically, without the use of a prosthesis.