Transhiatal Herniation Research Articles

A rare and severe complication after minimally invasive esophagectomy: First case of a left-sided tension pneumothorax caused by intrathoracic perforation of the herniated transverse colon. Case report and literature review

Nowadays, a minimally invasive surgical approach is increasingly being chosen to treat distal esophageal tumors. Here, postoperative hiatal herniation has been identified as a potentially severe complication. In such cases, it is still not known whether surgical or conservative treatment is preferable. In this report, we elaborate the case of a 62-year-old male patient who presented at our emergency department with severe chest pain. This patient had undergone minimally invasive esophagectomy with gastric pull-up 2 years prior to this event. Emergency computed tomography revealed a left-sided tension pneumothorax based on transhiatal herniation of the transverse colon causing an intrathoracic closed-loop obstruction with subsequent perforation. Immediate surgical treatment was initiated and the transverse colon could be successfully repositioned and resected. Nevertheless, the patient died due to postoperative septic shock in the setting of fecal peritonitis, mediastinitis, and pleuritis within 48 hours after surgery. We provide a detailed description of this rare case and provide a review of the literature concerning intrathoracic colonic herniations.

Case of Delayed Transhiatal Pancreatic Herniation After Esophagectomy.

Case of Delayed Transhiatal Pancreatic Herniation After Esophagectomy.

784 TRANSHIATAL HERNIA: AN UNDERDIAGNOSED BUT OVER-TREATED COMPLICATION AFTER MINIMALLY INVASIVE ESOPHAGECTOMY

Abstract Postoperative transhiatal hernia is a possible life-threatening complication following esophagectomy. The incidence and indications to treat remain open to debate with apparently an increase after minimally invasive esophagectomy (MIE). The aim of this study is to analyze a large series of patients after MIE in a single high-volume center with a transhiatal herniation after minimally invasive esophagectomy (THAMIE) and obtain new insights in this pathology. Methods We included all patients who underwent a MIE (Ivor Lewis and McKeown procedure) in our hospital between 2015 and 2020. Retrospective analysis of demographic, clinical and surgical data was performed. Outcomes of measure were incidence, initial clinical presentation, treatment of choice, postoperative complications and symptoms, herniation recurrence. Results In 341 MIE 25 (7.3%) patients were diagnosed with a THAMIE postoperatively. 4 patients (16.0%) were asymptomatic at the time of presentation. 5 patients (20%) were treated conservatively because of recurrent carcinoma. 20 patients received a laparoscopic reduction of the transhiatal hernia and cruraplasty (19 non-absorbable sutures, 1 mesh) regardless whether they were symptomatic or not. 25.0%(5/20) of the patients were operated in emergency settings and 5.0% (1/20) was converted to a laparotomy. Postoperatively 6 of the 18 symptomatic patients (33.3%) experienced no relief of symptoms and 40.0% (8/20) of the THAMIE recurred. 35% had serious postoperative complications (clavien-dindo IIIa or more) and mortality was 0.0%. Conclusion The incidence of 7.33% found in our data suggests that THAMIE is a common complication after MIE. We almost exclusively (95.0%) treated patients in a laparoscopic way. Due to the high percentage of morbidity (35.0% ≥ CD IIIa), recurrence (40.0%) and patients with unrelieved symptoms(33.3%) we recommend a conservative treatment for the asymptomatic patients, and further analysis of predictive symptoms associated with a THAMIE to evolve to a shared decision making algorithm for elective symptomatic patients.

Trans-hiatal herniation following esophagectomy or gastrectomy: retrospective single-center experiences with a potential surgical emergency

PurposeTrans-hiatal herniation after esophago-gastric surgery is a potentially severe complication due to the risk of bowel incarceration and cardiac or respiratory complaints. However, measures for prevention and treatment options are based on a single surgeon´s experiences and small case series in the literature.MethodsRetrospective single-center analysis on patients who underwent surgical repair of trans-hiatal hernia following gastrectomy or esophagectomy from 01/2003 to 07/2020 regarding clinical symptoms, hernia characteristics, pre-operative imaging, hernia repair technique and perioperative outcome.ResultsTrans-hiatal hernia repair was performed in 9 patients following abdomino-thoracic esophagectomy (40.9%), in 8 patients following trans-hiatal esophagectomy (36.4%) and in 5 patients following conventional gastrectomy (22.7%). Gastrointestinal symptoms with bowel obstruction and pain were mostly prevalent (63.6 and 59.1%, respectively), two patients were asymptomatic. Transverse colon (54.5%) and small intestine (77.3%) most frequently prolapsed into the left chest after esophagectomy (88.2%) and into the dorsal mediastinum after gastrectomy (60.0%). Half of the patients had signs of incarceration in pre-operative imaging, 10 patients underwent emergency surgery. However, bowel resection was only necessary in one patient. Hernia repair was performed by suture cruroplasty without (n = 12) or with mesh reinforcement (n = 5) or tension-free mesh interposition (n = 5). Postoperative pleural complications were most frequently observed, especially in patients who underwent any kind of mesh repair. Three patients developed recurrency, of whom two underwent again surgical repair.ConclusionTrans-hiatal herniation after esophago-gastric surgery is rare but relevant. The role of surgical repair in asymptomatic patients is disputed. However, early hernia repair prevents patients from severe complications. Measures for prevention and adequate closure techniques are not yet defined.

Transhiatal Visceral Herniation

Transhiatal esophagectomy is a surgical procedure performed for benign and malignant esophageal lesions. The postoperative complications include anastomotic leak, infection, atelectasis, hemorrhage, recurrent laryngeal nerve paralysis, chylothorax, tracheal laceration, and herniation of abdominal viscera through the hiatus, which is one of the rarest complications. We show a patient with a transhiatal herniation of a large abdominal content into the thorax as a chronic complication of this procedure.

Post esophagectomy diaphragmatic hernia: a case report of a rare cause of acute respiratory distress

BackgroundDiaphragmatic hernia is frequent among the elderly and is usually associated with mild chronic digestive and respiratory symptoms.Case presentationAn elderly post-esophagectomy male patient, in the early postoperative period of cardiac surgery, presented with acute respiratory distress. An emergent surgery was performed to reduce a giant diaphragmatic herniation.ConclusionsAn acute transhiatal herniation can cause serious respiratory impairment; surgical repair should be considered in select patients of cardiac surgery.

Transhiatal Herniation of the Pancreas as a Cause of Acute Pancreatitis

Introduction The two most frequent causes of pancreatitis are gallstones and alcohol, accounting for 80% of cases. Other less common causes include hypertriglyceridemia, trauma, toxins, drugs and other causes. Our case highlights a patient presenting with pancreatitis due to a large hiatal hernia. Case report A 95-year-old woman with history of prior cholecystectomy and known large hiatal hernia presented with severe epigastric pain that radiates to the back. She denied alcohol use, family history of pancreatitis, new medications or trauma. Vital signs were within normal limit. Physical exam was notable for abdominal wall hernia and moderate epigastric tenderness. Lab data revealed normal LFTs, but an elevated serum lipase of 9736 U/L and amylase of 1597U/L. Computed tomography of the abdomen with contrast large hiatus hernia containing most of stomach, portions of pancreas and omentum.1423_A.tif Figure 1: CT abdomen - Coronal view Pancreas indicated by red arrow Pancreatic duct indicated by white arrow Stomach indicated by blue arrowThe patient was managed conservatively with IV fluid and parenteral analgesia. Surgical repair of the herniation was discussed, due to advanced age and resolution of symptoms, a decision to avoid operative management was made. Discussion Transhiatal herniation of the pancreas is rare due to its retroperitoneal location and fixation by the ligament of Treitz. Acute pancreatitis as a complication of this phenomenon is uncommon. Symptoms consist of pain localized to the chest and epigastrium, dyspepsia, nausea, vomiting, and dyspnea. The diagnosis is confirmed by significant serum lipase elevation and imaging evidence of pancreatic herniation with inflammatory changes suggestive of pancreatitis A variety of mechanisms have been proposed to explain hernia-associated pancreatitis. The parenchymal trauma from repetitive transhiatal sliding may itself induce pancreatitis, or it may cause intermittent ischemia. Other possibilities include volvulus formation or intermittent folding of the pancreatic duct leading to pancreatic secretion against a fixed obstruction. Historically, patients were managed with immediate hiatal hernia repair, however recent cases have demonstrated successful supportive management. Severe cases involving incarceration, perforation, or unresponsiveness to medical therapy should be managed surgically Conclusion Pancreatic herniation is a rare entity which may lead rare complications, including pancreatitis. Our case report highlights the importance of maintaining a broad differential diagnosis when approaching patients to include uncommon causes of disease entities1423_B.tif Figure 2: CT Abdomen - Sagittal View Pancreas indicated by red arrow Stomach indicated by blue arrow1423_C.tif Figure 3: CT Abdomen - Coronal View Pancreas indicated by red arrow Pancreatic duct indicated by white Stomach indicated by blue arrow

Intrathoracic major duodenal papilla with transhiatal herniation of the pancreas and duodenum: A case report and review of the literature

Transhiatal herniation of the pancreas is an extremely rare condition. In the published literature we found only eleven cases reported in the period of 1958 to 2011. A coincidental hiatal herniation of the duodenum is described in two cases only. To our knowledge, we report the first case with a hiatal herniation of the complete duodenum and proximal pancreas presenting an intrathoracic major duodenal papilla with consecutive intrahepatic and extrahepatic cholestasis. A 72-year-old Caucasian woman was admitted to our department with a hiatal hernia grade IV for further evaluation. According to our recommendation of surgical hernia repair soon after the diagnosis of a transhiatal herniation of the proximal pancreas and entire duodenum, we had to respect the declared intention of the patient for a conservative procedure. So we were forced to wait for surgical repair within an emergency situation complicated by a myocardial infarction and reduced general condition. We discuss the therapeutic decision making process and a complete literature review of this rare entity.

Acute Ischemic Colitis Caused by Transhiatal Herniation and Incarceration of the Stomach and Transverse Colon

Purpose: An 89-year-old woman with a long-standing history of para-esophageal hiatal hernia was hospitalized with one-day duration of severe nausea, vomiting and abdominal pain, and multiple episodes of red blood per rectum. Physical examination showed diffuse abdominal tenderness worse in the left upper and lower quadrants. Laboratory data showed: hemoglobin 8.6 g/dl dL (range: 12-14), WBC 19.9 K/cu cmm (range: 4.7-11), platelet 208 K/cmm (range: 150-450) and lactate 3.8 mmol/L (range: 0.5-2.2). Computed tomography showed a large para-esophageal hernia and organo-axial volvulus of an entirely intrathoracic stomach. The herniated sac also contained portions of the transverse and left colon. Diffuse wall thickening involving the distal transverse colon, left colon and sigmoid colon and peri-colonic stranding were noted with a transition point at the hernia. This was most consistent with ischemic colitis due to transhiatal herniation and incarceration of the colon. The patient was treated with nil per os, nasogastric suction and antibiotics. An urgent surgical correction of the volvulus and hernia was planned; however, the patient opted for palliative care and declined surgery. A repeat CT in 24 hours showed spontaneous resolution of the gastric volvulus and colonic herniation. The patient remained hospitalized for three weeks and required parenteral nutrition as well as several blood transfusions because of severe rectal bleeding. Fortunately, she made a complete recovery. Transhiatal herniation and incarceration of the stomach and colon are rare and potentially life threatening complications of para-esophageal hernias. Early surgical intervention of large hernias may prevent a later catastrophe.Figure: CT abdomen showing colonic incarceration at hiatal hernia and wall thickening of distal colon (arrow).Figure: CT chest showing organoaxial volvulus of intrathoracic stomach.

Transhiatal herniation of intestine with circulatory collapse on anesthesia induction

Diaphragmatic herniation is known to create cardiorespiratory challenges for the anesthesiologist. With the increasing use of the transhiatal surgical approach for esophagectomy, the occurrence of transhiatal herniation of bowel is likely to be encountered. A case of circulatory collapse during induction of anesthesia in a patient with transhiatal herniation is presented.

NOTES for the cardia: antireflux therapy via transluminal access

The current standard for surgical antireflux therapy is laparoscopic Nissen fundoplication, but natural orifice transluminal endoscopic surgery (NOTES) enables even less invasive access to the peritoneal cavity. We therefore aimed to evaluate a NOTES approach to antireflux therapy. An animal study including 24 pigs (16 nonsurvival and eight survival). After the peritoneal cavity had been accessed via the rectosigmoid, the gastroesophageal junction (GEJ) was laid open using conventional endoscopic instruments. Thereafter, a transcutaneously introduced hook was used for tunneling and lifting of the distal esophagus. Finally, an antireflux ring was placed around the cardia. Animals were observed over 10 days in the survival series. Correct application of the prosthesis, adverse events as a result of the procedure, and bacterial contamination were evaluated by autopsy. The esophagogastric junction was strengthened by applying the ring prosthesis in 22 of 24 animals. Four bleeding episodes were observed, three of which were handled endoscopically. Correct placement of the prosthesis was accomplished in 21 of 22 animals. In the survival series, 1 pig died after transhiatal herniation of the stomach, and 1 pig suffered from peritonitis due to intraoperative contamination. In 7 of the 8 survival animals, no bacterial growth was noted by smear culture. The intervention had to be performed as a hybrid NOTES procedure in all cases. Exposure of the GEJ and placement of an antireflux prosthesis via a hybrid NOTES procedure is feasible, despite some complications. This approach may be considered as a basis for optimization and further development of pure NOTES antireflux procedures.

Mdct Diagnosis Of Isolated Colonic Hernia Through The Esophageal Hiatus

Colonic herniation through the esophageal hiatus is an unusual condition. Isolated trans-hiatal herniation of the transverse colon is very rare and only five cases have been reported. All these reported patients were symptomatic, and had dysphagia, epigastralgia, vomiting, dyspnea, cough, or palpitations. Hiatal hernia is an important clinical problem. Because of the severe complications of hiatal hernia, including bleeding, strangulation, and perforation, early diagnosis and treatment are important. A 75-year-old man who had prostate carcinoma was evaluated with multidetector computed tomography (MDCT). In this case, CT findings and clinical emphasis of the incidentally discovered isolated transverse colonic hiatal herniation was reviewed.

Early colonic transhiatal herniation and anastomotic leak after Ivor Lewis esophagectomy

Transhiatal herniation of the abdominal organs is a rare complication after esophagectomy. Surgical treatment is usually mandatory because of the high mortality associated with this condition. We present a case of colonic herniation that could contribute to failure of the esophagogastric anastomosis. Repair of both problems was performed through a right posterior thoracotomy.

Total oesophagogastric dissociation: experience in 2 centres

Background/Purpose Neurologically impaired (NI) children have an increased incidence of gastroesophageal reflux and many will require surgery. Methods The case notes of 50 NI children who underwent total oesophagogastric dissociation (TOGD) were reviewed. Thirty-four were done as a primary procedure, and 16 were rescues for failed fundoplications. Results There was no operative mortality. Morbidity consisted of 1 subphrenic collection, 1 oesophagojejunal dehiscence and 2 stenoses that responded to dilatation, and 2 bowel obstructions. In 1 case, partial gastric resection was needed because of transhiatal herniation of stomach. Gastrostomy feeding was established by 3 to 5 days. The mean hospital stay was 10.9 days. At 4 months to11 years of follow-up, there was no recurrence of reflux. Children who could swallow enjoyed oral feeds. Their general health and weight SD scores improved. Food aspiration, chest infections, and hospitalizations were reduced, with an improvement in quality of life. There were 5 late deaths in the “primary” and 7 in the “rescue” group from deterioration in their original condition. Conclusion Total oesophagogastric dissociation is a safe and versatile procedure without immediate mortality and limited surgery-related morbidity. Review of our practice suggests TOGD should be considered as a primary procedure in severely NI children with gastroesophageal reflux and significant oropharyngeal incoordination and dependence on enteral tube feeding. Rescue TOGD carries a greater morbidity because of previous surgery with consequent difficult dissection, poor oesophageal tissue, and higher incidence of vagal nerve injury.

Outcome of laparoscopic Nissen fundoplication in patients with body mass index ≥35

To date, few studies have examined the effect of morbid obesity on the outcome of laparoscopic antireflux surgery and results have been conflicting. The aim of this work was to study the outcome of laparoscopic Nissen fundoplication (LNF) in patients with body mass index (BMI) >or= 35. We prospectively followed 70 patients (15 men, 55 women) with a proven diagnosis of gastroesophageal reflux disease (GERD) and a mean BMI of 38.4 +/- 0.5 (range, 35-51) who underwent LNF. All patients underwent 24-h pH study, esophageal manometry, upper gastrointestinal (GI) endoscopy, and GERD symptom score before and 6 months after LNF. Surgical outcomes were compared to those of 70 sequential nonobese patients (BMI < 30) who also underwent LNF. LNF was completed laparoscopically in 69 of 70 patients in the morbidly obese (MO) group and in all 70 patients in the normal-weight (NW) group. The mean operative time for the MO group was not significantly longer than that for the NW group (55.9 +/- 2.3 min vs 50.0 +/- 2.1 min), but the mean length of stay was significantly longer (3.17 +/- 0.2 days vs 2.2 +/- 0.1 days, p < 0.0001) in the MO group. There was one postoperative complication (a transhiatal herniation of the stomach) in the morbidly obese group. In both patient groups, LNF resulted in a significant increase in lower esophageal sphincter (LES) pressures. This was associated with a significant decrease in percent acid reflux in 24-h testing and a significant improvement in GERD symptom score in both groups, although patients in the MO group had a significantly higher mean reflux symptom score after surgery than did those in the NW group. After a mean follow-up of 41.6 +/- 2.9 months, one patient in the MO group required reoperation and one proton pump inhibitor therapy (PRN PPI), as required. Morbid obesity does not adversely affect the outcome of LNF. The conversion rate is low when performed by an experienced surgeon.

Hernie diaphragmatique après œsophagectomie : à propos de deux cas et revue de la littérature

Diaphragmatic herniation of is uncommon after esophagectomy. The aim of this study was to report two cases of transhiatal herniation following esophagectomy, to analyse the contributing factors of this complication and to expose the preventive treatment, by means of a review of the litterature.

Discussion

Transhiatal herniation of colon is uncommon after transhiatal esophagectomy. Two patients with this complication are presented. Presenting symptoms vary depending on the size and contents of the hernia. Patients may be asymptomatic. The diagnosis is suggested by plain chest radiography, and treatment, in symptomatic patients, is surgical reduction of the hernia via a laparotomy.

Transhiatal Herniation of Colon After Esophagectomy and Gastric Pull-up

Transhiatal herniation of colon is uncommon after transhiatal esophagectomy. Two patients with this complication are presented. Presenting symptoms vary depending on the size and contents of the hernia. Patients may be asymptomatic. The diagnosis is suggested by plain chest radiography, and treatment, in symptomatic patients, is surgical reduction of the hernia via a laparotomy.(Ann Thorac Surg 1997;63:554–6)

Colonic interposition: radiographic evaluation.

This report reviews the clinical and radiographic features of 40 patients who underwent visceral esophageal substitution with colon for benign or malignant lesions of the esophagus. The incidence and radiographic identification of complications are discussed. All patients were routinely examined with barium esophagrams on postoperative day 10. If an anastomotic leak was suspected clinically before this time, studies were performed using water-soluble iodinated contrast material. Follow-up barium esophagrams were obtained 1-96 months after operation (average, 60 months) in 24 patients. Eight patients (21%) demonstrated asymptomatic "jejunization" of the colonic mucosa with no attributable clinical manifestations; this finding resolved in 1-3 months, without sequelae, and has not been reported before. The spectrum of ischemic changes in the colonic segment included mucosal edema, spasm, ulceration, loss of haustration, and frank necrosis. Radiographically detectable early postoperative complications included anastomotic leak in six (three pharyngocolic, three cervical esophagocolic) and aspiration of barium into the tracheobronchial tree due to incoordinated swallowing in eight. Late postoperative complications included anastomotic narrowing (12) malfunctioning of the colon due to impaired emptying (five), recurrent aspiration pneumonia (three), small bowel obstruction (three), transhiatal herniation of small bowel through the diaphragmatic hiatus (one), and reflux into the retained bypassed esophagus (one).