Gastric perforation secondary to incarcerated para-esophageal hiatal hernia in a French bulldog.

A 6-month-old, intact female, French bulldog was presented to the Emergency Department for evaluation of vomiting and diarrhea over the preceding week which had not responded to supportive medical therapy. Imaging studies identified an incarcerated para-esophageal hernia with peritoneal effusion and gas consistent with gastrointestinal perforation. Following stabilization, the dog underwent an exploratory laparotomy which confirmed an incarcerated hiatal hernia and gastric perforation. A gastrectomy was performed to repair the defect, and to prevent recurrence both a herniorrhaphy and esophagopexy were performed. Post-operative care required treatment for septic shock including vasopressor and hydrocortisone infusions and plasma transfusions for colloidal support. The patient was successfully discharged 4 days after surgery. The histopathology results identified spiral bacteria consistent with Helicobacter spp. which was subsequently treated with oral antibiotics and a proton pump inhibitor. The dog has had no further gastrointestinal signs in the 90 days since surgery. Gastric perforation and peritonitis can occur secondary to an incarcerated esophageal hiatal hernia, and if treated promptly can result in a successful outcome. This case demonstrates a novel etiology of gastric perforation which may be associated with brachycephalic breeds.

Une femelle bouledogue français intacte de 6 mois a été présentée au service des urgences pour une évaluation des vomissements et de la diarrhée au cours de la semaine précédente qui n'avaient pas répondu à un traitement médical de soutien. Les études par imagerie ont identifié une hernie para-œsophagienne incarcérée avec un épanchement péritonéal et des gaz compatibles avec une perforation gastro-intestinale. Après stabilisation, la chienne a subi une laparotomie exploratoire qui a confirmé une hernie hiatale incarcérée et une perforation gastrique. Une gastrectomie a été réalisée pour réparer le défaut et pour prévenir les récidives, une herniorraphie et une œsophagopexie ont été réalisées. Les soins postopératoires ont nécessité un traitement pour choc septique comprenant des perfusions de vasopresseurs et d'hydrocortisone et des transfusions de plasma pour le soutien colloïdal. La patiente a obtenu son congé avec succès 4 jours après la chirurgie. Les résultats d'histopathologie ont identifié des bactéries en spirale compatibles avec Helicobacter spp. qui a ensuite été traité avec des antibiotiques oraux et un inhibiteur de la pompe à protons. La chienne n'a plus eu de signes gastro-intestinaux dans les 90 jours qui ont suivi la chirurgie.Une perforation gastrique et une péritonite peuvent survenir à la suite d'une hernie hiatale oesophagienne incarcérée et, si elles sont traitées rapidement, peuvent donner un résultat positif. Ce cas démontre une nouvelle étiologie de perforation gastrique qui peut être associée aux races brachycéphales.(Traduit par Docteur Serge Messier).

Pancreatic herniation: a large pancreatic mass concealed within the intrathoracic cavity.

Cancer of unknown primary is a challenging entity. We present an elderly woman with metastatic cancer of unknown primary despite comprehensive imaging and immunohistochemical analysis. Based on a thorough history, a gastrointestinal source was suspected and a diagnosis of pancreatic cancer concealed within a type IV hiatal hernia was made using multimodal imaging. On review of prior imaging, due to the highly complex anatomy within our patient's hiatal hernia, the pancreatic mass was retroactively noted. While initial imaging may detect metastatic disease, identifying the primary malignancy requires a thorough history and physical examination, multimodal imaging where malignancy is suspected, and immunohistochemical analysis of metastatic deposits. Herniation of pancreatic cancer has not been previously described in the literature and serves as an important reminder of the importance of multimodal imaging in patients with significantly complex anatomy.

The structural and functional workings of KEOPS.

KEOPS (Kinase, Endopeptidase and Other Proteins of Small size) is a five-subunit protein complex that is highly conserved in eukaryotes and archaea and is essential for the fitness of cells and for animal development. In humans, mutations in KEOPS genes underlie Galloway-Mowat syndrome, which manifests in severe microcephaly and renal dysfunction that lead to childhood death. The Kae1 subunit of KEOPS catalyzes the universal and essential tRNA modification N6-threonylcarbamoyl adenosine (t6A), while the auxiliary subunits Cgi121, the kinase/ATPase Bud32, Pcc1 and Gon7 play a supporting role. Kae1 orthologs are also present in bacteria and mitochondria but function in distinct complexes with proteins that are not related in structure or function to the auxiliary subunits of KEOPS. Over the past 15 years since its discovery, extensive study in the KEOPS field has provided many answers towards understanding the roles that KEOPS plays in cells and in human disease and how KEOPS carries out these functions. In this review, we provide an overview into recent advances in the study of KEOPS and illuminate exciting future directions.

Estudio comparativo de precisión diagnóstica preoperatoria y la confirmación laparoscópica de hernia hiatal / Comparative study of preoperative diagnostic precision and laparoscopic confirmation of hiatal hernia

Resumen Introducción: La hernia hiatal (HH) de tipo I por deslizamiento es el tipo más frecuente, siendo difícil de definir objetivamente, por lo que el principal foco de controversia es su diagnóstico. El objetivo del presente trabajo es reportar los resultados respecto de la precisión diagnóstica del estudio preoperatorio y confirmarlo con el diagnóstico laparoscópico de este tipo de HH. Materiales y Método: Estudio prospectivo descriptivo de serie que incluyen pacientes con síntomas típicos de enfermedad por reflujo gastroesofágico, los cuales se sometieron a estudio con esófago-gastro-duodenoscopía, estudio manométrico y radiológico de esófago, estómago y duodeno con bario. Se incluyen sólo los pacientes en los cuales la endoscopía revela la existencia de HH por deslizamiento ≪ 5 cm. Estos pacientes se sometieron a tratamiento quirúrgico confirmándose o no la existencia de HH al momento de la exploración laparoscópica. Resultados: El valor predictivo positivo y sensibilidad para manometría fue de un 51,2% y 70%, para la radiología 91,7% y 80,5% y para endoscopia 80,3% y 70,7% respectivamente. Conclusión: Para el diagnóstico confiable de HH antes del tratamiento, las tres investigaciones mencionadas deben ser obligatorias antes de la cirugía.

Introduction: Being type I hiatal hernia (HH) the most frequent, is difficult to define objectively and therefore, the main focus of controversy is the diagnosis. The aim of this paper is to report the results regarding the diagnostic accuracy of the preoperative study and to confirm it with the laparoscopic diagnosis of hiatal hernia. Materials and Method: This descriptive and prospective study includes patients with typical symptoms of gastroesophageal reflux disease who underwent esophageal-gastro-duodenoscopy, manometry and radiological study of esophagus with barium swallow. Only patients in whom endoscopy reveals the existence of HH by sliding ≪ 5 cm are included. These patients underwent surgical treatment confirming or not the existence of HH at the time of laparoscopic exploration. Results: The positive pre- dictive value and sensibility for manometry was 51.2% and 70%, for radiology 91.7% and 80.5%, and for endoscopy 85.3% and 70.7% respectively. Conclusion: For the reliable diagnosis of HH before treatment, the three mentioned investigations must be mandatory before the surgery.

Endoscopic Prediction for Acid Reflux in Patients without Hiatus Hernia.

Background/Aims: A diagnosis of gastroesophageal reflux disease is challenging in patients who have reflux symptoms but do not respond to proton pump inhibitors nor have reflux esophagitis and hiatal hernia (HH) on endoscopy. This study examined the predictive role of the endoscopic findings, including the flap valve grade for pathologic acid exposure (PAE) to establish an endoscopic prediction model in patients with neither reflux esophagitis nor HH. Methods: Five hundred seventy-eight patients who underwent upper endoscopy and 24 hours pH monitoring for reflux esophageal symptoms without evidence of reflux esophagitis and HH were analyzed. The gastroesophageal flap valve (GEFV), esophageal metaplasia, and chronic atrophic gastritis were assessed. The association between the endoscopic parameters and PAE was evaluated. Results: Four hundred ninety-four patients were enrolled. The most common complaint was chest discomfort (42.3%) followed by globus (31.8%), dysphagia (7.9%), and heartburn (7.7%). PAE was present in 43 patients (8.7%). Multivariable analysis revealed PAE to be associated with the GEFV grade (p<0.001) and inversely associated with the chronic atrophic gastritis grade (p=0.005). Using these features, a predictive model was established and showed an area under the receiver operating characteristic curve of 0.705 (95% CI 0.619-0.790). The cutoff value of 12.0 had a sensitivity and specificity of 44.0% and 84.0%, respectively. Conclusions: A loosened GEFV is associated with a risk of PAE in patients with neither reflux esophagitis nor HH, while atrophic gastritis is preventive. On the other hand, the endoscopic predictive model revealed a low sensitivity for detecting PAE. Thus, reflux testing needs to be performed further when gastroesophageal reflux disease is suspected, even without endoscopic evidence.

Anatomic Observation of Recurrent Hiatal Hernia: Recurrence or Disease Progression?

BACKGROUND: Recurrence after hiatal hernia repair is common. The causes are uncertain. Our observation is the site of recurrence is primarily the nonsutured or nonreinforced anterior-left lateral portion of the hiatus. Our aim was to assess the distribution of hiatal hernia recurrence location as a basis for developing a theory of recurrence. METHODS: Consecutive patients who underwent repair of recurrent hiatal hernias from March 2012 to December 2019 were reviewed. Data collected included age, sex, date of operation, location of hiatal hernia recurrence, operative approach, method of hiatal hernia repair, fundoplication performed, need for gastrectomy, and additional procedures. RESULTS: One hundred and eight consecutive patients were studied. The distribution of recurrence locations was as follows: anterior 67%, posterior 12%, and circumferential 21%. Foreshortened esophagus was a contributing factor in 12%. Median time from the original repair to recurrence was 1.5 years (interquartile range 0.9 to 3.75 years) for posterior recurrences, 2.75 years (interquartile range 1.15 to 8.5 years) for circumferential recurrences, and 3.25 years (interquartile range 1.38 to 10 years) for anterior recurrences. Recurrences were repaired in a variety of techniques, depending on the clinical circumstances. CONCLUSIONS: Hiatal hernia recurrences due to failure of the crural closure were less common, but early, recurrences. The majority of recurrences were due to stretching of the hiatus anterior and to the left of the esophagus. We theorize that the pathophysiology of late hiatal hernia recurrence is widening of the anterior and left lateral portion of the hiatus secondary to repeated stress from differential pressures that eventually overcomes the tensile strength of the hiatus.

Modern era surgical outcomes of elective and emergency giant paraesophageal hernia repair at a high-volume referral center.

INTRODUCTION: Repair of giant paraesophageal hernia (PEH) has historically been associated with significant morbidity and mortality such that elective repair is only offered to symptomatic patients. Recent reports suggest modern era outcomes have improved such that elective repair may now be safer than historically thought. Furthermore, the morbidity of emergency surgery may still be significant. These changes may have important implications for patient selection for elective repair. The objectives of this study were to determine and compare modern era surgical outcomes after elective and emergency repair of giant PEHs at a high-volume tertiary care center. METHODS: A retrospective review was conducted for all Type II-IV giant PEH repairs performed between 1 January 2012 and 31 December 2017. Type 1 hiatal hernias, fundoplication for reflux, and any co-surgery other than cholecystectomy were excluded from the final analysis. Baseline patient demographics, operative details, postoperative complications within 30 days and in-hospital or 30-day mortality were tabulated from the electronic medical record. Data were reported as median (interquartile range) unless otherwise specified. RESULTS: A total of 352 cases were reviewed, of which 204 met inclusion criteria (18 emergency, 186 elective). Eight had Type II PEH, 146 had Type III, and 50 had Type IV. Median length of stay was shorter in the elective group [1 (1) day elective vs. 5 (7) days emergency, p < 0.0001], and emergency patients were less likely to return directly to their original residence at discharge (13, 72% emergency vs 185, 99.4% elective, p < 0.0001). There were significantly more major complications (Clavien-Dindo score ≥ 3) in the emergency group (5, 28% emergency vs. 10, 5% elective, p = 0.005). There were no perioperative deaths in either group. Morbidity and mortality in both groups were less than historically reported. CONCLUSIONS: Informed consent discussions and patient selection for repair of giant PEHs should reflect modern era and institution-specific outcomes.

Asymmetrical elevation of esophagogastric junction pressure suggests hiatal repair contributes to antireflux surgery dysphagia.

The radial distribution of esophago-gastric junction (EGJ) pressures with regard to troublesome dysphagia (TDysph) after antireflux surgery is poorly understood. Before and after antireflux surgery, end-expiratory and peak-inspiratory EGJ pressures were measured at eight angles of 45° radial separation in patients with reflux disease. All 34 patients underwent posterior crural repair, then either 90° anterior (N = 13) or 360° fundoplication (N = 21). Dysphagia was assessed prospectively using a validated questionnaire (score range 0-45) and TDysph defined as a dysphagia score that was ≥5 above pre-op baseline. Compared with before surgery, for 90° fundoplication, end-expiratory EGJ pressures were highest in the left-anterolateral sectors, the position of the partial fundoplication. In other sectors, pressures were uniformly elevated. Compared with 90° fundoplication, radial pressures after 360° fundoplication were higher circumferentially (P = 0.004), with a posterior peak. Nine patients developed TDysph after surgery with a greater increase in end-expiratory and peak-inspiratory EGJ pressures (P = 0.03 and 0.03, respectively) and significantly higher inspiratory pressure at the point of maximal radial pressure asymmetry (P = 0.048), compared with 25 patients without TDysph. Circumferential elevation of end-expiratory EGJ pressure after 90° and 360° fundoplication suggests hiatal repair elevates EGJ pressure by extrinsic compression. The highly localized focal point of elevated EGJ pressure upon inspiration in patients with TDysph after surgery is indicative of a restrictive diaphragmatic hiatus in the presence of a fundoplication.

The other explanation for dyspnea: giant paraesophageal hiatal hernia repair routinely improves pulmonary function.

Paraesophageal hiatal hernias (PEHs) are most commonly associated with gastrointestinal symptoms; less widely appreciated is their potentially important influence on respiratory function. We hypothesize that surgical repair of PEH will significantly improve not only gastrointestinal symptoms, but also preoperative dyspnea and spirometry scores. A prospective Institutional Review Board-approved database was used to review all patients undergoing PEH repair from 2000 to 2016. Patients with pre- and postoperative pulmonary function tests assessed by spirometry were included. Postoperative changes in spirometry measurements were compared to PEH size as reflected by the percentage of intrathoracic stomach observed on preoperative contrast studies. Patients were stratified according to improvement in forced expiratory volume in 1 second (FEV1). Patients with >12% ('significant') improvement in FEV1 after surgery were compared to the remaining patient population. In total, 299 patients met the inclusion criteria. Symptomatic improvement in respiratory function was noted in all patients after PEH repair. Age, gender, BMI, presenting symptoms, Charlson comorbidity index as well as preoperative comorbidities did not significantly impact the functional outcome. Spirometry results improved in 80% of the patients, 21% of whom showed an improvement of >20% compared to the preoperative level. 'Significant' improvement in respiratory function was seen in 122 of 299 (41%) patients. Patients presenting with moderate and severe preoperative pulmonary obstruction demonstrated 'significant' improvement in FEV1 in 48% and 40% of cases, respectively. Large PEHs, characterized by a percentage of intrathoracic stomach >75%, was strongly associated with 'significant' improvement in FEV1 (P = 0.001). PEHs can impact subjective and objective respiratory status and surgical repair can result in a significant improvement in dyspnea and pulmonary function score that is independent of preoperative pulmonary disease. Gastric herniation of more than 75% was associated with higher possibility for improvement of pulmonary function tests. Patients with persistent and unexplained dyspnea and coexistent PEH should be assessed by an experienced surgeon for consideration of elective repair.

Gender Specific Differences in Prevalence and Risk Factors for Gastro-Esophageal Reflux Disease.

BACKGROUND: Gender-related factors might play an important role in the development of reflux esophagitis (RE) and symptomatic gastro-esophageal reflux disease (GERD). We aimed to evaluate the prevalence and risk factors for RE and symptomatic GERD and determine whether gender specific differences exist. METHODS: This study was conducted on a health cohort consisting of 10,158 participants who underwent comprehensive health screening. Lifestyles and gastrointestinal symptoms were investigated using a self-reported structured questionnaire. Questionnaires about menstrual status were added for the women. RESULTS: The prevalence of RE in men was significantly higher than that in women (10.6% vs. 2.0%, P < 0.001); however, symptomatic GERD showed predominance in women (6.2% vs. 2.5%, P < 0.001). Although the prevalence of RE gradually increased with the duration of menopause stratified by decade (P = 0.007), that of symptomatic GERD rapidly increased across the menopausal transit in women. Apart from common risk factors of obesity and current smoking for RE, over 70 years of age in women and hiatal hernia and hypertriglyceridemia in men were significant risk factors. In symptomatic GERD, high somatization was a common risk factor. Excessive alcohol drinking was a significant risk factor in men, but not in women. CONCLUSION: This study showed a predominance of RE in men, but a predominance of symptomatic GERD in women. In women, dynamic increase in the prevalence of GERD is closely related to the menopause conditions and its duration. There are specific risk factors for RE and symptomatic GERD according to gender differences.

Giant hiatal hernias.

Dyspnoea is most often caused by disorders of the respiratory and/or cardiovascular systems. Much less often it is brought about by the displacement of abdominal organs into the thoracic cage. Hiatal hernias may give rise to diagnostic difficulties, as both clinical and radiological symptoms suggest different disorders. Computed tomography is the method of choice when making a diagnosis. We have presented a series of 7 cases of giant hiatal hernias, each with a varying course of the disease, clinical symptoms, radiological features and prognoses. In two of the cases, the hernias were of a post-traumatic nature. Four cases of large diaphragmatic hernias were found in elderly patients (over 90 years old). An advanced age and numerous coexisting chronic diseases disqualified most of the patients from surgical treatment despite the hernias' large sizes. In only one case was fundoplication performed with a good end result. Two patients died, and an extensive hernia was the cause of one of the deaths. Upper gastrointestinal symptoms were present only in a few of the patients. An early diagnosis of giant hiatal hernia is crucial for the patients to undergo prompt corrective surgeries.

Life-threatening bleeding for a large cameron ulcer. A novel description of a tailored-surgical strategy: report of a case and literature overview.

Hiatal hernias (HHs) are usually divided into two main groups: sliding and para-esophageal (torsional) ones. Sometimes patients presenting HHs experience progressive anemia, whereas rarely an acute anemia with melena or hematemesis can occur. In such cases a Cameron ulcer should be suspected and a careful esophago-gastro-duodenoscopy (EGDS) with a meticulous inspection of the mucosal folds along the neck of the hernia is the best examination in order to find out the ulcer itself. In front of massive hemorrhage due to a Cameron erosion, the first aim should be the control of the bleeding itself, in order to ree1Romastablish hemodynamic stability. The Authors report the case of a 72-year-old man presenting a severe bleeding secondary to a large Cameron ulcer in a para-esophageal hiatal hernia. Firstly, a combined medical-endoscopic therapy was tried; the patient underwent transfusions of pooled red blood cells and endovenous anti-acid therapy combined with an operative endoscopic treatment; unfortunately this initial approach failed, therefore the patient was referred to surgery. The surgeons realized a minimally invasive atypical gastric resection associated with the HH repair; the post-operative course was uneventful and no other rebleeding episodes occurred. The urgency treatment of a life-threatening bleeding for Cameron ulcers remains a very challenging problem as no univocal and standardized recommendation has been described in literature since now. In this case-report the Authors make an overview of the current literature on the treatment of Cameron ulcers, describing a novel surgical technique for massive upper gastro-intestinal bleeding secondary to these lesions.

Homozygous splicing mutation in NUP133 causes Galloway-Mowat syndrome.

OBJECTIVE: Galloway-Mowat syndrome (GAMOS) is a neural and renal disorder, characterized by microcephaly, brain anomalies, and early onset nephrotic syndrome. Biallelic mutations in WDR73 and the 4 subunit genes of the KEOPS complex are reported to cause GAMOS. Furthermore, an identical homozygous NUP107 (nucleoporin 107kDa) mutation was identified in 4 GAMOS-like families, although biallelic NUP107 mutations were originally identified in steroid-resistant nephrotic syndrome. NUP107 and NUP133 (nucleoporin 133kDa) are interacting subunits of the nuclear pore complex in the nuclear envelope during interphase, and these proteins are also involved in centrosome positioning and spindle assembly during mitosis. METHODS: Linkage analysis and whole exome sequencing were performed in a previously reported GAMOS family with brain atrophy and steroid-resistant nephrotic syndrome. RESULTS: We identified a homozygous NUP133 mutation, c.3335-11T>A, which results in the insertion of 9bp of intronic sequence between exons 25 and 26 in the mutant transcript. NUP133 and NUP107 interaction was impaired by the NUP133 mutation based on an immunoprecipitation assay. Importantly, focal cortical dysplasia type IIa was recognized in the brain of an autopsied patient and focal segmental glomerulosclerosis was confirmed in the kidneys of the 3 examined patients. A nup133-knockdown zebrafish model exhibited microcephaly, fewer neuronal cells, underdeveloped glomeruli, and fusion of the foot processes of the podocytes, which mimicked human GAMOS features. nup133 morphants could be rescued by human wild-type NUP133 mRNA but not by mutant mRNA. INTERPRETATION: These data indicate that the biallelic NUP133 loss-of-function mutation causes GAMOS. Ann Neurol 2018;84:814-828.

GERD: Presence and Size of Hiatal Hernia Influence Clinical Presentation, Esophageal Function, Reflux Profile, and Degree of Mucosal Injury.

A hiatal hernia (HH) is a frequent finding in patients with gastroesophageal reflux disease (GERD). We examined a consecutive series of patients with GERD diagnosed by a 24-hour pH monitoring. Based on the presence and size of HH on barium swallow, patients were divided into the following groups: no HH, HH <3 cm, HH 3-5 cm and HH >5 cm. A total of 175 patients were included: 43 with no HH, 86 with HH <3 cm, 34 with HH 3-5 cm, and 12 with HH >5 cm. Patients with larger HH had more frequent episodes of coughing and wheezing associated with episodes of reflux. High-resolution manometry showed that the increasing size of the HH was associated with decreasing pressure of the lower esophageal sphincter and weaker peristalsis. Ambulatory pH monitoring revealed that patients with larger HH had more acid reflux, in both the distal and proximal esophagus. Endoscopy showed that patients with larger HH had more severe esophagitis. Fifty per cent of patients with HH >5.0 cm had Barrett's esophagus. These findings should guide gastroenterologists and surgeons in choosing the appropriate therapy in patients with GERD and large HH.

Videoesophagography versus Endoscopy for Prediction of Intraoperative Hiatal Hernia Size.

Magnetic sphincter augmentation is a novel surgical procedure for gastroesophageal reflux disease. Limited dissection at the hiatus is one of the benefits of the procedure, but makes precise and accurate preoperative assessment of even small hiatal hernia critical. Retrospective cohort study of 136 patients having undergone both endoscopy (EGD) and videoesophagography followed by operative assessment for hiatal hernia during magnetic sphincter augmentation. The objective of the study is to determine which preoperative modality more accurately predicts operative hiatal hernia size. Videoesophagography underestimated operative measurement by 0.37 ± 1.41 cm (P = 0.003) and was less accurate in predicting intraoperative hiatal hernia size than EGD on linear regression analysis (ß -0.729, SE 0.057, P < 0.001). EGD was less accurate at predicting hiatal hernia size as patient age increased (ß -0.018, SE 0.007, P = 0.014) and with larger hernias (ß -0.615, standard error (SE) 0.067, P < 0.001); however, endoscopic measurements did not differ significantly from intraoperative measurements (0.93 ± 1.23 cm vs 1.12 ± 1.43 cm, P = 0.12). EGD better predicts the size of small hiatal hernia measured during subsequent laparoscopic surgery.

Rare Entities of Histopathological Findings in 755 Sleeve Gastrectomy Cases: a Synopsis of Preoperative Endoscopy Findings and Histological Evaluation of the Specimen.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is the most preferred technique in morbidly obese patients for weight loss. There is a controversy about the routine preoperative evaluation of the stomach and the routine microscopic examination of all LSG specimens. Our aim is to analyze the results of both preoperative upper gastrointestinal endoscopy and endoscopic biopsies and also the results of histopathological examination of LSG specimens. MATERIALS AND METHODS: The data of patients who underwent LSG from January 2011 to November 2016 were analyzed retrospectively from a prospectively collected database. Seven hundred fifty five of 819 patients who met the inclusion criteria were included in this study. Data on patients' demographic variables [age, gender, BMI (kg/m2)], preoperative upper GI endoscopy and biopsy results, postoperative histopathological results of the specimens, and the process of the patients with malignant histopathological investigation in the follow-up period were collected. RESULTS: This study involves 755 patients with a mean age of 39.6 ± 11.7 years and has 496 (65.6%) to 259 (34.4%) female to male ratio. None of the patients harbored macroscopic or microscopic malignant pathological finding in the preoperative assessment. Hiatal hernia was detected in 78 (10.2%) patients and gastric/duodenal ulcers were detected in 52 (6.8%) patients in endoscopy. Incidental malignant and/or premalignant histopathological findings-intestinal metaplasia (1.4%) and malignant lesions (0.5%)-were rarely found in the evaluation of the surgical specimens. CONCLUSIONS: Both preoperative endoscopic assessment and postoperative histopathological examination of the specimen are mandatory in LSG patients.

Long-term clinical outcomes after intrathoracic stomach surgery: a decade of longitudinal follow-up.

BACKGROUND: A subset of patients with large paraesophageal hernias have more than 75% of the stomach herniated above the diaphragm; such cases are referred to as intrathoracic stomach (ITS). Herein, we report longitudinal symptomatic outcomes over a decade after surgical ITS repair in a large patient cohort. METHODS: Patients who underwent surgical treatment for ITS from 01/2004 to 05/2016 were studied. Preoperative and follow-up data were prospectively collected. Patients completed a standardized symptom questionnaire 1 year postoperatively and at 2-year intervals thereafter. RESULTS: In total, 235 patients were reviewed. The mean age was 70.0 ± 11.6 years; 174 patients (74.0%) were women. Surgical procedures included 7 transthoracic repairs and 228 transabdominal repairs (222 laparoscopic, 2 open, 4 laparoscopic-to-open conversions). Anti-reflux procedures were performed in 173 patients (73.6%). 33 patients (14.0%) had mesh reinforcement of hiatal closure; 11 (4.7%) underwent Collis gastroplasty. Follow-up symptom questionnaires at 1, 3, 5, 7, 9, and 11 years were available for 81, 48, 47, 30, 33, and 38% of patients, respectively. Significant and lasting symptom improvement was reported at all follow-up time points. Mean satisfaction scores of 9.3, 9.1, 9.3, 9.0, 9.5, and 9.8 on a 1-10 scale were recorded at the aforementioned intervals. CONCLUSIONS: Long-term clinical outcomes confirm that laparoscopic ITS repair is safe and durable, and is associated with a high degree of patient satisfaction and symptom resolution.

Thoracic Endometriosis Syndrome Other Than Pneumothorax: Clinical and Pathological Findings.

BACKGROUND: Thoracic endometriosis syndrome refers to a broad spectrum of clinical manifestations related to the presence of ectopic intrathoracic endometrial tissue. Few studies have reported on manifestations other than pneumothorax. METHODS: Clinical, surgical, and pathology records of all consecutive women of reproductive age referred to our institution from September 2001 to August 2016 for clinically suspected thoracic endometriosis syndrome were retrospectively reviewed. After excluding women with pneumothorax, we enrolled 31 patients, divided into three subgroups: catamenial chest pain (n = 20), endometriosis-related diaphragmatic hernia (n = 6), and endometriosis-related pleural effusion (n = 5). RESULTS: Surgery was performed in 11 patients with catamenial thoracic pain (median age, 30 years; range, 23 to 42). Median pain intensity assessed on the 0 to 10 Visual Analogue Scale was 8 (range, 8 to 9) before surgery. At surgery, 8 patients had diaphragmatic endometriosis implants, which were resected with direct suture of diaphragm. At follow-up, median pain score was 3 (range, 0 to 8). In the group presenting with diaphragmatic hernia (median age, 36 years; range, 29 to 50), diaphragm was repaired by direct suture or placement of prosthesis in 4 and 2 cases, respectively. At follow-up, no sign of recurrent hernia was observed. Finally, among women with endometriosis-related pleural effusion (median age, 30 years; range, 25 to 42), surgical treatment was represented by evacuation of the pleural effusion and biopsy (n = 4) or removal (n = 1) of visible endometrial foci. CONCLUSIONS: Thoracic endometriosis syndrome is a poorly recognized entity responsible for various manifestations other than pneumothorax. In case of catamenial thoracic pain, diaphragmatic hernia and catamenial pleural effusion surgery should be advised in a multidisciplinary setting.

An alternative view on the necessity of EGD before sleeve gastrectomy.

BACKGROUND: Esophagogastroduodenoscopy (EGD) is particularly recommended for choosing a surgical method to be used with asymptomatic patients and for the assessment of symptomatic patients prior to sleeve gastrectomy. The presence of hiatal hernia, for instance, is a relative contraindication. EGD is used for malignancy scanning as well as surgical planning, but seems inefficient in determining postoperative complications. OBJECTIVE: Our aim was to investigate the effectiveness of the pathological evaluation of endoscopic biopsies obtained with esophagogastroduodenoscopy (EGD) according to Sydney classification prior to sleeve gastrectomy in identifying the risk of staple line leak, independently of clinical diagnosis. SETTING: Bakirköy Dr. Sadi Konuk Training and Research Hospital, Department of General Surgery. METHODS: Patients who underwent laparoscopic sleeve gastrectomy between January 2014-December 2016 received preoperative EGD as per the clinic's protocol and upon obtaining ethics board approval and patient consent. Biopsies were taken from the patients according to the Sydney protocol. The pathology results were examined retrospectively by considering the exclusion criteria. The results were given in line with the Sydney classification, and patients with and without Staple Line Leak were statistically compared. RESULTS: A total of 630 patients were enrolled in the study. Of these, 71.1% (n = 448) were female and 28.9% (n = 182) were male. Mean age was 38.9 years (17-68), mean body weight was 130.8kg (94-240) and body mass index (BMI) values were 47.4kg/m2 (36-106). In evaluation of median values, no statistically significant relationship was found between staple line leak and H. pylori occurrence grade (P = 0.438; P>0.05), activation grade (P = 0.568; P>0.05) or intestinal metaplasia grade (P = 0.319; P>0.05). Atrophy (P = 0.001; P<0.01) and chronic inflammation grade (P = 0.026; P<0.05) were significantly higher in Staple Line Leak patients. CONCLUSIONS: EGD prior to sleeve gastrectomy and biopsies obtained in line with the Sydney protocol predict Staple Line Leak risk.

The Importance of Age on Short-Term Outcomes Associated With Repair of Giant Paraesophageal Hernias.

BACKGROUND: Older patients have an increased incidence of paraesophageal hernia (PEH) and can be denied surgical assessment due to the perception of increased complications and mortality. This study examines the influence of age and comorbidities on early complications and other short-term outcomes of PEH repair. METHODS: From 2000 to 2016, data of surgically treated patients with PEH were prospectively recorded in an Institutional Review Board-approved database. Only patients whose hernia involved over 50% of the stomach were included. Patients were stratified by age (<70, 70 to 79, ≥80 years of age) and compared in univariate and multivariate analyses. RESULTS: Overall, 524 patients underwent surgical PEH repair (<70: 261 [50%]; 70 to 79: 163 [31%]; ≥80: 100 [19%]). Patients greater than or equal to 80 years of age had higher American Society of Anesthesiologists class, more comorbidities, larger hernias, and higher incidences of type IV PEH and acute presentation. Patients greater than or equal to 80 years of age had more postoperative complications, but not higher grade complications (Clavien-Dindo grade ≥IIIa). Median length of stay was 1 day longer for patients greater than or equal to 80 years of age (5 days versus 4 days for patients <70 and 70 to 79 years of age, respectively). Objective, radiologic hernia recurrence at 4.3 months postoperation was 17.3% and was not increased in the greater than or equal to 80 years of age group. After adjustment for comorbidities and other factors, age greater than or equal to 80 years was not a significant factor in predicting severe complications, readmission within 30 days, or early recurrence. CONCLUSIONS: PEH repair is safe in physiologically stable patients, irrespective of age. Incidence of complications is higher in older patients, but complication severity and mortality are similar to those of younger patients. Patients with giant PEH should be given the opportunity to review treatments options with an experienced surgeon.