Surgical Management of Persistent or New Symptoms After Hiatal Hernia Repair.

Following a hiatal hernia repair, patients can present with recurrent or new symptoms. Symptoms can occur anywhere from weeks to years after surgery. These may include recurrent reflux, dysphagia, regurgitation, weight loss, or deteriorating quality of life. While nonoperative management can be pursued in some patients, reoperation may be the only option in select patients. A thorough preoperative workup, including a repeat esophagram, upper endoscopy, +/- chest computed tomography (CT) scan, manometry, pH probe, and/or gastric emptying study, is warranted to better understand the pathophysiology of the presenting symptoms. If a recurrent hernia, slipped, or migrated wrap is identified, surgery is considered. Pseudoachalasia must also be ruled out if obstructive symptoms are observed at the hiatus. Such an exhaustive workup is indeed necessary to ensure accurate diagnosis and optimal outcome. In addition, an understanding of the factors that may have led to the recurrence will increase the chances of a successful reoperation. Although a technically demanding procedure, redo hiatal hernia repair utilizing a minimally invasive approach is increasingly being employed with promising outcomes. Herein, the steps of a redo hiatal hernia repair via a minimally invasive approach will be outlined and detailed.

Repair of type II paraesophageal hernia with Nissen fundoplication in a patient with von Willebrand disease and spondylolisthesis - a clinical case report.

Hiatal hernias continue to be fairly common in clinical practice. However, the variety of different symptoms presented by patients may hinder establishing the ultimate diagnosis. Nevertheless, currently, the diagnosis of hiatal hernia can be easily established, based on barium swallow radiography. We would like to present a clinical case report of a patient with complex medical history, including von Willebrand disease, degenerative spinal disease, and chronic sinusitis, who was finally diagnosed with hiatal hernia and treated with a standard laparoscopic Nissen fundoplication. Our case focuses on the significance of comorbidities on patients' symptoms, which sometimes may mislead the therapeutic process.

Self-reducing intrathoracic organo-axial gastric volvulus with paraoesophageal hiatus hernia in a toddler.

A toddler presented with complaints of multiple episodes of vomiting lasting 1 week. He had a history of similar episodes of vomiting several times as an infant. Clinically, he was underweight and had tachypnoea and tachycardia. Laboratory investigations revealed hyponatraemic metabolic acidosis. His chest radiograph revealed an intrathoracic herniation of the stomach with an atypical presence towards the right hemithorax, suggestive of a torsion. A contrast-enhanced CT of the chest and abdomen confirmed an intrathoracic gastric herniation, with an organo-axial gastric volvulus, with no features of strangulation. He underwent an emergency laparotomy and intraoperatively the stomach was found to have reduced to its intra-abdominal position, and the hernia and volvulus had also self-reduced. In view of the multiple symptomatic episodes, an anterior gastropexy was performed to prevent recurrences. The patient recuperated well and has not had any recurrences in the follow-up period. This report adds to the minimalistic literature.

Diagnostic Workup and Therapeutic Intervention of Hiatal Hernias Discovered as Incidental Findings on Computed Tomography.

BACKGROUND: Computed tomography imaging routinely detects incidental findings; most research focuses on malignant findings. However, benign diseases such as hiatal hernia also require identification and follow-up. Natural language algorithms can help identify these non-malignant findings. METHODS: Imaging of adult trauma patients from 2010 to 2020 who underwent CT chest/abdomen/pelvis was evaluated using an open-source natural language processor to query for hiatal hernias. Patients who underwent subsequent imaging, endoscopy, fluoroscopy, or operation were retrospectively reviewed. RESULTS: 1087(10.6%) of 10 299 patients had incidental hiatal hernias: 812 small (74.7%) and 275 moderate/large (25.3%). 224 (20.7%) had subsequent imaging or endoscopic evaluation. Compared to those with small hernias, patients with moderate/large hernias were older (66.3 ± 19.4 vs 79.6 ± 12.6 years, P < .001) and predominantly female (403[49.6%] vs 199[72.4%], P < .001). Moderate/large hernias were not more likely to grow (small vs moderate/large: 13[7.6%] vs 8[15.1%], P = .102). Patients with moderate/large hernias were more likely to have an intervention or referral (small vs moderate/large: 6[3.5%] vs 7[13.2%], P = .008). No patients underwent elective or emergent hernia repair. Three patients had surgical referral; however, only one was seen by a surgeon. One patient death was associated with a large hiatal hernia. CONCLUSIONS: We demonstrate a novel utilization of natural language processing to identify patients with incidental hiatal hernia in a large population, and found a 10.6% incidence with only 1.2%. (13/1087) of these receiving a referral for follow-up. While most incidental hiatal hernias are small, moderate/large and symptomatic hernias have high risk of loss-to-follow-up and need referral pipelines to improve patient outcomes.

High-resolution 3-dimensional tomography may be a useful tool for understanding the anatomy of hiatal hernias and surgical planning of patients eligible for laparoscopic or robotic antireflux surgery.

BACKGROUND: 3D computed tomography (CT) has been seldom used for the evaluation of hiatal hernias (HH) in surgical patients. This study aims to describe the 3D CT findings in candidates for laparoscopic or robotic antireflux surgery or HH repair and compare them with other tests. METHODS: Thirty patients with HH and/or gastroesophageal reflux disease (GERD) who were candidates for surgical treatment and underwent high-resolution CT were recruited. The variables studied were distance from the esophagogastric junction (EGJ) to the hiatus; total gastric volume and herniated gastric volume, percentage of herniated volume in relation to the total gastric volume; diameters and area of the esophageal hiatus. RESULTS: HH was diagnosed with CT in 21 (70%) patients. There was no correlation between the distance EGJ-hiatus and the herniated gastric volume. There was a statistically significant correlation between the distance from the EGJ to the hiatus and the area of the esophageal hiatus of the diaphragm. There was correlation between tomographic and endoscopic findings for the presence and size of HH. HH was diagnosed with manometry in 9 (50%) patients. There was no correlation between tomographic and manometric findings for the diagnosis of HH and between hiatal area and lower esophageal sphincter basal pressure. There was no correlation between any parameter and DeMeester score. CONCLUSIONS: The anatomy of HH and the hiatus can be well defined by 3D CT. The EGJ-hiatus distance may be equally measured by 3D CT or upper digestive endoscopy. DeMeester score did not correlate with any anatomical parameter.

Relief of Obstructive Shock with a Large Hiatal Hernia Occupying the Posterior Mediastinum by Urgent Endoscopy.

A 78-year-old man was admitted to our hospital with obstructive shock caused by a large hiatal hernia that occupied the posterior mediastinum. Tension gastro-duodenothorax was detected in his stomach and duodenum, and we performed urgent endoscopy to relieve shock. Large hiatal hernia occasionally leads to cardiac failure. This is the first reported use of urgent endoscopy to treat a large hiatal hernia.

Diagnostic Dilemma of Syncope: Esophageal Hiatal Hernia and High-risk Bundle-branch Block.

We herein report a complicated case of recurrent syncope accompanying bundle branch block and hiatal hernia of the esophagus. An 83-year-old woman presented with syncope. Echocardiography visualized the left atrium compressed by an esophageal hiatal hernia, which had potential to decrease the cardiac output. Although she underwent esophageal repair surgery, two months after the surgery, she presented to the emergency department again with complaints of syncope. At the return visit, her face was pale and her pulse rate was 30 beats per minute. Electrocardiography showed complete atrioventricular block. On reviewing the patient's previous electrocardiography findings, we found a record of trifascicular block. This case illustrates the importance of predicting atrioventricular blocks in patients with high-risk bundle-branch blocks. Keeping in mind high-risk bundle-branch blocks will help clinicians avoid anchoring bias due to a striking image masquerading as the true diagnosis.

Hiatal Hernia Repair: Can We Predict the Need for Mesh?

Introduction: The use of mesh for paraesophageal hernia repair is controversial due to concerns about long-term complications. This study aimed to investigate whether preoperative imaging characteristics of diaphragmatic hernia could predict the need for mesh repair. Methods: The records of all patients who underwent laparoscopic diaphragmatic hernia repair between September 2015 and September 2022 were reviewed. Patients' preoperative computerized tomography (CT) imaging was reviewed and was correlated with mesh repair. Results: A total of 53 patients were included in the study. Volumetric measurements were obtained from preoperative CT scans to assess hiatal defect area (HDA) and hernia sac volume (HSV). Mesh repair was required in 43.4% of cases, all among types II-IV. The mesh repair group had a higher mean hiatal neck height (50.8 ± 16.35 versus 43.22 ± 17.08 mm, P < .032) and higher HSV (708.53 ± 577.6 versus 346.866 ± 321.65 cm3, P < .003). There was also a borderline difference in HDA mean values (23.78 ± 17.22 versus 16.8 ± 10.41 cm2, P < .059). Conclusions: Preoperative HSV on CT scans can be a valuable predictor for the need for mesh repair during hiatal hernia surgery, aiding surgical planning and decision-making. Further research is needed to validate these findings and optimize hernia repair outcomes.

Visualization of deglutition and gastroesophageal reflux using real-time MRI: a standardized approach to image acquisition and assessment.

This study aims to develop a standardized algorithm for gastroesophageal image acquisition and diagnostic assessment using real-time MRI. Patients with GERD symptoms undergoing real-time MRI of the esophagus and esophagogastric junction between 2015 and 2018 were included. A 10 ml bolus of pineapple juice served as an oral contrast agent. Patients performed Valsalva maneuver to provoke reflux and hiatal hernia. Systematic MRI assessment included visual presence of achalasia, fundoplication failure in patients with previous surgical fundoplication, gastroesophageal reflux, and hiatal hernia. A total of 184 patients (n = 92 female [50%], mean age 52.7 ± 15.8 years) completed MRI studies without adverse events at a mean examination time of 15 min. Gastroesophageal reflux was evident in n = 117 (63.6%), hiatal hernia in n = 95 (52.5%), and achalasia in 4 patients (2.2%). Hiatal hernia was observed more frequently in patients with reflux at rest (n = 67 vs. n = 6, p < 0.01) and during Valsalva maneuver (n = 87 vs. n = 8, p < 0.01). Real-time MRI visualized a morphologic correlate for recurring GERD symptoms in 20/22 patients (90%) after fundoplication procedure. In a large-scale single-center cohort of patients with GERD symptoms undergoing real-time MRI, visual correlates for clinical symptoms were evident in most cases. The proposed assessment algorithm could aid in wider-spread utilization of real-time MRI and provides a comprehensive approach to this novel imaging modality.

Chronic Intrathoracic Gastric Volvulus Management: Could Less Be More?

Gastric volvulus is a rare medical condition that necessitates a high suspicion index to diagnose. Acute gastric volvulus will often present with nonspecific but severe symptoms of abdominal pain, nausea, vomiting, and in some instances, evidence of organ ischemia. In this case report, we present an 88-year-old woman who was admitted after a mechanical fall. On the third day of hospitalization, she complained of new-onset epigastric pain, nausea, and vomiting. Imaging demonstrated nonobstructed intrathoracic organo-axial gastric volvulus. Given the patient's significant comorbidities, surgical and endoscopic interventions were deemed high-risk (high risk of anesthesia and gastric perforation, respectively). This report evaluates the role of noninterventional conservative management in high-risk surgical patients with symptomatic acute and acute-on-chronic intrathoracic gastric volvulus. The present case and the current literature review suggest that supportive management may be appropriate to control disease symptoms, although it does not alter the disease's natural history, progression, and recurrence.

Laparoscopic Paraesophageal Hernia Repair With Nissen Fundoplication in a Patient With Ancient Schwannoma of the Gastroesophageal Junction.

Schwannomas are mostly benign tumors that originate from Schwann cells and are rarely seen in the gastrointestinal tract. Our patient is a 65-year-old female who was found to have a 1.5 cm lesion at the gastroesophageal junction, which was clipped and excised on endoscopy. Histologic examination demonstrated an ancient schwannoma. Two years afterward, she presented to our clinic for a large type III paraesophageal hernia. We took her to the operating room for a laparoscopic paraesophageal hernia repair and Nissen fundoplication. We performed an upper endoscopy during the case and found no recurrence of the ancient schwannoma. The case progressed well without complications. She was discharged on postoperative day 1 after tolerating a pureed diet and reported no issues in follow-up. In summary, we demonstrate a successful surgical outcome in a patient who had undergone resection of this rare tumor 2 years prior to her surgery.

Pseudo-hyperacute T Waves in a Giant Hiatal Hernia.

An 89-year-old woman with a giant hiatal hernia complained of persistent chest pain. An electrocardiogram (ECG) showed hyperacute T waves, suggesting the early phase of ST-elevation myocardial infarction. After endoscopic drainage for hiatal hernia, the chest pain disappeared, and the ECG abnormalities resolved. The present case illustrates that compression of the heart by a giant hiatal hernia can induce T wave elevation mimicking acute coronary syndrome.