Gangrene of the oesophago-gastric junction caused by strangulated hiatal hernia: operative challenge or surgical dead end.

BACKGROUND: Gangrene of the oesophago-gastric junction due to incarcerated hiatal hernia is an extremely uncommon emergency situation which was first recognized in the late nineteenth century. Early symptoms are mainly unspecific and so diagnosis is often considerably delayed. Aim of the study is to share experience in dealing with this devastating condition. MATERIAL: We encountered three male patients with gangrene of the oesophago-gastric junction caused by strangulated hiatal hernia within the last years. Clinical symptoms, surgical procedures and outcomes were retrospectively analyzed. Furthermore, we provide a history outline on the evolving surgical management from the preliminary reports of the nineteenth century up to modern times. RESULTS: Early symptoms were massive vomiting accompanied by retrosternal and epigastric pain. Hiatal hernia was already known in all patients. Nevertheless, clinical presentation was initially misdiagnosed as cardiovascular disorders. Upon emergency laparotomy gangrene of the oesophago-gastric junction was obvious while in one case even necrosis of the whole stomach occurred after considerable delayed diagnosis. Transmediastinal esophagectomy with resection of the proximal stomach and gastric pull up with cervical anastomosis was performed in two cases. Oesophago-gastrectomy with delayed reconstruction by retrosternal colonic interposition was mandatory in the case of complete gastric gangrene. Finally all sufferers recuperated well. CONCLUSIONS: Strangulation of hiatal hernia with subsequent gangrene of the oesophago-gastric junction is a life-threatening condition. Straight diagnosis is mandatory to avoid further necrosis of the proximal gastrointestinal tract as well as severe septic disease. Surgical strategies have considerably varied throughout the last 100 years. In our opinion transmediastinal oesophagectomy with interposition of a gastric tube and cervical anastomosis should be the procedure of choice if the distal stomach is still viable. Otherwise oesophago-gastrectomy is unavoidable. Delayed cervical anastomosis or reconstruction is advisable in instable, septic patients.

Hiatal hernia and disorders of the spine: a historical perspective.

Our understanding of esophageal disease and the foregut has evolved over the past 100 years, especially in recent times. Modern diagnostic technologies and new management paradigms have provided progressive insights into the anatomy, physiology, and normal and abnormal function of the esophagus, as well as improving patient care. Yet, the relationship between the esophagus and its close neighbor, the spine, is rarely discussed and likely underappreciated. Anatomic proximity and intertwined pathophysiology led early investigators to postulate relationships between esophageal disease and spinal abnormalities. More recent studies have illustrated a link between spinal disease and hiatal hernias. Objective radiographic measurements of kyphoscoliosis have correlated with increased hiatal hernia formation. Spinal abnormalities and disease of the esophageal hiatus are becoming more common in our aging population, with each carrying significant risk of morbidity and decreased quality of life. Operative planning and subsequent hiatal hernia repair must be undertaken in the context of these spinal abnormalities. A historical review of past publications related to the subject forms the basis for this publication, thus revealing insight and improving our understanding of the association between spinal abnormalities and hiatal hernias.

Rudolf Nissen (1896-1981)-perspective.

INTRODUCTION: Rudolf Nissen was one of the outstanding general surgeons of the last century. Between the years 1921 and 1933, he was the pupil and protégé of the famous surgeon Ferdinand Sauerbruch. He was nominated professor of surgery in 1930. Forced by the Nazi-Regime to resign his position, Nissen emigrated in 1933 first to Turkey and then in 1939 to the USA. Here, he held positions in hospitals at New York. Having been appointed to the Chair of Surgery at the University of Basle, Switzerland, he returned to Europe in 1952. Nissen was a critical prolific writer and excellent researcher, surgeon, and teacher. CONCLUSION: The first successful pneumectomy and lung lobectomy in man, as well as the description of surgical pathophysiology and treatment of gastroesophageal reflux disease, including hiatus hernia, are considered to be his most important pioneer work.

Laparoscopic upper gut surgery.

Australian surgeons have been prominent in the introduction, development, and consolidation of laparoscopic surgery of the upper gut. In doing this, some of the very best principles of surgical innovation have been in evidence: preliminary animal work in which to test hypotheses and techniques, followed by careful application and documentation in the clinical setting, randomized clinical trials and finally academic reporting and ongoing development. This review documents the introduction of laparoscopic surgery for gastroesophageal reflux, hiatus hernia, achalasia, gastroesophageal malignancy, obesity, and a range of emergency conditions in Australia. Those involved are regarded as world leaders in their field. A vital component of this success has been the close cooperation between surgeons and gastroenterologists within the Gastroenterological Society of Australia.

When did the esophagus start shrinking? The history of the short esophagus.

Even though the history of this condition extends for almost 100 years, the short esophagus (SE) is still one of the most controversial topics in esophageal surgery with its existence still denied by some distinguished surgeons. We reviewed the evolution behind the diagnosis and treatment of the SE and the persons who wrote its history, from the first descriptions by radiologists, endoscopists, and surgeons to modern treatment.

The history of hiatal hernia surgery: from Bowditch to laparoscopy.

OBJECTIVE: This review addresses the historical evolution of hiatal hernia (HH) repair and reports in a chronological fashion the major milestones in HH surgery before the laparoscopic era. METHODS: The medical literature and the collections of the History of Medicine Division of the National Library of Medicine were searched. Secondary references from all sources were studied. The senior author's experience and personal communications are also reported. RESULTS: The first report of HH was published in 1853 by Bowditch. Rokitansky in 1855 demonstrated that esophagitis was due to gastroesophageal reflux, and Hirsch in 1900 diagnosed an HH using x-rays. Eppinger diagnosed an HH in a live patient, and Friedenwald and Feldman related the symptoms to the presence of an HH. In 1926, Akerlund proposed the term hiatus hernia and classified HH into the 3 types that we use today. The first elective surgical repair was reported in 1919 by Soresi. The physiologic link between HH and gastroesophageal reflux was made at the second half of the 20 century by Allison and Barrett. In the midst of a physiologic revolution, Nissen and Belsey developed their famous operations. In 1957, Collis published his innovative operation. Thal described his technique in 1965, and in 1967, Hill published his procedure. Many modifications of these procedures were published by Pearson and Henderson, Orringer and Sloan, Rossetti, Dor, and Toupet. Donahue and Demeester significantly improved Nissen's operation, and they were the first to truly understand its physiologic mechanism. CONCLUSION: Hiatal hernia surgery has evolved from anatomic repair to physiological restoration.

The contribution of Allison and Nissen to the evolution of hiatus herniorrhaphy.

Even though it was not until 1950 that Barrett introduced the term "reflux esophagitis", this entity is now the most common disease afflicting the western world. Diaphragmatic herniation, recognized by Sennertus in 1541, was first repaired by Potemski (1889). Before World-War II, the condition was considered rare; symptomatology, as in external herniae, was ascribed to pinching of the stomach by the hernial ring. Only large protrusions, with signs of impending incarceration, volvulus, or strangulation, were operated upon. Modern understanding derives from studies of short, strictured esophagi. Because of endoscopic "gastric" biopsies in children, Findlay and Kelly considered them congenital "misplacements". However, Allison (1943), finding adults with ulceration and scarring, argued they were acquired. Later (1953) he concluded that the distal esophagus may be lined with metaplastic adenomatous epithelium which can harbor malignancy. His repair, reestablishing the crural pinchcock was, as pointed out by his countryman Collis (who in 1957 constructed a neo-esophagus from the Magenstrasse), inadequate. Nissen performed (1936) gastroesophagectomy in a case of peptic ulceration of the cardia. To avoid leakage he buried the anastomosis. Amazingly, 17 years later he learned that the patient had no reflux. He then successfully performed and reported (1956) fundoplication in a man and woman with gastroesophageal reflux disease. His operation remains the basis for surgical therapy today.

A selective history of groin herniorrhaphy in the 20th century.

Of the histories of the many operations available in a general surgeon's technical armamentarium, that of groin herniorrhaphy has been written about repeatedly. Many of these reports focus on developments prior to the twentieth century. This article, instead, details selective evolutionary changes relative to groin hernia surgery during the last nine decades. Among the surgeons discussed are Battle, Ferguson, La Roque, Cheatle, Gallie, Henry, Tanner, McVay, Shouldice, and Lichtenstein.

History of surgery of the esophagus.

The progress of esophageal surgery from the beginning of medical history through five historical eras, up to the second half of the 20th century, is reviewed. Progress was slow from the first surgical repair of the esophagus in ancient Egypt in 2500 B.C. until the end of the 19th century, when scientific discoveries made possible the solid beginnings of abdominal surgery. Thoracic surgery followed in the 20th century, with rapid strides in World War II. These wartime advances stimulated an interest in esophageal surgery in the postwar era, when operative techniques became well standardized and surgery of the esophagus was placed on a par with that of other parts of the gastrointestinal tract. Because of the limitations of time and space, much important material has had to be left out. Yet it is hoped that this brief historical overview will put in perspective the important advances of the second half of this century, which will be presented by our distinguished speakers. It has been a privilege for me to have had a part in the development of this type of surgery and to share these ideas with you.