Abnormalities of gastric emptying and pyloric reflux in uncomplicated hiatus hernia

We have measured the rate of gastric emptying of solid and liquid meals by an external scanning technique and have studied pyloric reflux by a radiological technique. Investigations were performed in patients with uncomplicated hiatal hernia, patients with uncomplicated duodenal ulcer and normal controls. There was a significant delay in the emptying of both solid and liquid meals in the patients with hiatal hernia compared with both the duodenal ulcer patients (solid meals P less than 0.01, liquid meals P less than 0.025) and with normal controls (solid meals P less than 0.05, liquid meals P less than 0.001). Duodenogastric reflux was observed in 35% of hiatal hernia patients compared with 24% of duodenal ulcer patients and no incidence in the controls.     

Incarcerated Paraesophageal Hernia Associated with Perforation of the Fundus of the Stomach: Report of a Case

We report herein a case of incarcerated paraesophageal hernia associated with perforation of the fundus of the stomach. A 71-year-old woman was transferred to our hospital after a diagnosis of gastrointestinal tract perforation had been made at a local hospital. Her history included an esophageal hiatal hernia. A laparotomy was performed which revealed that the antrum of stomach and the duodenal bulb had prolapsed into the esophageal hiatus and become incarcerated. This prolapse had caused stenosis in the corpus of the stomach, resulting in distension of the oral side of the stomach and thinning of the wall. A perforation, 15 mm long, was recognized in the major curvature of the fundus. The patient suffered respiratory failure postoperatively, necessitating respiratory support for 1 week. She was discharged on postoperative day 40. This case report serves to demonstrate that because of the very serious complications that may result from an untreated paraesophageal hernia, elective repair should be performed wherever possible even in asymptomatic patients. Received: July 28, 2000 / Accepted: November 20, 2000     

Kasten's syndrome]

The associated hiatal hernia, chronic cholecystitis and duodenal ulcer disease were diagnosed in 12 patients. Combined surgical operations were performed in 9 patients with a good long-term result.     

Nonreflux complications of hiatal hernia

Patients with massive incarcerated hiatal hernia and no appreciable esophagitis present with a distinctly different clinical picture from those with hiatal hernia and reflux peptic esophagitis. In a recent review, 17 patients were encountered with this problem. The patients were often elderly and presented with the following grave complications: upper gastrointestinal obstruction; upper gastrointestinal bleeding, both acute and chronic, from gastric ulcerations; and perforated gastric ulcerations. In these patients, the surgical approach is better accomplished through the abdominal route. These patients should be distinguished from those with a shortened esophagus resulting from chronic reflux peptic esophagitis who often require thoracotomy for surgical correction.     

Diagnosis and treatment of hemorrhage in patients with hiatal hernia.

A retrospective study examined the clinical course of 32 patients with hiatal hernia in whom hemorrhage of the upper gastrointestinal tract was a prominent symptom. Hemorrhagic esophagitis was the most common source of bleeding. Duodenal ulcer, gastritis, and gastric ulcer of the herniated stomach were other less frequent causes of hemorrhage in these patients. Hemorrhage from esophagitis is usually mild and chronically recurrent. Surgical correction of the hiatal hernia and reflux is adequate treatment for the patient with hemorrhage from esophagitis or gastritis of the herniated stomach. Hemorrhage from duodenal ulcer as well as gastric ulcer requires a procedure directed at these lesions. Because of the association of upper gastrointestinal bleeding in hiatal hernia with lesions other than esophagitis, a vigorous diagnostic approach with endoscopy is essential.     

Incarcerated recurrent inguinal hernia with covered and perforated appendicitis and periappendicular abscess: case report and review of the literature

We report the case of a 72-year-old woman with a covered and perforated appendicitis and periappendicular abscess within the hernial sac (Amyand’s hernia) of an incarcerated recurrent inguinal hernia after primary Shouldice repair. Initially, a preoperative CT-scan showed signs of an incarcerated femoral hernia. This would be the first reported case of an incarcerated recurrent Amyand’s hernia, which is an extremely rare condition.     

Laparoscopic management of large paraesophageal hiatal hernia

Background: Large paraesophageal hernias (POHs) predominantly occur in the elderly population. Early repair is recommended to avoid the risks associated with gastric volvulus. Methods: Data were collected prospectively during an 8-year period. Laparoscopic repair of POHs initially included circumcision of the sac and mesh hiatal repair. Sac excision and suture hiatal repair were later adopted. A fundoplication was also included, initially as a selective procedure. Results: Fifty-three patients with large POHs were treated by one surgeon. All had attempted laparoscopic repair, with four conversions to an open procedure. Symptomatic hernia recurrence occurred in five patients (9%). The 21 patients who had sac excision, hiatal repair, and fundoplication have remained free of symptomatic recurrence. The postoperative morbidity rate was 13%, with one death. Conclusions: Laparoscopic repair of large POHs remains feasible. We advocate complete sac excision, hiatal repair, fundoplication, and gastropexy to prevent early recurrence.     

Surgery of left paraduodenal hernia

The clinical presentation, embryologic and etiologic factors, and repair of left paraduodenal hernia are presented. A new operative procedure for cure of left paraduodenal hernia is presented that deals effectively with the sac and predisposing arch containing the inferior mesenteric vein without section of the vein. Repair is based upon the embryologically normal anatomy with restoration of the inferior mesenteric vein to its normal retroperitoneal position. This procedure has been successfully utilized in a case in which the paraduodenal hernia of small bowel was encountered concomitantly with a perforated duodenal ulcer.     

Laparoscopic treatment of paraesophageal hiatal hernia with incarceration of the pancreas and jejunum

We present a successful laparoscopic treatment of paraesophageal hiatal hernia with an incarceration of the pancreas and jejunum. The patient was a 75-year-old woman who had complaints of epigastric pain and dysphasia. A chest x-ray revealed a mediastinal air-fluid level. Chest computed tomography showed intestinal contents, body and tail of the pancreas, and the splenic artery within the mediastinum. At laparoscopy, jejunum was incarcerated into the mediastinal cavity through the internal hernia of transverse mesocolon. Body and tail of the pancreas and the splenic artery were also dislocated within the hernia sac. The operation time took 115 minutes. The patient tolerated a regular diet on the first postoperative day and was discharged uneventfully. There were no recurrence or abdominal symptoms during the 29-month follow-up period. In the case of asymptomatic paraesophageal hiatal hernia with incarcerating pancreas on diagnostic imagings, elective surgical treatment is required to prevent a critical outcome.     

Perforated appendicitis in an incarcerated scrotal hernia —A case report—

A 72 year-old man in whom perforated appendicits developed within an incarcerated scrotal hernia sac is presented herein, because of both its rarity in the literature and the difficulty encountered in establishing a diagnosis. If such an infection is limited to within the hernial sac, the prognosis is benign, however, the presence of peritoneal contamination affects the prognosis negatively. Moreover, there is no supplemental risk in performing a primary hernia repair following appendectomy in the same session.     

Perforated appendicitis in an incarcerated scrotal hernia--a case report

A 72-year-old man in whom perforated appendicitis developed within an incarcerated scrotal hernia sac is presented herein, because of both its rarity in the literature and the difficulty encountered in establishing a diagnosis. If such an infection is limited to within the hernial sac, the prognosis is benign, however, the presence of peritoneal contamination affects the prognosis negatively. Moreover, there is no supplemental risk in performing a primary hernia repair following appendectomy in the same session.     

Planned reduction of incarcerated groin hernias with hernia sac laparoscopy

Background: Laparoscopic techniques have been described as adjuncts in the management of acutely incarcerated groin hernias, with the intention of reducing operative morbidity and patients discomfort. However, the use of laparoscopy in acute incarcerations, as well as its appropriateness, remains to be elucidated. Herein we discuss the use of hernia sac laparoscopy in the algorithm of managing incarcerated groin hernias. Methods: Five patients presenting with small bowel obstruction secondary to incarcerated groin hernias underwent surgical reduction of the hernia followed by hernia sac laparoscopy. The purpose of hernia sac laparoscopy was to determine the viability of the incarcerated bowel segment based on color, peristalsis, and venous congestion. When bowel resection was required, a separate incision was made after repair of the hernia. Results: Bowel viability was assessed accurately with this method. Although hemorrhagic fluid in the hernia sac was noted in three patients, only one patient required a limited exploration through a separate incision for nonviable bowel. Postoperative recovery was standard, with no morbidity or mortality. Patients were discharged in 2–5 days. Conclusions: Hernia sac laparoscopy, without additional trocar placements, is a safe adjunct for determining the viability of the incarcerated bowel segment. This method reduces the need for laparotomy so long as the reduced incarcerated segment meets the criteria for viability. Videoscopic inspection potentially offers additional information, such as the existence of ascites and peritoneal tumors.     

Perforated appendix and periappendicular abscess within an inguinal hernia

We report an extremely rare case of complicated Amyand’s hernia. A 61-year-old male patient was admitted with clinical signs of incarcerated right inguinal hernia and localised tenderness in the right iliac fossa. He underwent emergency surgery and the operative findings included perforated appendix and periappendicular abscess within a right inguinal hernia sac. Appendectomy and Shouldice’s herniorrhaphy without prosthetic mesh placement were performed. Histology revealed the presence of a villous adenoma near the base of the appendix. We point out that although Amyand’s hernia is a very rare clinical entity, it should always be considered in the differential diagnosis in cases with clinical signs of incarcerated right inguinal hernia, especially when there are no pathological findings on the abdominal X-rays.     

Simultaneous operations in gastric and duodenal ulcer]

The experience with surgical treatment of 112 patients with gastric and duodenal ulcer disease associated with pathology of the abdominal organs is summarized. Most frequently in ulcer disease, sliding hiatal hernia (34.1% of cases) and adhesive disease (25.7%) were revealed. In all the patients, the simultaneous operations were performed. The incidence of postoperative complications was 13% and didn't exceed that in the control group of patients, who underwent only the operations on the stomach and duodenum.     

De Garengeot hernia: an analysis of our experience

Aim The presence of a vermiform appendix in a femoral hernia sac is termed De Garengeot hernia. It may present as a tender and/or erythematous groin swelling and is often misdiagnosed as an incarcerated or strangulated femoral hernia. The purpose of this study is to review the management of De Garengeot hernia at a single institution since 1991. Materials and methods A retrospective analysis of seven consecutive patients operated upon at our institution from 1991 to 2006 with De Garengeot hernia was undertaken. Patients’ demographics, treatment performed and postoperative outcome were analysed. Results There were three men and four women. The median age was 55 years. None of the patients were diagnosed preoperatively. The commonest presenting symptom was painful groin swelling. All patients therefore underwent emergency surgery with a presumptive diagnosis of either incarcerated or strangulated femoral hernia. Operative findings included four normal appendices, two inflamed appendices and one perforated appendix in the femoral hernial sac. Patients with normal appendix (n = 4) had mesh hernia repair without an appendicectomy. The rest of the patients (n = 3) with abnormal appendix underwent emergency open appendicectomy followed by sutured hernia repair. We had no deaths in this series and one minor wound infection. No recurrent hernia has been detected to date. Conclusion Inflammation of the appendix determines the type of hernia repair and surgical approach. Incidental appendicectomy in the case of a normal appendix is not preferred.     

Gangrenous appendicitis in Amyand’s hernia: Surgical approach under local anesthesia. Case report and review of the literature

Introduction and importanceAmyand hernia is a rare disease seen in approximatively 1% of all hernias, complications of it, like acute appendicitis, or perforated appendicitis are even more rare, about 0.1%. Its diagnosis is very difficult in the preoperative period: it is usually an incidental finding.Case presentationWe report an unusual case of perforated gangrenous appendicitis with peri-appendicular abscess occurring in an irreducible Amyand’s hernia. An 80-year-old male, with chronic obstructive disease and pulmonary emphysema, atrial fibrillation, acute myocardial infarction, underwent urgent surgery, under local anesthesia, for right incarcerated inguinoscrotal hernia.He was found to have a perforated gangrenous appendicitis with peri-appendicular abscess within a right indirect inguinal hernia sac. Appendicectomy and Bassini’s hernia repair were performed under local anesthesia without any complications.Clinical discussionThe treatment of Amyand’s hernia is not standardized. The current generally accepted algorithm for Amyand’s hernia is essentially contingent on the appendix’s condition within the hernia sac.ConclusionAppendectomy and primary herniorrhaphy, under local anesthesia, for type 3 of Amyand’s hernia, is a safe procedure and easy to perform and, if confirmed by further study, could be part of every surgeon’s knowledge.     

Effect of Helicobacter pylori eradication on the ulcer recurrence rate after simple closure of perforated duodenal ulcer: retrospective and prospective randomized controlled studies

BACKGROUND: The possible advantage of eradication of Helicobacter pylori in patients with perforated duodenal ulcer is unknown. This study was planned to assess the prevalence of H. pylori after simple closure of a perforated duodenal ulcer and to study the effect of H. pylori eradication on ulcer persistence and recurrence. METHODS: Some 202 patients were followed prospectively for 2 years after simple closure of a perforated duodenal ulcer (prospective group). A second group of 60 patients was reviewed 5 years or more after perforation closure (retrospective group). The prevalence of H. pylori in patients with perforated duodenal ulcer was compared with that in controls. Patients in the prospective group were randomized to receive either ranitidine alone or quadruple therapy (ranitidine, colloidal bismuth subcitrate, metronidazole and tetracycline) after operation. The incidence of H. pylori infection after the two treatments and the association with residual or recurrent ulcer were studied. In the retrospective group long-term ulcer recurrence was correlated with H. pylori status. RESULTS: The prevalence of H. pylori in patients with perforated duodenal ulcer was not significantly different from that in controls. At every interval of follow-up in the prospective group and in the retrospective group the H. pylori infection rate was significantly higher in patients who had recurrent or residual ulcers. CONCLUSION: Eradication of H. pylori after simple closure of a perforated duodenal ulcer should reduce the incidence of residual and recurrent ulcers.     

Pneumogastrography in the diagnosis of perforated peptic ulcer

During the 5 year period ending December 1982, 57 patients underwent operation for perforated peptic ulcer. Pneumogastrography was utilized in nine patients who were suspected of having perforation but who had equivocal physical findings and normal findings on initial roentgenographs. All patients with initial pneumoperitoneum or pneumoperitoneum after gastric insufflation were operated on within 6 hours of admission for a combined mortality rate of 9.7 percent. Patients without free air, initially equivocal examinations, and in whom pneumogastrography was omitted, experienced an average delay of 27 hours. The overall mortality rate in these patients was 28 percent. We conclude that pneumogastrography enhances the sensitivity of plain diagnostic roentgenography in confirming the diagnosis of perforated gastric or duodenal ulcer. Gastric insufflation is recommended whenever perforated peptic ulcer is considered in the differential diagnosis and initial films are inconclusive.     

Amyand’s hernia: a report of 18 consecutive patients over a 15-year period

Aim The presence of a vermiform appendix in an inguinal hernia sac is termed Amyand’s hernia. It may present as a tender inguinal or inguino-scrotal swelling and is often misdiagnosed as an incarcerated or strangulated hernia. The purpose of this study was to review the management of Amyand’s hernia at a single institution since 1991. Material and methods A retrospective analysis was undertaken of 18 consecutive patients with an Amyand’s hernia operated upon at our institution from 1991 to 2005. Patients’ demographics, treatment and postoperative outcome were analysed. Results There were 17 men and one woman. Their median age was 42 years. None of the patients was diagnosed preoperatively. The commonest presenting symptom was painful inguinal or inguino-scrotal swelling (83%). All patients, therefore, underwent emergency surgery with a presumptive diagnosis of either incarcerated or strangulated inguinal hernia. Operative findings included 11 normal appendices, four inflamed appendices and three perforated appendices in the inguinal hernial sac. Patients with a normal appendix (n = 11) had a mesh hernia repair without an appendicectomy. The rest of the patients (n = 7) with an abnormal appendix underwent emergency open appendicectomy followed by Bassini’s sutured hernia repair. One patient died in the postoperative period of pneumonia. Only one recurrent hernia has been detected, with a median follow-up time of 6.4 years. Conclusion The inflammatory status of the appendix determines the type of hernia repair and the surgical approach. Incidental appendicectomy in the case of a normal appendix is not favoured.