Benign surgical diseases of the gastro-oesophageal junction

Benign surgical conditions of the oesophagogastric junction (OGJ) are important causes of morbidity and in some cases mortality for patients. This article discusses both elective and emergency benign disorders of the OGJ, including their investigation and management. Elective conditions include gastro-oesophageal reflux disease (GORD), giant para-oesophageal hiatal herniae (GPHH), achalasia and other motility disorders. These conditions are now usually all managed laparoscopically when operative intervention is required. Emergency conditions include acute presentations of giant para-oesophageal hiatal herniae and OGJ perforations including Boerhaave's syndrome. These present diagnostic and management challenges to the surgeon and are associated with significant morbidity and mortality. Varices, gastro-intestinal stromal tumours (GISTS), ulcers and bleeding are not discussed in this article.     

A case of duodenal rupture secondary to massive inguino-scrotal hernia

Introduction

Surgical intervention for giant inguino-scrotal herniae in the acute setting is high risk with significantly increased incidence of morbidity and mortality. While uncommon in modern practise, there are several surgical issues and approaches that need to be considered when this problem presents.

Case Report and Discussion

We describe the unusual occurrence of acute duodenal rupture as a direct result of a giant inguino-scrotal hernia. The literature on the operative management of giant inguino-scrotal hernia is also reviewed.

Conclusion

Giant inguino-scrotal herniae are best managed electively with full preoperative work up and assessment. Surgery in the acute patient is fraught with difficulty leading to increased morbidity.     

Laparoscopic repair of giant paraesophageal hernia

Giant paraesophageal hernias (PEHs) account for less than 5% of all hiatal hernias. In contrast to the small type I hiatal hernia, nonsurgical management of giant PEHs may be associated with progression of symptoms and life-threatening complications including hemorrhage, strangulation, and death. Most giant PEHs are associated with a current or previous history of gastroesophageal reflux disease and represent progression of the typical type I hernia to a type III hernia. Conventional open repair is associated with good results and low mortality but also with a significant morbidity and a delay in return to routine activities in this frequently elderly population. Recently, short-term outcome studies have reported that minimally invasive approaches to PEH may be associated with less morbidity, shorter hospital stay, faster recovery, and excellent clinical results.     

Surgical management of hiatal herniae and oesophageal strictures in systemic sclerosis

Brain, R. H. F. (1973).Thorax, 28, 515-520. Surgical management of hiatal herniae and oesophageal strictures in systemic sclerosis. The clinical manifestations of 10 patients with systemic sclerosis whose oesophageal complications were managed by surgery are reported. Ninety per cent had a severe ulcerating type of oesophagitis and all had hiatal herniae demonstrable by contrast radiology. All but two had fibrous strictures.     

Penetration of a gastric ulcer into the right ventricle. A complication of para-oesophageal hiatus hernia

A 74-year-old woman presented with massive upper gastro-intestinal tract bleeding that necessitated an emergency laparotomy. At operation a para-oesophageal hiatal hernia with an ulcer in the herniated fundus of the stomach penetrating the right ventricle was discovered to be the source of the bleeding. Although various complications of para-oesophageal hiatal hernias have been reported, including bleeding, this is the first reported case of ulcer penetration into the ventricle.     

Improvement results in paraesophageal hernia

Paraesophageal hernias account for between 5 and 14% of hiatal hernias. Surgical management is complex and is currently one of the most debated subjects in surgery. Every symptomatic patient with a paraesophageal hernia and no contraindication for surgery should undergo repair. It is important to perform an evaluation that includes medical history, chest x-rays, barium swallow, upper endoscopy and manometry. Surgical approaches include open thoracic and abdominal access. Recently, laparoscopic surgery has become an option with less morbidity and mortality with results similar to open surgery. Essential technical aspects to improve results are reduction of the hernia sac, recognition and management of the short esophagus, hiatal closure and an antireflux procedure. Despite improving recurrence rates, use of synthetic mesh for hiatal closure has been associated with catastrophic complications; therefore, use of biologic mesh is preferred.     

Surgical treatment of para-oesophageal hiatal hernia.

The development of laparoscopic antireflux surgery has stimulated interest in laparoscopic para-oesophageal hiatal hernia repair. This review of our practice over 10 years using a standard transthoracic technique was undertaken to establish the safety and effectiveness of the open technique to allow comparison. Sixty patients with para-oesophageal hiatal hernia were operated on between 1989 and 1999. There were 38 women and 22 men with a median age of 69.5 years. There were 47 elective and 13 emergency presentations. Operation consisted of a left thoracotomy, hernia reduction and crural repair. An antireflux procedure was added in selected patients. There were no deaths among the elective cases and one among the emergency cases. Median follow-up time was 19 months. There was one recurrence (1.5%). Seven patients (12%) required a single oesophagoscopy and dilatation up to 2 years postoperatively but have been asymptomatic since. Two patients (3%) developed symptomatic reflux which has been well controlled on proton-pump inhibitors. Transthoracic para-oesophageal hernia repair can be safely performed with minimal recurrence.     

Total adventitial resection of the cardia: 'optimal local resection' for tumours of the oesophagogastric junction

INTRODUCTION

Little is published about the local resection of oesophageal cancers. We adopted the principles of rectal cancer surgery, ie standard surgical dissection techniques as well as standard pathological processing and reporting, and assessed the feasibility of applying them to oesophagogastric junction (OGJ) cancer.

METHODS

Over a two-year period consecutive patients with invasive cancers of the OGJ were studied. Following staging and neoadjuvant chemotherapy (NAC), a standard dissection defined as a total adventitial resection of the cardia (TARC) was performed. Standard histopathological processing involved external inking, photographing, transverse slicing and mounting of cut samples on megablocks. Hospital morbidity and mortality as well as survival at five years'' follow-up were assessed.

RESULTS

Forty consecutive patients had a TARC for OGJ carcinoma. Of these, 32 were offered NAC. Introducing TARC did not result in increased morbidity or mortality. Twenty-seven patients (68%) had an R0 resection that was directly related to the tumour stage and significantly related to a response to chemotherapy. Sixteen patients (42%) were alive five years after their TARC operation.

CONCLUSIONS

Although the adventitia of the OGJ is not as well developed as that of the rectum, TARC can be performed safely as a standardised resection for OGJ cancers. Whereas the R0 rate for early stage tumours is very high, it remains disappointingly low for T3N1 tumours despite NAC. Improved long-term survival for these advanced tumours will only be achieved with better neoadjuvant and adjuvant therapies.     

腹腔镜下巨大食管裂孔疝修补术25例

目的 探讨腹腔镜巨大食管裂孔疝修补术的临床特点和可行性.方法 2008年1月至2010年8月,应用腹腔镜治疗25例巨大食管裂孔疝,术中均使用专用补片修补食管裂孔,16例同时行胃底折叠术,记录围手术期相关指标,并随访观察治疗效果和术后复发情况.结果 25例均完成腹腔镜手术,手术85～210 min,平均106 min;术中出血量55～150 ml,平均94 ml.术后住院4～21天,平均6.8天.术后症状均得到缓解,无严重并发症,随访3～35个月,平均13.6个月,病人满意率为88%,4例出现轻度反酸症状,1例裂孔疝复发.结论 腹腔镜巨大食管裂孔疝修补术安全、可行,具有创伤小、恢复快、疗效可靠的特点,术中应用Bard CruraSoft补片可缩短手术时间,降低修补食管裂孔的难度,减少复发.

Abstract：

Objective To investigate the clinical characteristics and feasibility of laparoscopic repair of giant hiatal hernia. Methods From January 2008 to August 2010, 25 consecutive patients with giant hiatal hernia underwent laparoscopic repair. Crural closure was performed by means of two or three interrupted nonabsorbable sutures plus a tailored PTFE/ePTFE composite mesh. It was patched across the defect and secured to each crura with staples. Laparoscopic fundoplication was performed concomitantly in 16 cases according to the specific conditions of patients. Para-operative clinical parameters were recorded. All patients were routinely followed up. Clinical outcomes were collected and analyzed. Results All laparoscopic surgeries were accomplished successfully. The operating time was 85 -210 minutes (mean, 106 minutes) ,the operative blood loss was 55 - 150 ml( mean, 94 ml) ,the postoperative hospital stay was 4 -21 days( mean, 6.8 days). The symptoms in most cases were adequately relieved after operation. There was no severe postoperative morbidity. After the follow-up period of 3 - 35months ( mean, 13.6 months), the satisfaction rate of surgery was 88%. 4 cases had mild symptom recurrence of acid reflux.Hiatal hernia recurrence occurred in 1 case. Conclusions Laparoscopic repair of giant hiatal hernia is a safe and effective minimally invasive procedure, with the advantages of minimized trauma, quick recovery and reliable effect. The use of a tailored PTFE/ePTFE composite mesh ( Bard CruraSoft Mesh)for giant hiatal hernia proved to be effective in reducing the operation time and technique demands, and the rate of postoperative hernia recurrence, with a very low incidence of mesh-related complications.     

Giant paraesophageal hernia repair: Technical pearls

The optimal operative management of giant paraesophageal hiatal hernias continues to evolve, with recent series reporting promising results with minimally invasive approaches. The laparoscopic repair of a giant paraesophageal hernia is one of the more challenging cases a minimally invasive surgeon may perform. Our technical approach to this procedure involves a consistent emphasis on several key operative points: circumferential sac dissection with maintenance of crural integrity; extensive mediastinal esophageal dissection; crural closure with pledgeted sutures; wedge Collis gastroplasty for shortened esophagus; 3-stitch fundoplication incorporating esophageal tissue with each bite; additional sutures securing the top of the fundoplication to the crura; and biologic mesh buttressing. We believe that diligence paid toward these key steps permits laparoscopic giant paraesophageal hiatal hernia repair to be performed with similar outcomes as the open approach while avoiding the morbidity of thoracotomy or laparotomy.     

Laparoscopic gatrojejunostomy for palliation of gastric outlet obstruction in unresectable gastric cancer

Background: Gastric bypass through laparotomy is required traditionally when gastric outlet obstruction occurs secondary to a disease process (e.g., unresectable cancer). The recent trend toward minimally invasive procedures has led us to apply laparoscopic bypass surgery for gastric obstruction caused by unresectable advanced gastric cancer. Methods: From March 1998 to February 2000, 78 gastrojejunostomies (GJ) (45 open [OGJ] and 33 laparoscopic [LGJ] procedures) were performed for palliation of gastric outlet obstruction caused by advanced gastric, duodenal, papilla of vater, and pancreatic cancers at the Asan Medical Center. In 68 patients with advanced gastric cancer, OGJ (n = 38) and LGJ (n = 30) were performed. Of these, 10 OGJ patients were compared with 10 diagnosis-matched LGJ control subjects who underwent surgery during the same period in terms of age, gender, American Society of Anesthesiology (ASA) grading, previous abdominal surgery, operating time, time to oral food intake, pain-killer consumption, postoperative hospital stay, immune response, morbidity, and mortality. Immune parameters including serum white blood cells (WBC) count, tumor necrosis factor-a (TNF-a), interleukin-6 (IL-6), cortisol, and erythrocyte sedimentation rate (ESR) levels were assessed preoperatively and on postoperative days 1 and 3 between the two groups. With the patients under the general endotracheal anesthesia, we applied an upper midline incision in OGJ and inserted four trocars in LGJ. Side-to-side gastrojejunostomy was performed in a standard fashion. In LGJ, intracorporeal suture using 2-0 vicryl was performed to repair the gastrotomy and jejunotomy site after gastrojejunostomy using a 30-mm or 45-mm Endo-GIA stapler. Results: There were no significant differences between OGJ and LGJ in terms of gender, age, ASA grading, and previous abdominal surgery. In OGJ, antecolic isoperistaltic GJ was performed in 10 cases, but 8 antecolic and 2 retrocolic approaches were performed in LGJ with no conversion to open surgery. Operating time (113.5 ± 11.2 vs 100.5 ± 9.8 min), pain-killer consumption (540 ± 123.2 vs 430 ± 58.2 mg), and postoperative hospital stay (12.5 ± 3.9 vs 8.5 ± 2.9 days) were reported, respectively. Serum WBC and cortisol levels were slightly increased in both groups preoperatively and on postoperative days 1 and 3. Serum ESR, TNF-a, and IL-6 levels were significantly increased in the OGJ patients. Postoperative complications (9 with OGJ and 2 with LGJ) and postoperative death (1 in each group) occurred. During the follow-up period (3–23 months), there was one case of readmission in each group because of anemia and generalized pain. Conclusions: Laparoscopic GJ for the palliation of unresectable advanced gastric cancer can achieve excellent results with less suppression of immune function, lower morbidity, greater improvement of hemodynamic activities, and earlier recovery of bowel movements than OGJ.     

Giant hiatal hernia with gastric volvulus complicating pneumonectomy

Gastric volvulus is a potentially lethal condition. Pneumonectomy patients have decreased physiologic reserve, and thus they are more susceptible to morbidity and mortality from postoperative complications. We report successful management of a patient with hiatal hernia that resulted in acute gastric volvulus after left pneumonectomy.     

An approach to the management of para-oesophageal hiatus hernias

A variety of conservative and surgical options are available in the management of para-oesophageal hiatus hernia. However opinion is divided in regard to the best form of treatment. A series of 71 patients with para-oesophageal hiatus hernia has been studied, to assess hospital management and outcome after treatment. Case notes of all patients were reviewed, and a questionnaire sent to surviving patients. Of those patients treated surgically with an anatomical repair plus a fundoplication, 19% had recurrence of significant symptoms. In contrast, 55% of patients managed by an anatomical repair alone had recurrence of significant symptoms. Conservative management was undertaken in 29 of the 71 patients and 66% had recurrence of significant symptoms, with 13 proceeding to elective surgery. Nevertheless, there is a place for the conservative management of para-oesophageal hernias are usually combined type hernias with associated reflux symptoms and repair of the hernia should include an antireflux procedure.     

Quain hernia - A rare cause of acute small bowel obstruction. A case report and an updated literature review

Introduction and importanceInternal herniae are a rare cause of acute small bowel obstruction (SBO), accounting for <1% of all causes of SBO. Given their low incidence and often vague presenting symptoms there can be a delay in their diagnosis - which can lead to unnecessary morbidity for patients.Case presentationWe present a case of a 34 year-old nulliparous female who presented with acute abdominal pain and transpired to have a closed loop obstruction of her ileum through a congenital defect in her broad ligament, or a Quain hernia.DiscussionThis paper will describe this case and provide an updated literature review of Quain herniae from recent research. With regards to surgical management of these hernia, both laparoscopic and open approaches are appropriate as long as appropriately trained surgical staff are involved. If a contraltateral defect in the Broad ligament is identified, this should be repaired prophylactically at the time in order to prevent future instances of internal herniation.ConclusionIncreased awareness of the potential presenting symptoms and radiological features of Quain hernia, as outlined in this paper, is vital in order to reduce patient morbidity and mortality.     

Management of patients with musculoskeletal disease and burns

Musculoskeletal disorders include a wide range of disorders which affect the locomotor system (i.e. muscles, bones, joints and associated connective tissues like tendons and ligaments, which are listed in chapter XIII of the International Classification of Diseases – 10). While the primary pathology affects the locomotor system, a number of these disorders are associated with systemic complications, resulting in increased morbidity and mortality in the perioperative period. Burns are an acute emergency and require anaesthetic or critical care input for assessment of injuries, early surgical intervention or organ support. Major burns are a multisystem disorder and although they account for less than 5% of all new burns cases, their management is complex and requires multidisciplinary approach in a specialized centre. This article highlights the important considerations for perioperative management of these conditions.     

Management of patients with musculoskeletal disease and burns

Musculoskeletal disorders include a wide range of disorders which affect the locomotor system, i.e. muscles, bones, joints, and associated connective tissues like tendons and ligaments, which are listed in Chapter XIII of the International Classification of Diseases (ICD-10). While the primary pathology affects locomotor system, a number of these disorders are associated with systemic complications, resulting in increased morbidity and mortality in the perioperative period.Burns are an acute emergency and require anaesthetic or critical care input for assessment of injuries, early surgical intervention or organ support. Major burns are a multisystem disorder and although they account for less than 5% of all new burns cases, their management is complex and requires multidisciplinary approach in a specialized centre. This chapter highlights the important considerations for perioperative management of these conditions.     

Giant hiatal hernias: direct hiatus closure has an acceptable recurrence rate

The purpose of this retrospective study was to analyze our results after laparoscopic repair of giant hiatal hernias with direct closure of the hiatus, since the reports document a radiological recurrence rate as high as 42%. Various studies have shown that laparoscopic hernia repair is safe and effective, and carries a lower morbidity than the open approach, but the high recurrence rates still being reported (ranging from 10 to 42%) have prompted many authors to recommend using a prosthesis. This is a report on the follow-up of 38 patients with type III and IV hiatal hernia who underwent laparoscopic repair with direct hiatal closure without the aid of meshes. From January 2000 to March 2010, 38 patients with III and IV hiatal hernia were treated at the Surgery Division of Cisanello Hospital in Pisa. Data were collected retrospectively and included demographics, preoperative symptoms, radiographic and endoscopic findings, intraoperative and postoperative complications, postoperative symptoms, barium X-ray and follow-up by medical examination and symptoms questionnaire. The sample included 12 males and 26 females, between 36 and 83 years (median age 62) with 26 type III (68.4%) and 12 type IV (31.6%) hernias. There were no conversions to laparotomy and no intraoperative or postoperative mortality. A 360° Nissen fundoplication was performed in 22 patients (57.9%) and a 270° Toupet fundoplication in 16 patients (42.1%). One patient had intraoperative complications (2.6%), and postoperative complications occurred in another three (7.9%). The follow-up was complete in all patients and ranged from 12 to 88 months (median 49 months). Barium swallow was performed in all patients and recurrence was found in five patients (13.1%); three of these patients (7.9%) were asymptomatic, while two (5.2%) were reoperated. All 38 patients' symptoms improved. Judging from our data, the recurrence rate after laparoscopic giant hiatal hernia repair with direct hiatal closure can be lowered by complying with several crucial surgical principles, e.g., complete sac excision and appropriate crural closure, adequate esophageal lengthening, and the addition of an antireflux procedure and a gastropexy. We recorded a radiological recurrence rate of 13.1% (5/38) and patient satisfaction in our series was quite high (92%). Based on these findings, the laparoscopic treatment of giant hernias with direct hiatal closure seems to be a safe and effective procedure.     

Caudal anaesthesia in a patient with Hurler syndrome (mucopolysaccharidosis type I)

Children with any of the mucopolysaccharidoses are at a high risk of developing significant morbidity and mortality when a general anaesthetic is administered. This case report describes the use of a caudal epidural technique for the repair of bilateral inguinal herniae in a 10-month-old infant with Hurler syndrome (mucopolysaccharidosis type I).     

Repair of a giant inguinoscrotal hernia

Giant inguinoscrotal herniae are infrequent in developed countries nowadays, nonetheless they may still typically present after years of neglect. The morbidity associated with them can be significant. Surgical management, although challenging even for the experienced surgeon, enables the patient to return to a reasonable level of function and quality of life. We present a case of a giant right inguinoscrotal hernia, which was treated with a multi-stage extensive operation, following adequate pre-operative respiratory preparation. The operation included reduction of the hernial contents in the abdominal cavity following omentectomy, right hemicolectomy and splenectomy, hernioplasty and reconstruction of the abdominal wall with the preperitoneal use of a Composix mesh and finally reductive reconstruction of the scrotum. The technique described represents a successful combination of various techniques described for the management of these patients.     

Repair of a giant inguinoscrotal hernia.

We present a case of a long-standing, giant inguinoscrotal hernia extending to the patient's knees, complicated by intestinal obstruction. Initial management involved conservative treatment of the intestinal obstruction and optimising the patient's general condition. Surgical treatment included debulking the contents of the hernia sac by performing a right hemicolectomy and a small bowel resection, and reconstruction of the abdominal wall using Marlex mesh and a tensor fasciae latae flap. Although abdominal wall reconstruction for massive ventral or incisional herniae is well reported, inguinoscrotal herniae of this magnitude are much rarer and pose additional problems, which are discussed in this paper.