Attach importance to the influence of obesity on disease treatment of hernia and abdominal wall surgery / 中华消化外科杂志

With the great improvement of living and material conditions in China, obesity concomitant with hernia and abdominal wall diseases become very common. As the particularities of obesity and associated metabolic diseases, a series of pathophysiological changes caused by obesity will significantly affect the treatment of hernia and abdominal wall diseases. In the authors' opinions, accurately evaluation the severity of obesity and associated metabolic diseases and effec-tively controlling are important prerequisites for determining the timing of surgery and surgical planning. Weight loss before surgery is the basic principle of the treatment and immediate or staged individualized surgical treatment is the guarantee of the successful treatment for obesity patients with hernia and abdominal wall disease.

Diagnóstico ecocardiográfico de una hernia de hiato. Reporte de un caso / Echocardiographic diagnosis of a Hiatus Hernia: A case report

The diagnosis of a hiatus hernia (HH) is typically confirmed with an upper gastrointestinal barium X-ray, gastroscopy or upper-intestinal endoscopy. In several cases, HH has been diagnosed with an echocardiogram. We here describe a case of an HH visible on an echocardiogram in a male patient with chest pain.

Laparoscopic floppy Nissen fundoplication: evaluation of outcome in 34 patients operated without prior oesophageal pH and manometry

Background: Aim of the study was to evaluate prospectively the outcomes of laparoscopic floppy Nissen fundoplication in cohort of patients with typical symptoms of gastroesophageal reflux disease (GERD) and hiatus hernia without pre-operative 24 hours oesophageal pH and manometry study. Methods: Thirty-four patients with typical symptoms of GERD, from March 2009 to November 2019, were studied. The study was limited to patients with positive findings on upper GI endoscopy done by operating surgeon with typical symptoms (heartburn, regurgitation, and dysphagia) of GERD and hiatal hernia. Laparoscopic Nissen’s fundoplication was performed when clinical assessment suggested adequate oesophageal motility and length. Only 1 patient, who had negative endoscopic findings, underwent a 24-hour pH-monitoring before surgery. Outcome measures included assessment of the relief of the primary symptom responsible for surgery in the early postoperative period; the patient's evaluation of outcome and quality of life after surgery.Result: Laparoscopic Nissen’s fundoplication is an effective long-term treatment for GERD and may be performed in patients with typical symptoms of GERD and hiatus hernia and endoscopic findings suggestive of reflux esophagitis and patient who wants to get rid of life long proton-pump inhibitors (PPI) and antacids medication.Conclusions: Preoperative oesophageal manometry and 24-hour pH monitoring are not mandatory for laparoscopic fundoplication if the patient selection is appropriate but may be required in selected patients with atypical symptoms.

Gastric volvulus or just a large stomach? a case report with literature review of gastric volvulus and gastrointestinal pathology in acromegaly

Gastric volvulus is a surgical emergency that requires prompt recognition and management. The acromegalic patient has a number of pathophysiological factors that predispose to gastric volvulus and slow gastrointestinal (GI) transit. Authors aimed to present a case of hiatus hernia and gastric volvulus in a patient with acromegaly and review the current literature on GI anomalies in this population. A 70-year-old female presented to our institute with epigastric pain and coffee-ground vomiting on the background of acromegaly secondary to pituitary adenoma (resected in 1997). She was found to have a gastric volvulus and hiatus hernia which was repaired laparoscopically. She was discharged home but re-presented six days later with abdominal distension and vomiting. Computed tomography (CT) scan of abdomen showed recurrent gastric volvulus with involvement of the transverse colon. She underwent a laparotomy but no evidence of gastric or colonic volvulus was seen intra-operatively. The CT findings were attributed to a large stomach and coiled redundant transverse colon which could be misinterpreted as volvulus on imaging. Gastroparesis and slow bowel transit were the likely aetiology of this second presentation. This is consistent with literature reporting slow bowel transit and dolichocolon in acromegalic patients. Gastric volvulus is a rare finding associated with acromegaly. Structural anomalies in the anatomy of the acromegalic patient can make CT diagnosis challenging. This case demonstrates the need for caution when interpreting imaging in this cohort, as well as the need for further research on GI pathology associated with acromegaly.

Laparoscopic Fundoplication for Gastro-esophageal Reflux Disease and Hiatus Hernia: A Short Term Outcome of First 8 Cases

Background:Acute gastro-esophageal reflux disease is a common ailment in kashmiripopulation. Most of these patients are managed by gastroenterologist, physicians and surgeons in daily outpatient basis. Majority of them settle by medical management with the help of proton pump inhibiters, prokinetics and antacids., laparoscopic Nissen’s fundoplication (LNF) is currently the procedure of choice for the surgical management of GERD.Aims and Objectives:The aim of this study was to know the feasibility of laparoscopic fundoplication for hiatus hernia and acute gastro-esophagealrefluxdisease in termsof operative time, post operative pain, length of hospital stay, conversion rate and recurrence of symptoms.Materialsand Methods:The present prospective observational study was conducted in the Post-Graduate Department of General Surgery and minimal access surgery Government Medical College Srinagar from June 2013 to June 20117. The patients that were included in the studyhad symptomatic gastro-esophageal reflux(documented by endoscopy) with either persistent symptomsdespite adequate and prolonged medical treatment, CT documented hiatus hernia and patients, who wanted to avoid long-term medical treatment. The duration of reflux symptoms ranged from 9 months to 30 years (median 6 years). Patients who were excluded from the study were those unfit for anesthesia. Informedconsent was taken before surgery in the language, the patients understood.Results:This study includes 8 patients, with median age of 40 years (range 20-70 years). In the study group, 5 were males and 3 were females. The mean operative time was 90 minutes (range 60 t0 120 minutes). There were no major intra operative and postoperative complications. The postoperative pain was minimal as compared to open surgery. The median hospital stay was 3.5 days (range 3 -6 days). Two patients developed symptoms of bloating, early satiety, nausea and diarrhea. However these symptoms improved within weeks with a good response to appropriate medication. The median time until normal physical activity resumed was 2 weeks (range 3 days to 4 weeks). Median follow-up was 6 months (range1-12 months).The overall short-term results in appropriately selected patients were excellent. The recurrence of symptoms was not observed in any patient within follow up of 6 months. Conclusion:We conclude from our early series of 8 cases, that patients having long standing GERD not responding to medical management who areat a threat to develop barrettes esophagus should be given the benefit of laparoscopic fundoplication. However proper evaluation, patient selection is mandatory. The choice of fundoplication should be dictated by thesurgeon’s preference and experience. Currently, the main indication for laparoscopic fundoplication is represented by PPI-refractory GERD, provided that objective evidence of reflux as the cause of ongoing symptoms has been obtained by impedance-pH monitoring

Analytical Study of Upper Gastrointestinal Endoscopy – 200 cases

Background: Esophagogastroduodenoscopy (EGD) is an important tool to visualize the upper part of the gastrointestinal tract up to the duodenum. It has the added advantage of being not only a diagnostic but also a therapeutic tool. It’s importance in follow up cases is also well documented. It has indeed become a cost effective and reliable tool to modern surgery. Materials and methods: Clinically symptomatic cases of upper GI tract were made to undergo Upper GI Endoscopy after an informed written consent. The study covered 200 patients who were then analysed for different parameters. Our study showed that majority of patients were in their 3rd decade with a male: female ratio of 2.03:1. Pain in abdomen was the main presenting complaint. Study showed that 62% of patients were smokers whereas 71% were non alcoholic. Gastritis was the prominent finding in 41 (20.5%) cases followed by Hiatus Hernia and Reflux Esophagitis in 19.5% and 13% respectively. The study was found to be normal in 28 cases (14%). This study was also able to detect rare findings like esophageal polyp and Mallory Weiss tear. Endoscopy was also done in post Gastojejunostomy patients to assess the stoma from within. Conclusion: Endoscopy has proved to be a valuable tool in diagnosing as well as therapeutically treating patients with various pathologies. Upper GI endoscopy correlated well with the sign and symptom presentations in majority of patients and proved superior to conventional radiological studies. Thus endoscopy is not only useful and superior to many radiological investigations, but also helpful in therapeutic interventions as well as in follow up cases.

Transthoracic repair of diaphragmatic hiatus hernia with esophageal shortening where laparoscopic abdominal approach does not give satisfactory results.

A 50 year old female patient presented with history of regurgitation of food, heart burn, dyspepsia. Patient was investigated and presence of large hiatus hernia was confirmed on endoscopy, computed tomogram chest and barium swallow. Patient had severe symptoms even with maximum medical management, therefore surgical intervention was planned. Left posterolateral thoracotomy was done through sixth intercostal space. Mobilization of esophagus, reduction of stomach and Belsey Mark IV 270 degree anterolateral fundoplication was done. Patient was discharged on 7th postoperative day. First follow up was I month after the discharge and patient had significant relief from the preoperative problems.

Malrotation of Gut and Hiatus Hernia in a Child with Familial Dyskeratosis Congenita.

Dyskeratosis congenita (DKC) is a rare inherited genodermatosis. We report familial occurrence of the disease. The index patient 12 years old had all classical features of DKC. There are 4 other siblings in the family suffering from similar disease. In additions to the features of DKC, the index patient presented with pain abdomen and vomiting. On investigation he had malrotation of gut and hiatus hernia. To the best of our knowledge this is being documented for the first time in association with DKC.

Relapse of children's hiatus hernia and related factors concerning reoperation / 中华实用儿科临床杂志

Objective To explore the factors which are related to the reoperation and relapse hiatus hernia in children.Methods Between Jan.2002 and May 2013,64 patients who suffered from hiatus hernia in Children's Hospital of Fudan University were divided into uneventful group (U group,n =49) and reoperation group (R group,n =15).The ages at operation,barium swallow examinations,operative procedures,findings during the operation and the followup of these two groups were reviewed.Results The average ages at operation in U group and R group were (14.70 ± 0.79) months and (13.60 ± 0.59) months,respectively.The major symptoms before the second operation in R group was vomiting(6 cases),pneumonia (4 cases) and dysphagia (2 cases).Asymptomatic recurrence was found in 3 patients.Through barium swallow examination,short esophagus was found in 10 cases in U group,while 3 cases were reported in R group.However,during the operation,the length of intra-abdominal esophagus without tension could be obtained with average (3.33 ± 0.86) cm in these short esophagus patients,which was only (3.18 ± 1.14) cm in those normal esophagus patients.There was no significant difference between the U group and R group in the width of the hiatus and the ratio of stomach above the hiatus.The length of esophagus which mobilized during operation was shorter in R group than that in U group(P =0.003).The difference of operative methods and the ratio of large hernia between these two groups could not be found.The common cause of failure in R group was herniated fundoplication (9 cases),which was followed by disputed fundoplication (4 cases),twisted fundoplication (1 case) and rupture of esophagus (1 case).The average follow up time was (8.3 ± 4.2) months in R group.Vomiting was found in 3 patients,and pneumonia was found in one case in R group after the second operation.The symptoms of these four patients were relieved half year later postoperatively.Conclusions The age,symptoms,size of the hiatus,short esophagus,and the operative methods are not related to the reoperation in hiatus hernia.But if the length of intra-abdominal esophagus without tension was not obtained enough,it may contribute to the recurrence of hiatus hernia.Wrap herniation has now become the most common mechanism of failure requiring reoperation.

Congenital Right Intrathoracic Stomach Secondary to Hiatus Hernia in an Infant.

A four month old, female infant presented with acute onset respiratory distress and persistent, non-bilious vomiting for one day. The initial chest radiograph showed two large, fluid filled structures in the right hemi thorax. An upper GI contrast study showed right intrathoracic stomach with hold-up of barium in the pylorus. A diagnosis of congenital right intra-thoracic stomach with organo-axial torsion was made and patient underwent laparotomy and repair of the hiatal defect. The child is asymptomatic on follow up. The case is reported for unusual symptomatic presentation on early infancy.

Análise de 502 endoscopias na avaliação pré-operatória de pacientes a serem submetidos à cirurgia bariátrica: relação entre doença do refluxo gastroesofágico e índice de massa corpórea / Analysis of 502 endoscopies in preoperative evaluation of bariatric patients: relationship between gastroesophageal reflux disease andbody mass index

Objetivo. Descrever a relação entre índice de massa corporal (IMC), hérnia de hiato e a prevalência de doença do refluxo gastroesofágico, baseados no consenso de Montreal. Método. Revisão de prontuários médicos de 502 pacientes obesos, que foram submetidos a endoscopia digestiva altaantes de cirurgia bariátrica de janeiro de 2004 a dezembro de 2008. Idade, sexo, IMC, comorbidades e achados endoscópicos foram analisados. Os pacientes foram distribuídos em três grupos: aqueles com IMC de 35 a 39,9 kg/m2 no grupo A (GA); IMC de 40 a 49,9 kg/m2 no grupo B (GB) e IMC ≥ 50 kg/m2 no grupo C (GC). Os testes estatísticos utilizados foramcoeficiente de correlação de Pearson, Anova e Fisher. Resultados. Foram do sexo feminino 422 (84%) pacientes. A média de idade foi 37 anos (extremos: 17 a 67). A prevalência de infecção por H. pylori foi 43%. A distribuição foi: 186 pacientes (37%) estavam no GA, 284 (56,5%) no GB e 32 (6,5%) no GC. A prevalência geral de doença do refluxo gastroesofágico foi 34,6%, maior no GC (37,5%). A prevalênciageral de hérnia de hiato foi 15,9%, maior no GA (17,7%). Não houve correlação significativa entre IMC e prevalência de doença do refluxo gastroesofágico (p = 0,46) ou hérnia de hiato (p = 0,93). Houve correlação positiva entre doença do refluxo gastroesofágico e hérnia de hiato (r = 0,54; r2 = 0,29, p < 0,0001) e entre idade e doença do refluxo gastroesofágico (r =0,10; r2 = 0,01; p = 0,01). Não houve correlação entre infecção pelo H. pylori e doença do refluxo gastroesofágico (r = -0,06;p = 0,13). Conclusões. Alterações no IMC parecem não influenciar a prevalência de doença do refluxo gastroesofágico ou hérniade hiato. A doença do refluxo gastroesofágico é mais comum em pacientes com hérnia de hiato do que naqueles sem hérniade hiato. A infecção por H. pylori não está relacionada à doença do refluxo gastroesofágico.

Objective. To describe the relation among body mass index (BMI), hiatus hernia and prevalence of gastroesophageal reflux disease, based on Montreal Consensus. Method. Medical records of 502 obese patients which were submitted to upper gastrointestinal endoscopy before bariatricsurgery from January 2004 through December 2008 was reviewed. Age, sex, Body Mass Index (BMI), comorbidities and endoscopic findings were analyzed. Patients were alocated in three groups: BMI of 35 to 39.9 kg/m2 in GA; BMI of 40 to 49.9 kg/m2 in GB and BMI ≥ 50 kg/m2 in GC. Statistical tests used were Pearson product-moment correlation coefficient,Anova and Fisher. Results. 422 (84%) patients were female. Mean age was 37 years (17-67). H. pylori infection prevalence was 43%. 186patients (37%) were in GA, 284 (56.5%) in GB and 32 (6.5%) in GC. Global prevalence of gastroesophageal reflux disease was 34.6%, greater in GC (37.5%). Global prevalence of hiatus hernia was 15.9%, greater in GA (17.7%). There was no significant correlation between increases in BMI and prevalence of gastroesophageal reflux disease (p = 0.46) or hiatus hernia (p = 0.93). There was a positive correlation between gastroesophageal reflux disease and hiatus hernia (r = 0.54; r2 = 0.29, p < 0.0001) and between age and gastroesophageal reflux disease (r = 0.10; r2 = 0.01; p = 0.01). There was no correlation between H. pylori and gastroesophageal reflux disease (r = -0.06; p = 0.13). Conclusions. Changes in BMI were not shown to alter prevalence of gastroesophageal reflux disease or hiatus hernia. Gastroesophageal reflux disease is more common among patients with hiatus hernia than among those without hiatus hernia. H. pylori infection and gastroesophageal reflux disease were not found to be related.

La hernia hiatal y su relación con el reflujo gastroesofágico / Hiatus hernia and its relations with gastro-esophageal reflux

La hernia hiatal (HH) es una condición relativamente frecuente en la población adulta. Su relación con el enfermedad por refl ujo gastroesofágico (ERGE) no está clara. El objetivo de este estudio fue contribuir a defi nir esta asociación. Con éste propósito, realizamos un análisis prospectivo de 335 personas (entre 15-92 años, edad promedio 50,6, 55,49% del sexo femenino). Nuestro estudio consistió en una revisión de las historias clínicas y esofagogastroduodenoscopia (EGD) para determinar presencia de hernia hiatal y de manifestaciones endoscópicas de esofagitis de refl ujo (ER) para determinar si existe o no una relación entre HH y ERGE. Una HH fue encontrada en 104 casos (31,04%), 78 (75%) fueron evidenciadas en pacientes con síntomas de refl ujo gastroesofágico (RGE) y 26 825%) en sujetos asintomáticos para RGE (p= 0.0001). Sin embargo, cuando el hallazgo de HH fue evaluado en pacientes sintomáticos para ERGE 37,50% (72/208 casos) y en aquello sin síntomas 20,47% (26/127 casos), no se encontró diferencia estadística significativa (p >0.05). 40 sujetos (11,94%) de la cantidad total de individuos analizados tuvieron alteraciones endoscópicas de RGE (90%), 36 de ellos con síntomas de RGE (90%) y 4 (10%) asintomáticos para esta condición (diferencia estadísticamente significativa P< 0.0001). La asociación entre HH y hallazgos endoscópicos de RE fue evidenciada en 20 de 40 casos (50%). De ellos, 19 tenían síntomas de RGE (95%). Sólo 1 (5%) fue asintomático de RGE. Hallazgos a la EGD de RE sin HH se encontraron en los otros 20, 17 de ellos (85%) sintomáticos para ERGE y 15% asintomáticos. En ambos subgrupos una diferencia estadísticamente significativa (P < 0-001) fue encontrada entre pacientes con síntomas de RGE y aquellos sin síntomas, reforzando la relación existente entre HH, hallazgos endoscópicos de RE y síntomas de ERGE. HH sin hallazgos endoscópicos de ER fue reportada en 84 individuos, 60 de ellos con síntomas de ERGE (71,42%)...

Hiatus Hernia (HH) is a relatively frequent condition in adult population. Its relation with the gastro-esophageal refl ux disease (GERD) is not clear. The purpose of this study was contributing to the definition of this association. With this aim a prospective analysis was performed on 335 people (ranging and age of 15-92, average age of 50.6, 55.49% women). The study was based on reviewing the clinical records and esophagogastroduodenoscopies (EGD) for determining the presence of hiatus hernia and endoscopic manifestations of refl ux esophagitis (RE) as well in order to define if whether a relationship between HH and GERD does exist or does not. One HH was found in out of 104 cases (31.04%), 78 (75%) were evidences in patients with gastro-esophageal refl ux symptoms (GER), and 26 (25%) in GER-asymptomatic subjects (p= 0.0001). However, when assessing the HH finding in GERD-symptomatic patients - 37.50% (72/208 cases) - and in those without symptoms - 20.47% (26/127 cases) - no significant statistical difference was found - (p >0.05). 40 subjects (11.94%) out of the total amount of the analyzed subjects showed endoscopic GER disturbances - (90%). 36 out of them showed GER symptoms (90%) and 4 (10%) were asymptomatic for this condition (statistically significant difference: P< 0.0001). The association between HH and the ER endoscopic findings was evidenced in 20 out of the 40 cases (50%). From them, 19 showed GER symptoms (95%). Only 1 (5%) was GER-asymptomatic. ER’s GED findings without HH were locate in other 20 subjects, where 17 (85%) were GERD-symptomatic and 15% was asymptomatic. A statistically significant difference (P < 0-001) was found in both subgroups among patients with GER symptoms and those without symptoms, thus strengthening the relation existing among HH, the endoscopic findings, and GERD symptoms. HH without RE endoscopic findings was reported in 84 people, 60 of them with GERD symptoms (71.42%) and 24 without symptoms (28.57%)...

Endoscopic observations around the gastroesophageal junction in patients with symptomatic gastroesophageal reflux disease in South Asia.

Introduction We studied the inter-relationships of endoscopic findings around the gastroesophageal junction in patients with symptomatic gastroesophageal reflux. Methods Data were collected with regard to hiatus hernia (HH), columnar-lined esophagus (CLE), reflux esophagitis (RE) and gastroesophageal flap valve (GEFV), prospectively from 1,150 patients who underwent diagnostic upper gastrointestinal endoscopy for symptomatic gastroesophageal reflux. Results The frequency of HH, CLE and RE was 14.3% (n=165), 9.5% (n=109) and 13.3% (n=153), respectively. In the CLE group, 48 were histologically proven to have Barrett’s esophagus. Of all RE patients, 94.8% had mild esophagitis (LA-A and B) and this was associated with younger age, male gender, presence of HH, and grade 3 or 4 gastroesophageal flap valve (GEFV). Grades 3 and 4 GEFV were associated with HH, CLE, and RE. Conclusions Substantial proportion of patients with symptoms of GERD has abnormal endoscopic findings around the gastroesophageal junction.

Laparoscopic mesh for massive esophageal hiatal hernia / 中华消化内镜杂志

Objective To assess the clinical outcome of massive hiatal hernia repair by mesh via laparoscopic approach. Methods A total of 31 patients with massive hiatal hernia who underwent laparoscopic repair from March 2005 to January 2009 were enrolled in the study, among which mesh was used in 20 patients. The clinical outcomes of these patients were compared with other 11 patients without mesh repair procedures. Results Surgical repair, combined with Dor fundoplication, was successful in all 31 cases.Five patients in the mesh group developed post-operative recurrent symptoms, 2 ( 10% ) of whom were confirmed by imaging study. Six patients in non-mesh group had recurrent symptoms after operation and 4 (36. 4% ) were confirmed. Conclusion Laparoscopic repair of massive hiatal hernia is technially demanding with a high post-operative recurrent rate. Administration of intro-operative mesh can reduce the difficulty of the procedure and recurrence as well.

Laparoscopic Therapy for Esophageal Hiatus Hernia and Reflux Esophagitis Complicated with Cholecystolithiasis:Report of 27 Cases / 中国微创外科杂志

Objective To explore the feasibility of laparoscopic surgery for esophageal hiatus hernia and reflux esophagitis complicated with cholecystolithiasis.Methods Five trocars were used for the patients to perform laparoscopic hiatal hernia repair,followed by fundoplication(Nissen fundoplication in 21 cases and Toupet fundoplication in 6),and then LC.Results The procedures were completed in all of the 27 cases.The postoperative mean esophageal pressure of the patients was significantly higher than that before the operations [(19.32?4.11) mm Hg vs(7.30?1.36) mm Hg,t=-16.407,P=0.000],while the 24-hour pH value were decreased markedly(9.20?2.15 vs 160.16?50.30,t=16.387,P=0.000).No hemorrhage,intra-abdominal infection,biliary leakage occurred in this series.The patients were followed up for 1 to 24 months(1-6 months in 7 cases,and 7-24 months in 20 cases),during which no esophageal stenosis or incisional hernia were detected.Conclusions It is feasible to perform primary laparoscopic surgery for patients suffering from esophageal hiatus hernia and reflux esophagitis complicated with simultaneous cholecystolithiasis,if no contraindications.

Congenital Anomalies of the Diaphragm in Children.

Twenty children with various diaphragmatic anomalies, managed over a period of 3 years, are presented, These included congenital diaphragmatic hernia (CDH 10), congenital eventration of diaphragm (CDE 6) and hiatus hernia with gastro-esophageal reflux (HH-GER 4). Clinical presentation of these children was: respiratory distress (7), recurrent repiratouy tract infection with failure to thrive (11) and gastric volvulus (3). Two patients of gastric volvulus had acute surgical abdomen. The patients in respiratouy distress group were all newborns with CDH. Whereas, those who had gastric volvulus were CDE 2 and HH-GER 1. All children were operated through left subcostal transabdominal approach, except those with HH-GER who were explored through upper midline incision. Repair of diaphragmatic defect/placation was done in patients with CDH/CDE, whereas Nissen fundoplication (Loode wrap) was done in patients of HH-GER. Three newborns with CDH and one child with CDE and gastric volvulus died. All other 16 surviving children are doning well after 4 months to 3 years of follow up.