Routine Esophagograms After Hiatus Hernia Repair Minimizes Reoperative Morbidity: A Multicenter Comparative Cohort Study.

OBJECTIVE: Determine the utility of routine esophagograms after hiatus hernia repair and its impact on patient outcomes. BACKGROUND: Hiatus hernia repairs are common. Early complications such asre-herniation, esophageal obstruction and perforation, although infrequent, incur significant morbidity. Whether routine postoperative esophagograms enable early recognition of these complications, expedite surgical management, reduce reoperative morbidity, and improve functional outcomes are unclear. METHODS: Analysis of a prospectively-maintained database of hiatus hernia repairs in 14 hospitals, and review of esophagograms in this cohort. Results: A total of 1829 hiatus hernias were repaired. Of these, 1571 (85.9%) patients underwent a postoperative esophagogram. Overall, 1 in 48 esophagograms resulted in an early (<14 days) reoperation, which was undertaken in 44 (2.4%) patients. Compared to those without an esophagogram, patients who received this test before reoperation (n = 37) had a shorter time to diagnosis (2.4 vs 3.9 days, P = 0.041) and treatment (2.4 vs 4.3 days, P = 0.037) of their complications. This was associated with lower rates of open surgery (10.8% vs 42.9%, P = 0.034), gastric resection (0.0% vs 28.6%, P = 0.022), postoperative morbidity (13.5% vs 85.7%, P < 0.001), unplanned intensive care admission (16.2% vs 85.7%, P < 0.001), and decreased length-of-stay (7.3 vs 18.3 days, P = 0.009). Furthermore, we identified less intraoperative and postoperative complications, and superior functional outcomes at 1-year follow-up in patients who underwent early reoperations for an esophagogram-detected asymptomatic re-herniation than those who needed surgery for late symptomatic recurrences. CONCLUSIONS: Postoperative esophagograms decrease the morbidity associated with early and late reoperations, and should be considered for routine use after hiatus hernia surgery.

A delayed presentation of traumatic right hemidiaphragm injury repaired via a laparoscopic approach: A case report.

INTRODUCTION: Diaphragmatic injury is a rare clinical entity which presents a diagnostic and therapeutic challenge. It is three times more common following blunt trauma than penetrating trauma and results in larger tears. A high index of suspicion is required to diagnose diaphragmatic injury. A missed diagnosis following acute injury can later result in life-threatening complications. CASE PRESENTATION: We describe the successful management of a right hemidiaphragmatic injury presenting two weeks following blunt thoracoabdominal trauma using a laparoscopic mesh repair. DISCUSSION: Diaphragmatic injury is rare, with right-sided injuries less common due to the buffering effect of the liver. The diagnosis is made within 24 hours of injury in 75% of cases (Haranal and et al., 2018) [1]. In our patient, symptoms of a right-sided diaphragmatic injury manifested two weeks following a motor vehicle collision. A CT scan of the chest and abdomen confirmed the diagnosis. According to DeBlasio, intermittent symptoms of visceral herniation or incorrect x-ray interpretation are the main reasons for a delayed diagnosis (DeBlasio et al., 1994) [2]. Contrary to common practice where thoracotomy is the preferred method for repair in the absence of associated abdominal injuries, we demonstrated that a right-sided diaphragmatic injury can be successfully managed with a laparoscopic mesh repair. CONCLUSION: Traumatic diaphragmatic injury remains a challenge to emergency physicians and trauma surgeons. Clinicians should be aware of the differing clinical presentations, investigations, and management. Surgical repair can be achieved via laparoscopy, thoracoscopy, laparotomy, and/or thoracotomy. In the case of an isolated right-sided diaphragmatic injury, laparoscopic mesh repair should be considered.