The natural course of giant paraesophageal hernia and long-term outcomes following conservative management.

BACKGROUND: Accurate information on the natural course of giant paraesophageal hernia is scarce, challenging therapeutic decisions whether or not to operate. OBJECTIVE: We aimed to investigate the long-term outcomes, including hernia-related deaths and complications (e.g. volvulus, gastrointestinal bleeding, strangulation) of patients with giant paraesophageal hernia that were conservatively managed, and to determine factors associated with clinical outcome. METHODS: We retrospectively analysed charts of patients diagnosed with giant paraesophageal hernia between January 1990 and August 2019, collected from a university hospital in The Netherlands. Included patients were subdivided into three groups based on primary therapeutic decision at diagnosis. Radiological, clinical and surgical characteristics, along with long-term outcomes at most recent follow-up, were collected. RESULTS: We included 293 patients (91 men, mean age 70.3 ± 12.4 years) with a mean duration of follow-up of 64.0 ± 58.8 months. Of the 186 patients that were conservatively treated, a total hernia-related mortality of 1.6% was observed. Hernia-related complications, varying from uncomplicated volvulus to strangulation, occurred in 8.1% of patients. Only 1.1% of patients included in this study required emergency surgery. Logistic regression analysis revealed the presence of symptoms (odds ratio (OR) 4.4, 95% confidence interval (CI) 1.8-20.6), in particular obstructive symptoms (vomiting, OR 15.7, 95% CI 4.6-53.6; epigastric pain, OR 4.4, 95% CI 1.2-15.8 and chest pain, OR 6.1, 95% CI 1.8-20.6) to be associated with the occurrence of hernia-related complications. CONCLUSIONS: Hernia-related death and morbidity is low in conservatively managed patients. The presence of obstructive symptoms was found to be associated with the occurrence of complications during follow-up. Conservative therapy is an appropriate therapeutic strategy for asymptomatic patients.

Diaphragmatic Hernia Perforation Leading to Fecopneumothorax.

Hiatal hernia is a common diagnosis. Unless symptomatic, most hiatal hernias are not repaired; in rare cases, however, severe complications can develop during conservative treatment. Although fecopneumothorax occurrence has been described in trauma and related to colonic pathology, it has not been described as occurring from spontaneous strangulation of a hiatal hernia. Regardless of the etiology, prompt recognition of the rare occurrence of fecopneumothorax is imperative. This report describes the presentation, diagnosis, and treatment of a patient presenting with a type IV hiatal hernia that resulted in colonic ischemia, perforation, and fecopneumothorax.

Benefits of a Patient-centered Remote Therapy Monitoring Program Focusing on Increased Adherence to Wound Therapy.

INTRODUCTION: Patient nonadherence to wound care protocols may impact the efficacy of modalities, such as negative pressure wound therapy (NPWT). Recently, a remote therapy monitoring (RTM) system has been devised for use with NPWT for home care patients. OBJECTIVE: Three home care patients receiving NPWT are presented to examine the relationship between patients using the RTM system and Virtual Therapy Specialists (VTS). MATERIALS AND METHODS: Consent was secured from patients with either multiple comorbidities and/or wounds of varying complexity. Wounds were assessed as per their initial presentation, and all patients were discharged home with an RTM-equipped NPWT system to apply continuous subatmospheric pressure to their wound. Dressings were changed every 2 to 3 days. RESULTS: All 3 patients were women (age range, 53-72 years), who presented with the following wound types: recalcitrant abdominal wound, acute wound following ventral hernia repair, and dehisced wound following a hysterectomy. Patient 1 was treated with RTM-equipped NPWT for a duration of 88 days (6 nonadherent vs. 82 adherent days) and was adherent to the therapy 93.2% of the time. Patient 2 was treated with RTM-equipped NPWT for a duration of 57 days (8 nonadherent vs. 49 adherent days) and was adherent to the therapy 86.0% of the time. Patient 3 was treated with RTM-equipped NPWT for a duration of 16 days (2 nonadherent vs. 14 adherent days) and was adherent to the therapy 87.5% of the time. Each patient presented with a barrier to therapy adherence (eg, lack of access to residential clinical support, technical issues, or work demands) that was managed by VTS interactions. CONCLUSIONS: In these 3 cases, RTM-equipped NPWT and the patient-centric exchanges with the VTS through adherence calls helped promote consistent usage of RTM-equipped NPWT to address the patients' therapeutic needs and increase therapy adherence.

Clinical findings, diagnostic test results, and treatment outcome in cats with hiatal hernia: 31 cases (1995-2018).

BACKGROUND: Information regarding clinical signs, assessment, treatment, and outcome in cats with hiatal hernia (HH) is limited. OBJECTIVES: To characterize the clinical presentation of HH and medical and surgical outcomes in a cohort of affected cats. ANIMALS: Thirty-one client-owned cats with HH. METHODS: Medical records of cats with HH were retrospectively reviewed for signalment, history, results of diagnostic tests, details of surgical and medical treatments, complications, and outcome. Long-term follow-up data were obtained by telephone communication. Relationships between clinical variables and outcome were evaluated by regression analysis. RESULTS: Type I HH was present in 85.7% (24/28) of cats, and 64.5% (20/31) were >3 years of age at diagnosis. Twenty-one of 31 (67.7%) cats underwent surgical repair including phrenoplasty, esophagopexy, and left-sided gastropexy, and 10 of 31 cats were treated medically without surgery. Concurrent illness was common, and 77.4% cats had comorbidities. All cats survived to discharge, and median time to death or follow-up was 959 days (range, 3-4015 days). Cats treated medically survived longer than cats treated surgically, with median time to death or follow-up of 2559 and 771 days, respectively. CONCLUSIONS AND CLINICAL IMPORTANCE: Type I HH is the most common type of HH in cats. A congenital etiology is possible, but many cats with HH were >3 years of age at diagnosis and suffered from comorbidities, including upper airway obstruction. Case selection and the presence of comorbidities likely influenced the outcome. Cats with HH may not be diagnosed until disease is advanced or concurrent illness draws attention to clinical signs.

Watchful waiting versus elective repair for asymptomatic and minimally symptomatic paraesophageal hernias: A cost-effectiveness analysis.

OBJECTIVE: To evaluate the decision of watchful waiting (WW) versus elective laparoscopic hernia repair (ELHR) for minimally symptomatic paraesophageal hernias (PEH) with respect to cost-effectiveness. BACKGROUND: The current recommendation for minimally symptomatic PEHs is watchful waiting. This standard is based on a decision analysis from 2002 that compared the two strategies on quality-adjusted life-years (QALYs). Since that time, the safety of ELHR has improved. A cost-effectiveness study for PEH repair has not been reported. METHODS: A Markov decision model was developed to compare the strategies of WW and ELHR for minimally symptomatic PEH. Input variables were estimated from published studies. Cost data was obtained from Medicare. Outcomes for the two strategies were cost and QALY's. RESULTS: ELHR was superior to the WW strategy in terms of quality of life, but it was more costly. The average cost for a patient in the ELHR arm was 11,771 dollars while for the WW arm it was 2207. CONCLUSION: This study shows that WW and ELHR both have benefits in the management of minimally symptomatic paraesophageal hernias.

Unilateral lung agenesis, hiatal hernia and atrioventricular septal defect: a rare combination of congenital anomalies.

Unilateral lung agenesis is a relatively rare congenital anomaly with a reported incidence of 1 in 15 000 births. It is frequently associated with other congenital malformations. Some of the sequelae of lung agenesis are potentially life-threatening. Here, we report a case of left lung agenesis in association with hiatal hernia and atrioventricular septal defect, a rare combination of anomalies which have not been described previously in the literature.

Esophageal hiatal hernia: risk, diagnosis and management.

INTRODUCTION: Esophageal hiatal hernia involves abnormal abdominal entry into thoracic cavity. It is classified based on orientation between esophageal junction and diaphragm. Sliding hiatal hernia (Type-I) comprises the most frequent category, emanating from right crus of diaphragm. Type-II esophageal hernia engages both left and right muscular crura. Type-III and IV additionally include the left crus. Age and increased body mass index are key risk factors, and congenital skeletal aberrations trigger pathogenesis through intestinal malrotations. Familiar manifestations include gastric reflux, nausea, bloating, chest and epigastric discomfort, pharyngeal and esophageal expulsion and dysphagia. Weight loss and colorectal bleeding are severe symptoms. Areas covered: This review summarizes updated evidence of pathophysiology, risk factors, diagnosis and management of hiatal hernias. Laparoscopy and oesophagectomy procedures have been discussed as surgical procedures. Expert commentary: Endoscopy identifies untreatable gastric reflux; radiology is better for pre-operative assessments; manometry measures esophageal peristalsis, and CT scanning detects gastric volvulus and associated organ ruptures. Gastric reflux disease is mitigated using antacids and proton pump and histamine-2-receptor blockers. Severe abdominal penetration into chest cavity demands surgical approaches. Hence, esophagectomy has chances of post-operative morbidity, while minimally invasive laparoscopy entails fewer postoperative difficulties and better visualization of hernia and related vascular damages.

Influence of national centralization of oesophagogastric cancer on management and clinical outcome from emergency upper gastrointestinal conditions.

BACKGROUND: In England in 2001 oesophagogastric cancer surgery was centralized. The aim of this study was to evaluate whether centralization of oesophagogastric cancer to high-volume centres has had an effect on mortality from different emergency upper gastrointestinal conditions. METHODS: The Hospital Episode Statistics database was used to identify patients admitted to hospitals in England (1997-2012). The influence of oesophagogastric high-volume cancer centre status (20 or more resections per year) on 30- and 90-day mortality from oesophageal perforation, paraoesophageal hernia and perforated peptic ulcer was analysed. RESULTS: Over the study interval, 3707, 12 441 and 56 822 patients with oesophageal perforation, paraoesophageal hernia and perforated peptic ulcer respectively were included. There was a passive centralization to high-volume cancer centres for oesophageal perforation (26·9 per cent increase), paraoesophageal hernia (19·5 per cent increase) and perforated peptic ulcer (23·0 per cent increase). Management of oesophageal perforation in high-volume centres was associated with a reduction in 30-day (HR 0·58, 95 per cent c.i. 0·45 to 0·74) and 90-day (HR 0·62, 0·49 to 0·77) mortality. High-volume cancer centre status did not affect mortality from paraoesophageal hernia or perforated peptic ulcer. Annual emergency admission volume thresholds at which mortality improved were observed for oesophageal perforation (5 patients) and paraoesophageal hernia (11). Following centralization, the proportion of patients managed in high-volume cancer centres that reached this volume threshold was 88·0 per cent for oesophageal perforation, but only 30·3 per cent for paraoesophageal hernia. CONCLUSION: Centralization of low incidence conditions such as oesophageal perforation to high-volume cancer centres provides a greater level of expertise and ultimately reduces mortality.

[Osteopathie bei gastroösophagealem Reflux mit Hiatushernie: Ein Fallbericht gemäß der CARE-Leitlinie].

Hintergrund: Das Vorhandensein einer Hiatushernie kann das Auftreten einer gastroösophagealen Refluxerkrankung (GERD) als Komplikation bedingen. Konventionelle medizinische Therapiemaßnahmen können zu unerwünschten Ereignissen und Rezidiven führen. Bisher sind die Effekte von osteopathischen Behandlungen bei Hiatushernie und GERD nicht bekannt. Fallbericht: Eine 59-jährige Patientin mit endoskopisch diagnostizierter chronischer Gastritis, GERD und Hiatushernie beklagte einen persistierenden gastroösophagealen Reflux trotz konventionell-medizinischer konservativer Therapie. Die osteopathische Diagnostik ergab eine funktionelle Störung im Bereich des Magens und der Kardia mit einer Beteiligung zugehöriger Reflexzonen. Nach einer osteopathischen Behandlung als individuelle, befundorientierte Therapie ließen die Beschwerden erheblich nach. Die Hiatushernie war nach einer dieser Behandlung endoskopisch nicht mehr nachweisbar. Schlussfolgerungen: Dieser Fallbericht schildert die Symptomreduktion einer GERD nach osteopathischer Behandlung. In der endoskopischen Folgeuntersuchung fand sich die initial diagnostizierte Hiatushernie nicht mehr, diese Befund änderung könnte jedoch auf die unterschiedlichen Untersucher zurückgeführt werden. Prospektive kontrollierte klinische Studien sind notwendig, um den Stellenwert von osteopathischen Behandlungen bei GERD mit Hiatushernie zu untersuchen.

Effect of Esophageal Cancer Surgeon Volume on Management and Mortality From Emergency Upper Gastrointestinal Conditions: Population-based Cohort Study.

OBJECTIVE: To study the influence of esophageal cancer surgeon volume upon mortality from upper gastrointestinal emergencies. BACKGROUND: Volume-outcome relationships led to the centralization of esophageal cancer surgery. METHODS: Hospital Episode Statistics data were used to identify patients admitted to hospitals within England (1997-2012). The influence of esophageal high-volume (HV) cancer surgeon status (≥5 resections per year) upon 30-day and 90-day mortality from esophageal perforation (EP), paraesophageal hernia causing obstruction or gangrene (PEH) and perforated peptic ulcer (PPU) was analyzed, independent of HV esophageal cancer center status and patient and disease-specific confounding factors. RESULTS: A total of 3707, 12,411, and 57,164 patients with EP, PEH, and PPU, respectively, were included. The observed 90-day mortality was 36.5%, 11.5%, and 29.0% for EP, PEH, and PPU, respectively.Management by HV cancer surgeon was independently associated with significant reductions in 30-day and 90-day mortality from EP (odds ratio, OR 0.51, 95% confidence interval, CI, 0.40-0.66), PEH (OR=0.70, 95% CI 0.53-0.91), and PPU (OR=0.85, 95% CI 0.7-0.95). Subset analysis of those patients receiving primary surgery as treatment showed no change in mortality when performed by HV cancer surgeons.However HV cancer surgeons performed surgery as primary treatment more commonly for EP (OR=2.38, 95% CI 1.87-3.04) and PEH (OR=2.12, 95% CI 1.79-2.51). Furthermore surgery was independently associated with reduced mortality for all 3 conditions. CONCLUSION: The complex elective workload of HV esophageal cancer surgeons appears to lower the threshold for surgical intervention in specific upper gastrointestinal emergencies such as EP and PEH, which in turn reduces mortality.

Hiatal Hernia After Esophagectomy for Cancer.

BACKGROUND: Hiatal hernia (HH) after esophagectomy is becoming more relevant due to improvements in survival. This study evaluated and compared the occurrence and clinical course of HH after open and minimally invasive esophagectomy (MIE). METHODS: The prospectively recorded characteristics of patients treated with esophagectomy for cancer at 2 tertiary referral centers in the United Kingdom and the Netherlands between 2000 and 2014 were reviewed. Computed tomography reports were reviewed to identify HH. RESULTS: Of 657 patients, MIE was performed in 432 patients (66%) and open esophagectomy in 225 (34%). A computed tomography scan was performed in 488 patients (74%). HH was diagnosed in 45 patients after a median of 20 months (range, 0 to 101 months). The development of HH after MIE was comparable to the open approach (8% vs 5%, p = 0.267). At the time of diagnosis, 14 patients presented as a surgical emergency. Of the remaining 31 patients, 17 were symptomatic and 14 were asymptomatic. An elective operation was performed in 10 symptomatic patients, and all others were treated conservatively. During conservative treatment, 2 patients presented as a surgical emergency. An emergency operation resulted in a prolonged intensive care unit stay compared with an elective procedure (3 vs 0 days, p < 0.001). In-hospital deaths were solely seen after emergency operations (19%). CONCLUSIONS: HH is a significant long-term complication after esophagectomy, occurring in a substantial proportion of the patients. The occurrence of HH after MIE and open esophagectomy is comparable. Emergency operation is associated with dismal outcomes and should be avoided.

Autologous augmentation of hiatal hernia repair with filtered platelet concentrate improves tissue remodeling in a swine model.

INTRODUCTION: Autologus augmentation of wound remodeling with platelet concentrate is a burgeoning field with promising results. We hypothesized that the addition of filtered platelet concentrate (fPC) to an acellular biologic graft would improve crural healing and tissue integrity in hiatal hernia repair. METHODS: Sixteen healthy Yorkshire female pigs were divided into three groups: hiatus repair (HR) (n = 7), HR with biologic graft (HRM; n = 8, and HR with biologic graft and fPC (fPC; n = 9). Surgeries were performed by a single surgeon. Animals were euthanized at 8 weeks, and the distal esophagus with hiatus was harvested en-block. Tissue was graded by a histopathologist on collagen deposition, vascularization, and inflammation at the graft-hiatal interface. Tensile strength testing was performed using the Teststar IIs (MTS), coupled with a strain extensometer (Epsilon). Samples of equal dimensions were preloaded to 1 N and deformed at a constant rate of 0.2 mm/s. Statistical analysis was performed via Kruskal-Wallis one-way analysis of variance. RESULTS: Aspirate analysis revealed a mean platelet count of 3 million platelets/1 mL of aspirate. Animals in the fPC group had significantly increased mean chronic inflammation (3.1 ± 1.1 vs. 1.8 ± 1.6, 1.2 ± 1.2, p = 0.04) compared to HR alone and HR + biologic graft. Vascular deposition did not differ between groups (p = 0.8). A trend toward increased collagen deposition was demonstrated for the fPC group (1.4 ± 1.1 vs. 2.0 ± 0.6 in HR group and 3.0 ± 1.2 in HRM group, p = 0.06). There was a statistically significant increase in tensile strength, yield force, and Young's modulus in the fPC group compared with HR and HR + biologic mesh (p < 0.01). CONCLUSION: A trend toward increased collagen deposition and vascularity of the fPC group was demonstrated. In addition, there was an increase in tensile strength and yield force in the fPC group. Use of autologous fPC appears a safe and promising adjunct to wound remodeling and healing in a swine model.

Practice Patterns and Outcomes After Hospital Admission With Acute Para-esophageal Hernia in England.

OBJECTIVE: (i) To establish at a national level clinical outcomes from patients presenting with acute para-esophageal hernia (PEH); and (ii) to determine if a hospital volume-outcome relationship exists for the management of acute PEH. BACKGROUND: Currently, no clear guidelines exist regarding the management of acute PEH, and practice patterns are based upon relatively small case series. METHODS: Patients admitted as an emergency for the treatment of acute PEH between 1997 and 2012 were included from the Hospital Episode Statistics database. The influence of hospital volume upon clinical outcomes was analyzed in unmatched and matched comparisons to control for patient age, medical comorbidities, and incidence of PEH hernia gangrene. RESULTS: Over the 16-year study period, 12,441 patients were admitted as an emergency with a PEH causing obstruction or gangrene. Of these, 90.8% patients were admitted with PEH with obstruction in the absence of gangrene and 9.2% with PEH with gangrene. The incidences of 30 and 90-day mortality were 7% and 11.5%, respectively, which did not decrease during the study period. Unmatched and matched comparisons showed, in high-volume centers, there were significant reductions in utilization of emergency surgery (8.8% vs 14.9%; P < 0.0001), 30-day (5.3% vs 7.8%; P < 0.0001), and 90-day mortality (9.3% vs 12.7%; P < 0.0001). Multivariate analysis also confirmed high hospital volume was independently associated with reduced 30 and 90-day mortality from acute PEH. CONCLUSIONS: Acute PEH represents a highly morbid condition, and treatment in high-volume centers provides the appropriate multidisciplinary infrastructure to manage these complex patients reducing associated mortality.

Hiatal hernia.

Hiatal hernia refers to conditions in which elements of the abdominal cavity, most com- monly the stomach, herniate through the esophageal hiatus into the mediastinum. Hiatal hernias (type I) are the most common type (85-95 %). Types II, III and IV are all varieties of paraesophageal hernias. In Makuuchi classification, sliding hiatal hernia is readily diag- nosed by endoscopy when greater than 3 cm in axial span. In western countries, it is diag- nosed when greater than 2cm. High-resolution manometry with pressure topography plotting allows for precise localization and quantification of the individual physiological elements of the esophagogastric junction. In recent study, anti-reflux mucosectomy(ARMS) could represent an effective anti-reflux procedure.

Effect of IQoro(R) training in hiatal hernia patients with misdirected swallowing and esophageal retention symptoms.

CONCLUSION: Misdirected swallowing can be triggered by esophageal retention and hiatal incompetence. The results show that oral IQoro(R) screen (IQS) training improves misdirected swallowing, hoarseness, cough, esophageal retention, and globus symptoms in patients with hiatal hernia. OBJECTIVES: The present study investigated whether muscle training with an IQS influences symptoms of misdirected swallowing and esophageal retention in patients with hiatal hernia. METHODS: A total of 28 adult patients with hiatal hernia suffering from misdirected swallowing and esophageal retention symptoms for more than 1 year before entry to the study were evaluated before and after training with an IQS. The patients had to fill out a questionnaire regarding symptoms of misdirected swallowing, hoarseness, cough, esophageal retention, and suprasternal globus, which were scored from 0-3, and a VAS on the ability to swallow food. The effect of IQS traction on diaphragmatic hiatus (DH) pressure was recorded in 12 patients with hiatal hernia using high resolution manometry (HRM). RESULTS: Upon entry into the study, misdirected swallowing, globus sensation, and esophageal retention symptoms were present in all 28 patients, hoarseness in 79%, and cough in 86%. Significant improvement was found for all symptoms after oral IQS training (p < 0.001). Traction with an IQS resulted in a 65 mmHg increase in the mean HRM pressure of the DH.