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The Management of Paraesophageal Hernia

The Management of Paraesophageal Hernia. Joint Hospital Surgical Grand Round 21 October 2017. Background. Definition

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The Management of Paraesophageal Hernia

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  1. The Management of Paraesophageal Hernia Joint Hospital Surgical Grand Round 21 October 2017

  2. Background • Definition • Protrusion of any abdominal structure other than the esophagus into the thoracic cavity through a widening of the hiatus of the diaphragm, with the gastroesophageal junction remaining in place • Subtype of hiatal hernia • 5-10% • Relative preservation of posterolateral phrenoesophageal attachments around the gastroesophageal junction • Current Management of Paraesophageal Hernia; Farid K.MD, The American Surgeon; Dec 2011;77,12 • Guidelines for the management of Hiatal Hernia, SAGES, April 2013

  3. Sliding Mixed PEH Other organs involved Rolling Torrance Digestive Disease Institute

  4. Anatomy

  5. Etiology • Progressive weakening of the phrenoesophageal ligaments • Depletion of elastin fibers • Higher incidence of in the elder population • Median age: 61 Current Management of Paraesophageal Hernia; Kehdy F, MD, The Am Surgeon; Dec 2011;77,12

  6. Presentation Risk factors • May be asymptomatic • Dysphagia • Chest or epigastric pain • Reflux symptoms (26-70%) • Respiratory complications (9-59%) • Iron deficiency anemia (17-47%) • Age • Increased intra-abdominal pressure Current Management of Paraesophageal Hernia; Kehdy F, MD, The Am Surgeon; Dec 2011;77,12

  7. Diagnosis • X-ray • Barium swallow • Endoscopy • CT scan Kahrilas PJ, Kim HC, Pandolfino JE. Approaches to the diagnosis and grading of hiatal hernia. Best Pract Res Clin Gastroenterol 2008; 22:601.

  8. Plain Chest Radiographs (CXR) Case courtesy of Radswiki, Radiopaedia.org, rID: 11448 Case courtesy of Dr Maxime St-Amant, Radiopaedia.org, rID: 19256

  9. Barium Swallow Courtesy of David Y. Graham. MD

  10. Computed tomography

  11. Oesophagogastroduodenoscopy (OGD)

  12. Complications • Haemorrhage • Ulceration • Volvulus • Obstruction Kaneyama H, Kaise M, Arakawa H, Arai Y, Kanazawa K, Tajiri H. Gastroesophageal flap valve status distinguishes clinical phenotypes of large hiatal hernia. World J Gastroenterol 2010; 16(47): 6010-6015 Case courtesy of Dr Maxime St-Amant, Radiopaedia.org

  13. Management • All symptomatic paraesophageal hernia should be repaired surgically • If complication of gastric volvulus arise, limited resection for gastric reduction is required • Louie B, Blitz M, Farivar A, Orlina J, Aye R (2011) Repair of symptomatic giant paraesophageal hernias in elderly ([70 years) patients results in improved quality of life. J Gastrointest Surg 15(3):389–396 • Guidelines for the management of Hiatal Hernia, SAGES, April 2013

  14. Principle of Surgical Repair • Tension-free reduction of the stomach and esophagus in the abdominal cavity • Hernia sac excision • Re-approximation of the diaphragmatic crura • Kohn, G. P., Price, R. R., DeMeester, S. R., Zehetner, J., Muensterer, O. J., Awad, Z. T., ... Fanelli, R. D. (2013). Guidelines for the management of hiatal hernia. Surgical Endoscopy, 27(12), 4409-4428. doi:10.1007/s00464-013-3173-3 • Puri V, Jacobsen K, Bell JM, et al. Hiatal Hernia Repair with or without Esophageal Lengthening: Is There a Difference? Innovations (Philadelphia, Pa). 2013;8(5):341-347. doi:10.1097/IMI.0000000000000012.

  15. 1. Laparoscopic view 2. Dissection of the hernia sac 4. Mesh reinforcement 3. Posterior crural closure and anterior closure of the esophageal hiatus Management of large para-esophageal hiatal hernias; D.Collet,Journal of Viscera Surgery (2013)150,395-402

  16. Complications • Traumatic visceral injury • Esophageal perforation • Gastric lacerations • Ischemic necrosis • Less common • Vagus nerve injury • Splenic injury • Cardiac tamponade • Mesh erosion • Dysphagia Management of large para-esophageal hiatal hernias; D.Collet,Journal of Viscera Surgery (2013)150,395-402

  17. Three areas of controversies • Trans-abdominal vs Trans-thoracic approach • Mesh vs no mesh • Synthetic vs Biological

  18. Surgical approach Trans-thoracic Trans-abdominal • Left decubitus • Excellent visualization of esophagus • Easy esophageal mobilization • Quicker and less painful approach • Easier to assess the reduction hernia

  19. Trans-thoracic vs Trans-abdominal • No randomized controlled trial • 5 retrospective cohort studies • Geha et la • N = 100 • Complications rate • Thoracic 11% vs Abdominal 5% • Re-operation rate • Thoracic 11% vs Abdominal 0% • Other studies reports also favour trans-abdominal approach with lower peri-operative mortality and morbidities • Geha AS, Massad MG, Snow NJ, et al. A 32-year experience in 100 patients with giant paraesophageal hernia: the case for abdominal approach and selective antireflux repair. Surgery 2000;128:623–630. • F.Yan, Disease of the Esophagus (2009)22, 284-288; Outcomes of surgical treatment of intrathoracic stomach

  20. Mesh or not • Primary cruroplasty has been in mainstay of practice for many year • Suggest high recurrence rate up to 42% • Use of mesh was describe in 1998

  21. Mesh or not • Meta-analysis • V. Tam et al • 521 suture vs 673 mesh • Lower recurrence rate in mesh group (odd ratio 0.42, p-=0.014) • Decrease recurrence by using mesh in short term • Effect may also last to mid-term • Long-term data inadequate • Mesh complications • Long term safety not adequate • V.Tam, The American Journal of Surgery (2016)211, 226-238; A Systemic Review and Meta-analysis of mesh vs suture cruroplasty in laparoscopic large hiatal hernia repair • E.Asti, Hernia (2-18)21:623-628; Crura augmentination ith Bio-A mesh or laparoscopic repair of hiatal hernia: single-institution experience with 1000 consecutive patients • E.Asti; Surg Endosc (2016)30:5404-5409; Laparoscopic management of large hiatus hernia: five year conhort study and comparison o mesh-augmented versus standard crura repair

  22. Mesh Materials • Synthetic vs Biological • Serious complications of synthetic mesh • Esophageal erosion • Biologic mesh is reported to be more favourable • Biocompatible material that gradually degrades • Numerous observational studies • Craig G et al • N= 221 patient • Since July 2009 to October 2014 • None report on esophageal erosion Craig GC, January-March 2016 JSLS; Laparoscopic Hiatal Hernia Repair in 221 Patients: outcomes and experience

  23. Conclusion • Surgical repair should be offered to paraesophageal hernia • Laparoscopic abdominal approach is recommended • Repair with mesh decrease at least short term and mid-term recurrence rate • Still no data on long term recurrence rate • Biological mesh is preferred

  24. Thank you

  25. Mechanism of anti-reflux • 6 components • Peristalsis of esophagus • Lower esophageal sphincter • Crural diaphragm • Acting like pinchcock • Anatomical location of the gastroesophageal junction below the diaphragmatic hiatus (Intra-abdominal esophagus) • Acts as a flap valve • Mucosal rosette • Unimpeded gastric emptying

  26. Laparoscopic surgery • Rate of conversion to open surgery is 2 to 9% • The learning curve to achieve competence is estimated at 20 cases • Recommended by French since 2007 • Mean length of stay: 3 days • Retrospective studies

  27. Age limit or not • Elective repair above 65 year old was reported that would decrease quality of life with calculation from data before 2000s • Latest cohort studies suggest age may increase minor morbidity but not major morbidity or mortality

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