Acute hiatal hernias
V. Procházka 1; R. Svatoň 1; F. Marek 1; V. Čan 1; L. Kunovsky 2; D. Bartušek 3; J. Ivičič 1; Z. Kala 1
Chirurgická klinika Fakultní nemocnice Brno a Lékařské fakulty Masarykovy univerzity v Brně
1; Interní gastroenterologická klinika Fakultní nemocnice Brno a Lékařské fakulty Masarykovy univerzity v Brně
2; Klinika radiologie a nukleární medicíny Fakultní nemocnice Brno a Lékařské fakulty Masarykovy univerzity v Brně
Rozhl. Chir., 2019, roč. 98, č. 5, s. 207-213.
In surgical practice, hiatal hernias are often related to gastro esophageal reflux disease treatment in which continuous proton pump inhibitor administration is very successful. In large hiatal hernias, life threatening complications may occur. However, planned surgical repair of hiatal hernias is associated with very good functional outcomes with a low risk of postoperative complications. The incidence of large hiatal hernias grows with increasing age of the patient. In geriatric patients, internal comorbidities are also more frequent, including serious conditions. In these patients, one may hesitate whether to perform surgery with regard to the possible risk of postoperative complications. Conservative treatment of hiatal hernias is associated with a higher risk of stomach volvulus or severe bleeding as the most frequent complications.
We performed a retrospective study of patients operated on for a large hiatal hernia at the Department of Surgery, University Hospital Brno, between 2010 and 2016 (86 months). The patients were divided into 2 groups depending on the type of operation: acute (A) and elective (B). We evaluated demographic data, the nature of preoperative symptoms, type of surgery and postoperative complications.
120 patients were operated on for large hiatal hernia in this period of time. Group A involved 22 operated patients, group B 98 patients. There was a significantly higher number of laparotomies in the acute patient group compared to the elective group B (72.7 % vs. 23.5%, p<0.0001). Average surgery duration was longer in group A than in group B (133.8 minutes vs. 109.8 minutes). Postoperative complications were significantly more frequent in group A. They were also more severe and combined in a single patient. One death occurred in group A, in group B no patient died. Preoperative symptom analysis revealed a statistically significantly higher incidence of vomiting and breathing difficulties in group A. In group B, regurgitation and pyrosis were present with a significantly higher frequency.
In small hiatal hernias, the rate of complication occurrence is low. With growing size of the hernias, the risk of potentially life threatening acute complication increases. Stomach volvulus and severe bleeding in particular are the most frequent complications of hiatal hernias. Acute operations are associated with a significantly higher risk of postoperative complications than elective procedures. Surgical repair of hiatal hernia should be indicated in all symptomatic patients with a large hiatal hernia. In patients without clinical symptoms, surgical repair of hernia is recommended if there are no significant internal contraindications to surgery.
large hiatal hernia – laparoscopy – stomach volvulus – fundoplication
- Haas O, Rat P, Christophe M, et al. Surgical results of intrathoracic gastric volvulus complicating hiatal hernia. Br J Surg. 1990;77:1379−81.
- Treacy PJ, Jamieson GG. An approach to the management of paraoesophageal hiatus hernias. Aust NZ J Surg. 1987;57:813−7. doi:org/10.1111/j.1445-2197.1987.tb01271.x.
- Kasalický M, Koblihová E. Chirurgie hiátové kýly a refluxní choroby jícnu, Nissen nebo Toupet? Rozhl Chir. 2015;94:510−5.
- Pizza F, Rossetti G, Limognelli P, et al. Influence of age on outcome of total laparoscopic fundoplication for gastroesophageal reflux disease. World J Gastroenterol. 2007;13:740−7. doi: 10.3748/wjg.v13.i5.740.
- Tedesco P, Lobo E, Fisichella PM, et al. Laparoscopic fundoplication in elderly patients with gastroesophageal reflux disease. Arch Surg. 2006;141:289−92. doi: 10.1001/archsurg.141.3.289.
- Ruer V, Champault G. Diaphragmatic hernias. Journal de Chirurgie 2007;144:23−6.
- Ozdemir IA, Burke WA, Ikins PM. Paraesophageal hernia: a life-threating disease. Ann Thorac Surg. 1973;16:547−54.
- Sihvo EI, Salo JA, Rässänen JV, et al. Fatal complication of adult paraesophageal hernia: A population-based Study. J Thorac Cardiovasc Surg. 2009;137:419−24.doi: 10.1016/j.jtcvs.2008.05.042.
- Flanagan NM, McAloon J. Gastric volvulus complicating cerebral palsy with kyphoscoliosis. Ulster Med J. 2003;72:118−20.
- Kim HH, Park SJ, Park MI, et al. Acute intrathoracic gastric volvulus due to diaghragmatic hernia: a rare emergency easily overlooked. Cae Rep Gastroenterol. 2011;5:272−7. doi: 10.1159/000328444.
- Chau B, Dufel S. Gastric volvulus. Emerg Med J. 2007;72:118−24,446−7. doi: 10.1136/emj.2006.041947.
- Luketich JD, Raja S, Fernando HC, et al. Laparoscopic repair of giant paraesophageal hernia: 100 consecutive cases. Ann Surg. 2000;232:608−18.
- Hána L, Kasalický M, Koblihová E, et al. Urgentní chirurgické řešení volvulu žaludku při „upside-down stomach syndrome“. Rozhl Chir. 2015;94:531−4.
- Trastek VF, Allen MS, Deschamps C, et al. Diaphragmatic hernia and associated anemia: response to surgical treatment. J Thorac Cardiovasc Surg. 1996;112:1340–4. doi: 10.1016/S0022-5223(96)70149-6.
- Weston APOD. Hiatal hernia with cameron ulcers and erosions. Gastrointest Endosc Clin N Am. 1996;6:671−9.
- Camus M, Jensen DM, Ohning GV, et al. Severe upper gastrointestinal hemorrhage from linear gastric ulcers in large hiatal hernias: a large prospective case series of Cameron ulcers. Endoscopy 2013;45:397−400. doi: 10.1055/s-0032-1326294.
- Dindo D, Demartines N, Clavien P-A. Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Annals of Surgery 2004;240:205−13.
- Aly A, Munt J, Jamieson GG, et al. Laparoscopic repair of large hiatal hernias. Br J Surg. 2005;92:648−53. doi: 10.1097/SLA.0000000000000842.
- Fumagalli U, Bona S, Caputo U, et al. Are surgisis biomeshes effective in reducing recurrences after laparoscopic repair of large hiatal hernias? Surg Laparosc Endosc. 2008;18:433−6. doi: 10.1097/SLE.0b013e3181802ca7.
- Naim HJ, Smith R, Gorecki PJ. Emergent laparoscopic reduction of acute gastric volvulus with anterior gastropexy. Surg Laparosc Endosc Percutan Tech. 2003;13:389–91.
- Altintoprak F, Yalkin O, Dikicer E, at al. A rare etiology of acute abdominal syndrom in adults: gastric volvulus- cases series. Int J Surg Case Rep. 2014;5:731−4. doi:org/10.1016/j.ijscr.2014.08.024.
- Eckhauser ML, Ferron JP. The use of dual percutaneous endoscopic gastrostomy (DPEG) in the management of chronic intermittent gastric volvulus. Gastrointest Endosc. 1985;31:340–2.
- Jeong SH, Ha CY, Le YJ, et al. Acute gastric volvulus treated with laparoscopic reduction and percutaneous endoscopic gastrostomy. J Korean Surg Soc. 2013;85:47−50. doi: 10.4174/jkss.2013.85.1.47.