Paraesophageal hernia Flashcards

Question

which of the following is not performed routinely during pre-operative workup for PEH repair A. UGI series B. Endoscopy C. Manometry D. CT scan of chest and upper abdomen

Answer 1

Ans C all patients undergo upper endoscopy, barium swallow/upper GI series, and computed tomography of chest and upper abdomen. Oral contrast studies provide important information of gastric anatomy but most importantly length of the esophagus. Esophageal manometry and pH analysis are not required because they are unreliable and difficult to perform in this scenario. Shackleford 8e Pg 292. v

Answer 2

Ans A - Laparoscopic PHER is preffered for most patients both elective and emergency. However the three approaches have not been compared with one another in randomized trials and the optimal operative approach remains controversial and varies most depending on the surgeon training and experience. Shackleford 8e Pg 292. In an analysis approximately 40,000 patients from 1999 through 2008 from the NIS database 74% were performed open transabdominal, 17% were performed transthoracically and 9% were performed laparoscopically. Currently laparoscopic PEHR has surpassed open transabdominal repair as the most commonly performed procedure for PEHs. Shackleford 8e Pg 293.

Answer 3

Ans B - Open transadbominal approach is used in patients who have had a limited number of upper abdominal procedures in the past, and reserve the transthoracic approach for patients who have - failed previous trans-abdominal procedures - history of abdominal wall mesh - history of abdominal abscess, infection and contamination - significant elevated BMI >40. Shackleford 8e Pg 293. Proponents now advocate a transthoracic PEH repair should be performed instead of a transabdominal repair in patients who are obese, have a true shortened esophagus, have associated esophageal motility disorders, have a complex type IV PEH, have failed at least 2 trans-abdominal repairs, or have a midline abdominal incisional hernia repair with mesh. Shackleford 8e Pg 296.

Answer 4

Ans A - In the NIS study, transthoracic approach was associated with the - greatest hospital stay - greatest need for mechanical ventilation - greatest risk for pulmonary embolism Laparoscopic approach was associated with the shortest postoperative stay and the lowest risk of requiring mechanical ventilation. This is also associated with decreased overall cost. Although the risk of radiographic recurrence is higher with laparoscopic approach, reoperation rates are similar for both laparoscopic and open surgeries. Shackleford 8e Pg 293.

Answer 5

Ans D - Synthetic permanent material such as PTFE and Prolene is contraindicated for reinforcement or primary repair of hiatal defect because of serious and even life-threatening complications including esophageal erosion with ulceration and perforation as well as abscess formation. If crural fibers are disrupted during the dissection or the primary repair is under tension, the crural closure can be reinforced with biologic mesh such as porcine dermal matrix or bovine percardium. Biologic and bioresorbable mesh complications are usually only dysphagia as compared with erosion, perforation, stenosis, fibrosis and the need for complex reoperations because of synthetic non-absorbable materials. Mesh reinforcement of the hiatal hernia closure reduced the recurrence and reoperation rate but the overall complication rate was the same. Mesh reinforcement is preferrable in - - women older than 80 years old - steroid dependent patients - reoperations - COPD patients. Shackleford 8e Pg 293, 294.

Answer 6

Ans C - Thoracic surgeons argue that an open transthoracic PEHR is more durable compared with transabdominal repair because it permits more accurate intra-operative assessment of esophageal length, greater ease of performing an esophageal lengthening procedure (True Collis), greater ease of closing the hiatus without tension and a better exposure in obese patients. Shackleford 8e Pg 296.

Answer 7

Ans C - When an open transthoracic approach is used, the fundoplication that is included in the PEHR is near total 240 degree Belsey Mark IV repair. This is a 6 suture fundoplication of three sutures per two rows evenly positioned over the 240 degrees of the anterior stomach to cover 4cm of intra-abdominal esophagus. Shackleford 8e Pg 296

Answer 8

Ans A the mortality and morbidity rates are higher in patients who are 70 years or older, who underwent an emergent procedure, had multiple cormorbid conditions or had open transthoracic or transabdominal PEHR. Shackleford 8e Pg 298. Patients 80 years or older had higher ASA class, more comorbidities, larger PEHs, and higher incidence of type IV PEH and acute presentation. They had more post operative complications and hospital stay was 1 day longer. After adjustment for cormorbidities and other factors, age older than 80 years or older was not a significant factor in predicting severe complications, readmissions within 30 days or early recurrence. Older patients with giant PEHs should be given the opportunity to be evaluated by experienced surgeons for PEHR. Advanced age is no longer a contraindication for PEHR. Shackleford 8e Pg 298.

Answer 9

ANS B - The rate of radiographic recurrence is higher than that of clinical recurrence. Most patients with radiographic recurrence after PEHR are asymptomatic, whereas patients with clinical recurrence can usually have symptoms controlled with medications. Only a small percentage of patients will require reoperation for complications or intractable symptoms. Laparoscopic PEHRs have a higher radiologic recurrence rate than two open approaches, but most of these recurrences are clinically silent and do not require reoperations. Laparoscopic PEHR - radiographic recurrence of 25% and clinical recurrence of 10%. The majority of recurrences are sliding hernias less than 2cm in size. Shackleford 8e Pg 298, 299.

Answer 10

Ans C Hospital surgical volume was categorized as small (<6 operations per year), intermediate (6-20 operations per year) and high as more than 20 operations per year. Patients undergoing PEHR at high volume centres had fewer postoperative complications and shorter hospital stay and they were more likely to undergo a laparoscopic repair. Shackleford 8e Pg 299.

Answer 11

Ans B - the concept of relaxing incision is to create a defect adjacent to the area of interest that is less critical to allow the principal tissues to come together. But because there is pressure difference between thoracic and abdominal cavities all relaxing incisions must be closed and therefore even small diaphragmatic defects can lead to herniation of abdominal contents into the chest. PTFE is routinely used to close these defects, since there is a large experience with this mesh for chest wall and diaphragm reconstruction. Unlike other types of synthetic mesh the lung typically does not fuse to the PTFE mesh, so future thoracic surgical procedures if needed will not be made more complex. Unlike ventral hernia repairs the use of simple interrupted sutures to sew the PTFE mesh to the edges of the defect with no overlap works well on the diaphragm. This is likely possible because as the mesh contraacts the diaphragm has enough give to accomodate without tearing the stitches out. Infact the large amount of shrinkage that occurs with PTFE mesh may be beneficial in restoring a more natural contour to the diaphragm over time after a relaxing incision. Absorbable and biologic mesh should be avoided since it will not permanently repair the defect, setting the stage for hernia recurrence. Shackleford 8e Pg 301.

Answer 12

Ans C - The first step to allow crural movement and approximation is to ensure that the posterior sac has been well dissected off of the left crus. When the sac remains attached to the left crus, it can restrict movement and reapproximation of the crura. The second step is to create left pneumothorax. The will equilibrate the capnoperitoneum on the both sides allowing the left diaphragm to become floppy and facilitating its movement towards the right crus. If there is still excessive tension when trying to approximate the crura despite these maneuvres, a relaxing incision is the next recommended step. Shackleford 8e Pg 301.

Answer 13

Ans C Right sided relaxing incision is the preferred release, but the right crus must be atleast a centimeter wide to have enough tissue to reconstruct the hiatus. Particularly in the setting of reoperations the right crus may be so thin and scarred that there is insufficient room between the edge of the crus and the IVC to do a right sided relaxing incision. In these patients or when the right sided incision alone is insufficient then a left sided relaxing incision is necessary. It is important that the relaxing incision be made anterior to the apex of the hiatus not posteriorly at the base since the aorta, thoracic duct are near the base. A right relaxing incision is made by opening the right crus parallel to the IVC saving a 3cm cuff of tissue along the IVC. It is started in the midportion of the right crus and ends at the anterior crural vein. If this is insufficient then the vein can be ligated and the incision carried further anteriorly and medially. Diaphragm on the right is quite tendinous and therefore the incision can be made using cautery. The only structure on the right side to avoid injuring is the intra-thoracic vena cava and this should always be anterior and lateral to the incision. 1mm PTFE mesh is sewn on the right side with interrupted 3-0 sutures. Left sided incision is larger and needs more time to repair. It should be made laterally following the seventh rib. The phrenic nerve is protected on the right side by the vena cava but a radial incision on the left side puts the phrenic nerve at risk. The only other structure of significance with a left sided relaxing incision is the heart with should be anterior and medial to the site of the incision. Left pneumothorax should be created prior to starting the left incision. The incision is started lateral to heart nearly 1-2cm below the seventh rib and carried laterally towards the spleen to allow sufficient release. The left diaphragm is more muscular and therefore the incision made with ultrasonic devices. 2mm pTFE is sewn in with 0-Ethibond sutures. No drains were left in the pleural space or mediastinum and no patient developed pleural effusion prior to discharge. Shackleford 8e Pg 302, 303.

Answer 14

Ans E Patients at risk for acquired esophageal shortening include those with - - advanced GERD with esophagitis, Stricture, Long segment BE. - history of sarcoidosis - history of caustic ingestion - history of scleroderma - large sliding or paraesophageal hernia in some reports patients with PEH have the highest frequency of a short esophagus. The presence of both a large hiatal hernia (>5cm) and an esophageal stricture further increases the risk of shortened esophagus. A history of previously failed anti-reflux procedure with recurrent hiatal hernia should raise suspicion that length of the esophagus is short. The etiology of esophageal shortening in patients with a PEH is unclear, but may be related to loss of elasticity in the longitudinal esophageal muscle related to chronic loss of intra-abdominal fixation of the GEJ. Shackleford 8e Pg 305.

Answer 15

Ans D - A foreshortened esophagus can be effectively ruled out when a hiatal hernia fully reduces on barium esophagogram But in any non-reducing hiatal hernia a short esophagus may or may not be present. Therefore, although objective studies can rule out a shortened esophagus, none can accurately identify its presence. It can only be confirmed by intra-operative inability to reduce the GEJ below the hiatus by 2-3 cm after mediastinal esophageal mobilisation and posterior crural closure. Shackleford 8e Pg 305.

Answer 16

Ans C - Failure to obtain the adequate length of intra-abdominal esophagus is a leading cause of reherniation and breakdown of repair. Mediastinal mobilisation and posterior crural closure, paritcularly in a kyphotic patient are routinely used to add esophageal length. To accomplish a fundoplication without tension there should be 2-3 cm of intra-abdominal esophagus below the hiatal closure. The amount of intra-abdominal esophagus during laparoscopic surgery is deceptive because the pneumoperitoneum artificially elevates the diaphragm and gives the appearance of more esophageal length than is actually present. When deflation of the pneumoperitoneum occurs, the diaphragm descends and some of the apparent intra-abdominal esophageal length is lost. Shackleford 8e Pg 305.

Answer 17

Ans D The staple line of the gastroplasty is not reinforced but rather buried by the fundoplication. A partial Toupet or complete Nissen fundoplication was added to the Wedge Fundectomy Collis Gastroplasty in all patients. The fundoplication was kept as high on the gastroplasty as possible, preferably at the top near the GEJ. The importance of this is the fact that the gastroplasty is made from stomach and acid production by the gastroplasty above the fundoplication can lead to erosive esophagitis in some patients, particularly if there are several centimeters of gastroplasty above the fundoplication. It is also important to recognize that the gastroplasty tube is aperistaltic. Therefore bolus transport through the gastroplasty relies on the motility of the distal esophagus above the gastroplasty. Shackleford 8e Pg 306.

Answer 18

Ans B - Most studies report a short term higher reccurence rate of hiatal hernia when it has been repaired without mesh. Only one study has produced long term data on the use of bio-absorbable mesh and that study reports equally alarmingly high rates of recurrence of HH both with and without the use of mesh. There is a significant improvement in the QOL parameters both with and without mesh reinforcement. A findings which may not be associated with endoscopic or radiographic recurrence. Although mesh reinforcement at the hiatus seems to lessen the likelihood of short term radiographic recurrence, no evidence shows that this is still the case at longer term follow up. Reoperation when mesh has been used previously (regardless of mesh composition) is in the least case tedious, and in the worst case hazardous - commonly leading to the need for esophagogastrectomy. The routine use of mesh cannot be justified at present, and its use should be restricted to individual cases based on the treating surgeon's discretion and based on the intra-operative findings. Shackleford 8e Pg 312.