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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_901_Библиотеки_им_академика_М_И_Перельмана
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148
Hiatal hernia
T. Zohourian et al.
CXR Gastric bubble above the diaphragm
AP scout upper abdominal
radiograph shows a gastric
bubble both above (arrows) and
below the diaphragm
Complications
of hiatal
hernia
Management
CT abdomen
and pelvis
Gastric perforation, incarceration, strangulation, gastrointestinal bleeding (Cameron lesions),
respiratory compromise
If incarcerated paraesophageal hernia➔operative management
Medical management of GERD
Management of asymptomatic or mildly symptomatic patients remains controversial
Paraesophageal hernia through a
widened esophageal hiatus with
herniated contents lie adjacent to the
esophagus
Axial abdominal CT image with IV
contrast demonstrates the gastric
fundus and body (s) protruding into
the mediastinum alongside the
anteriorly displaced esophagus (e).
Not shown is the GE junction which
remains below the esophagus
Asymptomatic or mildly symptomatic patients can be treated expectantly
Indications for surgical management: Symptomatic patients refractory to medical management
and management of complications (gastric volvulus, gastrointestinal bleeding, obstruction,
strangulation, perforation, respiratory compromise secondary to a paraesophageal hernia
In emergency surgery (like for perforation or ischemia)➔Graham patch and PEG
placement➔then denitive surgery when patient is stable
5 Esophagus
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Hiatal hernia
149
Dissection of hiatus and hernia sac:
• Reduction of organs within the hernia sac
• Dissection of the hernia sac while avoiding injury to adjacent organs
• Preservation of crus on the abdominal side when dividing gastrohepatic omentum from right crus
of diaphragm
Key operative
steps for repair
of hiatal
hernia
• Excision of hernia sac from posterior mediastinum, dissection, not necessary to excise sac,
especially large hernias where vagal injury can occur
• Avoid transection of the Vagus nerves (LARP: Left anterior; right posterior)
• M obilization of stomach with division of short gastric vessels
Esophageal mobilization
• Mobilization of esophagus to level of inferior pulmonary veins or until >3cm of tension free
intrabdominal esophagus has been freed
Closure of hiatal defect
• Small defects: Tension free primary closure of crura inferior and posterior to the esophagus with
3–4 interrupted intracorporeal nonabsorbable sutures
• Mesh can be placed if: Crural bers are disrupted during dissection, large hernia defect, crural closure
under tension (controversial, likely mesh, but three clinical trials say biologic mesh is likely better)
Fundoplication
• Nissen fundoplication should be performed UNLESS patient has DYSPHAGIA—As it will
worsen the patient’s symptoms➔partial fundoplication (if dysphagia➔NEED MANOMETRY
preoperatively)
Anterior gastropexy (±)
Fixation of the stomach to the abdominal wall reduces the risk of gastric herniation into thoracic
cavity
Anterior gastropexy with sutures or anterior gastropexy with PEG tubes
Research
Reference Findings
Oelschlager BK, Pellegrini CA, Hunter J, etal. Biologic
prothesis reduces recurrence after laparoscopic
paraesophageal hernia repair: a multicenter, prospective,
randomized trial. Ann Surg. 2006;244(4):481–90
Patients who underwent laparoscopic paraoesophageal
hernia repair with placement of a biologic mesh,
compared to primary repair had less reoccurrence of
hiatal hernia at 6months without any mesh-related
complications
150
Research
T. Zohourian et al.
Reference Findings
Society of American Gastrointestinal and Endoscopic
Surgeons. Guidelines for the management of hiatal
hernia. 2013
All hiatal hernias found preoperatively or
intraoperatively during bariatric surgery should be
repaired to prevent any postoperative complications
Hiatal hernias
Types Characteristics Figure Management
Medical management of
GERD
If operative
intervention➔antireux
procedure
Repair of a type I hernia in the
absence of reux disease is not
necessary
Asymptomatic—Medical
management of GERD
Symptomatic—Surgical repair
All symptomatic
paraesophageal hiatal hernias
should be repaired
Type I
(sliding)
Type II
(true)
Displacement of GEJ above the
diaphragm
Stomach remains in usual
longitudinal alignment and
fundus remains below GEJ.No
hernia sac
Result of progressive disruption
of GEJ, and widening of the
hiatal hiatus, causing laxity in
the phrenoesophageal
membrane
Defect in phrenoesophageal
membrane causing fundus
herniation
Gastroesophageal junction in
normal position
Type III
(mixed)
Type IV Presence of organs other than
Mixture of Type I (GEJ) and
Type II
stomach in hernia sac (colon,
spleen, pancreas, small
intestine)
Routine elective repair of
completely asymptomatic
paraesophageal hernias may
not always be indicated.
Consideration for surgery
should include the patient’s
age and comorbidities
All hiatal hernias in patients
undergoing bariatric
procedures (Roux en Y
Gastric Bypass, Sleeve
Gastrectomy, placement of
adjustable gastric band
should be repaired
5 Esophagus
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Intraoperative case scenarios
Case scenario Management
Short esophagus If after mobilization of esophagus from the mediastinum,
less than 3cm is freed➔Neoesophagus creation (Collis
procedure) by vertical stapling of proximal stomach over
a large bougie from angle of his➔lesser curvature of
stomach
Frail patient that is not able to tolerate surgery Endoscopic hernia reduction with anterior gastropexy
with two PEG tubes to prevent volvulus
151
Patient with impaired esophageal motility and hiatal
hernia
Hiatal hernia repair with partial fundoplication (Toupet
fundoplication)
Complications of paraesophageal hernia repair and their management
Complications Characteristics Management
Intraoperative
CO2 retention
Post operative
bleeding
Pneumothorax/
Capnothorax
Hypercarbia
Respiratory depression
High end-tidal CO
Sudden drop in blood pressure,
tachycardia, ↑abdominal pain within the
rst 48h
↑ Ventilation pressure
↓Blood pressure
2
Reduce pneumoperitoneum to <11mmHg or
desufated briey
Keep patient ventilated until CO2 levels normalize
Bleeding from short gastric vessels
Division of proximal short gastric and posterior
gastric vessels prior to fundus mobilization
Intraoperative:
Reduce pneumoperitoneum to <11mmHg
Laparoscopic suctioning
Placement of drainage catheter if preventing
extubation
Post operative:
Small/asymptomatic: Treat nonoperatively
Symptomatic: Chest tube placement
Gastric
perforation
Thermal, traction on lower esophagus/
fundus/GEJ
Intraoperative➔repair with absorbable 3–0 Vicryl
either 1 or 2 layers. Placement of drain near repair
Need to patch with pleura or omentum
NPO status
Upper GI series after 72h
152
Complications of paraesophageal hernia repair and their management
Complications Characteristics Management
T. Zohourian et al.
Early: GEJ obstruction by migrated
fundoplication, tight fundoplication/crural
repair, twisting of GEJ
Delayed: Hiatal scarring due to stenosis
Dysphagia
Recurrence Dysphagia, heartburn, regurgitation,
vomiting, shortness of breath, chest pain
Upper GI series for diagnosis
Delayed gastric
emptying
Solid food retention
Reux and vomiting
Slipped wrap—Completion of mediastinal
dissection
Tight crural wrap—Removal of 1–2 sutures
Tight fundoplication—Convert 360➔180° by
removing anterior sutures
Delayed: Balloon dilatation of EGJ to 20mm
Reoperation—Fundoplication opened anterior and
hiatus repair assessed
Revision of the procedure
POEM—Pyloric dilation up to 30mm,
pyloromyotomy or gastric bypass, may have vagal
injury versus gastroparesis
Gastroesophageal Reux/Barrett Esophagus
Gastroesophageal reux disease
Classic symptoms: Heartburn, regurgitation, non-cardiac chest pain
Presentation
Diagnosis
Non-classic symptoms: Globus sensation, chronic cough, hoarseness, wheezing, nausea asthma,
dental erosions
Alarm symptoms: New onset dyspepsia in patient >50years old, GI bleeding, anorexia, dysphagia,
odynophagia, unintentional weight loss
Extraesophageal manifestations include laryngeal and pulmonary symptoms, which are caused by
(1) caustic injury to the larynx and lower respiratory tracts and (2) distal esophageal exposure,
triggering the vagal nerve reex leading to cough and bronchospasms
EGD: Evaluate alarm features or abnormal imaging
Esophageal manometry to exclude esophageal motility disorders
Barium esophagogram to exclude hiatal hernia
24-h pH monitoring➔gold standard for diagnosing GERD➔percent time with elevated acid
exposure: Normal <4%, borderline 4–6%, abnormal >6%
5 Esophagus
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Gastroesophageal reux disease
Lifestyle changes: Weight loss, HOB elevation, elimination of dietary triggers
No response➔proton pump inhibitors (PPI) trial for 3months
Management
No response➔surgical intervention
Indications for surgery: Patients who fail medical management, patients who develop
complications of GERD (stricture, Barret esophagus), patients who have extraesophageal
manifestations of GERD (cough, asthma, aspiration)
Magnetic sphincter augmentation (MSA)
Patients with GERD and normal esophageal motility
153
Indications
Key steps
Postoperative
care
Complications Dysphagia (5%), erosions (<1%) or migrations
Outcomes Long-term data on MSA indicate that there are similar rates of control of symptoms of GERD
Patients without Barrett esophagus or hiatal hernia >3cm
Patients without prior esophageal or gastric surgery
Limited dissection is key to preserve the phrenoesophageal ligament was initially advised➔newer
studies advocate for complete hiatal dissection, restoration oof intra- abdominal lower esophageal
sphincter length and crural closure
Pass the appropriately sized MSA in a tunnel created between the posterior esophageal wall and
the posterior vagal trunk➔avoid incorporating the posterior vagus nerve within the device
MSA should be positioned over the anterior surface of the EGJ at the level of the angle of his
insertion
Intraoperative EGD to conrm location of MSA
Early initiation of diet➔to prevent capsule formation that leads to dysphagia
when compared to the Nissen procedure, with more than 80% of patients not requiring proton
pump inhibitors at 5years
Research
Reference Findings
Dunn CP, Zhao J, Wang JC, etal.
Magnetic sphincter augmentation with
hiatal hernia repair: long term outcomes.
Surg Endosc 2021; 35:5607
Magnetic sphincter augmentation (MSA) can be used to treat GERD in
patients with prior hiatal repairs (≥3cm). Median DeMeester scores
decreased 42.45 to 9.10; severity of esophagitis improved from Class C
to B; 40% of patients experienced regression of their Barrett’s esophagus
Magnetic sphincter augmentation achieves excellent long-term
radiographic and clinical results, and a low overall need for reoperation
154
Squamous lined esophagus
Gastr
Barrett’s esophagus
Pathophysiology Stratied squamous epithelium (pale,
glossy)➔Columnar epithelium (red
velvet)
oesophageal
junction
Diagnosis At least 4 biopsies taken every 2cm segment of suspected area
Squamocolumnar junction is >1cm proximal to GEJ (salmon colored)
T. Zohourian et al.
Columnar lined esophagus
Classication of
Barrett
esophagus
Management
Long-segment (>3cm) versus short-segment (<3cm)
Barrett Esophagus case Management
Non-neoplastic metaplasia High-dose PPI
Surveillance: Every 3years
Low-grade intestinal dysplasia
➔Should be conrmed by a pathologist
Endoscopic eradication therapy (radiofrequency
ablation (RFA), cryotherapy or endoscopic mucosal
resection) or surveillance
➔RFA is preferred
High-dose PPI
Surveillance: Endoscopy+4-quadrant biopsy in
6months
High-grade dysplasia Endoscopic mucosal resection
Esophagectomy if invasive esophageal
adenocarcinoma
Surveillance: Endoscopy+4-quadrant biopsy every
3months
Case scenarios
Case scenarios Management
Patient with multiple comorbidities and Barrett’s
esophagus with high-grade dysplasia
Endoscopic mucosal resection
5 Esophagus
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Research
155
Reference Findings
Kwok, CS, Arthur AK, Anibueze CI, Singh S, Cavallazzi R, Loke
YK.Risk of Clostridium difcile infection with acid suppressing
drugs and antibiotics: meta-analysis. Am J Gastroenterol.
2012;107(7):1011–19
Gulmez SE, Holm A, Frederiksen H, Jensen TG, Pedersen C,
Hallas J.Use of proton pump inhibitors and the risk of
community-acquired pneumonia: a population-based case-control
study. Arch Intern Med. 2007;167(9):950–5
Khalili H, Huang ES, Jacobson BC, Camargo CA Jr, Feskanich
D, Chan AT.Use of proton pump inhibitors and risk of hip
fracture in relation to dietary and lifestyle factors: a prospective
cohort study. BMJ. 2012;344:e372
Cheungpasitporn W, Thongprayoon C, Kittanamongkolchai W,
Srivali N, Edmonds PJ, Ungprasert P, O’Corragain OA,
Korpaisarn S, Erickson SB.Proton pump inhibitors linked to
hypomagnesemia: a systematic review and meta-analysis of
observational studies. Ren Fail. 2015;37(7):1237–41
Sullivan R, Mulki R, Peter S.The role of ablation in the treatment
of dysplastic Barrett’s esophagus. Ther Adv Gastrointest Endosc.
2021. https://doi.org/10.1177/26317745211049967
Wani S, Rubenstein JH, Vieth M, Bergman J.Diagnosis and
management of low-grade dysplasia in Barrett’s esophagus:
expert review from the clinical practice updates committee of the
American Gastroenterological Association. Gastroenterology.
2016;151(5):822–35
PPIs taken for more than 1year are linked to
multiple medical problems: Osteoporosis and
higher risk of breaking a hip, hypomagnesemia,
pneumonia, and Clostridium difcile infection
Endoscopic mucosal resection, endoscopic
spray cryotherapy, photodynamic therapy, and
radiofrequency ablation when used to ablate
Barret esophagus are associated with an
elevated risk of recurrence of Barrett esophagus
For Barrett esophagus: Surveillance biopsies
should be performed in a four-quadrant fashion
every 1–2cm with target biopsies obtained from
visible lesions taken rst
Qumseya BJ, Wani S, Gendy S, Harnke B, Bergman JJ, Wolfsen
H.Disease progression in Barrett’s low-grade dysplasia with
radiofrequency ablation compared with surveillance: systematic
review and meta-analysis. Am J Gastroenterol.
2017;112(6):849–65
Rantanen TK, Oksala NKJ, Oksala AK, Salo JA, Sihvo
EIT.Complications in Antireux surgery: national-based analysis
of laparoscopic and open fundoplications. Arch Surg.
2008;143(4):359–65
Huang X, Chen S, Zhao H, Zeng X, Lian J, Tseng Y, Chen
J.Efcacy of transoral incisionless fundoplication (TIF) for the
treatment of GERD: a systematic review with meta-analysis. Surg
Endosc. 2017;31(3):1032–44. https://doi.org/10.1007/s00464-
016- 5111- 7. Epub 2016 Aug 5. PMID: 27495332
For low-grade Barrett esophagus➔progression
among patients with surveillance was
signicantly higher from those treated with
radiofrequency ablation
If antireux surgery is performed at a highvolume center, up to 90% of patients may
remain free of GERD after 10years
Transoral incisionless fundoplication has not yet
been shown to be superior to standard
fundoplication in GERD
156
Antireux Procedures
Antireux procedures
EGD: To evaluate anatomy and rule out Barrett esophagus
24-h pH monitoring vs BRAVO (48h wireless)
Preoperative
evaluation
Esophageal manometry: To assess esophageal motility before deciding on fundoplication type (if
motility is not normal➔partial fundoplication
Barium esophagogram to assess esophageal length and rule out hiatal hernia
Dissection of hiatus
• Take down of the left phrenogastric ligament and expose the left crus
T. Zohourian et al.
Key
operative
steps
• Take down the short gastric arteries➔to ensure tension free fundoplication
• Open gastrohepatic ligament (pars accida) and preserve any replaced left hepatic arteries
• Divide the right phrenoesophageal membrane and expose the right crus
• Continue the hiatal dissection circumferentially and place a penrose around esophagus to help with
retraction (avoid injury to the anterior and posterior vagus nerves)
Esophageal mobilization
• Mobilization of esophagus to level of inferior pulmonary veins or until >3cm of tension free
intrabdominal esophagus has been freed
Closure of hiatal defect
• Small defects: Tension free primary closure of crura inferior and posterior to the esophagus with
3–4 interrupted intracorporeal nonabsorbable sutures
• Large defects: Closure of crura after releasing incisions along either right or left crura muscle (right
preferred over left as it is bolstered by left lateral lobe of liver)
• Mesh can be placed if: Crural bers are disrupted during dissection, large hernia defect, crural
closure under tension
Dissection of sac versus excision of at least part for better fundoplication
Fundoplication
• Place a 56F or 60F bougie
• Pass the fundus posterior to the gastroesophageal junction
• Perform the “shoeshine” maneuver
• Place wrap on distal esophagus 2–2.5cm wrap
Place seromuscular permanent sutures from anterior fundus to esophagus to posterior fundus to
secure the fundoplication (avoid the anterior vagus nerve)➔keep fundoplication short and oppy
Posterior
5 Esophagus
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Intraoperative case scenarios
Case scenario Management
157
Intraoperative nding of short esophagus while doing
a Nissen fundoplication
Types of fundoplication
Nissen
Fundoplication
Key steps
Indications Normal esophageal
Posterior
360-degree wrap
Posterior crural
repair by
approximating right
and left right crus
motility
Normal esophageal
length
Toupet
Fundoplication Dor Hill
Posterior
270-degree wrap
Normal esophageal
length
Normal esophageal
length
Start with mediastinal mobilization if you still do not
have 3cm of esophagus intra-abdominal➔perform
Collis gastroplasty
Belsey Mark
IV
Anterior
90-degree wrap
Gastropexy of
gastric fundus to
diaphragm crura
Esophageal
dysmotility
Normal
esophageal
length
Posterior
gastropexy with
recreation of the
angle of his
gastropexy
Prior gastrectomy/
small stomach
Transthoracic
240-degree wrap
Extensive prior
abdominal
surgeries
Pulmonary disease
Severe obesity
Contraindications
Esophageal
dysmotility
Intrabdominal
esophageal length
<3cm)
Esophageal
dysmotility
Intrabdominal
esophageal length
<3cm)
Intrabdominal
esophageal
length <3cm)
Intrabdominal
esophageal length
<3cm)
Short esophagus
Intrabdominal
esophageal length
<3cm)
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