Hernia DOI 10.1007/s10029-014-1285-x
ORIGINAL ARTICLE
‘‘Acute intrathoracic stomach!’’ How should we deal with complicated type IV paraesophageal hernias? G. Ko¨hler • O. O. Koch • S. A. Antoniou K. Emmanuel • R. Pointner
•
Received: 4 March 2014 / Accepted: 7 July 2014 Ó Springer-Verlag France 2014
Abstract Purpose Management of emergently admitted patients due to a complicated large paraesophageal hernia with acute symptoms of an ‘‘intrathoracic stomach’’ is controversial. The aim of this study was to clarify whether emergency surgery in such cases should be the procedure of choice. Methods The retrospective analysis of patients who were hospitalized due to emerging acute symptoms of an ‘‘intrathoracic stomach’’ between January 2009 and May 2013 was used as method. Patients were categorized into three groups: emergency operation within 24 h after admission, semi-elective operation within the first 7 days after admission and elective operation. Results Twenty-four patients were identified. Only three (12.5 %) patients required laparoscopic emergency surgery and two incurred a perioperative complication. In consequence of persistent or early recurrent complaints a laparoscopic operation was required prior to discharge semielective in 6/24 (25 %) patients without complications. The remaining 15/24 (62.5 %) patients were free of complaints after conservative therapy, but all of them decided upon
Sisters of Charity Hospital is an Academic Teaching Hospital of the Universities of Graz and Innsbruck. G. Ko¨hler (&) O. O. Koch K. Emmanuel Department of General and Visceral Surgery, Sisters of Charity Hospital, 4010 Linz, Austria e-mail: [email protected] O. O. Koch R. Pointner Department of General Surgery, General Hospital Zell Am See, Zell am See, Austria S. A. Antoniou Center for Minimally Invasive Surgery, Hospital Neuwerk, Moenchengladbach, Germany
elective operation after informed consent. One minor complication occurred. Conclusion The majority of patients with acute symptoms due to an intrathoracic stomach can primarily be treated conservatively and timing of elective repair should be performed after resuscitation in a center of laparoscopic antireflux surgery. Keywords GERD Intrathoracic stomach Upside-down stomach Paraesophageal hernia Gastric volvulus
Introduction Hiatal hernias develop in 10-50 % of the general population and can be classified into four types: type I is a sliding hernia, which accounts for 85 % of all cases. The less common types II, III and IV are all varieties of paraesophageal hernias (PHs). The type IV hernia is associated with a large defect in the phrenoesophageal membrane, allowing various parts of the stomach or other organs to enter the hernia sac [1]. PHs are an uncommon type of real hernias in contrast to sliding hiatal hernias, because they consist of a true hernia sac including a peritoneal layer [2, 3]. PHs can be associated with serious complications, wherefore some authors recommend an operation even in asymptomatic patients for a long time [4]. Potential complications include gastric volvulus with gastric outlet obstruction or strangulation, gastric wall necrosis and perforation, hemorrhage and respiratory distress secondary to compression of the left main stem bronchus [5]. Commonly, symptoms of PH are abdominal fullness, nausea, swallowing disorders and heartburn [6]. The essentials of diagnosis are a detailed anamnesis and clinical examination, including current symptoms and
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previous medical therapies. PHs with complications are a rare condition and therefore often not initially considered as the underlying cause of these symptoms. It is also important to capture cardiac and pulmonary diseases. Moreover, usually performed are a chest X-ray, a blood analysis, an upper endoscopy and a video swallow. Esophageal manometry and acid analysis are expendable, because they are difficult to perform and the results are unreliable. A computed tomography of the trunk can be helpful to assess the hiatal defect size, the exact hernia location and content and also the position of the stomach [7]. The surgical principles lean onto a laparoscopic approach with reposition of the stomach or other herniated viscera, hernia sac excision and esophageal mobilization. The hiatal defect must be stably closed, eventually with some biological or prosthetic mesh materials and a fundoplication with fundophrenicopexia should be performed [8–11]. The difference between an acute intrathoracic stomach and a gastric volvulus is not always clear. In our experience, an intrathoracic stomach is always associated with variable degree of organoaxial volvulus. In practice, gastric volvulus mostly occurs as a complication of PHs and it can present as acute or chronic clinical manifestation depending upon the degree of obstruction and the rapidity of onset [5, 12]. The management of these patients is discussed controversially. Some authors advocate immediate surgery after diagnosis of an intrathoracic stomach with severe complaints [13]. Further, it is not clear how we should proceed with patients who are asymptomatic or have mild symptoms due to a PH. One option is ‘‘watchful waiting’’, and the other option is to recommend an elective operation to avoid potential life-threatening complications [14]. The aim of this study is contributed to clarify whether emergency operation is required in patients with acute symptoms caused by an ‘‘intrathoracic stomach’’ due to a type IV PH.
Methods This is a retrospective analysis of patients who were admitted to the Hospital of Sisters of Charity Linz/Austria and the General Hospital Zell am See/Austria between January 2009 and May 2013 due to acute and emerging symptoms attributed to an ‘‘intrathoracic stomach’’, as a complication of a type IV PH. In this connection, the following symptoms were determined: acute severe pain of upper abdomen or chest accompanied with dysphagia, nausea, urge to gag, vomiting and dyspnoea. If diagnostic findings resulted in an intrathoracic stomach, the patients were included in our study. The diagnostics comprised the following points:
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Fig. 1 Multi-slice contrast computed tomography of the thorax, showing an intrathoracic stomach
1.
2. 3. 4.
5. 6. 7.
Exact anamnesis inclusive onset and duration of complaints and previous diagnostic steps and medical treatments; clinical examination also in view of acute cardiac and pulmonary diseases; chest X-ray (Intrathoracic bubble); standardized blood analysis: serum lactate, CRP, kidney, electrolytes, coagulation and also including heart enzymes and d-dimer; cautious approach of gastroscopy if necessary with children gastroscope; video gastrografin swallow; multi-slice contrast computed tomography of the trunk (Fig. 1).
The initial therapy comprised management of fluid and electrolytes, intravenous analgesics, spasmolytics, proton pump inhibitors and the attempt to place a nasogastric tube. Patients were categorized into three groups, whereby the gravity of complaints and success of conservative treatment determined the assignment. 1.
2.
3.
Operation emergently within 24 h after admission (No chance of gastric tube placement, persistent severe abdominal/thoracic pain and vomiting). Operation semi-elective within the first 7 days after admission (recovery after conservative treatment but persistent or early recurrent symptoms). Operation elective in same hospital stay or after discharge and agreement on deadline within 4 weeks because of the risk of recurrent acute symptoms (freedom of symptoms after conservative treatment).
Patients’ data were retrospectively collected from the institution medical records (prospective conducted electronic database) and medical files.
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Fig. 3 Histoplasty with mesh
Fig. 2 Reposition of the stomach
The operative technique was similar and standardized in both hospitals performed by altogether four surgeons. The only difference was that fundoplication in Linz was made until 2012 in Nissen technique and afterwards in Toupet technique. The approach was laparoscopical in elective and emergency cases, except in patients with previous conventional extended operations of the upper abdomen. The operative steps included first reposition of the stomach (Fig. 2) or other herniated viscera, hernia sac excision and mobilization of the esophagus. The crural closure was made with non-absorbable single knot sutures. If the defect surface (hiatal surface area = HSA) was larger than 5.6 cm2, a prosthetic mesh was placed (Fig. 3). Intraoperative measurement of the HSA with subsequent tailoring of the hiatal closure to the hiatal defect is reported to be an effective procedure to prevent hiatal hernia recurrence and/ or intrathoracic wrap migration in laparoscopic antireflux surgery [15, 16]. The limit value for hiatal closure without meshes was set according to previous findings of primary suture closure complicated with tension and higher recurrence rates in cases of larger defects and/or weak diaphragmatic crura. On this basis, we considered 5.6 cm2 as a discriminant for the use of prosthesis [9, 16, 17]. For measuring the hiatal defect, the right and left crus and the crural commissure are dissected exactly. Then a ruler is brought intraabdominally. Firstly, the length of the crura is measured in centimeters beginning at the crural commissure up to the edge where the ‘‘Pars flaccida’’ from the gastrohepatic omentum begins (radius R). Afterwards, the circuit between the both crural edges is measured (s).Using these two values (R and s) the hiatal surface area (HSA) can be calculated by a formula. Moreover, a fundoplication and fundophrenicopexy were essential steps [15, 16]. The routine follow-up was conducted 3 months after surgery and comprised anamnesis, clinical examination, and gastroscopy. Twelve months after surgery it was
completed with a radiographic barium swallow examination. No regular additional follow-up was scheduled, but all patients were informed about outpatient re-evaluation at our consultation hours in cases of clinical signs of recurrence or if necessary, emergency re-admission at all hours. All patients were contacted by phone in march 2014 to assess recurrent symptoms with appropriate conservative or surgical treatment out of our department to update and complete the follow-up examination. Statistical analysis was performed using Statistical Package for Social Science (SPSS, Chicago, IL) for Windows. All data are presented as mean ± standard deviation, minimum, and maximum values. Only descriptive statistic was used.
Results Twenty-four patients were included, 14 female and 10 male. The mean age was 64 ± 14.2 years (range 34-86). The mean body mass index was 27.3 ± 3.7 kg/m2 (range 19.6-35.9). Twelve patients were treated and operated in the general hospital Zell am See and 12 patients in the Charity of Sisters Hospital Linz. A Toupet procedure was performed in 18 cases and a Nissen fundoplication in six patients (surgical technique was switched from Nissen to Toupet in Linz after six procedures because of the input of a new surgical leader). The mean HSA was 6.5 ± 1.2 cm2 (range 4.3-9.7). In 18 of 24 (75 %) patients, a synthetic mesh was placed, (Parietex compositeÒ, CovidienTM) because of a defect area larger than 5.6 cm2. The meshes were carefully fixed with short titan staples to avoid perforation of the diaphragm. No mesh-related complications occurred postoperatively and during the follow-up period. Emergency surgery Only three of 24 patients (12.5 %) required emergency surgery within 24 h. In all cases the indication was the
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appearance of the Borchardt’s triad [13]. This is composed of severe upper abdominal pain, unproductive vomiting and the inability to place a nasogastric tube. The level of serum lactate influenced the decision to proceed with emergency surgery, because of the assumption of an incarcerated hernia, volvulus and threat of gastric wall. The three emergency patients had all minimal increases of lactate (2.2-3.1 mmol/l). The approach was laparoscopic in all three cases and the diagnosis of an intrathoracic stomach was intraoperatively confirmed. A gastric wall necrosis has not been present, but in two of three patients intra- and perioperative complications occurred. In one case, a conversion to an open approach had to be performed because of a laparoscopic, not staunchable splenic bleeding. One more patient incurred a aspiration pneumonia but not a surgical complication. Semi-elective surgery Six patients (25 %) suffered from attenuated persistent or recurrent symptoms despite an initially successful conservative treatment. These patients underwent an operation within the first week after admission. All six surgical procedures were performed laparoscopically without intraand perioperative complications. Elective surgery Fifteen of 24 patients (62.5 %) were free of complaints under conservative management. Only proton pump inhibitors were given in the event of discharge. The indication for elective surgery was discussed and all 15 patients decided to undergo an operation within 4 weeks. Six patients desired to undergo the operation in the same hospital stay and nine patients preferred a recent admission for elective surgery. In 2/15 patients, we decided to follow an open approach because of previous open operations of the upper abdomen (1 9 left hepatectomy and 1 9 left pancreatectomy). There were no intra- and perioperative complications. The remaining 13 patients underwent elective laparoscopic surgery. One patient incurred a postoperative minor complication in the form of a wound healing defect in the ‘‘supra-umbilical’’ area of a trocar site with successful conservative treatment. Follow-up The routine 3-month follow-up after surgery was available for 21 of 24 patients including normal findings of clinical evaluation and gastroscopy in all cases. One year after surgery, 21 of 24 patients underwent radiographic barium swallow examination without objective evidence for recurrence in 19 patients. Two patients showed an
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asymptomatic radiological recurrence and required no further treatment. In all patients, a telephone interview was conducted in March 2014 and 21 of 24 patients replied to us. Twenty patients were free of complaints. No unplanned re-admissions at our surgical departments were required. During a follow-up period of mean 31 months (range 963), one symptomatic recurrence with surgical treatment outwards (laparoscopic re-fundoplication) occurred. No procedure-related or 30-day mortality occurred. Essential patients’ demographic, disease, treatment, and outcome characteristics are shown in Table 1.
Discussion Several potential mechanisms for translocation of the stomach into the thoracic cavity are being discussed: not only chronic acid reflux and abdominal pressure but also ultrastructural abnormalities at the muscular tissue of the crura [18]. Treatment options of patients with asymptomatic or mild symptomatic intrathoracic stomach are controversially discussed as well as patients’ management in acute symptomatic upside-down stomach. A systematic review from 2002 concluded that no general recommendation for surgery can be given to asymptomatic or mild symptomatic patients with PHs. In 83 %, a watch and wait strategy and in 17 %, elective surgery seemed to be the therapy of choice [19]. On the other hand, the results of a large population-based study of patients with intrathoracic stomach, which examined hospital costs and patients’ outcomes support the consideration of early elective repair [14]. Poulose et al. supported this statement and identified predictors of inpatient mortality due to PH repair in octogenarians. In conclusion, emergency surgery was the sole predictor of inpatient mortality with a six- to sevenfold increase compared to elective patients; wherefore, elective repair was recommended [20]. Sihvo et al. evaluated the cases of death, related to PHs. The high mortality rate of 16.4 % in conservative-treated patients might have been reduced by elective surgical intervention. So, the authors recommended the repair of PHs, at least in symptomatic patients. In this study, the mortality in emergency surgery compared to elective surgery was 5:1 [21]. Larusson et al. evaluated postoperative morbidity and mortality in patients undergoing laparoscopic PH repair. The authors concluded, that indication for surgery must be carefully balanced against the individual patient’s comorbidities (ASA III, IV), age ([70), symptoms and the potentially life-threatening complications [22]. Most studies converge to the conclusion, that about half of admissions related to PHs are emergent and emergency surgery increases mortality. Furthermore, conservative
Hernia Table 1 Patients’ essential demographics, disease, treatment and outcome characteristics Patient/ gender
Age/BMI
Serum lactate
Hiatal surface area
Operation technique
Timing for surgery
Open/ laparoscopic/ conversion
Complications
Follow-up (months)
1/male
48/23.5
1.3
7.4
Toupet
Semi-elective
Laparoscopic
No
63
2/female
71/30.6
1.6
9.7
Nissen
Semi-elective
Laparoscopic
No
Lost to follow-up
3/female
39/22.3
1.1
8.2
Nissen
Elective
Laparoscopic
No
59
4/male
64/26.4
0.6
5.1
Toupet
Elective
Open
No
53
5/female
73/28.5
2.8
6.7
Toupet
Emergent
Conversion
Splenicinjury
Radiogr. Recurr.
6/male
34/19.6
0.5
6.6
Nissen
Elective
Laparoscopic
No
48
7/female
81/31.3
0.6
5.4
Nissen
Semi-elective
Laparoscopic
No
46
8/female
83/24.9
0.8
6.5
Toupet
Elective
Laparoscopic
No
41
9/female
69/26.6
0.9
4.3
Nissen
Elective
Laparoscopic
Wound complication at trocar site
38
10/female
78/29.4
2.2
5.8
Nissen
Emergent
Laparoscopic
No
35
11/male
79/28.3
1.2
7.3
Toupet
Semi-elective
Laparoscopic
No
Radiogr. Recurr.
12/female
65/25.4
0.6
5.0
Toupet
Elective
Laparoscopic
No
31
13/female
58/27.8
0.8
6.4
Toupet
Elective
Laparoscopic
No
29
14/female
86/35.9
3.1
6.9
Toupet
Emergent
Laparoscopic
Aspiration pneumonia
24
15/male
67/22.4
1.3
5.8
Toupet
Elective
Laparoscopic
No
Lost to follow-up
16/female 17/male
45/30.5 59/23.4
0.5 0.5
5.4 6.4
Toupet Toupet
Elective Elective
Laparoscopic Laparoscopic
No No
21 Re-fundo outwards
18/female
73/26.4
0.5
6.7
Toupet
Semi-elective
Laparoscopic
No
19
19/female
66/27.8
0.8
7.1
Toupet
Elective
Laparoscopic
No
17
20/female
61/28.5
0.9
5.3
Toupet
Elective
Laparoscopic
No
15
21/male
68/31.9
1.1
7.2
Toupet
Semi-elective
Laparoscopic
No
Lost to follow-up
22/male
65/25.8
0.5
6.4
Toupet
Elective
Open
No
13
23/male 24/male
67/31.6 39/26.3
0.6 0.5
8.2 7.3
Toupet Toupet
Elective Elective
Laparoscopic Laparoscopic
No No
11 9
Mean
64 ± 14.2 27.3 ± 3.7
6.5 ± 1.2
SD
31 (Range 9-63)
Patients’ demographic and disease characteristics
treatment with risk of developing complications may lead to an increased mortality compared to elective surgery. Therefore, we would tend to perform elective surgery in patients with mild or recurrent symptoms due to type IV hernias also in advanced age if patients are suitable for surgery in view of comorbidities. For this reason, we advised our patients who were free of complaints after conservative treatment to undergo elective surgery within 4 weeks because of the risk for recurrent severe complaints and complications. All patients agreed after information. In contrast to previous studies, [14, 20] the results of our study suggest that emergency surgery is necessary only in the minority of patients. Surgeons in charge usually have
time to resuscitate and optimize the patient. In our setting, we have always an experienced laparoscopic antireflux surgeon available, which may not be the case in other centers. Particularly in the nighttime and weekend setting, this might be a problem. In such cases, there mostly remains time for the patients to be transferred to a center of laparoscopy. In rare cases, where no nasogastric tube can be placed and the patient is in a bad general health condition, an endoscopically assisted derotation and reposition of the stomach can be attempted. In the case of success, a percutaneous endoscopic gastrostomy (PEG) can theoretically be placed for stomach fixation if it remains not too far cephalad for secure PEG placement [23]. Potential
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problems must be expected with subsequent surgery in patients in whom a PEG tube has been placed previously for stomach fixation. Therefore, PEG placement should only be used as a durable solution and not as ‘‘bridge to surgery’’. We did not have to manage such a case, but we would decide upon open surgery. If derotation remains inefficient, immediate surgery is indicated [24]. The concept of derotation and maybe PEG tube placement might have been a treatment option in the three patients who had been subject to emergency surgery in our series, but all three patients were anaesthesiologically approved and suitable for surgery. Endoscopic placement of a gastric tube would possibly defer the intervention for few hours to be able to entrust it to an experienced surgeon if the organization did not allow to operate immediately, but in our department, an experienced visceral surgeon is on demand around the clock and was involved in the surgical treatment. Besides, a threat of the gastric wall was considered and because of these abovementioned reasons, the surgeons decided upon primary surgery. Endoscopic attempts of derotation might further be reserved for multimorbid and anaesthesiologically highrisk patients. However, anesthesiology safety manoeuvers to avoid aspiration before inducing anesthesia in occluded patients are tricky and a ‘‘crush induction’’ is required without ventilation after preoxygenation. Nevertheless, one patient postoperatively incurred aspiration pneumonia because no gastric decompression could be performed previous to anesthesia. Bhayani et al. compared the outcome of patients with obstructive PH regarding early (\24 h), and interval ([24 h, median 3.6 days after admission) surgery. The authors assumed that a prolonged delay for surgery may worsen patient outcomes [25]. However, in our study, all the patients, who were operated early elective, had no complications. The laparoscopic approach notoriously offers advantages to the patients. There are some studies which suggest the laparoscopic approach in repairing each form of PHs as feasible, effective and safe [26, 27]. In our experience, a surgeon with adequate expert knowledge in elective laparoscopic antireflux surgery can ensure safe laparoscopic operative management also in cases of emergency. However, in our study, we had one conversion in emergency surgery because of an iatrogenic splenic injury, whereby the splenic could be preserved. There were no conversions in semi-elective or elective laparoscopic surgery. Another point of discussion is the stable crural closure with or without mesh. It is not possible to answer this question by the current state of scientific knowledge [9, 17, 28]. The essence is that the incidence of recurrences could be reduced using meshes but complications such as fibrosis with dysphagia, or mesh migration and gastroesophageal
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erosions can occur. In total, there were three recurrences in our study population and all occurred after prosthetic reinforcement taking into account the dimensions of the hiatal orifice [5.6 cm2. Taking into consideration that all our study patients suffered from large hiatal defects with weak diaphragmatic crura, we suppose a higher rate of recurrences if we had used no meshes for hiatal reinforcement. Two of the patients concerned were asymptomatic and both patients were [70 years old. In view of that and regarding the fact that redo surgery after hiatal prosthetic reinforcement is tricky and associated with increased complications we decided upon ‘‘wait and see’’ strategy. Neither the efficacy of each individual technique, nor the safety of different mesh materials and shapes has been adequately investigated in the past. Tendentially, biologics seem to have higher failure rates, but synthetics have higher complication rates [17]. Stadlhuber et al. reported 28 patients with severe to life-threatening synthetic mesh-associated complications [29]. As a consequence of these findings, we changed our treatment standard for larger hiatal defects in terms of prospectively making reinforcement with a non-permanent option for tissue reinforcement. We recently use a designed web of biocompatible synthetic polymers that is gradually absorbed by the body, while its matrix of open pores serves as a scaffold for tissue generation. The material undergoes hydrolytic and enzymatic degradation, leaving no permanent material in the body. We see an advantage over biologics in uniformity, thickness, and consistency. Up to now, we have used a synthetic mesh, approved for intraperitoneal placement (Parietex composite, CovidienÒ) made of polyester with antiadhesive collagen coating to the visceral side. In 75 % of our patients, the mesh was used, because of a hiatal defect larger than 5.6 cm2. Tailoring of the hiatal closure to the hiatal defect is reported to be an effective procedure to prevent hiatal hernia recurrence and/or intrathoracic wrap migration in cases of larger defects and/ or weak diaphragmatic crura, if no tension-free closure is possible [9, 16, 17, 30]. In the remaining six cases with intrathoracic stomach, the defect area was not larger than 5.6 cm2. It was a very interesting clinical finding that obviously an intrathoracic stomach can even occur, when the size of esophageal hiatus is relatively small. This finding underlines results of a previous study, showing that hiatal hernia size often does not correlate with the real size of the defect [31]. Limitation of our study is the relative small number of patients, despite of consecutive inclusion of all patients over the 4-year time period with acute emergent symptoms due to an intrathoracic stomach in two centers of antireflux surgery. On the contrary, in the literature there are less data available dealing with the management of acute and
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complicated type IV PH. Another strength is the close cooperation of the two centers regarding similar diagnostic and treatment standards performed by highly experienced antireflux surgeons. There are two main goals in the treatment of patients: to solve the acute symptoms and to obtain long term symptom-free patients. The results of our study lead to the conclusion that the majority of patients with acute symptoms due to an intrathoracic stomach can mostly be initially conservatively treated. Afterwards, they should undergo early elective or elective laparoscopic surgery in a center of antireflux surgery for avoiding recurrent acute severe complaints and potential complications. Conflict of interest G. K. has no conflict of interest or financial ties to disclose, O.O.K. has no conflict of interest or financial ties to disclose, S.A.A. has no conflict of interest or financial ties to disclose, K.E. has no conflict of interest or financial ties to disclose, R.P. has no conflict of interest or financial ties to disclose.
15.
16.
17.
18.
19. 20.
21.
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ORIGINAL ARTICLE
‘‘Acute intrathoracic stomach!’’ How should we deal with complicated type IV paraesophageal hernias? G. Ko¨hler • O. O. Koch • S. A. Antoniou K. Emmanuel • R. Pointner
•
Received: 4 March 2014 / Accepted: 7 July 2014 Ó Springer-Verlag France 2014
Abstract Purpose Management of emergently admitted patients due to a complicated large paraesophageal hernia with acute symptoms of an ‘‘intrathoracic stomach’’ is controversial. The aim of this study was to clarify whether emergency surgery in such cases should be the procedure of choice. Methods The retrospective analysis of patients who were hospitalized due to emerging acute symptoms of an ‘‘intrathoracic stomach’’ between January 2009 and May 2013 was used as method. Patients were categorized into three groups: emergency operation within 24 h after admission, semi-elective operation within the first 7 days after admission and elective operation. Results Twenty-four patients were identified. Only three (12.5 %) patients required laparoscopic emergency surgery and two incurred a perioperative complication. In consequence of persistent or early recurrent complaints a laparoscopic operation was required prior to discharge semielective in 6/24 (25 %) patients without complications. The remaining 15/24 (62.5 %) patients were free of complaints after conservative therapy, but all of them decided upon
Sisters of Charity Hospital is an Academic Teaching Hospital of the Universities of Graz and Innsbruck. G. Ko¨hler (&) O. O. Koch K. Emmanuel Department of General and Visceral Surgery, Sisters of Charity Hospital, 4010 Linz, Austria e-mail: [email protected] O. O. Koch R. Pointner Department of General Surgery, General Hospital Zell Am See, Zell am See, Austria S. A. Antoniou Center for Minimally Invasive Surgery, Hospital Neuwerk, Moenchengladbach, Germany
elective operation after informed consent. One minor complication occurred. Conclusion The majority of patients with acute symptoms due to an intrathoracic stomach can primarily be treated conservatively and timing of elective repair should be performed after resuscitation in a center of laparoscopic antireflux surgery. Keywords GERD Intrathoracic stomach Upside-down stomach Paraesophageal hernia Gastric volvulus
Introduction Hiatal hernias develop in 10-50 % of the general population and can be classified into four types: type I is a sliding hernia, which accounts for 85 % of all cases. The less common types II, III and IV are all varieties of paraesophageal hernias (PHs). The type IV hernia is associated with a large defect in the phrenoesophageal membrane, allowing various parts of the stomach or other organs to enter the hernia sac [1]. PHs are an uncommon type of real hernias in contrast to sliding hiatal hernias, because they consist of a true hernia sac including a peritoneal layer [2, 3]. PHs can be associated with serious complications, wherefore some authors recommend an operation even in asymptomatic patients for a long time [4]. Potential complications include gastric volvulus with gastric outlet obstruction or strangulation, gastric wall necrosis and perforation, hemorrhage and respiratory distress secondary to compression of the left main stem bronchus [5]. Commonly, symptoms of PH are abdominal fullness, nausea, swallowing disorders and heartburn [6]. The essentials of diagnosis are a detailed anamnesis and clinical examination, including current symptoms and
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previous medical therapies. PHs with complications are a rare condition and therefore often not initially considered as the underlying cause of these symptoms. It is also important to capture cardiac and pulmonary diseases. Moreover, usually performed are a chest X-ray, a blood analysis, an upper endoscopy and a video swallow. Esophageal manometry and acid analysis are expendable, because they are difficult to perform and the results are unreliable. A computed tomography of the trunk can be helpful to assess the hiatal defect size, the exact hernia location and content and also the position of the stomach [7]. The surgical principles lean onto a laparoscopic approach with reposition of the stomach or other herniated viscera, hernia sac excision and esophageal mobilization. The hiatal defect must be stably closed, eventually with some biological or prosthetic mesh materials and a fundoplication with fundophrenicopexia should be performed [8–11]. The difference between an acute intrathoracic stomach and a gastric volvulus is not always clear. In our experience, an intrathoracic stomach is always associated with variable degree of organoaxial volvulus. In practice, gastric volvulus mostly occurs as a complication of PHs and it can present as acute or chronic clinical manifestation depending upon the degree of obstruction and the rapidity of onset [5, 12]. The management of these patients is discussed controversially. Some authors advocate immediate surgery after diagnosis of an intrathoracic stomach with severe complaints [13]. Further, it is not clear how we should proceed with patients who are asymptomatic or have mild symptoms due to a PH. One option is ‘‘watchful waiting’’, and the other option is to recommend an elective operation to avoid potential life-threatening complications [14]. The aim of this study is contributed to clarify whether emergency operation is required in patients with acute symptoms caused by an ‘‘intrathoracic stomach’’ due to a type IV PH.
Methods This is a retrospective analysis of patients who were admitted to the Hospital of Sisters of Charity Linz/Austria and the General Hospital Zell am See/Austria between January 2009 and May 2013 due to acute and emerging symptoms attributed to an ‘‘intrathoracic stomach’’, as a complication of a type IV PH. In this connection, the following symptoms were determined: acute severe pain of upper abdomen or chest accompanied with dysphagia, nausea, urge to gag, vomiting and dyspnoea. If diagnostic findings resulted in an intrathoracic stomach, the patients were included in our study. The diagnostics comprised the following points:
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Fig. 1 Multi-slice contrast computed tomography of the thorax, showing an intrathoracic stomach
1.
2. 3. 4.
5. 6. 7.
Exact anamnesis inclusive onset and duration of complaints and previous diagnostic steps and medical treatments; clinical examination also in view of acute cardiac and pulmonary diseases; chest X-ray (Intrathoracic bubble); standardized blood analysis: serum lactate, CRP, kidney, electrolytes, coagulation and also including heart enzymes and d-dimer; cautious approach of gastroscopy if necessary with children gastroscope; video gastrografin swallow; multi-slice contrast computed tomography of the trunk (Fig. 1).
The initial therapy comprised management of fluid and electrolytes, intravenous analgesics, spasmolytics, proton pump inhibitors and the attempt to place a nasogastric tube. Patients were categorized into three groups, whereby the gravity of complaints and success of conservative treatment determined the assignment. 1.
2.
3.
Operation emergently within 24 h after admission (No chance of gastric tube placement, persistent severe abdominal/thoracic pain and vomiting). Operation semi-elective within the first 7 days after admission (recovery after conservative treatment but persistent or early recurrent symptoms). Operation elective in same hospital stay or after discharge and agreement on deadline within 4 weeks because of the risk of recurrent acute symptoms (freedom of symptoms after conservative treatment).
Patients’ data were retrospectively collected from the institution medical records (prospective conducted electronic database) and medical files.
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Fig. 3 Histoplasty with mesh
Fig. 2 Reposition of the stomach
The operative technique was similar and standardized in both hospitals performed by altogether four surgeons. The only difference was that fundoplication in Linz was made until 2012 in Nissen technique and afterwards in Toupet technique. The approach was laparoscopical in elective and emergency cases, except in patients with previous conventional extended operations of the upper abdomen. The operative steps included first reposition of the stomach (Fig. 2) or other herniated viscera, hernia sac excision and mobilization of the esophagus. The crural closure was made with non-absorbable single knot sutures. If the defect surface (hiatal surface area = HSA) was larger than 5.6 cm2, a prosthetic mesh was placed (Fig. 3). Intraoperative measurement of the HSA with subsequent tailoring of the hiatal closure to the hiatal defect is reported to be an effective procedure to prevent hiatal hernia recurrence and/ or intrathoracic wrap migration in laparoscopic antireflux surgery [15, 16]. The limit value for hiatal closure without meshes was set according to previous findings of primary suture closure complicated with tension and higher recurrence rates in cases of larger defects and/or weak diaphragmatic crura. On this basis, we considered 5.6 cm2 as a discriminant for the use of prosthesis [9, 16, 17]. For measuring the hiatal defect, the right and left crus and the crural commissure are dissected exactly. Then a ruler is brought intraabdominally. Firstly, the length of the crura is measured in centimeters beginning at the crural commissure up to the edge where the ‘‘Pars flaccida’’ from the gastrohepatic omentum begins (radius R). Afterwards, the circuit between the both crural edges is measured (s).Using these two values (R and s) the hiatal surface area (HSA) can be calculated by a formula. Moreover, a fundoplication and fundophrenicopexy were essential steps [15, 16]. The routine follow-up was conducted 3 months after surgery and comprised anamnesis, clinical examination, and gastroscopy. Twelve months after surgery it was
completed with a radiographic barium swallow examination. No regular additional follow-up was scheduled, but all patients were informed about outpatient re-evaluation at our consultation hours in cases of clinical signs of recurrence or if necessary, emergency re-admission at all hours. All patients were contacted by phone in march 2014 to assess recurrent symptoms with appropriate conservative or surgical treatment out of our department to update and complete the follow-up examination. Statistical analysis was performed using Statistical Package for Social Science (SPSS, Chicago, IL) for Windows. All data are presented as mean ± standard deviation, minimum, and maximum values. Only descriptive statistic was used.
Results Twenty-four patients were included, 14 female and 10 male. The mean age was 64 ± 14.2 years (range 34-86). The mean body mass index was 27.3 ± 3.7 kg/m2 (range 19.6-35.9). Twelve patients were treated and operated in the general hospital Zell am See and 12 patients in the Charity of Sisters Hospital Linz. A Toupet procedure was performed in 18 cases and a Nissen fundoplication in six patients (surgical technique was switched from Nissen to Toupet in Linz after six procedures because of the input of a new surgical leader). The mean HSA was 6.5 ± 1.2 cm2 (range 4.3-9.7). In 18 of 24 (75 %) patients, a synthetic mesh was placed, (Parietex compositeÒ, CovidienTM) because of a defect area larger than 5.6 cm2. The meshes were carefully fixed with short titan staples to avoid perforation of the diaphragm. No mesh-related complications occurred postoperatively and during the follow-up period. Emergency surgery Only three of 24 patients (12.5 %) required emergency surgery within 24 h. In all cases the indication was the
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appearance of the Borchardt’s triad [13]. This is composed of severe upper abdominal pain, unproductive vomiting and the inability to place a nasogastric tube. The level of serum lactate influenced the decision to proceed with emergency surgery, because of the assumption of an incarcerated hernia, volvulus and threat of gastric wall. The three emergency patients had all minimal increases of lactate (2.2-3.1 mmol/l). The approach was laparoscopic in all three cases and the diagnosis of an intrathoracic stomach was intraoperatively confirmed. A gastric wall necrosis has not been present, but in two of three patients intra- and perioperative complications occurred. In one case, a conversion to an open approach had to be performed because of a laparoscopic, not staunchable splenic bleeding. One more patient incurred a aspiration pneumonia but not a surgical complication. Semi-elective surgery Six patients (25 %) suffered from attenuated persistent or recurrent symptoms despite an initially successful conservative treatment. These patients underwent an operation within the first week after admission. All six surgical procedures were performed laparoscopically without intraand perioperative complications. Elective surgery Fifteen of 24 patients (62.5 %) were free of complaints under conservative management. Only proton pump inhibitors were given in the event of discharge. The indication for elective surgery was discussed and all 15 patients decided to undergo an operation within 4 weeks. Six patients desired to undergo the operation in the same hospital stay and nine patients preferred a recent admission for elective surgery. In 2/15 patients, we decided to follow an open approach because of previous open operations of the upper abdomen (1 9 left hepatectomy and 1 9 left pancreatectomy). There were no intra- and perioperative complications. The remaining 13 patients underwent elective laparoscopic surgery. One patient incurred a postoperative minor complication in the form of a wound healing defect in the ‘‘supra-umbilical’’ area of a trocar site with successful conservative treatment. Follow-up The routine 3-month follow-up after surgery was available for 21 of 24 patients including normal findings of clinical evaluation and gastroscopy in all cases. One year after surgery, 21 of 24 patients underwent radiographic barium swallow examination without objective evidence for recurrence in 19 patients. Two patients showed an
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asymptomatic radiological recurrence and required no further treatment. In all patients, a telephone interview was conducted in March 2014 and 21 of 24 patients replied to us. Twenty patients were free of complaints. No unplanned re-admissions at our surgical departments were required. During a follow-up period of mean 31 months (range 963), one symptomatic recurrence with surgical treatment outwards (laparoscopic re-fundoplication) occurred. No procedure-related or 30-day mortality occurred. Essential patients’ demographic, disease, treatment, and outcome characteristics are shown in Table 1.
Discussion Several potential mechanisms for translocation of the stomach into the thoracic cavity are being discussed: not only chronic acid reflux and abdominal pressure but also ultrastructural abnormalities at the muscular tissue of the crura [18]. Treatment options of patients with asymptomatic or mild symptomatic intrathoracic stomach are controversially discussed as well as patients’ management in acute symptomatic upside-down stomach. A systematic review from 2002 concluded that no general recommendation for surgery can be given to asymptomatic or mild symptomatic patients with PHs. In 83 %, a watch and wait strategy and in 17 %, elective surgery seemed to be the therapy of choice [19]. On the other hand, the results of a large population-based study of patients with intrathoracic stomach, which examined hospital costs and patients’ outcomes support the consideration of early elective repair [14]. Poulose et al. supported this statement and identified predictors of inpatient mortality due to PH repair in octogenarians. In conclusion, emergency surgery was the sole predictor of inpatient mortality with a six- to sevenfold increase compared to elective patients; wherefore, elective repair was recommended [20]. Sihvo et al. evaluated the cases of death, related to PHs. The high mortality rate of 16.4 % in conservative-treated patients might have been reduced by elective surgical intervention. So, the authors recommended the repair of PHs, at least in symptomatic patients. In this study, the mortality in emergency surgery compared to elective surgery was 5:1 [21]. Larusson et al. evaluated postoperative morbidity and mortality in patients undergoing laparoscopic PH repair. The authors concluded, that indication for surgery must be carefully balanced against the individual patient’s comorbidities (ASA III, IV), age ([70), symptoms and the potentially life-threatening complications [22]. Most studies converge to the conclusion, that about half of admissions related to PHs are emergent and emergency surgery increases mortality. Furthermore, conservative
Hernia Table 1 Patients’ essential demographics, disease, treatment and outcome characteristics Patient/ gender
Age/BMI
Serum lactate
Hiatal surface area
Operation technique
Timing for surgery
Open/ laparoscopic/ conversion
Complications
Follow-up (months)
1/male
48/23.5
1.3
7.4
Toupet
Semi-elective
Laparoscopic
No
63
2/female
71/30.6
1.6
9.7
Nissen
Semi-elective
Laparoscopic
No
Lost to follow-up
3/female
39/22.3
1.1
8.2
Nissen
Elective
Laparoscopic
No
59
4/male
64/26.4
0.6
5.1
Toupet
Elective
Open
No
53
5/female
73/28.5
2.8
6.7
Toupet
Emergent
Conversion
Splenicinjury
Radiogr. Recurr.
6/male
34/19.6
0.5
6.6
Nissen
Elective
Laparoscopic
No
48
7/female
81/31.3
0.6
5.4
Nissen
Semi-elective
Laparoscopic
No
46
8/female
83/24.9
0.8
6.5
Toupet
Elective
Laparoscopic
No
41
9/female
69/26.6
0.9
4.3
Nissen
Elective
Laparoscopic
Wound complication at trocar site
38
10/female
78/29.4
2.2
5.8
Nissen
Emergent
Laparoscopic
No
35
11/male
79/28.3
1.2
7.3
Toupet
Semi-elective
Laparoscopic
No
Radiogr. Recurr.
12/female
65/25.4
0.6
5.0
Toupet
Elective
Laparoscopic
No
31
13/female
58/27.8
0.8
6.4
Toupet
Elective
Laparoscopic
No
29
14/female
86/35.9
3.1
6.9
Toupet
Emergent
Laparoscopic
Aspiration pneumonia
24
15/male
67/22.4
1.3
5.8
Toupet
Elective
Laparoscopic
No
Lost to follow-up
16/female 17/male
45/30.5 59/23.4
0.5 0.5
5.4 6.4
Toupet Toupet
Elective Elective
Laparoscopic Laparoscopic
No No
21 Re-fundo outwards
18/female
73/26.4
0.5
6.7
Toupet
Semi-elective
Laparoscopic
No
19
19/female
66/27.8
0.8
7.1
Toupet
Elective
Laparoscopic
No
17
20/female
61/28.5
0.9
5.3
Toupet
Elective
Laparoscopic
No
15
21/male
68/31.9
1.1
7.2
Toupet
Semi-elective
Laparoscopic
No
Lost to follow-up
22/male
65/25.8
0.5
6.4
Toupet
Elective
Open
No
13
23/male 24/male
67/31.6 39/26.3
0.6 0.5
8.2 7.3
Toupet Toupet
Elective Elective
Laparoscopic Laparoscopic
No No
11 9
Mean
64 ± 14.2 27.3 ± 3.7
6.5 ± 1.2
SD
31 (Range 9-63)
Patients’ demographic and disease characteristics
treatment with risk of developing complications may lead to an increased mortality compared to elective surgery. Therefore, we would tend to perform elective surgery in patients with mild or recurrent symptoms due to type IV hernias also in advanced age if patients are suitable for surgery in view of comorbidities. For this reason, we advised our patients who were free of complaints after conservative treatment to undergo elective surgery within 4 weeks because of the risk for recurrent severe complaints and complications. All patients agreed after information. In contrast to previous studies, [14, 20] the results of our study suggest that emergency surgery is necessary only in the minority of patients. Surgeons in charge usually have
time to resuscitate and optimize the patient. In our setting, we have always an experienced laparoscopic antireflux surgeon available, which may not be the case in other centers. Particularly in the nighttime and weekend setting, this might be a problem. In such cases, there mostly remains time for the patients to be transferred to a center of laparoscopy. In rare cases, where no nasogastric tube can be placed and the patient is in a bad general health condition, an endoscopically assisted derotation and reposition of the stomach can be attempted. In the case of success, a percutaneous endoscopic gastrostomy (PEG) can theoretically be placed for stomach fixation if it remains not too far cephalad for secure PEG placement [23]. Potential
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problems must be expected with subsequent surgery in patients in whom a PEG tube has been placed previously for stomach fixation. Therefore, PEG placement should only be used as a durable solution and not as ‘‘bridge to surgery’’. We did not have to manage such a case, but we would decide upon open surgery. If derotation remains inefficient, immediate surgery is indicated [24]. The concept of derotation and maybe PEG tube placement might have been a treatment option in the three patients who had been subject to emergency surgery in our series, but all three patients were anaesthesiologically approved and suitable for surgery. Endoscopic placement of a gastric tube would possibly defer the intervention for few hours to be able to entrust it to an experienced surgeon if the organization did not allow to operate immediately, but in our department, an experienced visceral surgeon is on demand around the clock and was involved in the surgical treatment. Besides, a threat of the gastric wall was considered and because of these abovementioned reasons, the surgeons decided upon primary surgery. Endoscopic attempts of derotation might further be reserved for multimorbid and anaesthesiologically highrisk patients. However, anesthesiology safety manoeuvers to avoid aspiration before inducing anesthesia in occluded patients are tricky and a ‘‘crush induction’’ is required without ventilation after preoxygenation. Nevertheless, one patient postoperatively incurred aspiration pneumonia because no gastric decompression could be performed previous to anesthesia. Bhayani et al. compared the outcome of patients with obstructive PH regarding early (\24 h), and interval ([24 h, median 3.6 days after admission) surgery. The authors assumed that a prolonged delay for surgery may worsen patient outcomes [25]. However, in our study, all the patients, who were operated early elective, had no complications. The laparoscopic approach notoriously offers advantages to the patients. There are some studies which suggest the laparoscopic approach in repairing each form of PHs as feasible, effective and safe [26, 27]. In our experience, a surgeon with adequate expert knowledge in elective laparoscopic antireflux surgery can ensure safe laparoscopic operative management also in cases of emergency. However, in our study, we had one conversion in emergency surgery because of an iatrogenic splenic injury, whereby the splenic could be preserved. There were no conversions in semi-elective or elective laparoscopic surgery. Another point of discussion is the stable crural closure with or without mesh. It is not possible to answer this question by the current state of scientific knowledge [9, 17, 28]. The essence is that the incidence of recurrences could be reduced using meshes but complications such as fibrosis with dysphagia, or mesh migration and gastroesophageal
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erosions can occur. In total, there were three recurrences in our study population and all occurred after prosthetic reinforcement taking into account the dimensions of the hiatal orifice [5.6 cm2. Taking into consideration that all our study patients suffered from large hiatal defects with weak diaphragmatic crura, we suppose a higher rate of recurrences if we had used no meshes for hiatal reinforcement. Two of the patients concerned were asymptomatic and both patients were [70 years old. In view of that and regarding the fact that redo surgery after hiatal prosthetic reinforcement is tricky and associated with increased complications we decided upon ‘‘wait and see’’ strategy. Neither the efficacy of each individual technique, nor the safety of different mesh materials and shapes has been adequately investigated in the past. Tendentially, biologics seem to have higher failure rates, but synthetics have higher complication rates [17]. Stadlhuber et al. reported 28 patients with severe to life-threatening synthetic mesh-associated complications [29]. As a consequence of these findings, we changed our treatment standard for larger hiatal defects in terms of prospectively making reinforcement with a non-permanent option for tissue reinforcement. We recently use a designed web of biocompatible synthetic polymers that is gradually absorbed by the body, while its matrix of open pores serves as a scaffold for tissue generation. The material undergoes hydrolytic and enzymatic degradation, leaving no permanent material in the body. We see an advantage over biologics in uniformity, thickness, and consistency. Up to now, we have used a synthetic mesh, approved for intraperitoneal placement (Parietex composite, CovidienÒ) made of polyester with antiadhesive collagen coating to the visceral side. In 75 % of our patients, the mesh was used, because of a hiatal defect larger than 5.6 cm2. Tailoring of the hiatal closure to the hiatal defect is reported to be an effective procedure to prevent hiatal hernia recurrence and/or intrathoracic wrap migration in cases of larger defects and/ or weak diaphragmatic crura, if no tension-free closure is possible [9, 16, 17, 30]. In the remaining six cases with intrathoracic stomach, the defect area was not larger than 5.6 cm2. It was a very interesting clinical finding that obviously an intrathoracic stomach can even occur, when the size of esophageal hiatus is relatively small. This finding underlines results of a previous study, showing that hiatal hernia size often does not correlate with the real size of the defect [31]. Limitation of our study is the relative small number of patients, despite of consecutive inclusion of all patients over the 4-year time period with acute emergent symptoms due to an intrathoracic stomach in two centers of antireflux surgery. On the contrary, in the literature there are less data available dealing with the management of acute and
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complicated type IV PH. Another strength is the close cooperation of the two centers regarding similar diagnostic and treatment standards performed by highly experienced antireflux surgeons. There are two main goals in the treatment of patients: to solve the acute symptoms and to obtain long term symptom-free patients. The results of our study lead to the conclusion that the majority of patients with acute symptoms due to an intrathoracic stomach can mostly be initially conservatively treated. Afterwards, they should undergo early elective or elective laparoscopic surgery in a center of antireflux surgery for avoiding recurrent acute severe complaints and potential complications. Conflict of interest G. K. has no conflict of interest or financial ties to disclose, O.O.K. has no conflict of interest or financial ties to disclose, S.A.A. has no conflict of interest or financial ties to disclose, K.E. has no conflict of interest or financial ties to disclose, R.P. has no conflict of interest or financial ties to disclose.
15.
16.
17.
18.
19. 20.
21.
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