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VCUDEATH AND COMPLICATIONS CONFERENCE
Complication Wrap necrosis, mediastinal
abscess, acute renal failure, pulmonary embolism
Procedure Laparoscopic repair of hiatal
hernia, Nissen fundoplication, gastropexy, upper endoscopy
Primary Diagnosis Type 4 giant paraesophageal hernia
Clinical History
82 yo male presenting with severe chronic reflux.
Heartburn, regurgitation, and shortness of breath with exertion
Denies chest pain Not relieved by PPI therapy
PMH: Prostate Ca, CAD, Htn, asthma, urinary incontinence, gout
PSH: radical prostatectomy, 4 vessel CABG, lap chole, cataract surgery
Soc: retired professor of English literature, married, 3 adult children, 2 drinks/day, no tobacco or drug use
EGD: Normal esophagus, hiatal hernia,
distended/tortuous stomach, normal duodenum Esophageal manometry:
Peristalsis of esophagus, hypotensive LES Stress test
Average functional capacity Terminated at 8.5 mets due to dyspnea/wheezing No chest pain or EKG changes EF 35%, no wall motion abnormalities on ECHO Cleared by cardiology for operative intervention
Extensive discussion of risks of surgery, elected to proceed
5/9 to OR Large hiatal hernia noted with entire stomach in chest
folded upon itself Stomach reduced and hernia sac partially excised Esophageal length adequate (no Collis required) Interrupted surgidac sutures placed posteriorly and
anteriorly with moderate residual hiatal defect Decision made to not place mesh Superior short gastric vessels ligated and floppy Nissen
performed over endoscope Small capsular tear on lateral left lobe of liver, controlled
with cautery JP left behind wrap Stomach pexied to anterior abdominal wall with surgidac
sutures x2 Pt left intubated and transferred to STICU
SCDs in place, SQ heparin started 10pm evening of operation
Extubated POD 1 Transferred to floor POD 2, started clear liquids
with no difficulties Drain noted to have bilious drainage, abdomen
benign Plan to d/c POD 4, however still requiring
oxygen at 4L POD 5 CRE 2.01, FENA 2.4, making good urine,
renal- no intervention required Progressive dyspnea, desaturations on 5/14 Troponin 1.7, chest CT to r/o PE and evaluate
for herniated wrap
Small subsegmental PE bilaterally Fluid collection in mediastinum with few
air locules, no herniation stomach Bilateral pleural effusions R>L
Transferred to ICU on heparin gtt, cardiology consult, lasix diuresis
5/16- JP noted to be cloudy Swallow study with no leak, amylase- 36, triglycerides-
106, cultures sent- polymicrobial Broad spectrum abx started, tolerating liquids with no
increase in JP drainage or abd pain, exam benign Unable to wean oxygen, WBC elevated, clinically stable CRE started increasing 5/20 with inability to diurese,
progressive right effusion, hyponatremia, BIPAP 5/22 placed right chest tube with +fungal growth, flucon
started, dialysis started 5/24 underwent CT chest and abdomen
Herniation of wrap with emphysematous gastritis
Possible leak versus abscess Large right pleural effusion with air locules,
complete RLL collapase
Pt taken emergently to OR for ex lap Drainage of large amount of purulence from
mediastinum Partial herniation of wrap into mediastinum Necrosis of nissen wrap with leak at suture site Wrap taken down and fundus excised, esophagus intact Mediastinum widely drained Gastrostomy, jejunostomy placed Pt transferred to ICU on multiple pressors, CVVHD Weaned off pressors Underwent VATS decortication on 5/30 Currently on vent, weaning off pressors, WBC trending
down
Analysis of Complication
• Was the complication potentially avoidable?– Yes: avoidance of surgery, preoperative pulmonary
function tests, hiatal hernia repair and gastrostomy with no nissen wrap, Collis-Nissen, hiatal hernia mesh
• Would avoiding the complication change the outcome for the patient?– Yes: reoperation, multiple complications, prolonged
hospitalization
• What factors contributed the complication?– Age, underlying anatomy, surgical judgment,
surgical technique
Pierre AF et al. Results of laparoscopic repair of giant paraesophageal hernias: 200 consecutive patients. Ann Thorac Surg. 2002 Dec;74(6):1909-15; discussion 1915-6.
incidence of hiatal hernia 5 per 1,000, but 95% of these are small, sliding type I hernias that are rarely associated with serious complications.
5% can be classified as giant paraesophageal hernias (PEHs)
GPEH are associated with progression of symptoms in up to 45% of patients.
In a classic report of nonsurgical observation of a group of minimally symptomatic patients with a GPEH, 26% died of catastrophic complications including torsion, gangrene, perforation, and massive hemorrhage (Skinner et al. 1967)
In the group of patients who develop gastric volvulus, the death rate can be as high as 100%
When repair is performed electively, the death rate is less than 1% to 2% in most series
Majority of these patients have esophageal shortening with GE junction in stomach and Collis gastroplasty should be favored with repair of GPEH
Pierre AF et al. Results of laparoscopic repair of giant paraesophageal hernias: 200 consecutive patients. Ann Thorac Surg. 2002 Dec;74(6):1909-15; discussion 1915-6. 8 type II hernias, 85 type III, and 7 type IV 69 Nissens, 112 Collis-Nissens, 12 partial
fundoplications, 6 other Median follow up 18 months
Pierre AF et al. Results of laparoscopic repair of giant paraesophageal hernias: 200 consecutive patients. Ann Thorac Surg. 2002 Dec;74(6):1909-15; discussion 1915-6. Excellent results were reported in
128 (84%) patients, 12 (8%) had a good result, 7 (5%) fair, and 5(3%) poor (QOL questionaire)
3 conversions to open surgery Complications occurred in 28%
overall Major postoperative complications
included stroke, myocardial infarction, pulmonary emboli, adult respiratory distress syndrome, and repeat operations (two for abscess and one each for hematoma, repair leak, and recurrent hernia)
1 death (bougie injury intraop, post-op leak, MOSF)
5 patient required reoperation for recurrent PEH
Evidence Based Literature
Oelschlager et al. Biologic prosthesis reduces recurrence after laparoscopic paraesophageal hernia repair: a multicenter, prospective, randomized trial. Ann Surg. 2006 Oct;244(4):481-90. 4 institutions, 108 lap paraesophageal
hernias 6 months 24% of primary repair had
recurrent hernia, 9% of biologic mesh buttressed
No difference in symptoms or quality of life 2011, 5 year follow up showed 59%
recurrent hernia in primary repair group, 54% in mesh repair
Teaching Points
Laparoscopic repair of giant paraesophageal hernias is feasible, however, it is a technically challenging operation with significant morbidity and mortality
Most series have significant rates of conversion to open, esophageal leaks, death
Long-term rates of reherniation are high Collis gastroplasty should be considered with all
GPEH due to significant rates of esophageal shortening
Consideration should be taken in elderly patients to pursue less intrusive surgical options
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