*Department of Surgery, Tainan Municipal Hospital, Show Chwan Medical Care
Corporation, 701 ROC, 670 Chung-Te Rd, Tainan, Taiwan
Corresponding author details:
Dr. Ming-Ho Wu
670 Chung-Te Rd, Tainan Department of Surgery
Show Chwan Medical Care Corporation
670 Chung-Te Rd, Tainan,Taiwan
Copyright:
© 2018 Ho Wu M, et al. This is
an open-access article distributed under the
terms of the Creative Commons Attribution 4.0
international License, which permits unrestricted
use, distribution and reproduction in any
medium, provided the original author and source
are credited.
Purpose: To emphasize aggressive surgery in the treatment of hiatal hernia based on a personal experience.
Materials and Methods: Twenty-four patients with hiatal hernia were surgically treated in a period of 9 years. They included 6 men and 18 women. The mean age was 76.5 years old (range 54~87). At referral, one had depended on ventilator for 47 days following a cardiopulmonary resuscitation, and other one had been treated by repeated blood transfusion for severe anemia. Seven others had coincidental surgical diseases.
Results: These hiatal hernias were type-1 in 6, type-3 in 15, and type-4 in 3. Eight (33.3%) patients had a huge hiatal hernia. All patients underwent laparotomy repair of hiatal hernia. Of them, 6 underwent concomitant and one underwent subsequent surgical procedure to treat the coincidental surgical diseases. Including the concomitant procedures, the mean operation time was 122 minutes (range 60 to 315). The mean length of postoperative hospital stay was 7.65 days (range 4 to 24). There was no operative death or recurrence.
Conclusion:
Patients with hiatal hernia had health problems and potential coincident surgical
diseases. Huge hiatal hernia usually induced cardiopulmonary compression even cardiac
arrest. Aggressive surgical repair is mandatory.
Hiatal hernia; Cardiopulmonary compression; Life threatening
Twenty-four patients with hiatal hernia were operated on in a 9-year period. These
patients had major symptoms, and some of them had coincident surgical diseases,
cardiopulmonary compression, and one life-threatening event. Aggressive surgery can
eliminate their clinical problems and risks of cardiopulmonary compression.
Hiatal hernia more commonly occurs in the aged adults, predominately in females.
Some researchers mentioned that these patients did not need surgical intervention
when the hernia is uncomplicated or asymptomatic [1]. However, some patients
had a huge hiatal hernia resulted in cardiopulmonary compression. To understand
the risks of hiatal hernia, this reports our limited data dealing the incidence of
huge hiatal hernia and coincident surgical diseases. Clinical data, risks, technical
considerations, and short-term results of patients with hiatal hernia are discussed herein.
We retrospectively reviewed patients with hiatal hernia treated by the first author between June 2009 and February 2018 (Table 1). A total of 24 patients with hiatal hernia, most patients were referred by our colleges, and one patient was referred from other hospital. They included 6 men and 18 women. The mean age was 76.5 years old (range 54~87). Vomiting and chest distress were the common symptoms. At referral, one had depended on ventilator for 47 days following a cardiopulmonary resuscitation, and other one had been treated by repeated blood transfusion for severe anemia. Seven others had coincidental surgical diseases; gall stones of 3, lung cancer, colon cancer, pericardial effusion, and inguinal hernia of each one. Patients’ demography, computed tomography, surgical procedure, and surgical outcome were reviewed.
Figure 1: The huge hiatal hernia refers the maximum transverse
diameter of the hernia (yellow) is longer than one-half of the
pleural cavity (pink). The data show 132.83 mm/201.55 mm > 50%
Table 1: The characteristics of these 24 patients with different type of hiatal hernia
According to the Hill’s classification of hiatal hernia, 6 patients
were type-1, one was type-2, 14 were type-3, and 3 was type-4
(Figure 2). Eight (33.3%) patients had a huge hiatal hernia (Table 2).
Huge hiatal hernias were more common in type-4 than Type-3 and
type 1 (p=0.011) (Table 3). All patients underwent laparotomy repair
of hiatal hernia, and seven of them also underwent other surgical
procedures to treat coincident surgical diseases simultaneously
(n=6) or subsequently (n=1). Including concomitant procedures,
the mean operation time was 122 minutes (range 60 to 315). The
mean length of postoperative hospital stay was 7.65 days (range 4
to 24). There was no operative death, complication, or recurrence.
Postoperative gastroesophageal reflux was not observed in this
series. A preoperative life-threatening event occurred on an
87-year-old woman. She had hiatal hernia for more than 9 years,
suddenly developed cardiopulmonary failure after a heavy meal.
The chest computed tomography showed severe cardiopulmonary
compression (Figure 3). Following 20 second cardiopulmonary
resuscitation at a regional hospital, the patient was transferred to a
medical center for ventilator support for 47 days. After referral, she
was successfully weaned from the ventilator on postoperative day 5.
Figure 2: Three patients with type-4 hiatal hernia, Left- herniation
of colon (arrow) and stomach, Middle- herniation of colon and
stomach with a placed NG tube (arrow), Right- herniation of
omentum (arrow) and stomach
Figure 3: In the patient who had one episode of cardiac arrest,
the images of axial view (left) and sagittal view (right) showed
cardiopulmonary compression by a huge hiatal hernia (arrow)
Table 2: Comparison between the two groups of patients with hiatal hernia
Table 3: Correlation of the type of Hill’s classification with huge hiatal hernias
In an analysis of nationwide data base of 23,514 patients with hiatal
hernia, the mean age was 56 years, and majority of the patients were
woman (64%) [1]. In our series, the hiatal hernias more commonly
occurred in elderly woman because 75% (18/24) were woman and
the mean age (76.5 years) was older than the aforementioned study.
In the nationwide data, 55% of patients with hiatal hernia underwent
open abdominal, 35% laparoscopic, and 10% open thoracic repairs [1]. Many researchers favored laparoscopic repair of the hiatal hernia
that could shorten the hospital stay and minimal postoperative
morbidities [2]. Banki reported a unique series; the most common
type was type IV presenting in 54 of 131 patients (41%), which
were treated by laparoscopic repair. Reoperation for symptomatic
recurrent hiatal hernia occurred in 8 of the 99 patients (8%) [3].
Serious complications of cardiac complications have been reported
in laparoscopic repair of hiatal hernia [4,5]. The complication could
be related with staple fixation of the mesh. In the present series,
all patients underwent limited laparotomy because of surgeon’s
preference. Romano defined a giant hiatal hernia that the presence of
more than 1/3 of the stomach in the chest, through the diaphragmatic
hiatus, representing the 5–10% of all hiatal hernias [6]. We define a
huge hiatal hernia when its maximum transverse diameter is longer
than one-half of the pleural cavity. This is easily measured in the
computed tomography. Some researchers have reported risks of the
mass effect of a huge hiatal hernia. Largehiatal hernia compressing the
heart, impingement of the left atrium, pulmonary veins, and coronary
sinus can result in reduced cardiac output [7]. The global heart
function was significantly impaired by a standardized meal in the
presence of a large hiatal hernia [8]. Saito reported an elderly woman
having postprandial cardiogenic syncope caused by gastric polypinduced pyloric obstruction [9]. Shoji reported a tension gastrothorax
successfully treated by thoracotomy. In our series, a life-threatening
hiatal hernia was also presented [10]. In the treatment of hiatal
hernia, the mass effect and coincident surgical diseases in these aged
adults should be considered.
The present study was limited by its retrospective nature and
small number of patients.
Patients with hiatal hernia usually had significant clinical
manifestations, and potentially had coincident surgical diseases
because of age factor. One-third of these patients presented with
cardiopulmonary compression including one event of cardiac arrest. Aggressive surgical repair of the hiatal hernia is mandatory when the
diagnosis is established.
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