Transcript Paraesophageal Hernia - VCU Department of Surgery

VCU
DEATH AND COMPLICATIONS
CONFERENCE
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Complication
 Wrap
necrosis, mediastinal abscess, acute
renal failure, pulmonary embolism
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Procedure
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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
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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
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EGD:
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Esophageal manometry:
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Peristalsis of esophagus, hypotensive LES
Stress test
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Normal esophagus, hiatal hernia, distended/tortuous stomach,
normal duodenum
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
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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
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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
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Small subsegmental PE bilaterally
Fluid collection in mediastinum with few air locules,
no herniation stomach
Bilateral pleural effusions R>L
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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
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Herniation of wrap with emphysematous gastritis
Possible leak versus abscess
Large right pleural effusion with air locules, complete RLL
collapase
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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
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Was the complication potentially avoidable?
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Would avoiding the complication change the outcome
for the patient?
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Yes: avoidance of surgery, preoperative pulmonary function
tests, hiatal hernia repair and gastrostomy with no nissen wrap,
Collis-Nissen, hiatal hernia mesh
Yes: reoperation, multiple complications, prolonged
hospitalization
What factors contributed the complication?
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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.
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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.
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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.
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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
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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.
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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
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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