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Hiatal hernia surgery forum. Catastrophic Complications of Hiatal Hernia: Symptoms, Treatments, and Surgical Interventions

by alexxlab

What are the potential catastrophic complications of hiatal hernia. How can hiatal hernia be diagnosed and treated effectively. What surgical interventions are available for severe cases of hiatal hernia. When should patients consider surgery for hiatal hernia.

Understanding Hiatal Hernia: Definition, Types, and Prevalence

A hiatal hernia occurs when a portion of the stomach protrudes through the diaphragm into the chest cavity. This condition can vary in severity and presentation, ranging from asymptomatic cases to those causing significant discomfort and complications.

There are two main types of hiatal hernias:

  • Sliding hiatal hernia: The most common type, where the stomach and esophagus slide up and down through the hiatus.
  • Paraesophageal hiatal hernia: A less common but potentially more serious type, where a portion of the stomach pushes through the hiatus alongside the esophagus.

Hiatal hernias are relatively common, especially in adults over 50 years old. Studies estimate that up to 60% of people over 60 may have a hiatal hernia, though many cases remain undiagnosed due to lack of symptoms.

Recognizing Hiatal Hernia Symptoms: From Mild Discomfort to Severe Complications

While many hiatal hernias are asymptomatic, others can produce a range of symptoms that significantly impact quality of life. The severity of symptoms often correlates with the size and type of hernia.

Common symptoms of hiatal hernia include:

  • Heartburn and acid reflux
  • Difficulty swallowing (dysphagia)
  • Chest pain or pressure
  • Regurgitation of food or sour liquid
  • Shortness of breath
  • Chronic cough or throat irritation

In more severe cases, hiatal hernias can lead to catastrophic complications that require immediate medical attention. These may include:

  • Strangulation: When the blood supply to the herniated portion of the stomach is cut off
  • Perforation: A tear in the stomach or esophagus wall
  • Volvulus: Twisting of the stomach, which can lead to obstruction
  • Bleeding: From ulcers that may form in the herniated stomach tissue

Diagnostic Approaches for Hiatal Hernia: From Physical Exams to Advanced Imaging

Accurately diagnosing a hiatal hernia is crucial for determining the appropriate treatment plan. Healthcare providers employ various diagnostic tools and techniques to confirm the presence and assess the severity of a hiatal hernia.

Physical Examination and Medical History

The diagnostic process typically begins with a thorough physical examination and review of the patient’s medical history. While these steps alone cannot definitively diagnose a hiatal hernia, they can provide valuable insights and guide further testing.

Imaging Studies

Several imaging techniques are commonly used to diagnose hiatal hernias:

  • Barium swallow X-ray: Patients swallow a contrast liquid that highlights the upper digestive tract on X-rays
  • CT scan: Provides detailed cross-sectional images of the chest and abdomen
  • MRI: Offers high-resolution images without radiation exposure

Endoscopic Procedures

Upper endoscopy, also known as esophagogastroduodenoscopy (EGD), allows direct visualization of the esophagus, stomach, and upper small intestine. This procedure can identify hiatal hernias and assess for any associated complications or conditions.

Conservative Management: Non-Surgical Approaches to Hiatal Hernia Treatment

For many patients with mild to moderate hiatal hernias, conservative management can effectively alleviate symptoms and prevent complications. These non-surgical approaches focus on lifestyle modifications and medication.

Lifestyle Changes

Simple adjustments to daily habits can significantly reduce hiatal hernia symptoms:

  • Eating smaller, more frequent meals
  • Avoiding trigger foods (e.g., spicy, fatty, or acidic foods)
  • Maintaining a healthy weight
  • Elevating the head of the bed while sleeping
  • Quitting smoking
  • Limiting alcohol consumption

Medications

Various medications can help manage symptoms associated with hiatal hernias:

  • Antacids: Provide quick relief from heartburn and acid reflux
  • H2 receptor blockers: Reduce stomach acid production
  • Proton pump inhibitors (PPIs): Offer long-term reduction in stomach acid
  • Prokinetics: Improve stomach emptying and strengthen the lower esophageal sphincter

Surgical Interventions for Hiatal Hernia: When Conservative Management Falls Short

While conservative management is often effective, some patients may require surgical intervention. Surgery is typically recommended for large hernias, severe symptoms unresponsive to medication, or in cases of complications.

Indications for Surgery

Common reasons for considering hiatal hernia surgery include:

  • Persistent symptoms despite medical management
  • Large paraesophageal hernias
  • Recurrent hernia-related complications
  • Impaired quality of life due to hernia symptoms

Surgical Techniques

Several surgical approaches are available for treating hiatal hernias:

  1. Laparoscopic Nissen fundoplication: The most common procedure, involving wrapping the upper part of the stomach around the lower esophagus
  2. Toupet fundoplication: A partial wrap of the stomach around the esophagus
  3. Dor fundoplication: Another partial wrapping technique
  4. Mesh repair: Used in some cases to reinforce the hiatal closure

These procedures can be performed laparoscopically in most cases, offering shorter recovery times and reduced complications compared to open surgery.

Potential Complications of Hiatal Hernia Surgery: Weighing the Risks and Benefits

While hiatal hernia surgery is generally safe and effective, it’s important for patients to understand the potential risks and complications associated with these procedures.

Common Complications

Some of the more frequent complications following hiatal hernia surgery include:

  • Dysphagia (difficulty swallowing)
  • Gas bloat syndrome
  • Recurrence of the hernia
  • Infection at the surgical site
  • Damage to nearby organs

Rare but Serious Complications

In rare cases, more severe complications may occur:

  • Esophageal perforation
  • Bleeding requiring transfusion
  • Myocardial infarction
  • Pulmonary embolism

It’s crucial for patients to discuss these potential risks with their surgeon and weigh them against the benefits of the procedure.

Post-Operative Care and Recovery: Ensuring Optimal Outcomes After Hiatal Hernia Surgery

Proper post-operative care is essential for a smooth recovery and optimal outcomes following hiatal hernia surgery. Patients should be prepared for a period of adjustment and follow their healthcare provider’s instructions closely.

Immediate Post-Operative Period

In the days following surgery, patients can expect:

  • Hospital stay of 1-3 days for most laparoscopic procedures
  • Pain management with medications
  • Gradual reintroduction of fluids and soft foods
  • Encouragement to walk and perform breathing exercises

Long-Term Recovery

Full recovery from hiatal hernia surgery typically takes 4-6 weeks. During this time, patients should:

  • Follow a specific diet plan, gradually reintroducing solid foods
  • Avoid heavy lifting and strenuous activities
  • Attend follow-up appointments with their surgeon
  • Report any unusual symptoms or complications promptly

Living with Hiatal Hernia: Long-Term Management and Lifestyle Adjustments

Whether managed conservatively or surgically, living with a hiatal hernia often requires ongoing attention to lifestyle factors and potential symptom recurrence.

Dietary Considerations

Maintaining a diet that minimizes reflux and hernia symptoms is crucial. This may include:

  • Avoiding large meals, especially before bedtime
  • Limiting intake of acidic, spicy, and fatty foods
  • Staying hydrated, but avoiding large quantities of fluids with meals
  • Incorporating foods that may help reduce reflux, such as ginger and oatmeal

Ongoing Monitoring

Regular check-ups with a healthcare provider are important for:

  • Assessing the effectiveness of current management strategies
  • Monitoring for potential complications or recurrence
  • Adjusting treatment plans as needed

By staying vigilant and maintaining open communication with their healthcare team, patients with hiatal hernias can effectively manage their condition and maintain a good quality of life.

CATASTROPHIC COMPLICATIONS OF HIATUS HERNIA | JAMA Surgery

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Article

November 1952


WILLIAM P. KLEITSCH, M.D.

Author Affiliations

OMAHA

From the Departments of Surgery of the Creighton University School of Medicine and the United States Veterans Hospital.


AMA Arch Surg. 1952;65(5):665-672. doi:10.1001/archsurg.1952.01260020657003

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Abstract

AN ESOPHAGEAL hiatus hernia is frequently asymptomatic or unsuspected until it is discovered accidentally when roentgenograms of the gastrointestinal tract are made because of other pathology.1 Not uncommonly, however, such hernias do produce symptoms. It is important to note that these symptoms, although mild and intermittent, form a definite symptom complex if truly caused by hiatus hernia. This symptom complex consists of substernal or epigastric pain, acid eructations, and, most characteristically, aggravation of the pain precipitated by maneuvers which increase intra-abdominal pressure. 2

Because of the fact that many esophageal hiatus hernias are asymptomatic and many of those that are symptomatic are only mildly so, there has been a controversy as to what should be done about them. Errors in diagnosis are frequent, and the significance of hiatus hernia is often overlooked. Frequently the dilemma is solved (?) by the physician by prescribing medical treatment consisting of a bland

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Modified Anterior Crural Repair for Hiatal Hernia | JAMA Surgery

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April 1982


Robert H. Wilbee, MD

Author Affiliations

From the Medical Center of Las Cruces, New Mexico.


Arch Surg. 1982;117(4):510-511. doi:10.1001/archsurg.1982.01380280088019

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Abstract

† Excellent relief from symptomatic hiatal hernia was obtained with a simple surgical procedure in which the two halves of the right crus were closed anterior to the esophagus, after which the lesser curvature of the gastric fundus was attached to this bed by the tails of same sutures.

(Arch Surg 1982;117:510-511)

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  • Academic Medicine

  • Acid Base, Electrolytes, Fluids

  • Allergy and Clinical Immunology

  • Anesthesiology

  • Anticoagulation

  • Art and Images in Psychiatry

  • Assisted Reproduction

  • Bleeding and Transfusion

  • Cardiology

  • Caring for the Critically Ill Patient

  • Challenges in Clinical Electrocardiography

  • Climate and Health

  • Clinical Challenge

  • Clinical Decision Support

  • Clinical Implications of Basic Neuroscience

  • Clinical Pharmacy and Pharmacology

  • Complementary and Alternative Medicine

  • Consensus Statements

  • Coronavirus (COVID-19)

  • Critical Care Medicine

  • Cultural Competency

  • Dental Medicine

  • Dermatology

  • Diabetes and Endocrinology

  • Diagnostic Test Interpretation

  • Drug Development

  • Electronic Health Records

  • Emergency Medicine

  • End of Life

  • Environmental Health

  • Equity, Diversity, and Inclusion

  • Ethics

  • Facial Plastic Surgery

  • Gastroenterology and Hepatology

  • Genetics and Genomics

  • Genomics and Precision Health

  • Geriatrics

  • Global Health

  • Guide to Statistics and Methods

  • Guidelines

  • Hair Disorders

  • Health Care Delivery Models

  • Health Care Economics, Insurance, Payment

  • Health Care Quality

  • Health Care Reform

  • Health Care Safety

  • Health Care Workforce

  • Health Disparities

  • Health Inequities

  • Health Informatics

  • Health Policy

  • Hematology

  • History of Medicine

  • Humanities

  • Hypertension

  • Images in Neurology

  • Implementation Science

  • Infectious Diseases

  • Innovations in Health Care Delivery

  • JAMA Infographic

  • Law and Medicine

  • Leading Change

  • Less is More

  • LGBTQIA Medicine

  • Lifestyle Behaviors

  • Medical Coding

  • Medical Devices and Equipment

  • Medical Education

  • Medical Education and Training

  • Medical Journals and Publishing

  • Melanoma

  • Mobile Health and Telemedicine

  • Narrative Medicine

  • Nephrology

  • Neurology

  • Neuroscience and Psychiatry

  • Notable Notes

  • Nursing

  • Nutrition

  • Nutrition, Obesity, Exercise

  • Obesity

  • Obstetrics and Gynecology

  • Occupational Health

  • Oncology

  • Ophthalmology

  • Orthopedics

  • Otolaryngology

  • Pain Medicine

  • Pathology and Laboratory Medicine

  • Patient Care

  • Patient Information

  • Pediatrics

  • Performance Improvement

  • Performance Measures

  • Perioperative Care and Consultation

  • Pharmacoeconomics

  • Pharmacoepidemiology

  • Pharmacogenetics

  • Pharmacy and Clinical Pharmacology

  • Physical Medicine and Rehabilitation

  • Physical Therapy

  • Physician Leadership

  • Poetry

  • Population Health

  • Professional Well-being

  • Professionalism

  • Psychiatry and Behavioral Health

  • Public Health

  • Pulmonary Medicine

  • Radiology

  • Regulatory Agencies

  • Research, Methods, Statistics

  • Resuscitation

  • Rheumatology

  • Risk Management

  • Scientific Discovery and the Future of Medicine

  • Shared Decision Making and Communication

  • Sleep Medicine

  • Sports Medicine

  • Stem Cell Transplantation

  • Substance Use and Addiction Medicine

  • Surgery

  • Surgical Innovation

  • Surgical Pearls

  • Teachable Moment

  • Technology and Finance

  • The Art of JAMA

  • The Arts and Medicine

  • The Rational Clinical Examination

  • Tobacco and e-Cigarettes

  • Toxicology

  • Translational Medicine

  • Trauma and Injury

  • Treatment Adherence

  • Ultrasonography

  • Urology

  • Users’ Guide to the Medical Literature

  • Vaccination

  • Venous Thromboembolism

  • Veterans Health

  • Violence

  • Women’s Health

  • Workflow and Process

  • Wound Care, Infection, Healing


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90,000 Testimonials from K. Puchkov’s patients operated on for hiatal hernia.

06/22/2020 13:44:00
Tsukanova Natalia

Congratulations to Professor Konstantin Viktorovich Puchkov and the entire staff of the Swiss University Clinic on their professional holiday – Medical Worker’s Day. Thank you, dear colleagues (I am a doctor myself), for your hard and invaluable work: you help people restore their health, and sometimes save their lives. Low bow to you!!!
I am infinitely grateful to Konstantin Viktorovich for the successful operation on 03/16/20 for my HH. I got rid of a long-term problem and found a full life. Many specialized clinics refused me an operation, citing my advanced age, I am 74 years old, the presence of chronic concomitant diseases, large hernias and the age of the process. At best, they did not guarantee a positive result. Prof. Puchkov, having familiarized himself with the anamnesis, with my analyzes, examinations, without hesitation, agreed.
I have read a book by prof. Puchkova “How to become a successful surgeon and remain so all my life” in one breath, with great interest, and she made an indelible impression on me. Many have not read this book, and I want to tell people who have health problems about an outstanding surgeon, a wonderful person, Professor Konstantin Viktorovich Puchkov. I admire his high professionalism. He has deep knowledge, vast experience and creative skills. He is a talented, first-class surgeon. The operation that K.V. Puchkov performed on me, right?
has been worked for a long time by a French surgeon, but only for open abdominal operations. Prof. K.V. Puchkov was the first to perform this operation in a laparoscopic approach. He developed the surgical technique himself, proved its excellent efficiency and received a patent for this invention. Puchkov individually, sometimes not standard, approaches the treatment of each patient and chooses the method and volume of the operation that will be optimal for him. K.V. Puchkov owns many related specialties and successfully operates in general surgery, urology, and gynecology,
in both coloproctology and plastic surgery. This allows him to perform simultaneously (simultaneously) up to 5 operations on various organs with combined diseases of the abdominal cavity, small pelvis and retroperitoneal space. KV Puchkov loves his profession, is devoted to it. This is his calling. The purpose of his life, as I understood from the book I read, is to achieve excellence, to be the best in my profession, not to stop there, to go forward, constantly improving. He uses the latest, advanced methods of treatment, including those developed by himself.
K.V. Puchkov loves not only his job, but also loves people whom he has faithfully served for decades. Despite the very busy schedule of work (from morning until late at night, operations, bypasses and consultations between them), he finds time to talk with the patient, calm him down before the operation, inspire confidence in the success of the operation, evoking a feeling of trust and peace in the patient’s soul.
KV Puchkov has charisma. He radiates calmness, confidence in himself and in his work, high responsibility to patients, self-control, purposefulness, goodwill towards people, great diligence. He helps many people to restore health and a full life. This is the meaning and purpose of his whole life. Patients come to him from all over the country, as well as from other countries. He has great authority and recognition in our country and abroad. He speaks at Russian and foreign congresses, conducts a master class
sy with demonstration operations both in Russia and in the West, publishes many scientific papers. monographs, has a scientific title: doctor of medical sciences. He has performed tens of thousands of laparoscopic operations, including those developed by himself, protected by patents. He is rightfully considered one of the best surgeons in the world in the field of laparoscopic surgery, urology, coloproctology, gynecology, oncology. .He was awarded the honorary badge “Golden Laparoscope.”
I am proud that we have such a surgeon as Konstantin Viktorovich Puchkov. I will recommend him, in case of health problems, to my relatives, friends, acquaintances. He will not leave you in trouble and will always come to the rescue.
Konstantin Viktorovich, I am infinitely grateful to you for your responsible and conscientious work, for your talent as a surgeon. I wish you health, happiness and success in achieving new discoveries and achievements.
With deep respect and gratitude.

Diaphragmatic hernias

Diaphragmatic hernias

general information

For patients, all cases of diaphragmatic hernias can be divided into safe and potentially dangerous variants. The safe option is most often represented by sliding hiatal hernias. Dangerous hernias include defects in the diaphragm through which it is dangerous by infringement or when large volumes of the contents of the abdominal cavity move into the chest. Safe hernias require observation and only in some cases surgical treatment. Dangerous diaphragmatic hernias need to be operated on immediately.

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What is the danger of a sliding hernia of the esophageal opening of the diaphragm.

Diaphragmatic hernia itself is harmless in most cases. However, diaphragmatic hernia can contribute to the development of the reflux of stomach contents into the lumen of the esophagus – gastroesophageal (gastroesophageal reflux). Gastroesophageal reflux disease (GERD, GERD) develops.

Prolonged exposure to acid (from the stomach) or alkaline (from the duodenum) reflux on the esophagus leads first to inflammatory changes (esophagitis), then to changes in epithelial cells (metaplasia – Barrett’s esophagus), and then to cancer of the esophagus.

How often do we see diaphragmatic hernia GERD

Hiatus hernia (HH) and gastroesophageal reflux disease (GERD) are common diseases in gastroenterology and often require surgical treatment. According to the survey, the presence of symptoms of gastroesophageal reflux is detected in 30-40% of the population, and up to 25% of patients in this group need constant medication, and up to 15% – exclusively in surgical treatment.

Endovideosurgical interventions for gastroesophageal reflux disease and hiatal hernia.

The area of ​​the esophageal-gastric junction is considered to be anatomically “uncomfortable”, therefore, in traditional antireflux surgery, adequate access is a key issue.

Over the past century, surgical techniques have improved. Domestic surgeons Yu.E. Berezov, B.V. Petrovsky, N.N. Kanshin, A.F. Chernousov, A.I. this branch of surgery.

The main disadvantages of open operations are a significant traumatic effect on tissues, severe pain in the postoperative period, as well as infectious complications from surgical wounds and the formation of postoperative hernias. Regardless of the constitution of the patient, an extended median laparotomy, often with the removal of the xiphoid process, is necessary to ensure free access to the diaphragmatic pedicles, esophagus, and gastric fundus.

A new stage and rise in the treatment of HH and GERD is associated with the development and implementation of EVH technologies in clinical practice.

In 1991, Nathanaon, Cuschieri, and Shimi reported the first laparoscopic anti-reflux surgery, round ligament gastropexy. In the same year, B.Dallemagne (Belgium) and T.Geagea (Canada) performed the first Nissen laparoscopic operation.

Since 2000, in a number of countries, among laparoscopic interventions on the abdominal organs, antireflux operations have become second only to cholecystectomy in frequency.

Today, endovideosurgical antireflux operations are widely used in the world and are the method of choice.

The main advantages of laparoscopic access are: good visualization of the intervention area; ease of manipulation in the area of ​​the esophageal-gastric junction; low invasiveness, which determines the absence of a pronounced pain syndrome in the early postoperative period; low percentage of postoperative hernia formation; good cosmetic effect; economic benefit associated with a reduction in the duration of hospitalization and the consumption of medicines and dressings

Indications for endovideosurgical interventions for GERD and HH are:

To date, indications for surgical treatment of GER have been formulated. Some of them require clarification and further justification.

1. Lack of effect from conservative treatment.

2. Progression of the disease, despite the maximum dose of drugs. According to statistics, in 40% of patients in this group, continued drug treatment leads to the development of complications in the form of ulceration, stricture and secondary shortening of the esophagus over the next 5 years, and the risk of subsequent surgical treatment increases dramatically. Therefore, patients in this group should be operated on as soon as possible.

3. The need for long-term and intensive drug treatment. Young patients suffering from gastroesophageal reflux, the presence of which is confirmed during the examination, are ideal candidates for surgical treatment. Coley et al. proved to significantly reduce the cost and improve the results of treatment with a surgical approach in a group of patients younger than 49 years.

4. The patient’s unwillingness to carry out long-term drug treatment due to the high cost of the latter, the inconvenience or danger of side effects.

5. Non-compliance by the patient with the regimen of drug treatment.

6. Esophagitis of 3-4 degrees, which persists after repeated long courses of conservative treatment, in case of alternating acid and alkaline reflux. It has been proven that taking antisecretory drugs in this group of patients is ineffective.

7. Moderately pronounced esophagitis (1-2 degrees) in patients with signs of mechanical insufficiency of the cardia and frequent episodes of GER.

8. The presence of an axial hernia of the esophageal opening of the diaphragm with gastroesophageal reflux (usually refractory to drug treatment).

9. Paraesophageal HH, even without signs of GER.

10. Complicated course of GER, including the formation of ulcers, strictures of the esophagus, Barrett’s esophagus, severe pulmonary complications. This group clearly demonstrates the benefits of surgical treatment of GER, which allows patients to return to a normal quality of life without the need for further medication. In case of strictures of the esophagus, the need for dilatation of the cardia after antireflux surgery is reduced fivefold, and extraesophageal, including pulmonary manifestations of GER are stopped

11. Severe respiratory manifestations of GER, such as aspiration, frequent pneumonia, chronic laryngitis. Only 50% of patients in this group have chest pain, heartburn, or endoscopy findings. However, a comprehensive examination using modern methods can confirm the presence of gastroesophageal reflux.

12. Concomitant diseases of the abdominal cavity requiring surgical intervention.

Indications for surgical treatment of GERD can be somewhat expanded using endovideosurgery, as a less traumatic intervention with a relatively low risk.

The main contraindications to laparoscopic interventions should be considered: severe cardiovascular disorders; respiratory failure; disorders of the blood coagulation system; late pregnancy; previous operations on the upper floor of the abdominal cavity.

Methods of surgical treatment for sliding hernias of the esophageal opening of the diaphragm

Currently, there are several methods of laparoscopic antireflux operations, however, Nissen, Dor and Toupet methods are mentioned and analyzed in the literature as the most commonly used.

The choice of the method of surgical support depends on the nature of the underlying and concomitant diseases, the preference of the surgeon, and remains one of the most discussed problems in this section of surgery. As a rule, the fundoplication is supplemented with an anterior or posterior crurorrhaphy. In pediatric practice, synthetic prostheses are sometimes used to replace large hernial defects.

Results of treatment of diaphragmatic hernias (laparoscopic fundoplications).

Our clinic has the experience of 238 anti-reflux surgeries using endovideosurgical technologies.

To correct the function of the gastroesophageal junction, we performed the following types of EVC fundoplications: by the Nissen method 15 (6. 3%), by the Toupet method – 35 (14.7%), by the Dor method 188 (79%).

The average duration of EVH antireflux surgery is 70-90 minutes and depends on the method of fundoplication.

Intraoperative complications were noted in 5 (2.4%) patients (esophageal perforation – 1, spleen injury – 1, pleura injury – 1, bleeding from the crus of the diaphragm – 2). Only in 1 case of esophageal perforation, access conversion was required to eliminate the complication.

In the first two days of the postoperative period, the patient can drink. On the third day after the operation, liquid food is allowed, on the fourth – soft food. The patient switches to a normal diet with the use of dense food (bread, hard fruits, vegetables, etc.) from the 6th week after the operation.

Painkillers in the immediate postoperative period are used as needed.

In our experience, in the absence of complications, most patients can be discharged from the hospital 3-4 days after surgery.

In the postoperative period, we studied the results of treatment at 1 and 6 months after surgery.

Subjectively, in the immediate postoperative period, 8 (3.9%) patients had short-term dysphagia, which spontaneously stopped by the time the patients were discharged and was probably associated with postoperative edema in the intervention area.

After the Nissen operation, one patient developed signs of impaired swallowing of solid food, pain in the epigastrium. An endoscopic examination revealed a narrowing of the lumen of the esophagus in the region of the LES, which made it difficult to carry out the endoscope, due to the increased pressure of the fundoplication cuff. The patient underwent two courses of endoscopic bougienage with a positive effect.

In one elderly patient, a month after the Dor fundoplication, signs of severe gastroesophageal reflux appeared simultaneously with cholecystectomy.