paraesophageal hernia - web-duke-shares-01.oit.duke.edu · –sac excision –collis lengthening...
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Department of Cardiothoracic Surgery
Paraesophageal Hernia
Inderpal (Netu) S. Sarkaria, M.D.
Vice Chairman, Clinical Affairs
Director, Robotic Thoracic Surgery
Co-Director, Esophageal and Lung Surgery Institute
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Department of Cardiothoracic Surgery
Speaker/Education: Intuitive Surgical
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Department of Cardiothoracic Surgery
Types of Hiatal Hernias
Type I
Type II
Type III
Organoaxial volvulus
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Department of Cardiothoracic Surgery
Typical Esophagram of Giant PEHIntra-
thoracic
Stomach
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Department of Cardiothoracic Surgery
Clinical Presentation
• Asymptomatic
– Air-fluid level on CXR
• Pain
• Postprandial fullness
• Nausea
• Regurgitation
• Anemia
• Emergent
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Department of Cardiothoracic Surgery
Evaluation
• Endoscopy
• Barium radiography
• Manometry?
• Computed Tomography?
• Acute Setting
– Laboratory (acid-base/electrolyte derangements, sepsis)
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Department of Cardiothoracic Surgery
Acutely symptomatic patients (toxic) require open surgery
• Laparotomy if there is no evidence of chest contamination
• Left thoracotomy if there is evidence of gastric necrosis with chest contamination
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Department of Cardiothoracic Surgery
Natural History of Giant Hernia
• PEH patients followed for a decade
– 21% presented with strangulation
– Mortality of emergency repair (17%)
– Mortality with elective repair (<5%)
• All patients with giant HH should be repaired
Skinner DB, Belsey RH; J Thorac Cardiovasc Surg. 1967 Jan;53(1):33.
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Department of Cardiothoracic Surgery
Surgical Principles• Re-establish normal anatomy!
• Atraumatic hernia reduction
• Obtain tension free intra-abdominal esophageal length– Complete excision of hernia sac
– High mediastinal dissection
– Clear anatomic confirmation of GEJ - Esophageal fat pad dissection
• Crural preservation– Atraumatic handling and dissection – preserve the peritoneal lining
• Vagal preservation
• Tension free crural repair– Mobilization of crura
– Suture reinforcement? Pledgets?
– Crural reinforcement/reconstruction? Mesh?
– Esophageal lengthening? Collis?
– Decrease diaphragmatic tension? Decrease intraperitoneal pressure? Induce pneumothorax?
• Gastrofundoplication
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Department of Cardiothoracic Surgery
Mediastinal Dissection
• Many structures in confined space
– Inferior pulmonary vein
– Azygous vein
– Right atrium
– Airway (right and left mainstem, carina)
– Pleural spaces
– Aorta
– IVC
• Difficult visualization augments the problem
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Department of Cardiothoracic Surgery
Thoracic Approach
• Able to mobilize more esophagus
• Avoid the need for Collis gastroplasty
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Department of Cardiothoracic Surgery
Maziak and Pearson. Open Repair of Giant PEH with Collis Gastroplasty and Belsey. Annals Surgery 1998
• 94 patients with intra-thoracic stomach (type III) operated upon over a 20 year period
• Operative approach
– Left thoracotomy
– Sac excision
– Collis lengthening procedure for shortened esophagus
– No deaths, 1% leak rate
• 91% with good results, 9% with fair results
• At a mean follow-up of 10 years only 2 re-operations required
• Sets the gold-standard for outcomes
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Department of Cardiothoracic Surgery
• 10-year retrospective, Belsey vs Laparoscopic
• 118 Belsey matched 1:1 (year, gender, age)
• Recurrence similar: 8.4% vs 16.1%
– Wedge gastroplasty protective of recurrence
• Esophageal leak higher with Nissen: 0% v 6.8%
• Higher reoperation with Nissen: 2.5% v 9.3%
• GERD HRQL similar
• Single surgeon vs multiple surgeons
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Department of Cardiothoracic Surgery
UPMC GPEH Experience
• 662 patients
• 1997-2008
• Median age 70 (range 19-92)
• 30 day mortality 1.7% (11 patients)
• Quality of Life
– 90% good to excellent results
• Reoperation 3.2% (21)
• Compatible with “gold-standard” open series
Luketich et al. Outcomes after a decade of laparoscopic giant paraesophageal hernia repair. JTCVS 2010
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Department of Cardiothoracic Surgery
Laparoscopic “Hand over Hand” Reduction
of Intrathoracic Stomach
Atraumatic Reduction of Stomach
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Department of Cardiothoracic Surgery
Laparoscopic Sac Dissection and Excision
Hiatal opening
Hernia sac
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Department of Cardiothoracic Surgery
Assessment of Esophageal LengthCardia location
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Department of Cardiothoracic Surgery
Esophageal Lengthening
May not be required with
good mobilization and
high mediastinal
dissection
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Department of Cardiothoracic Surgery
Fundoplication and Crural Repair
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Department of Cardiothoracic Surgery
Karush & Sarkaria. Op Tech in CV and Thoracic Surgery 2014
GPEH: Initial View
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Department of Cardiothoracic Surgery
GPEH: Initial Sac Retraction
Karush & Sarkaria. Op Tech in CV and Thoracic Surgery 2014
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Department of Cardiothoracic Surgery
GPEH: Initial Sac Dissection
Karush & Sarkaria. Op Tech in CV and Thoracic Surgery 2014
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Department of Cardiothoracic Surgery
GPEH: Mediastinal Dissection
Karush & Sarkaria. Op Tech in CV and Thoracic Surgery 2014
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Department of Cardiothoracic Surgery
GPEH: Pleural Rent Closure
Karush & Sarkaria. Op Tech in CV and Thoracic Surgery 2014
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Department of Cardiothoracic Surgery
GPEH: Mediastinal Dissection
Karush & Sarkaria. Op Tech in CV and Thoracic Surgery 2014
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Department of Cardiothoracic Surgery
Collis Nissen
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Department of Cardiothoracic Surgery
Collis-Nissen – Robotic Stapler3:00; 6:00; 7:20
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Department of Cardiothoracic Surgery
Thank You
Inderpal S. Sarkaria, MD
Vice Chairman, Clinical Affairs
Director, Robotic Thoracic Surgery
Co-Director, Esophageal & Lung Surgery Institute
Department of Cardiothoracic Surgery
University of Pittsburgh Medical Center