Alicuben Evan T, Luketich James D, Levy Ryan M, Kelsom Corey, Lloyd Gabriella, Witek Tadeusz, Sarkaria Inderpal S, Baker Nicholas, Christie Neil, Awais Omar
Department of Cardiothoracic Surgery, University of Pittsburgh, 5200 Centre Avenue, Suite 715, Pittsburgh, PA, 15232, USA.
Department of Cardiovascular and Thoracic Surgery, UT Southwestern Medical Center, Dallas, TX, USA.
Surg Endosc. 2025 Sep;39(9):6102-6107. doi: 10.1007/s00464-025-11924-w. Epub 2025 Jul 14.
The purpose of our study was to examine outcomes following a novel approach to management of incarcerated giant paraesophageal hernia in a non-elective setting. Surgical dogma has dictated performing a fundoplication, but we have hypothesized that this is unnecessary in patients without significant reflux presenting with predominantly obstructive symptoms.
Patients who presented to the emergency room between January 2010 and June 2024 with symptomatic giant incarcerated paraesophageal hernia with operative repair performed during the same hospitalization were included. An absence of pre-operative reflux symptoms was required. Operative steps included hernia sac reduction, mediastinal mobilization with vagal and crural lining preservation and primary crural closure. An Angle of His reconstruction was performed, and the fundus was sutured to the left hemidiaphragm immediately anterior to the spleen. Objective follow-up was obtained via esophagram, endoscopy, and CT scan.
There were 255 patients with a median age of 81 years. All operations were performed with minimally invasive techniques. The median post-operative length of stay was 6 days. The 30-day mortality was 3.5%, mostly related to complications of pneumonia. Objective follow-up was available in 230 patients at a median of 13 months. There were 13 hiatal hernia recurrences (5.7%): 7 medium (3-4 cm), and 6 large. There were 7 patients that had any heartburn at last follow-up and all were well controlled with medication. Reoperation was performed in 2 patients due to recurrent obstructive symptoms following vomiting episodes. No patient required reoperation for severe reflux.
Meticulous hiatal hernia repair with crural closure and restoration of normal anatomy is a safe and effective option in patients presenting in non-elective settings without a significant reflux history. Given increased morbidity with urgent operations, elective repair of giant paraesophageal hernia should be considered in all patients.
我们研究的目的是在非择期情况下，研究一种治疗嵌顿性巨大食管旁疝的新方法的疗效。手术原则一直要求进行胃底折叠术，但我们推测，对于主要表现为梗阻症状且无明显反流的患者，这是不必要的。
纳入2010年1月至2024年6月期间因有症状的巨大嵌顿性食管旁疝到急诊室就诊，并在同一住院期间进行手术修复的患者。要求术前无反流症状。手术步骤包括疝囊复位、保留迷走神经和膈脚内衬进行纵隔松解以及膈脚一期缝合。进行His角重建，并将胃底缝合至脾脏前方紧邻的左半膈。通过食管造影、内镜检查和CT扫描进行客观随访。
共有255例患者，中位年龄为81岁。所有手术均采用微创技术。术后中位住院时间为6天。30天死亡率为3.5%，主要与肺炎并发症有关。230例患者获得客观随访，中位随访时间为13个月。有13例食管裂孔疝复发（5.7%）：7例中等大小（3 - 4厘米），6例大的。在最后一次随访时有7例患者有烧心症状，所有患者通过药物治疗均得到良好控制。2例患者因呕吐发作后出现复发性梗阻症状而再次手术。没有患者因严重反流需要再次手术。
对于无明显反流病史的非择期就诊患者，精心进行食管裂孔疝修补并缝合膈脚以及恢复正常解剖结构是一种安全有效的选择。鉴于急诊手术的发病率增加，所有患者都应考虑择期修复巨大食管旁疝。
