Complicated paraesophageal hernia due to distal gastrointestinal obstruction

Aim: To describe difficulties, surprises and risks in urgent surgery in patients with complicated large paraesophageal hernia (PEH) and distal gastrointestinal obstacle. Methods: Three cases with known PEH, I woman 78 yrs, II man 88 and III man 78, were urgently operated for strangulated/volvulised PEHs (I, II), and complete bowel obstruction due to strangulated dolichosigmoid volvulus (III). Cardiorespiratory embarrassment in all and sepsis in case I were encountered. Case I had coexistent incarcerated abdominal wall hernia, II had a previous-day gastroscopy that revealed a prepyloric lesion, and III a history of gastroesophageal reflux and constipation. Radiographies and chest-abdomen CT helped diagnosis. The findings are of in case I, after freeing the entrapped into the abdominal hernia bowel, the gastric fundus and body were found strangulated in mediastinum, fundus was ruptured, and antrum was ischaemic; total gastrectomy/splenectomy with stapled closure of esophagus and duodenum were performed. In case II, the whole stomach with prepyloric obstructive lesion was volvulised in mediastinum; distal gastrectomy/ splenectomy, gastrojejunostomy, cruroraphy and fundopexy were performed. In case III, the strangulated dolichosigmoid volvulus was the prominent pathology, moreover, incarceration of gastric fundus and transverse colon in PEH sac were found; extended Hartmann's colectomy, caecopexy, reduction of PEH contents, cruroraphy and fundopexy were performed. Results: Cases I and II were transferred intubated to ICU. Case I was never stabilized died after 50 hours; histology confirmed gastric necrosis. Case II was extubated at day 4, supported for pulmonary insufficiency, discharged at day 28; histology revealed antral ischaemia and obstructive prepyloric pT2 adenocarcinoma. Case III had uneventful outcome; histology revealed dolichosigmoid necrosis. Followup of cases II and III (16 and 4 months respectively) is uneventful as far as the hernia complications are concerned. Conclusions: Obstructive conditions distal to large PEHs may trigger acute complications in hernia sac contents, independently of the prominent indication to urgent surgery.

Biography :

Avgoustou C has specialized in General Surgery, working in the Greek National Health System since 1988, and his main areas of interest are Colon and Pelvic Surgery, Hepatobiliary Surgery, Gastric Surgery and Thyroid Surgery. He has been Director of Surgery in the Surgical Department of General Hospital of Nea Ionia ''Constantopoulion - Aghia Olga - Patission'' since 2008. He is Member of numerous Medical Societies. He has participated in hundreds of Congresses, with presentation of his work in 160, international in their majority. He has 111 publications, with 42 of them in international English-language Medical Journals. He has been trained in specific surgical topics, such as laparoscopic surgery, thoracic surgery, pelvic surgery etc.

E-mail: avgoustouk@yaho.gr

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