VCUDEATH AND COMPLICATIONS CONFERENCE

Complication Wrap necrosis, mediastinal

abscess, acute renal failure, pulmonary embolism

Procedure 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

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

EGD: Normal esophagus, hiatal hernia,

distended/tortuous stomach, normal duodenum Esophageal manometry:

Peristalsis of esophagus, hypotensive LES Stress test

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

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

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

Small subsegmental PE bilaterally Fluid collection in mediastinum with few

air locules, no herniation stomach Bilateral pleural effusions R>L

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

Herniation of wrap with emphysematous gastritis

Possible leak versus abscess Large right pleural effusion with air locules,

complete RLL collapase

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

• Was the complication potentially avoidable?– Yes: avoidance of surgery, preoperative pulmonary

function tests, hiatal hernia repair and gastrostomy with no nissen wrap, Collis-Nissen, hiatal hernia mesh

• Would avoiding the complication change the outcome for the patient?– Yes: reoperation, multiple complications, prolonged

hospitalization

• What factors contributed the complication?– 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.

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. 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. 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

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. 4 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

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