IntroductionLarge esophageal hiatal hernias occur most commonly in elderly patients with comorbidities, in whom even an elective surgery cannot be performed without high risks. Although fundoplication is recommended for esophageal hiatal hernia repair, we prefer not to limit our options to fundoplication, as obstruction is a frequent main complaint. We favor an anterior gastropexy approach instead to perform anti-reflux surgery and prevent recurrent protrusion and torsion of the incarcerated organ with minimal risk. The aim was to evaluate the safety and effectiveness of anterior gastropexy for large hiatal hernia in elderly patients with comorbidities.Case presentationWe retrospectively evaluated 8 patients who underwent laparoscopic anterior gastropexy for large hiatal hernia (type III or IV) since 2006. All patients were women with a median age of 82 years (range, 74–87 years). The major complaint was obstruction in all patients, with relatively mild reflux symptoms. They underwent successful laparoscopic surgery with no conversion to laparotomy.Fundoplication was performed in 4 cases. No perioperative complications occurred, and the main complaint resumed rapidly in all patients, without recurrence during postoperative follow-up of median 48 months (range, 5–77 months).ConclusionLaparoscopic anterior gastropexy is safe and effective and can be considered as one of the practical surgical options for large hiatal hernias in elderly patients, whom surgical intervention should be minimized due to their comorbidities.
Gastric reflux into the remnant esophagus after subtotal or partial esophagectomy is associated with impairment in patient quality of life. We evaluated the feasibility, safety, and potential effectiveness of a novel procedure using a new endoscopic suturing device to create an anti-reflux valve (funnel) in pigs after esophagectomy with gastric tube reconstruction. The endoscopic procedure was performed in four pigs using a semi-full-thickness endoscopic suturing system (OverStitch; Apollo Endosurgery, Austin, Texas, USA). The operating time, funnel height, ratio of the height of the funnel to the diameter of the gastric tube, and adverse events associated with the procedure were evaluated. The "reflux angle" was measured morphologically and functionally during a reflux induction test, using contrast medium or artificial gastric fluid, by tilting the operating table gradually from a head up to a head down position. Reflux angles before and after funnel creation were compared. The procedure was successful in all four animals. The median operating time was 43 minutes, and the median funnel height was 17 mm (56.7 % of gastric tube diameter). There were no adverse events associated with the procedure. The reflux angle was lower after the procedure compared with before in both morphological and functional assessments in all four cases. Endoscopic anti-reflux funnel creation using OverStitch was feasible, safe, and potentially effective.
Most cases of adult intussusception are caused by neoplastic lesions, and idiopathic adult intussusception is very rare. We present a case in which laparoscopic surgery was performed for idiopathic adult intussusception initially reduced by colonoscopy. A 53-year-old woman presented to the emergency department of our hospital with intermittent lower abdominal pain. Contrast-enhanced computed tomography and ultrasonography of the abdomen showed a concentric structure in the ascending colon. We diagnosed intussusception. Colonoscopy achieved successful reduction before surgery. Twelve days after this reduction, laparoscopic surgery was performed. Histopathological examination did not reveal any causative pathology; therefore, idiopathic adult intussusception was diagnosed. The postoperative course was uneventful, and the patient was discharged on postoperative day 14. Preoperative colonoscopy should be utilized to diagnose the main lesion and may be useful for reducing adult intussusception. Laparoscopic surgery is both minimally invasive and safe and can be performed following endoscopic reduction.
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