1. VCU DEATH AND COMPLICATIONS CONFERENCE

2.  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

3. 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

4.  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

6.  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

7.  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

8.  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

9.  Small subsegmental PE bilaterally  Fluid collection in mediastinum with few air locules, no herniation stomach  Bilateral pleural effusions R>L

10.  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

11.  Herniation of wrap with emphysematous gastritis  Possible leak versus abscess  Large right pleural effusion with air locules, complete RLL collapase

12.  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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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