Modern Treatment of Paraesophageal Hernia: Preoperative Evaluation and Technique for Laparoscopic Repair
ABSTRACT This article reviews the preoperative evaluation of patients with paraesophageal hernia (PEH) and details the principles and components of a laparoscopic PEH repair. Complete hernia sac dissection and excision, adequate esophageal mobilization, reapproximation of the crura, and creation of an antireflux barrier make up the key steps in any repair and are described. Although the preferred operative approach to PEH has undergone significant modification, especially since the introduction of minimally invasive laparoscopic techniques, many controversies still exist. The decision of whether to use mesh to reinforce the crural closure remains an unresolved issue in the surgical literature, and further evolution in this and other areas of PEH surgery is sure to occur in the near future.
- Journal of cardiothoracic and vascular anesthesia 08/2013; 28(1). DOI:10.1053/j.jvca.2013.02.004 · 1.48 Impact Factor
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ABSTRACT: This paper reports on the neurophysiology of the esophagus, including on the uneven distribution of innervation in the esophagus, reflected by the increased sensitivity and perception of gastroesophageal reflux disease (GERD) events in the proximal rather than distal esophagus; the role of the enteric nervous system (ENS) in swallowing; the role of the physiological stress-responsive systems, including the autonomic nervous system (ANS) and the hypothalamic-pituitary-adrenal (HPA) axis in mediating esophageal pain; the advances in understanding pain mechanisms and brain structure provided by technological imaging advances; investigations into the efficacy of the descending-pain control system, including diffuse noxious inhibitory control (DNIC); the role of abnormal nervous signaling in afferent pathways in the pathogenesis of Barrett's esophagus (BE); and the contribution of the esophageal mucosa to reflux symptoms.Annals of the New York Academy of Sciences 10/2013; 1300(1):53-70. DOI:10.1111/nyas.12238 · 4.31 Impact Factor
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ABSTRACT: Background The surgical treatment of paraesophageal hernias remains a challenge due to the lack of consensus regarding principles of operative treatment. The objectives of this study were to achieve consensus on key topics through expert opinion using a Delphi methodology. Methods A Delphi survey combined with a face-to-face meeting was conducted. A panel of European experts in foregut surgery from high-volume centres generated items in the first survey round. In subsequent rounds, the panel rated agreement with statements on a 5-point Likert-type scale. Internal consistency (consensus) was predefined as Cronbach’s α > .80. Items that >70 % of the panel either rated as irrelevant/unimportant, or relevant/important were selected as consensus items, while topics that did not reach this cut-off were termed “undecided/controversial”. Results Three survey rounds were completed: 19 experts from 10 countries completed round one, 18 continued through rounds two and three. Internal consistency was high in rounds two and three (α > .90). Fifty-eight additional/revised items derived from comments and free-text entries were included in round three. In total, 118 items were rated; consensus agreement was achieved for 70 of these. Examples of consensus topics are the relevance of the disease profile for assessing surgical urgency and complexity, the role of clinical history as the mainstay of patient follow-up, indications for revision surgery, and training and credentialing recommendations. Topics with the most “undecided/controversial” items were follow-up, postoperative care and surgical technique. Conclusions This Delphi study achieved expert consensus on key topics in the operative management of paraesophageal hernias, providing an overview of the current opinion among European foregut surgeons. Moreover, areas with substantial variability in opinions were identified reflecting the current lack of empirical evidence and opportunities for future research.Surgical Endoscopy 11/2014; 29(8). DOI:10.1007/s00464-014-3918-7 · 3.31 Impact Factor