Ann Thorac Surg 2008;85:321-322. doi:10.1016/j.athoracsur.2007.07.054
© 2008 The Society of Thoracic Surgeons
Case Reports
Traumatic Right Paraesophageal Hernia After Belsey Mark IV Fundoplication
Megan L. Durr, BS*,
Stephen C. Yang, MD
Department of Surgery, Division of Thoracic Surgery, Johns Hopkins Medical Institution, Baltimore, Maryland
Accepted for publication July 19, 2007.
* Address correspondence to Ms Durr, 600 N Wolfe St, Blalock 240, Baltimore, MD 21287 (Email: durr{at}jhmi.edu).
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Abstract
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We report the case of a 70-year-old woman with a long history of achalasia and gastroesophageal reflux disease who presented with an acute right-sided paraesophageal hernia after a motor vehicle accident. Six months before the accident, she underwent an elective Belsey Mark IV fundoplication to reduce a hiatal hernia. The traumatic paraesophageal hernia traversed the diaphragm at a weakness opposite the fundoplication. The clinical presentation, surgical management, and previous literature are discussed.
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Introduction
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Traumatic right-sided diaphragmatic hernias are extremely rare owing to hepatic protection and the congenitally stronger right hemidiaphragm [1]. Most diaphragmatic hernias occur in the posterolateral area on the left side of the diaphragm because it is an embryologic area of weakness [2]. Diaphragmatic hernias can be congenital or traumatic in origin. Congenital hernias generally manifest early in life, and traumatic hernias manifest immediately or several months after the incident.
Numerous cases of congenital right-sided hernias have been published, but very few cases of traumatic right-sided hernias have been reported [1]. We report the case of a 70-year-old woman who sustained a traumatic right-sided paraesophageal hernia through the esophageal hiatus opposite a previous Belsey Mark IV fundoplication.
The patient initially presented with difficulty swallowing and a 20-pound weight loss during a 3-month period. She was previously diagnosed with achalasia, for which she had undergone more than 20 esophageal dilations over 40 years. Esophagram demonstrated a dilated and tortuous esophagus with absence of primary peristalsis, with a distal "bird’s beak" appearance, an epiphrenic diverticulum, and a 3-cm type I hiatal hernia. The patient underwent a diverticulectomy, esophageal myotomy, and Belsey Mark IV partial fundoplication through a limited left thoracotomy approach. The diaphragmatic crura were approximated over a 50F Maloney dilation. The patient tolerated the operation well, and a cine-esophagopharyngogram on postoperative day 5 demonstrated no extravasation, no reflux, and excellent esophageal emptying. She was discharged on postoperative day 8 tolerating a soft diet.
Six months after this operation, the patient was the driver in a sudden decelerating motor vehicle accident and sustained multiple orthopedic injuries, including left scapular and clavicular fractures. Severe emesis also developed. The diagnosis of a paraesophageal hernia was made by a computed tomography scan that demonstrated an intrathoracic stomach that did not pass contrast distally after 45 minutes (Fig 1).
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Fig 1. Computed tomography scan of the thorax after a motor vehicle accident shows an intrathoracic stomach on the right side.
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Owing to the potential of a strangulation and near total obstruction of the paraesophageal hernia, she underwent emergency exploratory laparotomy. During flexible esophagoscopy, a liter of dark bilious material was aspirated from the distal esophagus. There was significant difficulty advancing the scope into the stomach. During the laparotomy, the paraesophageal hernia was found in the right thorax above the esophageal hiatus. The stomach had herniated through the open space opposite the pervious Belsey Mark IV partial fundoplication where the diaphragm had partially torn on the right above the location of the Belsey crus approximation. The fundoplication was intact, with the esophagogastric junction below the hiatus.
Once the stomach was manually reduced to its natural position, the crus were reapproximated with interrupted #2 Ticron sutures (US Surgical/Syneture, Norwalk, CT) with Teflon pledgets (DuPont, Wilmington, DE); a gastrotomy/jejunostomy tube was also inserted and the site tacked to the antrum. The esophagoscope was then easily advanced into the stomach after the paraesophageal hernia reduction.
After an uncomplicated postoperative course, the patient was transferred to a physical rehabilitation unit to recover from her injuries.
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Comment
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Past reports demonstrate a high degree of long-term success of the Belsey Mark IV procedure. In 1997, Fenton and colleagues [3] reported a 95% success rate for a study including 276 patients, with failure defined as a need for reoperation after initial Belsey Mark IV operation. The cited failures include two recurrent hiatal hernias and two iatrogenic esophageal perforations in the operating room during esophagoscopy. The report did not discuss the possibility of developing a traumatic paraesophageal hernia, but it stressed the increasing importance of assessing long- and short-term results of the evolving Belsey Mark procedure [3].
A similar study from 1999 [4] listed the late complications and side effects in 89 patients receiving the Belsey Mark IV operation as transient dysphagia (18%), persisent severe dysphagia (13.5%), moderate dysphagia (10%), postthoracotomy incisional pain (5.6%), bloating (3.4%), difficulty belching (2.2%), and flatulence (1.1%). This study reported one death due to an acute myocardial infarction and cited the success rate of the Belsey operation in patients without preoperative esophagitis as 91.7%. Failure was defined as recurrence of reflux, hiatal hernia, or a new persistent procedure-related symptom [4].
Concomitant injuries delay many diagnoses of posttraumatic diaphragmatic rupture, which can lead to life-threatening complications including strangulation of abdominal viscera or compression of the heart and lungs. Because diaphragmatic hernias often occur after blunt trauma, exploratory laparotomy should include close examination of the diaphragm. Previous reports indicate that examination should focus on the area around the esophageal hiatus and near the left posterolateral area to identify any diaphragmatic ruptures.
We now suggest that the right side of the diaphragm should be kept in mind during the trauma evaluation and examined closely during surgery if the patient has undergone a previous fundoplication. If a diaphragmatic hernia is identified during the laparotomy, surgical repair can be initiated immediately. An abdominal surgical approach is used for most emergency paraesophageal hernia repairs, and previous studies have indicated the success of this method [5].
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References
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- Neal JW. Traumatic right diaphragmatic hernia with evisceration of stomach, transverse colon and liver into the right thorax Ann Surg 1953;137:281-284.[Medline]
- Hood RM. Traumatic diaphragmatic hernia Ann Thorac Surg 1971;12:311-324.[Abstract/Free Full Text]
- Fenton KN, Miller Jr JI, Lee RB, Mansour KA. Belsey Mark IV antireflux procedure for complicated gastroesophageal reflux disease Ann Thorac Surg 1997;64:790-794.[Abstract/Free Full Text]
- Alexiou C, Salama FD, Beggs D, Brackenbury ET, Knowles KR. Comparison of long-term results of total fundoplication gastroplasty and Belsey Mark IV antireflux operations in relation to the severity of oesophagitis Eur J Cardiothorac Surg 1999;15:320-326.[Abstract/Free Full Text]
- McElwee TB, Myers RT, Pennell TC. Diaphragmatic rupture from blunt trauma Am Surg 1984;50:143-149.[Medline]
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Abstract
Introduction
