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P051: ACUTE GASTRIC ISCHEMIC NECROSIS: A CONSEQUENCE OF PROLONGED RETCHING AFTER SUCCESSFUL PARAESOPHAGEAL HERNIA REPAIR
Enoch Yeung, MD; Burt Cagir, MD, FACS; Robert Fanelli, MD, MHA, FACS, FASGE; Guthrie / Robert Packer Hospital
Background: The recurrence rate after laparoscopic repair of paraesophageal hernia has been reported to range from 7 to 44% detected radiographically, but the need for reoperation remains uncommon, ranging from 0.5 to 10%. Ischemic necrosis is rare due to an extensive gastric blood supply. However, ischemic necrosis can present with non-specific symptoms leading to delay in diagnosis, increasing the probability of an acute complication like visceral perforation. In the patient with prior paraesophageal hernia repair, food impaction, retching, and epigastric pain should prompt immediate evaluation with a high index of suspicion for hernia recurrence. Only through timely intervention can acute complications be avoided.
Case Presentation: We report a case of acute gastric ischemic necrosis developing in a 57-year-old female after dietary indiscretion, dysphagia, and retching. After initial stabilization, chest radiographs suggested fluid in the left hemithorax, and computed tomography (CT) obtained to rule out esophageal perforation suggested superioposterior herniation of the left shoulder of her fundoplication through the paraesophageal hernia repair that had been undertaken seven months prior. Urgent esophagogastroduodenoscopy (EGD) excluded persistent food bolus impaction, and revealed friable, erythematous, and ischemic appearing mucosa in the cardia and proximal gastric body, suggesting necrosis of a portion of the prior fundoplication. The patient was immediately transferred to the operating room for laparoscopic exploration. The left shoulder of the fundoplication was noted to be partially herniated through the still intact prior paraesophageal hernia repair. The diaphragm was incised left anterolaterally, allowing the hernia to be reduced. The fundoplication was taken down and the ischemic proximal body of the stomach now was seen to have improved perfusion. The necrotic segment of fundus was sharply demarcated, and was managed with laparoscopic sleeve gastrectomy. Intraoperative EGD demonstrated healthy esophagogastric tissue throughout, and an intact staple line during underwater testing. Postoperatively, the patient recovered uneventfully after a brief admission. She was seen as outpatient 1 week after discharge reporting no symptoms.
Conclusion: Acute gastric necrosis following fundic herniation through an intact paraesophageal hernia repair due to prolonged retching is a rare occurrence. Even with swift diagnosis and treatment, necrosis occurs quickly. Any delay in surgical intervention may result in more extensive tissue loss and systemic complications. We suggest that the possibility of hernia recurrence should be considered promptly in patients having had prior hiatus hernia surgery who present with acute abdominal symptoms.
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