Giant Hiatal Hernia With Acute Manifestation of Complete Esophageal Obstruction: Case Report

Abstract Introduction Hiatal hernia is a common condition with rising incidence in western society. The prevalence rises in patients with morbid obesity, age and female gender. Up to 95% are sliding hernias, often asymptomatic or causing symptoms typical for gastroesophageal reflux disease, 5% are paraesophageal hernias which according to the grading may be asymptomatic. Symptomatic hernias are associated with more severe symptoms, higher rate of complications and need of acute surgical management. Case Presentation We present a case of a 64-year-old female patient with BMI 39 and acute upper abdominal pain, nausea and vomiting. Computed tomography showed giant paraesophageal hernia containing the entire stomach, oral part of duodenum with D2 stenosis and head of the pancreas. We performed laparoscopic reposition of giant hernia and Nissen fundoplication. Defect was reconstructed with semi-absorbable mesh, gastropexy to diaphragm was performed and Jackson-Pratt drain was inserted in the remaining cavity. The patient was discharged on day 6. Post-operatively tolerating liquids. One month later, the patient presented with inability of per os consumption and vomiting. Computed tomography verified impacted solids in distal esophagus along with compression by seroma in mediastinum. Acute gastroscopy was performed and mechanical clearance of impacted food was accomplished. CT navigated percutaneous drainage of collection was considered, but was technically unfeasible. Further course of hospitalization was uneventful and the patient was discharged tolerating liquid diet. Discussion Postoperative therapy and rate of complications in grade IV giant paraesophageal hiatal hernias is challenging, burdened by high morbidity including long-term seroma formation.