E112 Masterclass with Colin Schieman on Paraesophageal Hernias
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Chad Ball 00:12
Welcome to the Cold Steel podcast hosted by Ameer Farooq and myself, Chad Ball. We consider it an absolute privilege to bring you guests from around the world who are truly experts in their craft. Our mission is to offer you a combination of not only master classes on clinical surgery topics, but also insights into achieving personal growth, productivity, and fulfillment as both a surgeon and perhaps more importantly, as a human.
Ameer Farooq 00:42
This week, we're joined once again by Dr. Colin Shieman for a masterclass on paraesophageal hernias. Dr. Shieman is a previous guest on the podcast and is a thoracic surgeon in Calgary. In this episode, we discuss types of paraesophageal hernias, the management of gastric volvulus, as well as operative approaches to repair.
Chad Ball 01:03
And maybe we should start right at the beginning with what I think a lot of general surgeons, you know, see day to day, incidentally, and less commonly symptomatic, but wondering how you frame the topic of paraesophageal hernia, how common it is, how often it's symptomatic, and how it generally sort of flows through a referral process.
Colin Shieman 01:27
For sure, so I guess just before I start, I would just say, I'm a thoracic surgeon. And so I do find that thoracic surgeons and general surgeon think slightly differently of this problem, although not hugely. And in addition to that, I would say that there's quite a bit of sort of personal touch and how people think about these problems. So I suspect not everybody will agree with what I'm going to say. But that some parts of this are a bit more opinion heavy than others. And so, I mean, basically, as you've said, Chad, these are these are common problems. If you look closely for them, you see them in a lot of imaging studies done for other reasons. And so there's a lot of patients diagnosed with hiatal hernias or paraesophageal hernias. We don't know the exact sort of societal incidence, but there's an interesting study that showed that up to 25% of CT scans done for other reasons will show some element of a hiatal hernia. Obviously, the vast majority of those are going to be not symptomatic. And so we see quite a few of them incidentally. And then I think another element, even just to sort of frame the discussion, that gets confusing is how do you describe them and classify them? And so you know, the words hiatal hernia, paraesophageal hernia and gastric globulus often get used interchangeably or are related. And so just to start the discussion, I think it's helpful to just explain how I think about them. So hiatal hernias and paraesophageal hernias sort of represent a spectrum of the same problem with gastric volvulus, typically resulting from larger paraesophageal hernias as the stomach migrates up, often flips around on itself. And so they all involve some migration upwards through the diaphragmatic hiatus into the lower mediastinum. Classically, we talk about the four types. I'm not sure how critical that is for our discussion today. But I think just to frame how I think about it - that the sliding hernias, the type 1s or the small ones are by far the most common, those are about 85%. And those are the ones that are often sort of affiliated with reflux disease. Whereas when I think of the word paraesophageal hernia, which is I think, what we're gonna mostly chat about today, those are kind of the types 2s, 3s and 4s, which are bigger and they make up about 15% of the hiatal hernias. As you know, the 4s are the ones that other organs herniated through. The type 3s are probably the most common ones we see with migration of the g junction in the stomach, and the type 2s are this sort of rare entity where the fundus migrates, but the g junction stays where it's supposed to. And then just to set the stage, we often see them in elderly female patients - sometimes they tend to be seen in patients who are more obese. And so it is it is largely a disease of elderly patients. Although we absolutely have younger patients. We operated on a patient in their 30s this week that had one, but that would be the prototypical patient. And I think it's important to really differentiate them from patients that have had previous hiatal surgery - that in my brain is a completely different sort of challenging problem - if they had previous hernias or other esophageal problems. But anyways, I'll stop there.
Ameer Farooq 05:07
It's funny how many surgical diseases we treat every day, but don't really have a good sense of the pathophysiology behind them. You know, can you talk a little bit about the pathophysiology of paraesophageal hernias?
Colin Shieman 05:22
Yeah, it's tricky. I mean, I almost think about that in reverse, like, I know that the common features are this laxity of the so-called phrenoesophageal ligaments or attachments where the esophagus and fundus kind of traverse through the diaphragm and for whatever reason, these patients, they get dilation of that diaphragmatic hiatus and then we think partly because of negative, you know, so-called negative intrathoracic pressure, which we generate as part of our respiratory cycle, you get this upward kind of pulling or migration force caudally. And that kind of draws the fundus and the g junction upwards, and you get this elongation of that sort of peritoneal envelope and the sack begins to develop. And so, but honestly, we don't really know why people get them. There's not a etiologic risk factor, other than just some of the, as I said, some of the correlated features are associated features that we talked about.
Ameer Farooq 06:24
Right. So you talked about the types and the fact that a lot of these get picked up asymptomatically on other imaging. How do these patients, if they do have issues, what are the kinds of issues that you typically see - like when you're seeing them in the clinic, and you're kind of trying to figure out if these patients are, "symptomatic"? What are the types of things that you're looking for on presentation?
Colin Shieman 06:52
So, I guess the first thing, honestly, as you've already touched on is just - Are they symptomatic at all? And, a large percentage are not. But as I try to work through that, you know, the classic features that I ask them about: Do you have acid reflux disease? Do you have dysphagia postprandial pain, weight loss, early satiety, those would be I think, the big hernia specific symptoms that I would be looking for. And often, as you know, Ameer, often I'm trying sort of in my brain to make sure that they're symptomatology isn't perhaps from some other unrelated entity, you know, like, is it sort of gallbladder problem or something like that, for example.
Ameer Farooq 07:41
How much do you care about other, you know, they talk about these extra pulmonary, I guess, more in the context of GERD, but, you know, even related to paraesophageal hernias, how much do you, you know, weight the findings of you know, someone who gets recurrent aspiration pneumonias and, you know, sometimes it's actually very difficult, I think, to pin those extra pulmonary symptoms on their paraesophageal hernias. So how do you kind of suss that out?
Colin Shieman 08:15
Yeah, that's tricky. So, there's, as you've alluded to, there's sort of two groups of patients that I'll be referring to. In my brain is those patients with the small hernias or the sort of reflex presentation, and then the patients with the paraesophageal hernias. And both of them can have overlap with this challenge that you're describing. So, I do take the extra [inaudible] symptoms very seriously. Because, you know, for example, aspiration pneumonia can be q life threatening problem. And that would certainly push me towards more aggressive management for either of those, those sort of subtypes of hiatal hernias. But as you know, reflux diseases is a tricky sort of problem to wade through in the spectrum of functional disorders and determine, you know, is there dyspnea? Is there cough? Is that episode of pneumonia they had a few years ago, is that somehow related to this hernia? And conceptually, my brain, I usually have to try to understand how that's possible. If they have, you know, a small-sized hernia, how could that pathophysiology evolve? And I would workup those patients perhaps slightly differently than some of the ones with the foregut symptom.
Ameer Farooq 09:33
So, I do want to come back to the workup of these patients because I think that's super important. But, you know, let's see for the patient who either is "asymptomatic," I know one of your colleagues, Dr. Gelfand, he always says, "Well, in my experience, there's never really been a patient who has a paraesophageal hernia. Like not a type 1, but one of the other types that isn't symptomatic in some way. But you know, I guess the questions are twofold. One is, do you see patients who, you know, have even large paraesophageal hernias that are asymptomatic? And the second is if you do have a patient who is "asymptomatic," - or let's say minimally symptomatic on a PPI, how do you approach that patient? Or do you still offer them surgery? Or how do you go about dealing with that?
Colin Shieman 10:22
What I would say is, I would agree that a lot of the bigger ones patients will have symptoms. But having said that, a lot of them will not. And I certainly don't push too hard on you to elucidate that. But I guess, try to answer your question. If patients are living well, eating and drinking the foods that they like and they're not particularly troubled by the presence of this hernia, then I don't really go much beyond that. I really don't work them up. And I talk to them a bit about the significance of their hernia, the potential risks of the hernia, which maybe we'll get to it today. But I'm quite comfortable to counsel them that this is an incidental finding that they just need to be aware of. And I think that thinking has changed a lot in the last 10 to 20 years. Even when I was in my residency, the presence of a giant or a large hernia itself was regarded as a potentially life-threatening problem at some point down the road. And so some surgeons advocated repairing virtually all of them - and I believe - and certainly in my practice - that has changed a lot. The patient that's well controlled on a PPI probably doesn't need much of a workup or certainly doesn't need an operation as a starting point.
Ameer Farooq 11:46
I think that sounds very reasonable to me; it makes a lot of sense to me, in my own mind. Can we talk a little bit about the workup? And what are the types of imaging or other types of studies that you'll do for these patients preoperatively? And just, I guess, what are the things that you're sort of thinking about in terms of your workup that you're trying to rule in or rule out or make sure that's not part of the equation?
Colin Shieman 12:16
Yeah, that's a good question. I sort of, in my brain, try to get a better understanding of the anatomy of the hernia to characterize it, to get a sense of the function of the esophagus, and just to make sure there's no other pertinent associated problems. And so, typically, when I see them, they'll either have had done or I will order a contrast esophagogram, both for anatomic and functional imaging. I do an upper endoscopy on virtually all of them. If I'm contemplating surgery, I've evolved to doing CT scans on all them, which certainly I don't think is universally done, but it just gives me a really nice sort of anatomic framework for what I'm dealing with. And so that's my workup for the sort of larger hernia that I believe is symptomatic and I'm evaluating. For the small hernias or the sliders or where reflex is the predominant issue, I'm certainly much more cautious in those scenarios, and I would absolutely recommend esophageal manometry and training for pH studies in those patients. This isn't universally believed, but I don't find [inaudible] pH studies reliable or helpful in larger hernias at all as the anatomy of the hernia itself, and the function is distorted enough that I can't integrate that into my decision-making. I always check their hemoglobin levels. As you know, a lot of these patients have an associated anemia either from overt blood loss from Cameron ulcers or just this assumed microscopic blood loss which is often associated with hernias.
Ameer Farooq 13:57
What are you looking for anatomically? Can you talk a little bit about like what exactly are you looking out for on the CT or the contrast study and how does that affect your decision-making?
Colin Shieman 14:11
So, for one, I want to see if they have a hernia at all. Two, I want to see how big it is. Because to see if they in fact have paraesophageal component, as you say. And then I can also, from the CT scan, I can get, from the contrast esophagram I can get a sense of if they have, you know, normal esophageal emptying or any manifestations of physical holdup or obstruction of the g junction. Or sometimes they can comment on profound reflux on the esophagram. And then on the CT scan, you get this really beautiful picture when you look at the coronal films of how big is the diaphragmatic defect. You know, how much intra-abdominal fat is there? How much of the stomach is actually herniated? Because it's not always, to be honest, it's often underestimated. So the CT scan - often I'll find myself a bit struck as to how big the hernia is. And then it just helps me to sort of tailor my operative recommendation. So those are the key things that I'm looking at on CT and the esophagram.
Ameer Farooq 15:29
So, I do want to talk about a case that I actually saw when I was doing a locum this year, and it gave me considerable heartache and stomach ache and all the aches possible, because I thought I would have to do an emergency surgery. But I saw an 82- year-old-lady when I was on call at night, and of course, you know, it was like, midnight on a Friday. And so she presented with severe epigastric pain and vomiting after eating breakfast. She had no melena or hematochezia and her past medical history was pretty significant. She had diabetes, chronic kidney disease from glomerulonephritis, hypertension, dyslipidemia, and she had an x-ray and a CT scan, both of which were consistent with gastric volvulus. So, Dr. Shieman, can you talk to us a little bit about what is a gastric volvulus? Maybe a little bit about the types and how do you approach this scenario?
Colin Shieman 16:28
So, yeah, I'm not surprised that this caused a bit of heartache, I find most of the emergency consults involving [inaudible] are challenging - just to make you feel better. And so to answer your question, the terms again are super confusing. And so even still, when I hear the term gastric volvulus, I imagine in my brain, the stomach flipped upon itself in some type of a dangerous way, with the associated obstruction and potential vascular compromise, like you think of with a sigmoid or cecal volvulus, for example. And that doesn't quite translate to the stomach in the same way. And so, without a diaphragmatic hernia, the stomach almost never, not never, almost never just spontaneously flips about on itself in a dangerous way, simply because it has so many anatomic attachments like the gastrosplenic ligament, the gastrocolic ligament, the short gastric - it's fairly attached in multiple places. When that does occur, it's so-called primary gastric volvulus, a super rare entity. So, really, the term gastric volvulus is almost always used in the context of a paraesophageal hernia, or so called secondary gastric volvulus. And as I alluded to earlier as the diaphragmatic defect enlarges, and as the stomach migrates caudally, in the larger hernias, it almost has to have some folding. And so typically what happens is the fundus migrates in front of and above the g junction into the mediastinum. And it develops a sort of anterior twist. And so in my brain, functionally, the words gastric volvulus and hernia are kind of one in the same thing for the larger hernias. And so I think, as I cautioned earlier, they're often kind of used interchangeably. And then you can get yourself a bit confused if you try to classify the volvulus. You know that the traditional mesenteroaxial sort of obvious with the antrum flipped up towards the g junction versus the organoaxial, it kind of flips around its long axis. I don't find these terms very accurate or meaningful or useful. And I think of all the large hernias as having some element of a mix of these...
Ameer Farooq 18:58
Do you think of it? Do you approach that patient differently depending on the way that it's twisted, like this patient for sure did have a gastric [inaudible] obstruction that I saw, and she definitely had a significant amount of pain. So it wasn't just that it was an imaging finding. Does your approach to that patient change depending on the way that it looks on the CT scan? Like, even apart from, you know, obviously, if there's ischemia, or necrosis of the wall on the CT that's a different story. But anatomically, does it make a difference to the way you approach that patient? Whether it's mesoaxial or organoaxial?
Colin Shieman 19:36
Yeah, I would say, no, not really. It's challenging. I would say that perhaps, I think one of the more important teaching points is a patient comes in with some type of abdominal complaint, and they have imaging which shows a large hernia, and I think often their symptoms can be mistakenly attributed to the hernia. So different than the patient you just described. But, but I would caution people that often the hernia that has been there for decades is likely the same as it was on the x-ray, you know, 5 or 10 years ago. And these elderly patients, they often will have some previous imaging. And the hernia is actually just a bit of a red herring. So that's just one, I guess, small teaching point. But, but more specifically, to answer your question, I actually do exactly sort of what you're alluding to. And I try really hard when I'm looking at that CT scan to get a sense of, Is there some element of strangulation or something acute, which has happened here? So, if you have not just the presence of the hernia so much, but if you have like fairly massive dilation of the stomach, as you said, you know, now you're thinking there's an obstruction, and perhaps they're developing some element of a closed loop or you know, some part of this volvulus is different than this hernia has been in the past. I do look very much to see if I can map out some of the vasculature and you get some of those radiographic features of perfusion or ischemia or, or absence of perfusion of the wall, you're looking for free air and some of those other more catastrophic findings. So, when I'm looking at a CT scan, in that emergency setting, I'm trying to 1: ask myself if this hernia is even relevant, and then 2: is this stomach looking like it's now obstructed and or compromised.
Ameer Farooq 21:30
Practically speaking, Dr. Shieman, what do you do with that patient in the emergency department? You know the textbooks will talk about dropping an NG in to try and decompress that and then checking an x-ray to get the NG below the diaphragm. But I'm curious as someone who deals with this all the time, but what are your practical considerations for someone who comes in? You look at the CT scan and you're convinced there is an element of an obstruction? What do you do next?
Colin Shieman 22:00
Sure, I think the management is really tailored around, Is this stomach in trouble? And so as you said, you know, you kind of have that clinical sense as a general surgery, Now is this patient sick and is this patient in trouble? And often they're kind of borderline. If they're overtly in shock with an acute abdomen, as you know [inaudible] the management's fairly self evident. But, not to overlook that or wash over that - I sort of try to adhere to my principles of sepsis management, such as fluid resuscitation, empiric antibiotics. I usually put them on an IV proton pump inhibitor, because usually somewhere in the history, there's a dark-coloured emesis or something to suggest that. And then, as you said, the critical intervention that trumps all else is that nasogastric tube with the hopes that you can slide it down and decompress a portion of that now- distended and potentially obstructed stomach. And so we will go to great lengths to get that nasogastric tube. And because it literally is the total game changer. And so you know, it's fairly evident if it's worked or not, you know, the tube goes down, and occasionally it can't be passed. But, but thankfully, I'm grateful to say this, most often it can be passed, and you have this large release of, you know, dark-coloured sort of coffee ground, fluid, often a litre or more. Patient feels better. And certainly I as the caregiver have this big sigh of relief, because now I have a completely less emergent problem on my hands probably. So I would say that's my initial management, then, if not yet done, you know, you get the good CT scan, and then you kind of go from there and try to make sure that although maybe perhaps you've been lucky and you got the stomach decompressed within nasogastric tube, that they don't have signs of gastric compromise. If that sort of life saving needs a gastric tube and it's not possible to be placed, you don't give up there. I would then sort of progress to an attempt at endoscopic placement of the nasogastric tube with a gastroscopy, which you can usually get a little bit of more physical distinction and forward pressure and pop into that closed loop component and then place the nasogastric tube, evacuate some of it with the NG tube, start with the gastroscope, and go from there. Obviously, as I said, but it's important to repeat, if the patient is in big trouble, if they're in shock, if they got an acute abdomen and they got evidence of radiographic perforation or gastric ischemia then you're not going to get off...
Ameer Farooq 24:56
Thankfully for me, as you suggested, my patient did all right. NG went in and I breathed a sigh of relief and unclenched my stomach. I'm curious what your timeframe is, then let's say when you have that patient who's been decompressed? What is sort of your management going forward? Are you, you know, completely letting them settle down for, you know, a couple days or a week? Do you take them to the ER and in a couple of days, how do you approach the patient going forward after that?
Colin Shieman 25:33
So I, when the nasogastric decompression is possible, which thankfully, it is in the majority of people, obviously, the patients get admitted, they get observed very closely, particularly in that first 24 hours in case you've missed some ischemia or necrosis, make sure they don't deteriorate. And then I very intentionally drag my feet for a bit, usually at least a week, and sometimes closer to two weeks, just to correct some of that, sort of metabolic surge to relieve some of that gastric inflammation, or tissue compromise and edema. And let things settle down. I usually will put them on parenteral nutrition during that time. And I say that because I think surgery in that very early period is so, for example, in the emergency cases, but even if in that first early period, is quite a bit trickier - the stomach is harder to work with. It's a bit thicker and boggier, it's a little bit harder to reduce. And I think it makes the repair more challenging and complicates it a little bit. And so I intentionally avoid that altogether unless they're in trouble. And then actually, you know, in some rare cases, and in the extremely frail, high-risk elderly patient or somebody severely demented in their 90s, or some variation of that, and you legitimately worry about their ability to withstand a major operation. Occasionally, we'll just rechallenge them in a couple of weeks with oral intake with the sort of thought process that, well, you know, they've had this hernia for decades, perhaps we'll get lucky and things will still flow through. And occasionally it works, I would say, I can't give you a number, I mean, but I would say that's not always the case. But occasionally it is if you're desperate to do that. I do think a lot of those patients quite honestly have some element of chronic partial obstruction. They haven't been doing well for a while, but I've gotten away with a couple of times, but I would say the majority are going to need surgery on that admission for sure.
Ameer Farooq 27:56
I think that segues really nicely to the next sort of scenario that I want to talk about, which is how you approach this operation. So you know, you have an elective paraesophageal hernia repair. Can you walk us through in sort of 10 steps or less or, you know, in broad, 30 000-foot kind of way how you approach that operation?
Colin Shieman 28:24
So, I mean, as you know, there's a variety of operative approaches. And I do actually kind of think about the patient that you just described, that gets admitted kind of emergently, a little bit different than the patient I see in the clinic who's, let's say, less symptomatic. So, as you know, there's a variety of ways to fix these, either through abdominal repair such as laparoscopy or laparotomy or thoracic approaches through low left thoracotomy. And, you know, there's much discussion, opinion and interest in the merits of these different approaches and a lot of strong feelings around what is best. And I can honestly say that I use all three approaches that I just described, depending on the clinical situation. And so I always get a bit anxious when people are 100% committed to one approach. For the urgent or emergent repair, I would personally suggest an abdominal approach. And I think if you do hiatal hernia repairs as part of your elective practice, you could very well consider a laparoscopic approach with the understanding that often they just tend to be a little bit harder than the than the purely elective operations. If that seems daunting to you, or if you're in a more urgent situation than that, then upper midline laparotomy is probably going to be the most versatile and user-friendly approach in this scenario. But I could go on about the different merits of why I would choose a different approach. But regardless, really the surgical principles or the tenets of the operation remain - reduction of the hernia sac and its contents, mobilization and resection of the sac, curled closure, and then some type of abdominal fixation of the stomach, either through some variation of a fundoplication, or a gastropexy. And then often, both of those fundoplication and some type of a gastropexy to surrounding tissues. As you know, I've done these procedures with you, as well as I've done them with Chad. And it's actually not any more complicated than that, in a sense. And I literally do those steps as I do the procedures. And perhaps I could explain, you know, certain elements of that, if you want. I would say that transthoracic repairs can be a bit more anatomically disorienting if it's not something you do often. So I'd be really nervous to suggest that to somebody who doesn't do this regularly. In fact, I would say that these are challenging enough that if you can convert this to a non-emergency, you could probably make the case that they should be done by people that do them regularly, because they just can be hard, they can be hard. And the anatomy can be distorted, the tissue planes can be challenging. And then, as you know, the recurrence rates can be high. And so they're fraught with challenges. In terms of if you're going to take this on, so for example, if you had to take that patient in the ER, the other night that you described, you know, I would strongly recommend you put a headlight on, you get a fixed abdominal retractor in place, and a fairly skilled assistant to help you just with some of the tissue exposures. That would be kind of a general principle.
Ameer Farooq 31:59
I am a bit curious, given your expertise with doing both approaches, when would you choose a transthoracic approach versus an abdominal approach? And I have a whole bunch of questions obviously, about some details on how you do the operation. But maybe we can just start there - like when would you choose through the chest or through the abdomen?
Colin Shieman 32:25
So, I think this is probably morphing into the slightly more controversial parts of this disease management. So in my personal opinion, I think you're on safe ground if you say I'm going to do the complex recurrences through the left chest, I would say there's certainly a body of literature and there's a lot of people that have large series of doing redo hernias, laparoscopically or transparently, but that's not a bad indication to do them through the chest, as they can be quite, I think a bit more straightforward, that way. Certainly people that have had, as I said, these often happen in elderly patients and a lot of people have had multiple abdominal previous operations. So, you know, if you're cautious about a hostile abdomen, the left chest is a great approach. And then, for me, I find it nice for the really massive hernias, like i.e., the entire stomach is in the chest, and/or the patients are quite obese, and - not infrequently - those two things together. I'm not sure that every person would agree with that. But for those patients, I use the left-chest approach, just for the sheer quality of the exposure, the dissection and the repair. I just think it's like particularly in the obese patient with a large, large hernia. I just think that's a dramatically stronger repair. But I suspect not everybody would agree.
Ameer Farooq 34:06
Yeah, I'm gonna be selfish here for a bit given that I'm not a thoracic surgeon and I'm not going to be one. So I'm going to pick your brain a little bit on the laparoscopic sort of approach to this because I think a lot of our audience are general surgeons and would be more used to that type of approach. So can you talk maybe briefly about sort of how you have the position if you're going to do this operation laparoscopically? And then I think the perennial question that always comes up here is what kind of wrap do you do? Are you doing a Nissen? Are you doing a Dor? Does it depend? Can you talk a little bit about that?
Colin Shieman 34:45
Yeah, for sure. So, I would agree with the sentiment of your question - is that I think the general surgeons that do take these on will obviously be more, I think, comfortable and facile with the abdominal approach than the laparoscopic approach specifically. I don't think that's particularly controversial. So for me personally, when I do these laparoscopically, as I've already said or alluded to, I'm a bit selective about the approach I use. I place them in sort of a modified Fowler position or arms outstretched, although, you can very comfortably do these through like a modified lithotomy position. You know, I generally place four or five ports, you know, various spacings in the epigastrium depending on your preferences. And then I think, you know, laparoscopically it's very, very doable. You have longitude, you first reduce the stomach, you place longitudinal traction on the stomach, and in fact, you kind of intentionally grasp that gastrohepatic ligament, and often you actively try to efface that sac. And then you incise that delineation. Often, you get some clues around the anterior sort of orifice of the hiatus or along the right crus, and then you intention to get yourself into that sac space. And as you mobilize that and retract it into the abdomen, by definition, you're adding length, you're reducing the stomach, you're taking tension down, and you're sort of adhering to your principles. And so, I would say that the instrumentation isn't that critical. I use a Nathanson liver retractor. But that's just because it's fairly easy. And then in terms of ... to jump to your second part of your question about the wrap and stuff. So I guess before you contemplate the wrap, you know, you want to make sure that you really intentionally mobilize the hiatus as much as you can, and thankfully laparoscopy is very well suited to going quite high. I often will try to excise a good portion of the sac just because it kind of just gets in the way - not because I think it's a critical part of the procedure, but it just kind of tidies up the repair. You want to make sure that both pillars, your diaphragm are nicely exposed. And once you kind of have that you're feeling good, because I would say getting to that point is the hardest part for me in an elective repair. Often just with the distortion of the anatomy, properly mobilizing and reducing and excising that sac is, for me, the challenging parts of the case. Once you're there, I think things just sort of fall nicely into place. So you suture up the crura posteriorly with your interrupted sutures; I use some Ethibond sutures, but silks or some type of a non-absorbable sutures, generally what I would recommend. You try to reduce the size of that diaphragmatic defect. And then lastly, you kind of make your decision around the wraps. You know, one of the other principles that I should mention is you want to try to ensure that you've got sufficient mobilization so that therefore you have sufficient length of the esophagus. Ideally, we'd avoid the whole short esophagus debate today, but you just want to make sure that there's not a ton of longitudinal traction of the esophagus into the chest, which to be honest, is rarely the case when you've done a good mobilization. And then the wrap question is super interesting. And so I honestly think that's actually changing as we speak. And so I don't think it would have been a stretch for 5/10 years ago to say, you reduce them; you do a 360 degree Nissen fundoplication, often over a Bougie, and then you're done. And more and more, I feel that people are changing that approach and converted that to some type of a partial fundoplication, and/or quite a deliberate, sort of widespread gastropexy. And so my personal favourite at the moment is once I've got the diaphragm closed, I do a modified wrap, like which is a partial anterior Dor fundoplication, where you just kind of swing the anterior fundus up, and you tack it both to the sort of lateral edges of the esophagus and the g junction. But perhaps, in my brain, more important than that is that you tack it multiple places to the diaphragm, almost like to pexy the defect or to pexy that whole space closed. And I've heard of several other sort of people that do this regularly, modifying their approach. And it's attractive because you avoid the risks of the fundoplication, sorry, the Nissen fundoplication, you avoid some of the concerns about esophageal obstruction, dysphagia, much less of an issue of a partial wrap, and you also get this really nice, kind of broad-based closure of the defect in the area, rather than as you know, Ameer, when you do the Nissen, you kind of have this this knob of the fundoplication, which just almost seems like the perfect thing to migrate up through the hiatus. You know what I mean. And so I've made that transition and I know some of our colleagues, some of our friends in Calgary have made that modification as well. As well, I've talked to some people recently around the country that have made that change.
Chad Ball 40:24
I love the way that you describe that there's so much of surgery, right? That you look and you feel and you touch it, and if it makes you feel sort of warm and fuzzy, so to speak, it's probably a pretty good solution. So I love it. Colin, I want to ask you about two specific things that I think carry controversy. When do you use mesh, when do you not use mesh? What's that literature look like? Number 1. And number 2 would be when do you place a G tube or a fixation tube? Why don't you?
Colin Shieman 40:54
Oh, man, you're going right to the tough stuff. So I would say my answer for the mesh question is actually very basic. I never, I virtually never use mesh. But to elaborate on it, I will go to great lengths to avoid the use of mesh up to and including a partial reduction of the hernia and fixation. I have yet to use it for a paraesophageal hernia repair. Other than those that are some complex variations such as, you know, multiple time redo or some post-traumatic diaphragmatic hernia where you have, you know, if you have more tissue loss or loss of laxity of tissues, and even then I do almost anything to avoid placement of the mesh. I just regard it as a super dangerous, potentially life-threatening curveball that you introduce to the situation. And I'm just alluding to, you know, delayed mesh erosion of the esophagus. And I've been involved in those cases. And those are complete disasters. And so, Chad, as you know, there's actually a huge body of literature around the use of mesh for hiatal hernias and paraesophageal hernias. And I think it's fair to say, there was a huge enthusiasm for use of mesh, and there's tons of interesting varieties, multiple RCPs, using it. And even still, there's some real experts who advocate for it. But as I said, I've never had to use it, and I've never regretted not using it. Even if, as I say that, that meant some form of a partial reduction and fixation, which I must say is a pretty rare sort of compromise you have to accept. And then what do you feel in terms of G tubes or other fixation tubes? So I think this has also evolved a bit as well. So I think the thought of an additional principle of the case of gastropexy, or gastric fixation, somewhat separate from the principle of the wrap itself, I think is a key and important step to try to minimize your risk of recurrence. And so, as you say, you know, historically, the G tube was considered that technique of abdominal fixation. And there's certainly practitioners who still use it. For me personally, I don't use G tubes in hiatal hernia repairs, but I do acknowledge the importance of abdominal fixation. And so I try to avoid the morbidity and added complexity in the home care of the G tube by fixing the stomach as part of the repair. And as I just alluded to, with multiple sutures of the stomach to either the crura posteriorly, as well as often quite deliberately and separately, to the anterior abdominal wall. And so, you know, the classic would be in a laparoscopic repair, with placement of multiple anterior sutures from the reduced stomach to the anterior abdominal wall, typically with like, the Carter-Thomason suture pass or some something like that. And I think that's actually fairly recent in the evolution and I think quite a few practitioners I think are evolved to that addition. So I don't use the G tubes currently.
Chad Ball 44:37
Yeah, I think that's a superb answer. You know, Colin, we can't thank you enough, and I'll reiterate to our listeners that I've seen you do a couple of these and your technique is superb and the results are eloquent. So I think we all listen very carefully to what you say. I was wondering about the very last thing before we let you go - if you could take us out in terms of post operative care. So, do you swallow study these patients? How does your diet progression happen? And how do you monitor them? Or do you have to monitor them - radiologically or otherwise for recurrences? And thanks again.
Colin Shieman 45:13
So again, I sound like a broken record. I would say this has evolved in the last 5 to 10 years kind of as I would humbly suggest we've become a bit enlightened to challenging sort of traditional surgical dogma with the gentle push that ERAS has made us all reconsider everything. And so I, like things in my other domains of surgery, I've moved towards more minimalism. And so as routine care, no, I don't do esophagograms. I never really have done them for this operation. If for some reason I was worried about an esophageal injury or a leak, or some element of the repair that made me worried perhaps I would do it if I was cautious to feed them. But I would say that's not really typically a thing unless perhaps you're doing an emergency where there's some concern of ischemia or something. There was an early in-hospital recurrence, which is thankfully rare, but often a dreaded complication, a contrast study might help you sort out if that's what entity you're dealing with. I typically keep them NPO for, you know, a day and then I slowly reintroduce oral intake. I don't use nasogastric tubes. Nothing special but just if you will, maybe less than we used to recently do for these. And then in terms of your question about recurrence - and so, that's a whole, kind of, topic unto itself. If you look really closely and try hard to find recurrence for these, you're gonna find a lot of recurrences. I generally think of recurrences as clinical entities more than radiographic entities in the sense that when people are doing well, aside from you know, x-rays and follow-up as needed, I don't usually have a super complex long-term strategy for managing these patients. So if they're unhappy, their symptoms aren't great, then I'll assess them for recurrence and I think by far the best test for that is a CT scan. A lot of times, Chad, with question of recurrence is tricky, like do they have a little bit of a knuckle at the hiatus and is that just post-op or is that the top part of your wrap - like you can drive yourself crazy trying to think about these. The real big recurrences where it's not at all subtle, thankfully, those are pretty rare. But they're not that rare, unfortunately. Even the real proponents, the hard for laparoscopic advocates would acknowledge that the recurrence rate is unfortunately quite high for the laparoscopic repair. And so that's why I've started to evolve to doing it a bit more selectively. But that's my personal approach right now, Chad.
Ameer Farooq 48:18
You've been listening to Cold Steel, the official podcast of the Canadian Journal of Surgery. If you've liked what you've been listening to, please leave us a review on iTunes. We'd love to hear your thoughts, comments or feedback. Send us an email at [email protected] or tweet at us @CanJSurg. Thanks again.