Northwell Health, Lenox Hill Hospital New York, NY, United States
Benjamin Ascherman, MD, MBA1, Nicholas Condiles, MD1, Michael Ma, MD2, Liang R. Cui, MD3, Vladimir Ornstein, MD4 1Northwell Health, Lenox Hill Hospital, New York, NY; 2Lenox Hill Hospital, Northwell Health, New York, NY; 3Northwell Health - Lenox Hill Hospital, New York, NY; 4Lenox Hill Hospital - Northwell, New York, NY
Introduction: Postoperative ileus and small bowel obstruction (SBO) are commonly managed with supportive measures alone. However, in refractory cases, surgical management may be indicated. We present a case of partial SBO complicated by previously asymptomatic large paraesophageal hernia.
Case Description/Methods: A 75-year-old female with hypertension, hyperlipidemia, peripheral vascular disease, and a previous total abdominal hysterectomy presented with a left hip fracture following a fall. Two days after a total hip arthroplasty, she developed bilious emesis, constipation, and a paucity of flatus. Abdomen was soft, with mild distension and LLQ tenderness. Labs that morning had been notable for WBC 16.65 and Na 130, but were otherwise unremarkable. Supportive management with nasogastric tube decompression produced minimal improvement. CT demonstrated a large paraesophageal hernia with NGT draining proximally in the subdiaphragmatic portion of stomach. The distal portion remained distended in the paraesophageal hernia (Image 1a). An EGD was performed which visualized the paraesophageal hernia with gastric volvulus, with no evidence of ischemia (Image 1b). The NGT was advanced into the distal stomach for gastric decompression to bridge to surgical intervention. The patient was subsequently taken to the OR for laparoscopic paraesophageal hernia repair with Nissen fundoplication. Following clinical improvement and hernia repair, the patient was discharged to subacute rehabilitation.
Discussion: While acute nonoperative decompression may successfully reduce volvulus and obstruction, it carries a high recurrence rate. Surgical approaches include gastropexy or fundoplication. While both open and laparoscopic options offer high likelihood of symptomatic resolution, recent data suggest that differences in post-operative complications, mortality, length of hospital stay, and cost favor a laparoscopic approach.1
We present a patient with a previously asymptomatic paraesophageal hernia who developed postoperative SBO complicated by gastric volvulus refractory to NGT decompression. Prompt diagnosis can minimize potential complications, including obstruction, gastric necrosis, and perforation, thereby improving patient outcomes.
Hosein S, Carlson T, Flores L, Armijo PR, Oleynikov D. Minimally invasive approach to hiatal hernia repair is superior to open, even in the emergent setting: a large national database analysis. Surg Endosc. 2021 Jan;35(1):423-428.
Disclosures: Benjamin Ascherman indicated no relevant financial relationships. Nicholas Condiles indicated no relevant financial relationships. Michael Ma indicated no relevant financial relationships. Liang Cui indicated no relevant financial relationships. Vladimir Ornstein indicated no relevant financial relationships.
Benjamin Ascherman, MD, MBA1, Nicholas Condiles, MD1, Michael Ma, MD2, Liang R. Cui, MD3, Vladimir Ornstein, MD4. P2089 - Gastric Volvulus Developing in Previously Asymptomatic Paraesophageal Hernia, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.