Diaphragmatic Hernia with Gastric Volvulus and Complete Gastric Outlet Obstruction

Our plain-English summary of Diaphragmatic Hernia with Gastric Volvulus and Complete Gastric Outlet Obstruction, by H. Al-Masari, H. Nofal, R. Majdalawi, et al (Journal of Minimally Invasive Surgery, 2020).

The study

• Authors: H. Al-Masari, H. Nofal, R. Majdalawi, R. Ainawi, A. Alwahedi, T. Mahdi
• Journal: Journal of Minimally Invasive Surgery
• Published: 2020;23(4):197-200
• Type of article: Case report
• Cited by: 1 article, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

A combination of Cytoreductive surgery (CRS) along with hyperthermic intraperitoneal chemotherapy (HIPEC) considers a crucial approach in treating designated patients with alimentary and gynecological malignancies with the involvement of the peritoneal cavity. The foremost frequent surgical complications are leakage, digestive perforations, fistulas, intestinal obstruction, abscess, and peripancreatitis. This report presents a case of a patient with a late acquired herniation of guts through the diaphragm after CRS and HIPEC that were already done 6 months back. A 26 -yearold male previously treated with CRS and HIPEC for testicular mesothelioma with peritoneal involvement, was admitted to our unit with the diagnosis of gastric outlet obstruction. His CT scan illustrated a left diaphragmatic hernia involving the stomach and splenocolic flexure. Each denudation of the diaphragmatic serosa throughout CRS which typically occurs during the surgical operation in a combination of the HIPEC heat can explain such complication. The herniation is extremely uncommonly diagnosed after CRS and HIPEC. Surgical techniques for hernia repair can be done by direct suturing of the defect or closure with artificial or biological tissue, each technique is a potential surgical technique for repair with reliable long-run results.

Copyright © 2020 The Journal of Minimally Invasive Surgery. All rights reserved.

In plain English

This was a case report of one man, treated at Al-Qassimi Hospital in Sharjah, United Arab Emirates. The case description gives his age as 27 and the abstract as 26. He was diagnosed with left testicular mesothelioma in October 2018. In April 2019 he had cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC), plus 4 cycles of chemotherapy. In September 2019 he was referred with repeated vomiting, sudden severe abdominal swelling and absolute constipation. Imaging showed his stomach pushed up through the left side of the diaphragm and twisted (organoaxial volvulus), completely blocking its outlet. At emergency surgery the stomach was found upside down in the chest, along with part of the small bowel and colon. Part of the stomach wall showed signs of reduced blood supply. Surgeons switched from keyhole to open surgery and closed the diaphragm defect with non-absorbable sutures. The authors suggested that surgical stripping of the diaphragm lining, with HIPEC heat, could explain the hernia. They concluded this rare complication should be considered after peritonectomy with HIPEC. The article did not discuss asbestos exposure or report the patient's outcome.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: case report (single patient)
• Who was studied: One man from the Emirates with no previous medical history, described in the case section as 27 years old (26 in the abstract). He was diagnosed with left testicular mesothelioma in October 2018 and referred to the Department of General Surgery, Al Qassimi Hospital, Sharjah, in September 2019.
• Exposure: No asbestos or other environmental exposure is reported. The event studied followed treatment: cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) in April 2019, plus 4 cycles of chemotherapy (Cisplatin, Pemetrexed, and Bevacizumab).
• Main results:
  • In September 2019 the patient presented with repeated vomiting, sudden severe abdominal distension, absolute constipation and failure to thrive. Tests showed a WBC count of 16.5, CRP of 215 and an Hg level of 15 (units not given).
  • A chest X-ray showed the gastric shadow herniated through the left hemidiaphragm. A gastrografin swallow study showed organoaxial volvulus and complete gastric outlet obstruction.
  • At emergency laparoscopic exploration the stomach was upside down in the thorax with part of the small bowel and colon, and there was evidence of partial ischemia of the stomach wall.
  • The operation was converted to open laparotomy because the stomach was incarcerated and adherent to the left lung tissue. The herniated organs were reduced, the diaphragmatic defect was closed in two layers with non-absorbable sutures, a protective gastrostomy tube was placed, and a left chest tube was inserted.
• The authors' conclusion: The authors concluded that diaphragmatic hernia is rarely diagnosed after CRS and HIPEC compared with other complications. They said it should be considered when performing peritonectomy, especially in the upper quadrant with HIPEC, and that surgery is the best choice for relieving symptoms. They proposed, as a possible explanation, that cautery and hyperthermia injure the diaphragm muscle during peritonectomy.

Topics

Medical terms in this study, explained in our Lexicon: Cytoreductive Surgery, HIPEC, Peritoneal Cavity, Diaphragm, Testicular Mesothelioma, CT Scan.

Related studies

• Left diaphragmatic hernia complicated by perforation of an intrathoracic gastric ulcer into the aorta: report of a case — Y. Saito, Y. Yamakawa, et al. (2000)
• Abnormal pulmonary function associated with diaphragmatic pleural plaques due to exposure to asbestos — K.H. Kilburn, R.H. Warshaw (1990)
• Biological materials for diaphragmatic repair: initial experiences with the PeriGuard Repair Patch® — P. Zardo, R. Zhang, et al. (2011)
• Long term survival and perioperative propensity score matched outcomes of diaphragmatic resections compared to stripping in cytoreductive surgery + intra-peritoneal chemotherapy — B. Singh, G. Singh, et al. (2020)
• Polytetrafluoroethylene or Acellular Dermal Matrix for Diaphragmatic Reconstruction? — J.K. Bassuner, D.C. Rice, et al. (2017)
• A new technique of diaphragmatic patch fixation in extrapleural pneumonectomy — M. Schiavon, A. De Filippis, et al. (2010)

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