Discussion
Surgery for incarcerated paraesophageal hernia or UDS has to be performed emergently as incarceration can become irreversible and severe bleeding can occur due to distension and vascular dilation. Moreover, ischemia and gastric perforation are on the verge. However, there are no clear evidence or existing guidelines on the management of acute paraesophageal hernia or UDS. Referring to this, Bawahab and colleagues have proposed algorithms based on the results of a series of 20 patients with acute presentation of paraesophageal hernia. From this data and our experience, we suggest prompt open surgery in cases of unstable patients. However, from our point of view, in case of gastric perforation or if there is any gastroscopic evidence of advanced gastric ischemia in stable patients, an initial laparoscopic approach is justifiable in case of adequate expertise, otherwise emergent open repair is suggested. In stable patients with acute presentation and mechanical gastric outlet obstruction due to incarceration as in the presented case, emergent laparoscopic reduction and repair is reasonable and prudent after urgent contrast-enhanced computer tomography and decompressing gastroscopy. For patients with acute presentation but without mechanical gastric obstruction and without gastric ischemia, we suggest a semi-elective repair. In summary, laparoscopic reduction and repair of acute paraesophageal hernia and UDS was shown to be safe in patients without gastric perforation or ischemia as well as feasible with low morbidity and mortality affording the benefits of minimally-invasive surgery. Moreover, studies have been published reporting on percutaneous endoscopic gastrostomy (PEG) as useful and feasible approach. Tabo et al. described a method facilitating the endoscopic reposition of the stomach by inserting a gastric balloon and to fixate the stomach subsequently applying the PEG-method (intraabdominal fixation of the stomach by gastrostomy). It may be an effective approach in elderly patients as the periprocedural risk is very low. In our young patient, however, we decided in favor of a laparoscopic approach repairing the hernia gate as sustainable therapy. In a series of 40 patients we could show that laparoscopic treatment of UDS is safe and highly effective using a laparoscopic hiatoplasty and anterior hemifundoplication.
As to the diagnosis in the ED, a high index of suspicion is essential when patients present acutely with epigastralgia and symptoms of upper gastrointestinal obstruction indicating mechanical gastric outlet obstruction. In our series, 5 of 50 patients with UDS (10%) presented with acute symptoms, two of them with gastric incarceration, one with upper gastrointestinal bleeding and one patient with omentum incarceration. In another series of 147 patients, Allen and colleagues revealed that in 95% of all patients with UDS symptoms occurred which were primarily obstructive. Complications of hiatal hernia are rarely considered in patients presenting with acute chest or epigastric pain as well as acute gastric outlet obstruction. Obstructive symptoms can range from mild nausea, bloating, postprandial fullness, dysphagia, retching or vomiting but rarely lead to the diagnosis in the ED. Hence, there is a high risk to mis- and underdiagnose an incarcerated UDS. Treatment as acute coronary syndrome (ACS) can have fatal consequences as gastric perforation. Although information and sensitivity are low, plain chest radiography should be the first diagnostic tool whereby other differential diagnoses can be considered or ruled out. As a more reliable tool to work out the details of this important differential diagnosis contrast-enhanced thoracoabdominal computer tomography is suitable especially for the detection of complications as well as the decision for indicating surgery. Impossibility of naso-gastric tube application as in our patient can be an evidence for gastric incarceration or volvulus as it is described by the Borchardt's Triad consisting of the inability to pass a naso-gastric tube, usually unproductive retching as well as epigastric pain and distension. The presented case shows the diagnostic challenge of acute presentation of paraesophageal hernia or UDS as they rarely feature one's lists of differential diagnoses of acute epigastralgia or chest pain. Having confirmed the correct diagnosis, immediate decompressing esophago-gastroscopy and emergent surgery with reduction, hernia repair and antireflux procedure are able to prevent life-threatening complications.