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World Journal of
Clinical Cases
World J Clin Cases 2020 March 26; 8(6): 1002-1187
ISSN 2307-8960 (online)
Published by Baishideng Publishing Group Inc
W J C C World Journal of
Clinical Cases
Contents Semimonthly Volume 8 Number 6 March 26, 2020
REVIEW
1002 Gut microbiota and nutrient interactions with skin in psoriasis: A comprehensive review of animal and
human studies
Damiani G, Bragazzi NL, McCormick TS, Pigatto PDM, Leone S, Pacifico A, Tiodorovic D, Di Franco S, Alfieri A, Fiore M
1013 Microbiota-gut-brain axis and its affect inflammatory bowel disease: Pathophysiological concepts and
insights for clinicians
Sinagra E, Utzeri E, Morreale GC, Fabbri C, Pace F, Anderloni A
MINIREVIEWS
1026 Distal esophageal spasm: Update on diagnosis and management in the era of high-resolution manometry
Gorti H, Samo S, Shahnavaz N, Qayed E
ORIGINAL ARTICLE
Retrospective Study
1033 Clinical course of percutaneous cholecystostomies: A cross-sectional study
Er S, Berkem H, Özden S, Birben B, Çetinkaya E, Tez M, Yüksel BC
1042 Clinical characteristics and 28-d outcomes of bacterial infections in patients with hepatitis B virus-related
acute-on-chronic liver failure
Li C, Su HB, Liu XY, Hu JH
1056 Application of hybrid operating rooms for treating spinal dural arteriovenous fistula
Zhang N, Xin WQ
1065 Ruxolitinib add-on in corticosteroid-refractory graft-vs-host disease after allogeneic stem cell
transplantation: Results from a retrospective study on 38 Chinese patients
Dang SH, Liu Q, Xie R, Shen N, Zhou S, Shi W, Liu W, Zou P, You Y, Zhong ZD
META-ANALYSIS
1074 Laparoscopic surgery for early gallbladder carcinoma: A systematic review and meta-analysis
Feng X, Cao JS, Chen MY, Zhang B, Juengpanich S, Hu JH, Topatana W, Li SJ, Shen JL, Xiao GY, Cai XJ, Yu H
1087 Long-term clinical performance of flapless implant surgery compared to the conventional approach with
flap elevation: A systematic review and meta-analysis
Cai H, Liang X, Sun DY, Chen JY
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March 26, 2020 Volume 8 Issue 6
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Contents World Journal of Clinical Cases
Volume 8 Number 6 March 26, 2020
1104
1108
1116
1129
1137
1142
1150
1158
1164
1172
1180
CASE REPORT
Diagnosis and management of glandular papilloma of lung: A case report
Wu CW, Chen A, Huang TW
Abnormal serum carbohydrate antigen 19-9 levels in a patient with splenic retiform haemangioendothelioma
concomitant with hepatic amyloidosis: A case report
Sun KD, Zhang YJ, Zhu LP, Yang B, Wang SY, Yu ZH, Zhang HC, Chen X
Hepatoid carcinoma of the pancreas: A case report and review of the literature
Zeng SX, Tan SW, Fong CJTH, Liang Q, Zhao BL, Liu K, Guo JX, Tao J
Successful treatment of systemic sclerosis complicated by ventricular tachycardia with a cardiac
resynchronization therapy-defibrillator: A case report
Chen YY, Yan H, Zhu JH
Metabolic and genetic assessments interpret unexplained aggressive pulmonary hypertension induced by
methylmalonic acidemia: A case report
Liao HY, Shi XQ, Li YF
Hyoid-complex elevation and stimulation technique restores swallowing function in patients with lateral
medullary syndrome: Two case reports
Jiang YE, Lyu QQ, Lin F, You XT, Jiang ZL
Microscopic removal of type III dens invaginatus and preparation of apical barrier with mineral trioxide
aggregate in a maxillary lateral incisor: A case report and review of literature
Liu J, Zhang YR, Zhang FY, Zhang GD, Xu H
Cerebral venous sinus thrombosis following transsphenoidal surgery for craniopharyngioma: A case report
Chang T, Yang YL, Gao L, Li LH
Hepatoid adenocarcinoma of the stomach: Thirteen case reports and review of literature
Zhang ZR, Wu J, Li HW, Wang T
Growth hormone therapy for children with KBG syndrome: A case report and review of literature
Ge XY, Ge L, Hu WW, Li XL, Hu YY
Laparoscopic repair of complete intrathoracic stomach with iron deficiency anemia: A case report
Yasheng D, Wulamu W, Li YL, Tuhongjiang A, Abudureyimu K
WJCC https://www.wjgnet.com
March 26, 2020 Volume 8 Issue 6
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Contents World Journal of Clinical Cases
Volume 8 Number 6 March 26, 2020
ABOUT COVER Editorial Board Member of World Journal of Clinical Cases, Woon-Man Kung,
MD, MSc, Assistant Professor, Surgeon, Department of Exercise and Health
Promotion, College of Education, Chinese Culture University, Taipei,
Taiwan
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Medicine, General and Internal (quartile in category Q3).
RESPONSIBLE EDITORS FOR
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NAME OF JOURNAL
World Journal of Clinical Cases
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ISSN 2307-8960 (online)
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March 26, 2020 Volume 8 Issue 6
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W J C C World Journal of
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Submit a Manuscript: https://www.f6publishing.com World J Clin Cases 2020 March 26; 8(6): 1180-1187
DOI: 10.12998/wjcc.v8.i6.1180 ISSN 2307-8960 (online)
CASE REPORT
Laparoscopic repair of complete intrathoracic stomach with iron
deficiency anemia: A case report
Duolikun Yasheng, Wubulikasimu Wulamu, Yi-Liang Li, Airexiati Tuhongjiang, Kelimu Abudureyimu
ORCID number: Duolikun Yasheng
(0000-0003-1092-1391);
Wubulikasimu Wulamu
(0000-0003-4264-9580); Yi-Liang Li
(0000-0002-5251-7496); Airexiati
Tuhongjiang (0000-0002-0228-1569);
Kelimu Abudureyimu
(0000-0001-6219-4929).
Author contributions: Yasheng D
and Li YL were the surgeons in
charge of the patient, reviewed the
literature and interpreted the
imaging findings; Wulamu W
reviewed the literature and was
mainly responsible for writing and
revising the manuscript;
Tuhongjiang A reviewed the
literature and collected the data;
Abudureyimu K, Yasheng D and
Li YL performed the surgery;
Abudureyimu K was responsible
for the supervision and revision of
the manuscript for important
intellectual content; All authors
issued final approval for the
version to be submitted.
Informed consent statement:
Informed written consent was
obtained from the patient for
publication of this report and any
accompanying images.
Conflict-of-interest statement: The
authors declare that they have no
conflict of interest.
CARE Checklist (2016) statement:
The authors have read the CARE
Checklist (2016), and the
manuscript was prepared and
revised according to the CARE
Checklist (2016).
Open-Access: This article is an
open-access article that was
selected by an in-house editor and
Duolikun Yasheng, Yi-Liang Li, Airexiati Tuhongjiang, Kelimu Abudureyimu, Department of
Minimally Invasive Surgery, Hernia and Abdominal Wall Surgery, People’s Hospital of
Xinjiang Uygur Autonomous Region, Urumqi 830001, Xinjiang Uygur Autonomous Region,
China
Wubulikasimu Wulamu, Department of Gastrointestinal Surgery, The University of Hong Kong-
Shenzhen Hospital, Shenzhen 518053, Guangdong Province, China
Corresponding author: Kelimu Abudureyimu, MD, Chief Doctor, Executive Vice President,
Professor, General Surgeon, Department of Minimally Invasive Surgery, Hernia and
Abdominal Wall Surgery, People's Hospital of Xinjiang Uygur Autonomous Region, 91
Tianchi Road, Tianshan District, Urumqi 830001, Xinjiang Uygur Autonomous Region, China.
klm6075@163.com
Abstract
BACKGROUND
Giant paraesophageal hiatal hernias (HH) are very infrequent, and their spectrum
of clinical manifestations is large. Giant HH mainly occurs in elderly patients,
and its relationship with anemia has been reported. For the surgical treatment of
large HH, Nissen fundoplication is the most common antireflux procedure, and
the reinforcement of HH repair with a patch (either synthetic or biologic) is still
debatable.
CASE SUMMARY
We report on a case of giant paraesophageal HH in a middle-aged male patient
with reflux symptoms and severe anemia. After performing a series of tests and
diagnostic approaches, results showed a complete intrathoracic stomach
associated with severe iron deficiency anemia. The patient underwent successful
laparoscopic hernia repair with mesh reinforcement and Nissen fundoplication.
Postoperatively, reflux symptoms were markedly relieved, and the imaging
study showed complete reduction of the hernia sac. More importantly, anemia
was resolved, and hemoglobin, serum iron and ferritin level were returned to the
normal range. The patient kept regular follow-up appointments and remained in
a satisfactory condition.
CONCLUSION
This case report highlights the relationship between large HH and iron deficiency
anemia. For the surgical treatment of large HH, laparoscopic repair of large HH
combined with antireflux procedure and mesh reinforcement is recommended.
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March 26, 2020 Volume 8 Issue 6
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fully peer-reviewed by external
reviewers. It is distributed in
accordance with the Creative
Commons Attribution
NonCommercial (CC BY-NC 4.0)
license, which permits others to
distribute, remix, adapt, build
upon this work non-commercially,
and license their derivative works
on different terms, provided the
original work is properly cited and
the use is non-commercial. See:
http://creativecommons.org/licen
ses/by-nc/4.0/
Manuscript source: Unsolicited
manuscript
Received: December 17, 2019
Peer-review started: December 17,
2019
First decision: January 13, 2020
Revised: February 10, 2020
Accepted: March 5, 2020
Article in press: March 5, 2020
Published online: March 26, 2020
P-Reviewer: Bandyopadhyay SK,
Sugimoto H
S-Editor: Dou Y
L-Editor: Filipodia
E-Editor: Qi LL
Key words: Complete intrathoracic stomach; Giant paraesophageal hiatal hernia; Iron
deficiency anemia; Nissen fundoplication; Mesh reinforcement; Case report
©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
Core tip: Giant paraesophageal hiatal hernia (HH) usually occurs in elderly patients and
is relatively rare. We present a case of complete intrathoracic stomach in a 46-year-old
male with reflux symptoms and severe iron deficiency anemia. The patient underwent
successful laparoscopic hernia repair with mesh reinforcement and Nissen
fundoplication. Postoperatively, reflux symptoms and iron deficiency anemia were
resolved. The patient remained in a satisfactory condition. This case highlights that large
HH is a potential cause of iron deficiency anemia. For the surgical treatment of large
HH, laparoscopic repair of large HH combined with antireflux procedure and mesh
reinforcement is recommended.
Citation: Yasheng D, Wulamu W, Li YL, Tuhongjiang A, Abudureyimu K. Laparoscopic
repair of complete intrathoracic stomach with iron deficiency anemia: A case report. World J
Clin Cases 2020; 8(6): 1180-1187
URL: https://www.wjgnet.com/2307-8960/full/v8/i6/1180.htm
DOI: https://dx.doi.org/10.12998/wjcc.v8.i6.1180
INTRODUCTION
Classically, hiatal hernias (HH) are divided into four types according to the anatomic
position of the gastric cardia. Among all types of HH, type I or sliding HH, is the most
common with a prevalence of 95%, while the combination of types II, III and IV, or
paraesophageal HH, account for around 5% of all HH[1]. Therefore, paraesophageal
HH are relatively rare and usually occur in elderly patients. A giant HH is defined as
a hernia that consists of > 30% of the stomach herniating through the diaphragmatic
hiatus into the thorax[2], which makes it more uncommon among paraesophageal HH.
Clinical manifestations of giant HH are unspecific, making their clinical diagnosis
somewhat difficult. However, the relationship between large HH and anemia has
previously been reported. Likewise, the association of gastroesophageal reflux disease
and HH has long been established. Yet some reported that the patients with HH may
have esophagitis or Barrett’s esophagus[3,4]. Hence, we report a case of a middle-aged
patient with complete intrathoracic stomach, or a giant paraesophageal HH, who
presented with reflux symptoms and anemia. Written consent was obtained from the
patient, and the study was approved by the Ethics Committee of People's Hospital of
Xinjiang Uygur Autonomous Region (Protocol number: KY2018122001).
CASE PRESENTATION
Chief complaints
A 46-year-old male was admitted to our hospital with chief complaints of heartburn,
regurgitation and belching for the last 5 years, and symptoms could be worsened after
having a meal. The main symptoms were as follows: Dizziness, hypodynamia and
occasionally with nausea and vomiting as well as chest tightness.
History of present illness
Approximately 4 mo earlier, the patient noted that the symptoms worsened even with
the medicines and was referred to our hospital.
History of past illness
A diagnosis of HH and iron deficiency anemia (IDA) was made by another hospital,
and the patient received omeprazole (40 mg bid) and domperidone (10 mg tid) per
day. In addition, the patient received several blood transfusions with the total volume
of 1200 mL (the lowest hemoglobin level was 55 g/L). After discharge, the patient
took the medicines for a long period of time. His conditions improved only while
consistently taking the medicine.
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Physical examination
The patient was 170 cm in height and 84 kg in weight with body mass index of 29.07
kg/m2. On examination, after admission to our hospital, the temperature was 36.7 °C,
the pulse was 96 beats per minute, the blood pressure was 135/83 mmHg, and the
respiratory rate was 18 breaths per minute. Bowel sounds were present. The
remainder of the examination was normal. He did not have carotid bruits or jugular
venous distention, nor did he have cardiac or pulmonary murmur or rub on
auscultation.
Laboratory examinations
Laboratory test results were significant for hemoglobin (105 g/L, normal 130-175
g/L), serum iron (6.06 μmol/L, normal range 11-30 μmol/L), serum ferritin (9.1 μg/L,
normal range 15-200 μg/L), oxygen partial pressure (61 mmHg, normal range 80-105
mmHg) and oxygen saturation (91%, normal range 95%-98%).
Imaging examinations
Chest X-ray demonstrated an intrathoracic gastric bubble with increased bilateral
lung marking (Figure 1). Chest computed tomography with volumetric analysis
demonstrated post-mediastinal location of the whole stomach along with peritoneal
fat compressing both bilateral lung and heart (Figure 2). Furthermore, quantitative
measurements for the size of the hernia sac, diameter of hernia port, volume of hernia
sac and thoracic cavity as well as a ratio of volume of hernia sac to intrathoracic cavity
were 13.4 cm × 18.6 cm, 6 cm, 1476.4 cm3, 4025 cm3 and 36.7%, respectively. Barium
contrast radiography confirmed large HH and the configuration of the stomach
within the hernia suggested an organoaxial volvulus (Figure 3).
Further diagnostic work-up
Electrocardiogram and cardiac ultrasonography did not show any abnormalities. To
clarify the current and other related possible diagnosis, a series of studies were
performed. However, esophageal high-resolution manometry and 24-hr multichannel
intraluminal impedance-pH monitoring showed the presence of HH with an elevated
level of lower esophageal sphincter of 9.6 cm high, pathological acid reflux and
DeMesster score of 64.6 (Figure 4).
FINAL DIAGNOSIS
The final diagnosis of the presented case is giant paraesophageal HH and IDA.
TREATMENT
After careful preoperative evaluation for surgical repair, a successful laparoscopic
hernia repair with mesh reinforcement and Nissen fundoplication was carried out in
accordance with the guidelines recommended by the Society of American
Gastrointestinal and Endoscopic Surgeons[5]. The patient was positioned in supine,
split-leg position, and the chief surgeon stood between the patient’s legs, while the
assistant surgeon stood on the patient’s left. Four ports and a homemade liver
retractor were used for surgical access. The initial port of 12 mm was placed supra-
umbilically for the laparoscope. After entry, the abdomen was explored looking for
iatrogenic injury and the presence of intra-abdominal adhesions that would hinder
subsequent port placement. A 12 mm port was then placed just below the left costal
margin in the mid-clavicular line as the main working port. The other two 5 mm ports
were also placed, one just below the right costal margin in the mid-clavicular line, and
the other in the left flank. A separate 3 mm subxiphoid incision was made for the
reverse “7” shaped, homemade liver retractor as shown in the pictures (Figure 5A and
5B).
Firstly, an atraumatic grasper was used to grasp the anterior epigastric fat pad.
Then the stomach was retracted downward and toward the left lower quadrant to
reposition. Subsequently, dissection was preformed until diaphragmatic crura were
well displayed, along with the preservation of hepatic branch of the anterior vagus
nerve. Then, 3 cm of tension-free esophagus was repositioned intra-abdominally
(Figure 5C). The hiatus was then repaired posteriorly with interrupted nonabsorbable
sutures. As the patient’s hiatal defect reached 8 cm, we preformed mesh
reinforcement using Parietex™ Composite hiatal mesh provided by Medtronic
(Minneapolis, MN, United States). Finally, Nissen fundoplication was completed. The
360° wrap was created by grasping the right and left portion of the mobile funds and
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Figure 1
Figure 1 Preoperative chest X-ray. An intrathoracic gastric bubble with increased bilateral lung marking.
pulling them behind the esophagus and sutured together in front of the anterior part
of the abdominal portion of the esophagus. The length of the wrap was 2 cm with
three sutures. At the end, a gastropexy was performed by suturing the posterior
fundus to the inferior crus with three interrupted permanent sutures (Figure 5D).
Estimated blood loss was 20 mL, and it took 80 min for the surgical procedure.
OUTCOME AND FOLLOW-UP
For the first day after surgery, abdominal examination revealed normal bowel sounds,
then the gastric tube was removed. In the following days, the patient started a liquid
diet. According to the patient’s statement, almost all of the preoperative discomforts
were gradually resolved. After discharge from the hospital, the patient presented to
our department at 1-mo post-surgery for follow-up. Neither distinctive abnormalities
nor hernia recurrence were observed from the chest X-ray (Figure 6). The patient had
an increase in postoperative hemoglobin, serum iron and serum ferritin level (135
g/L, 18.3 μmol/L and 92.4 μg/L, respectively).
DISCUSSION
Paraesophageal HH are defined as the condition in which gastroesophageal junction
and components of the abdominal cavity, most commonly the stomach, herniated via
esophageal hiatus into the mediastinum. However, most large paraoesophageal HH
occur in elderly patients with the incidence rate of > 60% above the age of 70 years
and is a relatively rare condition[6]. Interestingly, our case was a middle-aged male
patient, and it indicates that the physicians should be aware of the presence of HH
when making clinical diagnosis for the patient with atypical characteristics. Some
studies have reported that the formation of HH is related to obesity[7]. Therefore, high
body mass index can be one of the risk factors contributing to large HH in this patient,
whose body mass index (29.07 kg/m2) is close to the category of obesity.
It is crucial to distinguish between symptomatic paraesophageal HH and
asymptomatic or minimally symptomatic HH. Generally, symptomatic patients are
recommended for surgical repair to prevent subsequent acute complications, such as
strangulation, perforation and bleeding. In addition to HH repair, laparoscopic
antireflux procedure is a well-established treatment for patients suffering from reflux
disease associated with HH, especially for large paraoesophageal HH. Nissen
fundoplication is the most commonly used procedure for the treatment of
gastroesophageal reflux disease due to its good postoperative long-term reflux control
results in approximately 90% of patients[8].
In view of these facts, the patient underwent successful HH repair reinforced by a
“U” shaped mesh with Nissen fundoplication. Even though the reinforcement of the
HH repair with a patch (either synthetic or biologic) is still debatable, a meta-analysis
reported by Targarona et al[9] concluded that prosthetic reinforcement was beneficial
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Figure 2
Figure 2 Chest computed tomography with volumetric analysis. Post-mediastinal location of the whole stomach
along with peritoneal fat compressing both bilateral lung and heart.
with an acceptable rate of secondary complications. Another meta-analysis of three
randomized studies also reported that prosthetic reinforcement had a four-fold
decrease in 1-year risk of recurrence[10]. Therefore, according to related studies and our
experience, HH repair with mesh reinforcement is recommended for symptomatic
HH patients, especially for large paraoesophageal HH patients.
The relationship of IDA with HH has been studied, and it is reported that HH is a
cause of gastrointestinal bleeding and increases the risk of subsequent IDA[11]. Gray et
al[12] suggested that the prevalence of Cameron lesion, which is considered to be a
source of gastrointestinal bleeding, is known to vary with HH size, with the highest
prevalence occurring in large HH patients. They identified large HH as a major risk
factor for IDA. In our case, the patient’s reflux-related symptoms completely resolved,
and his hemoglobin level was returning to a normal range after the operation.
Consequently, this case report complements the other studies and strengthens the
evidence that large HH may be a cause of anemia.
CONCLUSION
Complete intrathoracic stomach, or giant HH, is very infrequent, and its spectrum of
clinical manifestations is large. This report presented a case of giant HH in a middle-
aged male patient with reflux symptoms and severe anemia. Although studies have
reported that large HH mainly occurs in elderly patients, one possible factor
contributing to the situation in this relatively young patient might be his high body
mass index.
According to the literature mentioned above and our case report, there appears to
be a relationship between large HH and IDA and indicates that large HH may be a
potential cause of IDA. Surgical repair of large HH relieves IDA symptoms as
reported by others[13-15] and as seen in our patient. More importantly, for the patients
suffering from reflux-related symptoms with large HH, antireflux procedure and
mesh reinforcement are recommended.
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Figure 3
Figure 3 Barium contrast radiography. Confirming large hiatal hernia, and the configuration of the stomach within the hernia suggested an organoaxial volvulus.
Figure 4
Figure 4 Esophageal high-resolution manometry. The presence of hiatal hernia with an elevated level of lower esophageal sphincter of 9.6 cm high, pathological
acid reflux.
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Figure 5
Figure 5 Mesh reinforcement and Nissen fundoplication. A: The homemade liver retractor. External view of reverse “7” shaped, homemade liver retractor; B:
Intra-operative view of the retractor; C: Repositioning of intra-abdominal esophagus. Three centimeters of tension-free esophagus was repositioned intra-abdominally;
D: Three hundred sixty degree Nissen fundoplication and mesh reinforcement.
Figure 6
Figure 6 Postoperative chest x-ray at 1-mo follow up. There were no distinct abnormalities observed.
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