Search

Patients with GPEH form a heterogeneous group, and we still have more questions than answers. Although we have used the past 100 years to become adept at repairing GPEH, it is time we attempt to address our knowledge gaps. Conflict of Interest Statement The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.

Thoracic foregut surgical emergencies, such as esophageal perforations and incarcerated hiatal hernias, can be challenging in geriatric patients. Untreated, these conditions are associated with high morbidity and mortality, yet surgical intervention and repair often involve complex procedures associated with high morbidity and mortality and/or loss of independence in geriatric patients. This chapter discusses the diagnosis and management of esophageal perforation and incarcerated hiatal hernias in the geriatric population, with special emphasis on minimally invasive and robotic surgical approaches.

To the Editor, We are grateful to Dr. Boone and colleagues for their insightful comments regarding our report on the incidence of incarcerated hiatus hernia after robotic-assisted transhiatal esophagectomy [1]. We agree with Dr. Boone and colleagues that a complication of an incarcerated hiatal hernia should not be induced by a transthoracic approach, as the integrity of the hiatus is maintained by this surgical technique. We wish to mention that our purpose in performing total esophagectomy via robotic transhiatal approach is to eliminate thoracoscopy or thoracotomy either by minimally invasive techniques, such as that utilized by Dr. Boone and coworkers, or as defined and reported by Luketich et al. [2]. Similar to the robotic thoracoscopic and minimally invasive thoracoscopic–laparoscopic approaches, the robotic-assisted transhiatal approach has minimal blood loss, NCCN guideline-recommended lymph node retrieval, acceptable operating times, and low mortality rates. A robotic-assisted transhiatal approach minimizes patient pain and discomfort compared with a thoracic approach, as well as reduces the risks of pulmonary complications that necessarily arise from entering the chest cavity. Relatively few reports of a transhiatal robotic approach for esophagectomy exist in the published literature [3–5]. Since our group is one of the few adopting this approach, the primary intent of the report was to share lessons learned from our initial experience with other surgeons who might wish to pursue this technique. We reiterate that in individuals with an already widened hiatus, a robotic transhiatal procedure poses a risk of stretching the hiatus to a point where a paragastric hiatus hernia may result. As mentioned in our publication, the technique that we suggest is a lateral repair approach by use of an onlay biologic mesh over the lateral part of the hiatus to decrease the size of the hiatus, thereby not impinging on the stomach and possibly compromising the blood supply to the gastric pull-up. Additionally, suturing the graft to the gastric pull-up prevents herniation of small bowel or colon through the hiatus. In closing, we acknowledge the fact that a thoracoscopic esophagectomy would certainly minimize the chances of an incarcerated hiatal hernia. However, since our implementation of the preventive technique (within selected patients) described in our report, we have not encountered any complications of incarcerated hiatus hernia within our practice.

A case of intermittent obstruction of a sliding hiatal hernia is presented. The obstruction occurred when the patient's stomach was totally above the diaphragm. The anatomy of sliding hiatal hernias is discussed, as well as the presenting signs and symptoms of obstruction in sliding hiatal hernias.

This book, edited by Dr. Skinner and the group at Johns Hopkins jointly with Dr. Belsey of Bristol, England, is a clearly written, concise monograph emphasizing the modern trend in management of gastroesophageal reflux and hiatal hernia. The chapters on function and pathology of reflux esophagitis, the material on diagnostic tests, represent a thorough coverage of the modern emphasis on reflux rather than the anatomical component of hiatal hernia. If anything, the pendulum has swung a bit too far to the exclusion of problems related to the incarceration of the viscus in the posterior mediastinum. The fact that an incarcerated hiatal hernia may cause symptoms varying from pressure symptoms to perforation in the posterior mediastinum may go unappreciated because of present day overemphasis on reflux as the primary cause of both symptoms and complications of hiatal hernia. On the other hand, as Dr. Skinner and his colleagues indicate, surgeons have