Herniated pancreatic body within a paraesophageal hernia

Abstract

A hiatal hernia can be classified as one of four types according to the position of the gastroesophageal (GE) junction and the extent of herniated stomach. Type I, or sliding hernias, account for up to 95% of all hiatal hernias and occur when the GE junction migrates into the posterior mediastinum through the hiatus. Type II occurs when the fundus herniates through the hiatus alongside a normally positioned GE junction. Type III is a combination of types I and II hernias with a displaced GE junction as well as stomach protruding through the hiatus. Type IV paraesophageal hernias are the rarest of the hiatal hernias. Usually, colon or small bowel is herniated within the mediastinum along with the stomach. We present a case of a paraesophageal hernia with the mid-body of the pancreas as part of the hernia contents.

Asymptomatic isolated partial hiatal herniation of the pancreas: MDCT evaluation and anatomical explanation: Case report and review of literature

“…The body of the pancreas may thus reach, through a partial detachment of its posterior fusion fascia, the posterior, retroperitoneal portion of the esophagogastric junction and herniates into the esophageal hiatus. The proposed mechanisms that lead to total or partial intrathoracic herniation of the pancreas may be multiple: -Failure of closure of the pleuroperitoneal canal as in Bochdalek hernia (Cushieri and Wilson, ; Oliver et al, ). -Traction or pulsion of a vascular pedicle by other organs, with stretching of the transverse mesocolon (Kafka et al, ; Chevallier et al, ; Katz et al, ; Gremmels et al, ; Saxena et al, ; Tagaya et al, ; Maksoud et al, ; Rozas and González, ; Coughlin et al, ). -Persistent pneumoenteric defect in the medial aspect of the right lung base (Coral et al, ). …”

“…It is therefore clear that isolated hiatal total or partial pancreatic hernia is anatomically difficult to explain and in fact it has been described only one case (Gremmels et al, 2003). Of all the other patients with a hiatal hernia, the stomach was also present in the hernia (Chevallier et al, 2001;Saxena et al, 2006;Maksoud et al, 2010;Rozas and Gonz alez, 2010;Coughlin et al, 2011), the duodenum in one (Kafka et al, 1994), the jejunum in other one (Tagaya et al, 2007). The upper third of the posterior surface of the stomach and the posterior surface of the esophago-gastric junction are devoid of peritoneum (naked areas) and occupied by dense cellular tissue that suspends the stomach to the diaphragm wall in a fairly strong way, thus representing fixed region of the stomach (Testut and Latarjet, 2006).…”

“…-Traction or pulsion of a vascular pedicle by other organs, with stretching of the transverse mesocolon (Kafka et al, 1994;Chevallier et al, 2001;Katz et al, 2002;Gremmels et al, 2003;Saxena et al, 2006;Tagaya et al, 2007;Maksoud et al, 2010;Rozas and Gonz alez, 2010;Coughlin et al, 2011).…”

“…Hiatal hernia has been found in as many as 20% of patients undergoing upper gastrointestinal endoscopy (Loffeld and van der Putten, 2002). In contrast, herniation of the pancreas through the gastroesophageal hiatus is an extremely rare condition with no more than eight cases described in the English literature (Kafka et al, 1994;Chevallier et al, 2001;Gremmels et al, 2003;Saxena et al, 2006;Tagaya et al, 2007;Maksoud et al, 2010;Rozas and Gonz alez, 2010;Coughlin et al, 2011) (Table 1), while has been described only one case of isolated pancreatic hiatal hernia (Katz et al, 2002). These patients may remain symptom free (Katz et al, 2002) or may eventually show signs of acute pancreatitis by ischemia caused by the abnormal traction on the pancreas (Chevallier et al, 2001;Tagaya et al, 2007;Maksoud e al., 2010) or by the total incarceration of the gland in a paraesophageal hernia without pancreatic volvulus (Kafka et al, 1994).…”

Pancreatic herniation: a rare cause of acute pancreatitis?

“…A type IV herniation is extremely rare, accounting for only between 5% and 7% of all paraesophageal hernias,4 with the colon being the most common viscera to herniate in addition to the stomach 5. A pancreatic herniation, however, has only been reported a handful of times 5–13.…”