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. 2013 Jun 27;5(6):202-6.
doi: 10.4240/wjgs.v5.i6.202.

Intrathoracic major duodenal papilla with transhiatal herniation of the pancreas and duodenum: A case report and review of the literature

Tarkan Jäger  1 , Daniel Neureiter, Clemens Nawara, Adam Dinnewitzer, Dietmar Ofner, Wolfram Lamadé
Affiliations

Intrathoracic major duodenal papilla with transhiatal herniation of the pancreas and duodenum: A case report and review of the literature

Tarkan Jäger et al. World J Gastrointest Surg. .

Abstract

Transhiatal herniation of the pancreas is an extremely rare condition. In the published literature we found only eleven cases reported in the period of 1958 to 2011. A coincidental hiatal herniation of the duodenum is described in two cases only. To our knowledge, we report the first case with a hiatal herniation of the complete duodenum and proximal pancreas presenting an intrathoracic major duodenal papilla with consecutive intrahepatic and extrahepatic cholestasis. A 72-year-old Caucasian woman was admitted to our department with a hiatal hernia grade IV for further evaluation. According to our recommendation of surgical hernia repair soon after the diagnosis of a transhiatal herniation of the proximal pancreas and entire duodenum, we had to respect the declared intention of the patient for a conservative procedure. So we were forced to wait for surgical repair within an emergency situation complicated by a myocardial infarction and reduced general condition. We discuss the therapeutic decision making process and a complete literature review of this rare entity.

Keywords: Diaphragmatic hernia; Hiatal hernia; Intrathoracic duodenum; Intrathoracic pancreas; Paraesophageal hernia.

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Figures

Figure 1
Figure 1
Computed tomographic scan obtained after oral administration of contrast. A: Frontal plane; B: Sagittal plane. The duodenum (D) lies dorsal to the atrial chambers. The descending duodenum is in immediate proximity to the left atrial (LA) chamber. The diaphragm is pointed out as the red dashed line. P: Head of pancreas; CBD: Common bile duct; STO: Stomach; DB: Duodenal bulb; DD: Descending duodenum; HD: Horizontal duodenum; AD: Ascending duodenum; AO: Aorta.
Figure 2
Figure 2
Intraoperative findings. A: After midline laparotomy; B: After reposition of the hiatal content; C: After closure with non-absorbable mesh. Asterisk indicates constriction of the common bile duct; Asterisks indicate closure of the esophageal hiatus with mesh and non-absorbable sutures. STO: Stomach; PY: Pylorus; J: Jejunum; CBD: Enlarged common bile duct; LHL: Left hepatic lobe; P: Pancreas; D: Duodenum; DIA: Diaphragm; GEJ: Gastroesophageal junction.
See this image and copyright information in PMC

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