Case notes

A 71-year-old gravida 0 female presented with a 3-week history of nausea, vomiting, anorexia, and unintentional weight loss. Her past medical history was significant for hypertension, rheumatoid arthritis, type 2 diabetes, and a 15-year history of an asymptomatic diaphragmatic hernia. A computerized tomograph of the abdomen and pelvis revealed solid and cystic bilateral adnexal masses measuring in conglomerate 16 × 12 × 12 cm with tumor markers significant for an elevated CA 19-9 of 479 U/mL and CA-125 of 1906 U/mL. An ultrasound-guided peritoneal biopsy revealed clear cell ovarian cancer. Imaging of the chest revealed a large diaphragmatic hernia containing portions of colon, stomach, and a large omental cake which formed a heterogeneously enhancing mass (14 × 12 × 11 cm) compressing the right atrium ( Figures 1 and 2 ).

Coronal view of paraesophageal hernia containing bowel and omental caking

Wolfe. A case of symptomatic paraesophageal hernia. Am J Obstet Gynecol 2014 .

Cross-sectional view demonstrating bowel and omental mass present in the thoracic cavity

Wolfe. A case of symptomatic paraesophageal hernia. Am J Obstet Gynecol 2014 .

Comment

The combination of a Type IV paraesophageal hernia (PEH) and ovarian cancer is rare. Hiatal hernias affect 10-50% of the population but over 85% are Type I (sliding hiatal hernia). PEHs (types II-IV) account for up to 5% of all hiatal hernias surgically treated. A giant or Type IV PEH, defined as protrusion of stomach along with other organs including colon, spleen, and small bowel, is a rare form of diaphragmatic hernia with presenting symptoms including dysphagia, vomiting, reflux, and early satiety. Serious complications include incarceration, strangulation, perforation, and respiratory or cardiovascular compromise. Traditionally, repairs of type IV PEHs are performed through either an open laparotomy or a thoracotomy; however, recent literature supports the use of laparoscopic repair of PEHs, including type IV, with either primary or mesh supported closure.

Given this patient’s significant metastases in the herniated contents, and newly diagnosed acute deep venous thrombosis and pulmonary emboli, neoadjuvant chemotherapy was started with plans for an interval debulking with hernia repair in conjunction with thoracic surgery. Unfortunately, the patient’s disease progressed rapidly despite chemotherapy and the patient expired before surgical intervention.