Case Report
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World J Gastrointest Surg. Jun 27, 2013; 5(6): 202-206
Published online Jun 27, 2013. 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, Daniel Neureiter, Clemens Nawara, Adam Dinnewitzer, Dietmar Öfner, Wolfram Lamadé
Tarkan Jäger, Clemens Nawara, Adam Dinnewitzer, Dietmar Öfner, Department of Surgery, Paracelsus Medical University, 5020 Salzburg, Austria
Daniel Neureiter, Institute of Pathology, Paracelsus Medical University/Salzburger Landeskliniken, 5020 Salzburg, Austria
Wolfram Lamadé, Department of Surgery, Helios Spital, 88662 Überlingen, Germany
Author contributions: Jäger T wrote the manuscript, carried out the literature review and organized the figures; Öfner D and Neureiter D performed research and contributed new aspects; Dinnewitzer A and Nawara C helped carry out the literature analysis and assisted in writing the manuscript; Lamadé W made substantial contributions to conception, design and revised for final approval.
Correspondence to: Tarkan Jäger, MD, Department of Surgery, Paracelsus Medical University, Müllner Hauptstraße 48, 5020 Salzburg, Austria. ta.jaeger@salk.at
Telephone: +43-662-448251086 Fax: +43-662-448251008
Received: December 24, 2012
Revised: April 9, 2013
Accepted: May 8, 2013
Published online: June 27, 2013
Processing time: 182 Days and 12.6 Hours
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: Hiatal hernia; Paraesophageal hernia; Intrathoracic pancreas; Intrathoracic duodenum; Diaphragmatic hernia

Core tip: Hiatal herniation of the pancreas is a rarity. In the world literature we identified 11 cases reported from 1958 to 2011. A 72-year-old Caucasian woman was admitted to the hospital with symptoms of mechanical cholestasis such as mild jaundice, pruritus, diarrhea and fatigue. Our case illustrates the serious sequelae of a hiatal hernia (HH) type IV that can occur when treated conservatively and therefore we recommend that all HH type IV should be repaired as soon as possible after the diagnosis. Despite of the fatal outcome we were encouraged to publish this case to improve future decision finding processes in similar cases.