The altered profile of a donated cadaver population: challenges for teaching and research?

Efforts by anatomists over the recent past, have converted the cadaver population in a South Afri-can institution from a predominantly unclaimed population into one purely derived from donors. Concurrent with this transformation were noticea-ble changes in cadaver demographics, which raised concerns for aspects of teaching and re-search. The aim of this study was therefore to ex-plore the effects of donation on the demographics and anatomical integrity of the Schools 2017 ca-daver population. The provenance, ancestry, sex and age of 74 cadavers were investigated. Dis-sected cadavers were studied to ascertain the general condition of their anatomy. Variations in tissue integrity, morphology and overt pathologies were surveyed. Cadavers represented only one population group with slightly more females (54%). The majority of the cohort (62%) was aged be-tween 71 and 90 years. With regards to anatomical integrity, 60% of the cadavers presented with ad-hering fascia, but no significant differences in the quantity of fat were found across the sample. High levels of muscle tearing and atrophy (76%) oc-curred and variations in visceral anatomy were noted. Various surgical interventions and overt pathologies were also observed. The donated ca-daver population differed from previous unclaimed cadaver populations in that they consisted of only White, older individuals. Variations, surgical inter-ventions and pathologies offer staff in anatomy an opportunity to engage with more clinically-oriented teaching, as well as introducing students to the discipline of gerontology.

Causes of unsuccessful surgical treatment of hiatal hernia

Hiatal hernia is the most common type of visceral anatomy disorder, observed in people under 30 years of age in 10%, older than 50 years in 60%. Four types of hiatal hernias (IIV) are distinguished by the variant of the disturbances in the relationship between the esophagus, stomach, and diaphragm. Indications for surgical treatment of hiatal hernias are gastroesophageal reflux or anatomical disorders, which have a risk of developing life-threatening conditions (obstruction or necrosis of the stomach). An unresolved problem in this part of surgery is the high rate of disease recurrence, reaching 1015 4060%. The subjective reasons for the unsatisfactory results of surgical treatment of this pathology include technical errors in performing interventions (insufficient mobilization of the esophagus, stomach, legs of the diaphragm, incomplete excision of the hernial sac) and flaws in perioperative support (insufficient analgesia, vomiting, cough). The objective factors of the repeated displacement of the abdominal organs into the chest are the large size of the hiatal opening (more than 5 cm in maximum dimension), the insufficient mechanical strength of the legs of the diaphragm (hypotrophy, fibrosis) and the shortening of the esophagus (reduction of the abdominal part length less than 5 cm). Each of the noted factors plays a own role, together determining the success or failure of the surgical intervention. Understanding the basic principles and unresolved issues in this field of surgery is a prerequisite for its further development.

Poor results of surgical treatment of hiatal hernias. Is there a solution to the problem?

Hiatal hernias are the most common violation of visceral anatomy. Indications for surgical treatment of this pathology include refractory gastroesophageal reflux or anatomical changes, which carry a risk of developing life-threatening conditions. An unresolved problem in this area of surgery is the high recurrence rate of the disease, reaching 1040%. Subjective causes of unsatisfactory results are technical errors in performing interventions and violations of perioperative management. Compliance with the methodology of operations and the rules of patient management can minimize this group of factors. Large size of the hiatal opening, mechanical weakness of diaphragm crura and shortening of the esophagus are considered to be objective causes for the recurrent disease. An effective way to increase the reliability of the plastic esophageal opening of the diaphragm is the use of prosthetic materials. When the esophagus is shortened, it is possible to increase its length with the stomach (gastroplasty) or with the formation of a fundoplication wrap in the chest. Another option to increase the reliability of the operation may be fixing the stomach to the anterior abdominal wall (gastropexia) to prevent its redeployment to the chest. The use of this arsenal of techniques allows to reduce the frequency of unsatisfactory results after surgical treatment of hiatal hernias by up to 510%.

SURGICAL TREATMENT OF RECURRENT HIATAL HERNIAS

OBJECTIVE. Hiatal hernias are the most common type of visceral anatomy disorder. The unresolved problem of surgical treatment of this pathology remains the high frequency of its relapse. Currently, it is believed that repeated surgical interventions for hiatal hernia are technically difficult, carry a high risk of complications and have unsatisfactory long-term results.MATERIAL AND METHODS. In the period from 2015 to 2019, 55 patients with this pathology were operated. In 52 (94.5 %) cases, the revision operation was performed laparoscopically, in 3 (5.5 %) – through left-side thoracotomy. The technique of the operation implied the removal of hiatal hernia and the implementation of antireflux reconstruction. In five (9.9 %) patients with a shortened esophagus, the fundoplication wrap was originally created in the chest; in 50 (90.1 %), normal anatomy was restored.RESULTS. Long-term results ranging from 12 to 48 months were evaluated in 53 (96.4 %) cases. The natural position of the esophagus and stomach in relation to the diaphragm was detected in 43 (81.1 %) patients, relapse of hiatal hernia – in 5 (9.4 %). In 5 patients, the fundoplication wrap formed in the chest was functional. The absence of gastroesophageal reflux was observed in 41 (91.8 % of patients who had GERD before surgery). In 4 (8.8 %) cases, including one patient with antireflux reconstruction in the chest, a relapse of the disease occurred.CONCLUSION. The presented results allowed the surgical treatment of recurrent hiatal hernias reasonable and effective.The authors declare no conflict of interest.The authors confirm that they respect the rights of the people participated in the study, including obtaining informed consent when it is necessary, and the rules of treatment of animals when they are used in the study. Author Guidelines contains the detailed information.