Giant hiatal hernia with intrathoracic pancreas - a single center case series and literature review.

BACKGROUND: The intrathoracic herniation of the pancreas is extremely rare 1 2 3. A review of the literature identified only 37 cases reported since 1981 unrelated to prior esophagectomy 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35. Symptoms may be absent, nevertheless cholestasis or acute pancreatitis can occur and so three subtypes can be classified 3. CASE SERIES: We report three cases of intrathoracic pancreatic herniation associated with Type IV hiatal hernia. One patient showed elevated cholestasis. None developed acute pancreatitis. Two patients underwent surgery, one was treated conservatively. LITERATURE REVIEW AND DISCUSSION: Hiatal hernias are often asymptomatic but may cause thoracic, or gastrointestinal symptoms 9. Surgery indication and timing remain controversial 1 2 36 37. Intrathoracic pancreatic herniation is rare and technically challenging, especially the pancreatic repositioning 1 2 3 34. Cholestasis or pancreatitis has been reported mainly in cases involving herniation of the pancreatic body and tail. Based on the clinical presentation, three subtypes can be defined 3 19. We analyzed the published cases and our own, classifying them by the herniated pancreatic portion and corresponding subtype. CONCLUSION: None of our patients developed acute pancreatitis, regardless of the herniated pancreatic portion. Given the rarity, individualized management and continued case reporting are essential to improve understanding and guide optimal treatment.