Paraesophageal Hiatal Hernias

Bradley J. Phillips, MD

Burn-Trauma-ICUAdults & Pediatrics

In general…

• Optimal management is controversial.

• Points of contention– Appropriate evaluation of patients– Optimal surgical approach– +/- Antireflux procedure accompanying repair– Option of laparoscopic technique

Ferguson, Cameron 6th ed.

Types (1)

hiatal hernias are classified according to the position of the

esophagogastric junction

and the existence of a true hernia sac.

• Type I (sliding)– Leading edge of the hernia is the

esophagogastric junction, which is displaced into an intrathoracic position.

– The longitudinal axis of the stomach is aligned with the esophagus.

– There is often no true hernia sac nor is there any paraesophageal component.

Types (2)

Type II & Type III are referred to as “paraesophageal hernias”.

• Type II (rolling)– The esophagogastric junction is in its normal intraabdominal location

– The hernia sac (containing portions of the gastric fundus and body) develops alongside the esophagus

• Type III– The esophagogastric junction is displaced into the thorax and like a Type II,

the hernia sac contains portions of the gastric fundus or body.

Type II & Type III

The “Type IV” hernia ?

• increasingly common with advancing age

• more often among women than men

• symptoms are often associated with GERD

Relative Frequency According to Age

• Type I: hatched bars

• Type II & III: solid bars

Basic prevalence of Type I hernias…

Diagnosis

• Typical symptoms

• Suspicious CXR

• Chest C.T.

• Upper GI Series

• In urgent situations:– Placement of NG tube & subsequent coiling

Often difficult to assess the location of the actual

junction…

Management (1)

• Evaluation– Endoscopy– Esophageal Motility Studies– Manometry & pH Monitoring

• 1/3 of pts will have atypical peristalsis of the esophageal body

• ½ of symptomatic pts will have abnormal pH results

Management (2)

• Indications for Operation– Type I– Type II & III

• Associated with a high-risk of complications

• “catastrophic” in 20 – 30% of pts

• Symptoms do not predict risk…

Management (3)

• Findings that may prompt surgery (even in those pts that are “not optimal”)

– Symptoms of obstruction– Reflux– Anemia

• Trying to avoid:– Further aspiration– Hemorrhage– Transfusion requirements

Surgical Techniques

• Principles similar to other hernia operations

• Need to anchor the stomach

• Fundoplication is controversial

• Transthoracic vs. Transabdominal…

Results & Outcomes

Mean duration of follow-up is 1 yr.

1. Short-term:

• Mortality less than 1%

• Major complication rate up to 30%

2. Future role of laparoscopic approach…

Post-op C.T.

Post-op C.T.

Post-op C.T.

Paraesophageal Hiatal Hernias…

questions ?