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pain should be evaluated for underlying coronary artery
disease as the cause of their symptoms. Once this is
excluded, along with other potential pathology, suspected
paraesophageal hernias should be evaluated with a barium
swallow. This study provides a “snap shot” of the
esophagogastric anatomy and allows for classification of
the type of hiatal hernia. Any organoaxial rotation of the
stomach can be seen as well. It is less sensitive for the
evaluation of mucosal pathology and esophageal motility.
Endoscopy (EGD) should be performed on all patients to
assess for esophagitis, Barrett’s esophagus, peptic
stricture, Cameron’s ulcers, and malignancy. Of note,
Cameron’s ulcers are the most common source of anemia
in these patients but are not always found on endoscopy;
they are transient in nature and can be difficult to visualize
in the distorted gastric anatomy associated with large
paraesophageal hernias. Peptic strictures, if found, should
be biopsied and dilated as needed preoperatively.
Although esophageal manometry can be done, it is often
difficult to pass the probe effectively in the setting of a
paraesophageal hernia or an intrathoracic stomach.
Manometry is not critical to the preoperative workup.
The patient in this scenario undergoes further workup of
his hiatal hernia. A barium swallow demonstrates a large
paraesophageal hernia: The gastroesophageal junction
(GEJ) remains at the level of the diaphragm with gastric
antrum herniating into the chest (Figure 1). An EGD is then
performed, which confirms a large hiatal hernia with a
paraesophageal component. A Cameron’s ulcer is found
near the hiatal hernia (Figure 2A,B). The surveyed mucosa
is otherwise normal.
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FIGURE 1 • Barium contrast study showing a large para esophageal hernia.
FIGURE 2 • Upper endoscopy demonstrating a large paraesophageal
hernia with Cameron’s ulcer (
arrow
) and otherwise normal mucosa.
Discussion
The patient in this scenario has a Type II hiatal hernia.
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There are four types of hiatal hernias. Type I or the sliding
hiatal hernia is the most common, accounting for 90% to
95% of hiatal hernias. It is characterized by migration of the
GEJ through the hiatus. Type II hernias are true
paraesophageal herni as where the GEJ remains in its
normal anatomic position below the diaphragm; the gastric
fundus herniates above the GEJ though the hiatus. Type III
or mixed-type hiatal hernias are characterized by herniation
of both the GEJ and gastric fundus above the diaphragm.
These tend to be large hernias with more than 50% of the
stomach located in the mediastinum. Finally, Type IV hiatal
hernias occur when a Type II or III hernia exists and other
organs (e.g., spleen and/or colon) migrate into the thorax
as well.
Paraesophageal hernias are more common in elderly
patients aged 60 to 70 years. It remains unclear as to why
certain individuals develop paraesophageal hernias. It is
theorized that hernia formation is likely related to the
progression of a hiatal hernia in conjunction with increased
intra-abdominal pressure, as is seen in obesity and COPD.
Diagnosis and Treatment
Symptomatic patients with paraesophageal hernias
warrant surgical repair. Rarely, patients present with acute
obstruction secondary to gastric volvulus. These patients
should be decompressed with a nasogastric tube. If
necessary, endoscopy can be utilized for decompression.
This will often provide relief of the patient’s symptoms and
allows for preoperative resuscitation. These patients should
be definitively repaired within a few days of presentation.
Controversy exists regarding the surgical management of
asymptomatic paraesophageal hernias. Historically,
studies suggest that up to 30% of asymptomatic patients
with paraesophageal hernias will develop potentially
devastating complications such as strangulation and
perforation. However, recent data suggests that the
incidence of developing such complications is much lower
than the previously reported. Because of this there is some
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support for the observation of asymptomatic patients aged
65 years or older. For the most part however, most patients
with paraesophageal hernias are at a minimum, mildly
symptomatic with occasional bloating, heartburn, or
episodic dysphagia. Given the likelihood of symptom
progression over time in this elderly population, we
advocate early elective repair.
Surgical Approach
Various approaches to paraesophageal hernia repair have
been described, including open transabdominal,
transthoracic (thoracotomy), or laparoscopic
transabdominal. Recently, the laparoscopic approach has
become the preferred method of repair. Yet controversy
exists in the literature regarding the long term efficacy of
laparoscopic paraesophageal hernia repair versus open
repair. Advocates of an open approach argue that there is
a lower recurrence rate with a repair performed via
laparotomy or thoracotomy. Laparoscopic advocates
contend that not all recurrences warrant surgical
intervention as many are asymptomatic. Furthermore, the
use of biomesh as part of the paraesophageal hernia
repair has been shown to decrease recurrence rates at
least in the short term. Because of the less invasive
approach, we advocate laparoscopic repair of
paraesophageal hernias. In this elderly patient population,
the proven benefits related to perioperative recovery far
outweigh the potential for a recurrence of unclear clinical
significance.
Regardless of the surgical approach, there are four
fundamental steps to paraesophageal hernia repair:
1. Complete reduction of the stomach and GEJ into the
abdominal cavity without tension
2. Complete reduction and excision of the hernia sac
3. Crural closure
4. Fixation of the stomach in the abdomen with
fundoplication or gastropexy
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Laparoscopic paraesophageal hernia repair is performed
with the patient positioned split-legged or in lithotomy with
the surgeon standing between the patient’s legs. Access to
the abdominal cavity can be gained with an open or closed
technique. The camera port should be placed
approximately 15 to 17 mm inferior to the xiphoid process
and to the left of midline, through the rectus muscle. Fivemillimeter ports are placed under direct vision along the left
and right costal margin, each approximately 10 cm away
from the xiphoid process. These serve as the surgeon’s
operating ports. A lateral 5-mm port is placed further along
the right costal margin for the atraumatic liver grasper; this
is used to elevate the left liver lobe facilitating exposure of
the hiatus. Another 5-mm port is placed in the right upper
quadrant for the assistant. The hernia is first reduced with
gentle traction. Excessive traction can lead to injury to the
stomach and should be avoided. Dissection of the hernia
sac begins along the inner border of the crura—we prefer
starting this dissection along the left crus, continuing over
the crural arch to the right crus. This plane between the
hernia sac and the crura is developed bluntly and
dissection proceeds into the mediastinum. Care must be
taken to identify the pleural edges and reflect them laterally.
Once reduced intra-abdominally, any excess sac should be
removed from its gastric attachments. The short gastric
vessels are then divided which further facilitates exposure
of the base of the crura. There is often a large posterior
esophageal fat pad which must be reduced to allow for
complete visualization of the crural base. This allows for
placement of a Penrose drain around the esophagus and
vagus nerves for traction. Esophageal lengthening is
achieved with circumferential dissection of the esophagus
within the mediastinum. The crural defect is then closed
posterior to the esophagus using multiple, nonabsorbable
pledgeted sutures. A partial or full fundoplication over a 60French bougie is then fashioned. Any large defect is should
be reinforced with a U-shaped biomesh sutured to the
apices of the crura. Caution must be exercised in large,
long-standing paraesophageal hernias, as the vena cava
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can be pulled quite close to the right crus.
Potential pitfalls of the operation include pneumothorax,
injury to the vagus, serosal injury to the stomach, and
esophageal injury. If a pneumothorax is recognized, one
can usually continue the operation with the patient on
positive-pressure ventilation without difficulty. These more
often occur on the left, where it can be difficult to identify
pleural edge from hernia sac. At the conclusion of the case,
the pneumothorax can be evacuated with a red-rubber
catheter placed through the hiatal closure and put to waterseal. Injury to the anterior vagus nerve can occur during
reduction of the hernia sac. One must be sure to identify the
nerve that is often lifted off of the esophagus, making it
more susceptible to injury. Excessive traction on the
stomach during reduction can result in serosal tears. These
should be primarily repaired at the time of injury. Finally,
although esophageal perforations are rare, inadvertent
myotomies during dissection of the hernia sac are not
infrequent.
Special Intraoperative Considerations
Gastric perforation may occur in the patient with acute
gastric volvulus. This can usually be avoided with early
decompression and surgical intervention. These
perforations usually occur on the anterior surface of the
fundus and can be repaired primarily laparoscopically.
Short esophagus can be a challenge, limiting
esophageal mobilization to allow for 3 to 4 cm of tensionfree, intra-abdominal esophagus. Esophageal length can
usually be achieved by high mediastinal dissection. Rarely,
a Collis gastroplasty is warranted.
Management of the critically ill patient can be difficult. If
the patient cannot tolerate extensive surgery, the surgeon
should attempt separation of the sac from the esophagus
and stomach, crural closure, and gastropexy (G-tube or
suture pexy).
Postoperative Management
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Postoperative CXR is not routinely performed unless
clinically indicated. Small pneumothoraces are often seen
and not treated. Routine nasogastric decompression is not
warranted. Patients are left NPO the day of surgery and
antiemetics are given prophylactically to prevent retching.
Patients are started on a clear liquid diet without
carbonated beverages on postoperative day 1 and
advanced to a mechanical soft diet as tolerated. Patients
are usually discharged home on postoperative day 1 or day
2, depending on oral intake and mobility.
Unexplained tachycardia or shortness of breath
mandates immediate UGI study with gastrograffin followed
by barium to evaluate for a leak. If a leak is found,
immediate exploration with primary repair and drainage is
warranted. Exploratory laparoscopy can also be liberally
used to rule out postoperative bleeding or leak.
Case Conclusion
The patient undergoes a laparoscopic paraesoph
ageal hernia repair with Toupet fundoplication. He does
well ostoperatively and is discharged to home on
postoperative day 2.
TAKE HOME POINTS
Paraesophageal hernias ae common in the elderly.
Symptoms may be vague and nonspecific.
Most paraesophageal hernias should be repaired
electively.
Paraesophageal hernias can be safely repaired
through a laparoscopic approach.
Principles of repair include complete reduction of the
hernia sac, crural closure, and
fundoplication/gastropexy.
SUGGESTED READINGS
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Edye MB, Canin-Endres J, Gattorno F, et al. Durability of laparoscopic
repair of paraesophageal hernia. Ann Surg. 1998;228(4):528–535.
Lal DR, Pellegrini CA, Oeslschlager BK. Laparoscopic repair of
paraesophageal hernia. Surg Clin N Am. 2005;85:105–118.
Oelschlager BK, Pellegrini CA. Paraesophageal hernias: open,
laparoscopic, or thoracic repair? Chest Surg Clin N Am. 2001;11(3):589–
603.
Skinner DB, Belsey RH. Surgical management of esophageal reflux and
hiatus hernia. Long term results with 1030 patients. J Thorac Cardiovasc
Surg. 1967;53(1):33–54.
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14
Gastroesophageal Reflux Disease
JONATHAN F. FINKS
Presentation
A 55-year-old otherwise healthy, mildly obese (body
mass index 33) woman is referred for evaluation of
refractory heartburn and regurgitation. Her symptoms
have been present for approximately 10 years. She
initially attempted lifestyle changes, including cessation
of smoking and caffeine use, as well as weight loss, but
did not have significant relief. Her symptoms have
improved with use of twice daily proton pump inhibitors
(PPIs), but she continues to have breakthrough
symptoms, especially after eating and when lying down.
Differential Diagnosis
The leading diagnosis based on these symptoms is
gastroesophageal reflux disease (GERD). An important
consideration is whether or not there is an accompanying
hiatal hernia, as this can influence the choice of treatment.
The differential diagnosis also includes achalasia. Patients
with achalasia most often present with dysphagia, but they
will occasionally present with complaints of regurgitation
and heartburn. In the case of achalasia, heartburn occurs
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several hours after eating and usually results from
fermentation of undigested food within the esophagus.
Certain “alarm” symptoms, including dysphagia,
odynophagia, weight loss, anemia, and gastrointestinal
bleeding, should prompt a search for esophagogastric
malignancy.
Workup
For patients with classic symptoms (heartburn and
regurgitation), a good therapeutic response to a trial of PPI
therapy is diagnostic of GERD. Further workup is
indicated, however, in patients over 50, those with frequent
breakthrough symptoms or whose symptoms have
persisted for over 5 years, and those with alarm symptoms
as mentioned above.
For patients with dysphagia, a
barium swallow
is a
good first study, as it allows for assessment of esophageal
strictures (benign and malignant) and diverticula.
Furthermore, the barium swallow provides a detailed view
of the anatomic relationships of the stomach, esophagus,
and diaphragm, allowing for identification of hiatal hernias
(Figure 1). A barium swallow is also a good confirmatory
study for patients with manometric evidence of achalasia.
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