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34 Paraesophageal Hernias
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disruption- degeneration of the muscles, reduced muscle bers,
increased inammatory cell inltrate, and increased interstitial
spaces [9, 10].
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Presentation andEvaluation
Presentation
Patient evaluation begins with a thorough history and physical
exam. Many PEH are asymptomatic or have subclinical or unrecognized symptoms. Foregut and upper respiratory symptoms predominate, and their frequency will vary by clinical practice.
Patients present in their 7th and 8th decades with heartburn (30–
65%), chest pain (19–48%), dysphagia (5–48%), early satiety
(7–50%), dyspnea (48%), and cough (14%) [11, 12]. Detailed
investigation might identify more insidious symptoms such as
avoiding particular foods (14%), decreased meal size (18%), and
avoiding an evening meal (10%) [11]. Anemia is often observed
among patients undergoing hiatal hernia repair (23–41%), but it is
also common among patients in their 7th and 8th decades without
a hiatal hernia [11–13]. As the proportion of intrathoracic stomach increases, there is a stronger association with symptoms of
early satiety, anemia, dyspnea, and decreased meal size [11].
Physical exam is commonly nonspecic. However signs of
weight loss, respiratory disease, and previous abdominal surgery
should be noted. All patients undergoing elective surgery should
be assessed for tness and optimized if necessary.
Rarely do patients present with signs and symptoms of acute
gastric volvulus, including epigastric pain, dry retching, and
inability to pass a nasogastric tube, known as Borchardt’s triad.
Hill provides a good description of gastric volvulus with the
observation of regurgitation of saliva, substernal chest pain, and
complete inability to swallow liquids or solids in addition to
Borchardt’s triad [14].
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I. R. Kriley et al.
Evaluation
Radiography
Chest X-ray may reveal a gastric bubble or other hollow viscous
above the diaphragm or a nasogastric tube coiled above the diaphragm but will not provide detailed anatomic information.
Barium esophagram provides more detailed information than
chest X-ray regarding the relationship between the GEJ and the
diaphragmatic hiatus and can differentiate type II and III hiatal
hernias. However, it is less sensitive and specic than endoscopy
for the type of PEH [15]. On the other hand, barium esophagram
has been shown to be superior to endoscopy in diagnosing type I
hiatal hernias in morbidly obese patients [16]. Esophagram can
also identify esophageal dilatation (Fig.34.1) or achalasia, ndings which will change management and are important since
manometry cannot be performed in all patients with PEH [17, 18].
Gastric volvulus (Fig.34.2), esophageal stricture, and esophageal
diverticulum (Fig.34.3) and a short esophagus are other ndings
possible on esophagram. Gastric volvuli can be organo-axial or
mesentero-axial with organo-axial being more common. The
Fig. 34.1 Dilated esophagus in a patient with aperistalsis and a moderatesized PEH, EGD showing LA D Esophagitis. The patient is a 64-year-old
female that underwent a laparoscopic hiatal hernia repair and a partial fundoplication due to absent motility. She experienced complete relief of GERD
symptoms and no post-operative dysphagia
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Fig. 34.2 Organoaxial gastric volvulus on esophagram and appearance on
EGD.The patient is a 68-year-old female who presents to the clinic with a
longstanding history of worsening chest pain, progressive dysphagia, and
reux. She underwent an uncomplicated robotic-assisted paraesophageal hernia repair with mesh and a Toupet fundoplication with good response
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Fig. 34.3 Large PEH and an epiphrenic diverticulum. The patient is a
57-year-old female with longstanding dysphagia. A laparoscopic PEH repair
with a Heller myotomy/Toupet fundoplication was performed. The diverticulum was mid esophageal and could not be reached laparoscopically and was
not excised. The patient experienced complete resolution of symptoms postoperatively
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organo-axial volvulus appears in a “C” conguration with the
greater curvature of the stomach lying superiorly [19].
Computed tomography provides the most detailed anatomic
information for hiatal hernias including the position of the GEJ in
relation to the diaphragm, the degree of gastric herniation, and the
presence of other abdominal organs in the hernia sac. CT scan is
utilized selectively if a complicated or a “giant” PEH is suspected
or to evaluate for other intraabdominal pathology.
I. R. Kriley et al.
Endoscopy
Esophagogastroduodenoscopy (EGD) should be performed preoperatively in patients with PEH.In patients with PEH, no gastroesophageal ap valve is present, and the esophageal lumen is
wide open and easily visualized (Hill grade IV) [20]. A type III
PEH can be distinguished from a type II PEH by observing the
squamocolumnar junction 2cm proximal to the crural indentation
on the gastric lumen, comparing the relationship of the squamocolumnar junction to the hiatus on retroexion, and assessing
whether or not the fundus is herniated alongside the endoscope
[21]. EGD can also identify intraluminal pathologies such as
esophagitis, Barrett’s esophagus, Cameron’s ulcers, and malignancy. Difculty or inability to reach the duodenum in the presence of a large hiatal hernia is diagnostic for a volvulus [1].
Assessment of the size of the hernia on the EGD can be misleading. The best measure of the size of the PEH may be its intraoperative assessment [22].
Manometry andpH Monitoring
High-resolution manometry (HRM) can help diagnose hiatal hernias based on the degree of separation between the LES and the
crural diaphragm (Fig. 34.4). HRM however does not alter the
management of PEH if an esophagram has been performed.
Passing the manometry probe beyond the GEJ into the stomach
can be challenging in most patients, limiting the data that can be
reliably obtained. If the catheter can be advanced, the ndings of
abnormal motility and esophagogastric junction (EGJ) outow
obstruction are common; however, hiatal hernias have not been
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Fig. 34.4 A 2.7cm hiatal hernia diagnosed on HRM (white arrow) and size
conrmed on esophagram. The patient is a 52-year-old female with classic
symptoms of GERD and high distal esophageal acid exposure who responded
well to a Nissen fundoplication
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shown to be an independent risk factor for esophageal dysmotility
[23, 24]. Pre-operative HRM results are not associated with symptomatic outcomes after surgery [25]. Those with abnormal
manometry results report similar degrees of dysphagia to those
with normal manometry results after PEH repair. Omitting
manometry does not lead to more dysphagia regardless of whether
a total or partial fundoplication is performed [26]. Preoperative
dysphagia is usually the best predictor of postoperative dysphagia
in these patients. Testing pH is not routinely performed since the
problem is anatomic, and it does not change the management.
Treatment
Indications forSurgery
Surgery is indicated for symptomatic PEH. In the last century,
elective repair was advocated to prevent acute volvulus. An analytic model, reported in 2002, of a hypothetical cohort of patients
with asymptomatic or minimally symptomatic PEH (belching or
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heartburn) compared elective repair to watchful waiting [27, 28].
The model revealed that the mortality of emergent PEH repair
was overestimated (5% vs 17% reported in the literature), the
annual rate of developing acute symptoms requiring surgery was
1.16%, and the policy of elective repair for patients greater than
65 years old resulted in a reduction of quality adjusted life years
(10.78 vs 10.65).
Rarely, a patient will present with acute volvulus, which is a
surgical emergency. The principles of treatment include decompression of the stomach via a nasogastric tube, intravenous uid
resuscitation, reduction of the volvulus, repair of the underlying
condition predisposing to the volvulus, and xation of the stomach via gastropexy. The patient’s age, frailty, and comorbidities
should also be taken into consideration as a majority of cases
occur in the elderly population [29]. In frail patients, endoscopy
to reduce the volvulus and gastropexy with percutaneous endoscopic gastrostomy (PEG) may be sufcient [30, 31]. When acute
gastric volvulus is secondary to a PEH, as are the majority of
cases, the laparoscopic technique has been shown to be safe and
feasible and follows the standard technique for PEH repair including a fundoplication as a point of xation for the stomach [29,
32–34] (Fig.34.5).
I. R. Kriley et al.
Surgical Technique
Minimally invasive repairs of PEH are well established and are
associated with decreased intraoperative injury, decreased hospital mortality (0.6% vs 3%), decreased wound healing, bleeding,
urinary, septic, respiratory, and cardiac complications, and
decreased length of stay (4.2 vs 8.5 days) compared to an open
approach [35]. Presently, over 90% of PEH repairs are performed
by a minimally invasive approach with an open approach most
often reserved for emergent or difcult and re-operative cases
[36]. The patient is placed in a split leg position and a ve-trocar
approach for a foregut operation is utilized. Basic principles of
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Fig. 34.5 Pre- and post-operative esophagram of a patient with a redo paraesophageal hernia repair. The patient is a 49-year-old female with two prior
paraesophageal hernia repairs with mesh/Nissen fundoplication who presented with dysphagia. Pre-op esophagram shows a triangular conguration
of the incarcerated proximal stomach. Intraoperatively dense adhesions were
found in the mediastinum along with a short esophagus. A paraesophageal
hernia repair was performed along with a Collis gastroplasty and conversion
to a Roux-en-Y gastric bypass. Post-operative course was complicated by a
pulmonary embolism but complete resolution of foregut symptoms
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repair include reduction of hernia contents, complete sac excision,
high mobilization of the esophagus to obtain 2–3cm. of intraabdominal length, tension- free crural approximation with selective
mesh reinforcement, and nally the addition of an anti-reux procedure.
Post-Operative Care
Nausea and cough should be prevented aggressively [37]. A liquid
diet can be started on the rst post-operative day and should be
continued for 1–2 weeks. Routine contrast esophagram in asymptomatic patients is not necessary but often performed to assess
post-operative anatomy.
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I. R. Kriley et al.
Robot Vs Laparoscopy
While robotic platforms are increasingly being utilized no randomized control trials have compared laparoscopic and robotic
approaches to PEH repair. Recent large retrospective experiences
comparing laparoscopic and robotic PEH repair have been published with differing conclusions [38, 39]. A group in NewYork
reported on PEH repairs for 128 patients, including 84 laparoscopic and 44 robotic hiatal hernia repairs with no advantage
observed in hospital length of stay, 30-day readmission, 30-day
reoperation rate, and complication rates [39]. In contrast, a report
from Texas included 293 patients, including 151 laparoscopic and
142 robotic hiatal hernia repairs observed reduced mean operative
time (158 min, range 132–188, vs 186 min, range 152–232),
fewer complications (9[6.3%] vs 29[19.2%]), and shorter length
of stay (1.3 vs 1.8 days) for those undergoing robotic surgery [38].
In both studies, the robotic repair groups had higher proportions
of patients who were undergoing surgery for recurrent PEH, suggesting that surgeons perceive an advantage to the robotic
approach in more difcult cases.
Mesh
With recurrence rates ranging from 10–72% after cruroplasty
there is a signicant interest in reducing recurrences [40]. Mesh
reinforcement of cruroplasty for PEH repair has been investigated
in several randomized trials [40–42]. Well-designed and conducted randomized trials with long-term follow-up and rigorous
objective anatomic and symptomatic evaluation did not demonstrate a reduced recurrence rate with mesh reinforcement [41–43].
Large, randomized trials reported recurrence rates of 50–54%
with mesh and 39.3–59% without mesh in long-term follow-up.
Neither group was shown to be signicantly different [41, 42].
Both trials, using validated questionnaires to assess symptoms,
found that symptoms were improved in both groups, with the
exceptions of higher dysphagia and chest pain scores, greater
frequency of diarrhea, and greater likelihood of adopting dietary
restrictions among people who received absorbable mesh [42].
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Major complications related to both absorbable and nonabsorbable mesh include intraluminal esophageal erosion, hiatal
stenosis, dense brosis, and cardiac tamponade [44–47]. Even in
the absence of major complications, mesh placement can make
revisional surgery more difcult and increase the rate of major
resections from 4.4% to 30%, especially in cases where mesh was
placed at the initial operation [48]. Given a lack of reproducible
benet, evidence of worse dysphagia, and numerous reports of
major complications related to mesh placement at the hiatus, routine mesh reinforcement of cruroplasty in PEH repair is not supported by the literature. There may be a role for selective mesh
placement, but this strategy is not yet dened. Mesh placement
should be considered on a case-by-case basis.
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Antireux Procedure
A total or partial fundoplication is routinely performed during
PEH repair. Even in the absence of heartburn, most patients with
type II PEH have elevated esophageal acid exposure [49, 50].
Patients with PEH report improvement in heartburn symptoms
after PEH repair with an antireux procedure. Omitting an antireux procedure could put patients at risk for reux esophagitis [51,
52]. Recent reports show good outcomes with the use of magnetic
sphincter augmentation in lieu of a fundoplication in conjunction
with PEH repair [53, 54].
Gastropexy
The addition of gastropexy to help reduce the rate of recurrence of
PEH has also yielded mixed results. A French group reported a
retrospective analysis of PEH repair with and without anterior
abdominal wall suture gastropexy [55]. The rate of recurrence
was higher among the patients who did not undergo gastropexy
(50% vs 10.8%), but the group who did not undergo gastropexy
was small (11 patients), follow-up was limited (65.2% of patients
were objectively evaluated for recurrence), and the study was not
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randomized. Diaz et al evaluated 116 patients who underwent
PEH repair with or without gastropexy with similar recurrence
rates [56]. In emergent cases in frail patients, hernia reduction
with gastropexy with a gastrostomy tube may be the safest and
most appropriate approach.
I. R. Kriley et al.
Short Esophagus
The importance of mediastinal dissection to obtain adequate
esophageal length is well recognized. A subset of patients have a
short esophagus despite its existence being controversial and its
presence denitively determined only after mediastinal dissection
is complete. Some surgeons rarely perform esophageal lengthening
procedures while others perform them frequently [18, 19]. If
2–3 cm of intraabdominal esophagus cannot be achieved with
mediastinal dissection alone, an esophageal lengthening procedure should be performed.
Outcomes
With long-term follow-up, PEH recur at a rate of 50% [40, 41,
57]. Despite the high rate of hernia recurrence, most patients
enjoy an improvement in symptom severity and quality of life.
Prior to repair, 30–90% of patients presented with heartburn [11,
12, 58]. After repair, the rates of heartburn decreased to 22.9%,
which was sustained after 5 years of follow-up. Some investigators reported up to 93% of patients enjoying an improvement in
heartburn [11, 41, 46]. Others have reported signicant and sustained improvement in symptom severity and reux-related quality of life, but liberation from antacid medication is not guaranteed
[12, 58]. Other common symptoms associated with PEH, such as
dysphagia, regurgitation, early satiety, chest pain, dyspnea, and
bloating, also improved after repair [11, 57–60]. Resolution of
anemia after PEH repair was more common among those with
symptomatic anemia and those with esophagogastric erosions or
ulcers [13].
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