Complex and acute paraesophageal hernias—type IV, strangulated, and irreducible

Abstract

Hiatal hernias (HH) can be classified into 4 types, with type IV paraesophageal hernias (PEH) being the most complex. Type IV PEH contain stomach and other abdominal viscera, such as colon, small bowel, pancreas or spleen, within the hernia. While, most HH can be evaluated and managed on an elective basis, some can present acutely, making their management challenging. Patients presenting with acute PEH, especially type IV PEH, can be in extremis necessitating prompt intervention. In both the acute and non-acute PEH chest X-ray, CT scan, contrast swallow, and upper endoscopy (EGD) are all useful diagnostic and, in some cases, therapeutic modalities. Prompt decompression either by nasogastric tube or endoscopy can mitigate deleterious complications such as strangulation and organ ischemia. However, even if decompression is successful, timing of subsequent repair remains unclear, although some evidence suggests that semi-elective repair facilitates optimization of these patients who may be older and have significant comorbidities. Assessing viability of incarcerated viscera is critical and may require resection or second look procedures. Type IV hernias can present more complex technical challenges. There is divergence in evidence on the mortality and morbidity risk in patients presenting with acute type IV PEH, needing emergent repair. At the very least, emergent repair is disruptive, and at worst can be quite complicated, especially in frail elderly patients who already have higher risk of morbidity/mortality at baseline.