Overview and Management of Paraesophageal Hernias

Abstract

At present, controversy exists regarding the management of hiatal hernia and its associated conditions such as gastroesophageal reflux disease (GERD) and chronic anemia. The majority of the controversy stems from the variable definitions of hernia types based on anatomic changes at the hiatus, and the accuracy of diagnostic tests in differentiating these anatomic abnormalities. In general, hiatal hernia can be defined as migration of either the stomach or esophagogastric junction and occasionally other visceral organs into the mediastinum, in the setting of deterioration of the phrenoesophageal ligament and widening of the hiatus. Patients with large mixed hiatal hernias, with migration of the fundus and the cardia into the chest, usually have severe GERD. Additionally, these patients may develop short esophagus over time due to inflammation and scarring of the esophagus, which may lead to further surgical challenges. The diagnostic management of these patients entails assessment of anatomical changes, as well as an extensive functional workup via GI function studies to evaluate all possible pathophysiologic causes. Patients with massive hiatal hernias do carry the infrequent but increased risk of presenting as a surgical emergency. Additionally, these patients may suffer long term from sequelae of aspiration and other respiratory problems. Surgical management is performed today by laparoscopic resection of the hernia sac, reconstruction of the hiatal anatomy, and by adding a laparoscopic fundoplication. These can be complex procedures and should be performed by an experienced team.