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Paraesophageal Hiatal Hernias. Bradley J. Phillips, MD Burn-Trauma-ICU Adults & Pediatrics. In general…. Optimal management is controversial. Points of contention Appropriate evaluation of patients Optimal surgical approach +/- Antireflux procedure accompanying repair

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paraesophageal hiatal hernias

Paraesophageal Hiatal Hernias

Bradley J. Phillips, MD

Burn-Trauma-ICU

Adults & Pediatrics

in general
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
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
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
Type II & Type III

The “Type IV” hernia ?

slide6

increasingly common with advancing age

  • more often among women than men
  • symptoms are often associated with GERD
relative frequency according to age
Relative Frequency According to Age
  • Type I: hatched bars
  • Type II & III: solid bars

Basic prevalence of Type I hernias…

diagnosis
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
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
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
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
Surgical Techniques
  • Principles similar to other hernia operations
  • Need to anchor the stomach
  • Fundoplication is controversial
  • Transthoracic vs. Transabdominal…
slide13

Results & Outcomes

  • Short-term:
    • Mortality less than 1%
    • Major complication rate up to 30%
  • Future role of laparoscopic approach…

Mean duration of follow-up is 1 yr.