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Paraesophageal Hiatal Hernias
Bradley J. Phillips, MD
Burn-Trauma-ICUAdults & Pediatrics
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)
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)
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
The “Type IV” hernia ?
• increasingly common with advancing age
• more often among women than men
• symptoms are often associated with GERD
Relative Frequency According to Age
• Type I: hatched bars
• Type II & III: solid bars
Basic prevalence of Type I hernias…
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)
• 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)
• 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)
• 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
• Principles similar to other hernia operations
• Need to anchor the stomach
• Fundoplication is controversial
• Transthoracic vs. Transabdominal…
Results & Outcomes
Mean duration of follow-up is 1 yr.
1. Short-term:
• Mortality less than 1%
• Major complication rate up to 30%
2. Future role of laparoscopic approach…
Post-op C.T.
Post-op C.T.
Post-op C.T.
Paraesophageal Hiatal Hernias…
questions ?