paraesophageal hernia

6/18/2016
PARAESOPHAGEAL HERNIA
Subrato J. Deb, MD
Associate Professor of Thoracic Surgery
University of Oklahoma Health Sciences Center
History of Hiatial Hernia Surgery
Henry Ingersoll Bowditch reviewed the
early series of hiatal hernias described at
postmortem examination in 1846 and
probably should be credited with the first
description of what is now referred to as a
paraesophageal hernia.
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Typical Patient
• Elderly female with
kyphosis
Mixed
Evolution of Gastric Hernias
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Types of Hernia
Type I [sliding]:
· the GEJ has risen above the diaphragmatic hiatus
· the stomach forms the posterior wall of the hernia sac.
· >90% of cases.
· Reflux associated.
Type II [pure paraesophageal]:
· the GEJ remains below the diaphragm
· a portion of the stomach, most commonly the fundus, herniates through the
hiatus, alongside the esophagus.
· Rare ( 1%).
Type III [mixed]: ( most common non Type I)
the GEJ herniates to the chest , along with a paraesophageal component.
~10%.
Type IV [massive]:
another intra-abdominal organ migrates to the chest with the stomach (colon,
spleen, small bowel ~1 %)
Types of Hiatial Hernias
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Symptoms
Elective
• GERD > 90%
• Dysphagia > 80%
• Regurgitation
• Chronic anemia ( > 30%)
• Chest pain
• Dyspnea
• Nausea/ Emesis
• Weight loss
Urgent/Emergent
• Obstructive symptoms
• Nausea- protracted
• Inability to vomit
• Continuous pain
(chest/epigastrum)
• Ischemic findings
• Same as above
• Signs of SIRS
• Early Satiety
Considerations for Surgery
• All patients are symptomatic (Type II-IV)
• Patients with Type I typically have GERD and easy to treat with anti-
reflux procedure such as Nissen fundoplication.
• Considerations for Type III hernia
• Risk of progression 15% per year (limited data).
• Annual probability of needing emergency surgery 1.1%
• Gastric gangrene = HIGH mortality
• Esophageal perforation = HIGH mortality
• Most patients are symptomatic
• Mechanical problem !! Can’t be treated with medications and dilation.
Stylopoulos, et al. Paraesophageal hernias: operation or observation.
Ann Surg 2002
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Diagnosis and Evaluation –
plain chest radiographs
Practice Guidelines
SAGES
• CXR
• Contrast Study
• CT scan
• EGD
• Manometry
• pH testing
CT of Gastric Hernias
Type III hernias
NORMAL
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Type IV hernia
Stomach is
twisted
Constrast
Study
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EGD
Cameron’s ulcers = chronic anemia
Gastric Volvulus
• Organoaxial
• most common
• Rotates along long axis
• Mesenteroaxial
• Rotates along short axis
• Combo- often seen
• Borchardt’s triad
•
•
•
•
Epigastric Pain
Unproductive retching
Inability to pass NG tube
Represents total gastric
obstruction
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Treatment - overview
Myth
• Too old to have surgery = wrong. Surgery
can be done in almost all patients regardless
of co-morbidities.
Surgery – 4 step process
•
•
•
•
Resect Hernia Sac and Reduce viscera
Closure of Diaphragmatic defect
Esophageal Mobilization and Lengthening
Anti-reflux procedure
Laparoscopic Surgery
• Port placement varies
• Dorsal lithotomy
• CO2 insufflation
• Surgical time 4-5 hours
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8 cm > High Risk Closure
DANGER AREA
First step: Find plane between
hernia sac and crura, preserving
peritoneum on crura
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Hernia Sac Inversion
Reduced Stomach
Excise
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Esophageal Dissection
LA and IPV
10 cm
Crural Closure
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Crural Closure- pearls
• Free spleen into LUQ
• Dissect the left crura
inside the mediastinum
• Relaxing incision if
unable to close
• Bring the left crura to
the right
Crural Closure
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Laparoscopic Wedge Gastroplasty
Wedge Fundectomy
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Failure to recognize shortened esophagus
will place the wrap on the tubularized
cardia
Fundoplication- ensure short and loose
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Completed Wrap
2 cm
Best Open Surgery Results
• MASSIVE HIATUS HERNIA: EVALUATION AND
SURGICAL MANAGEMENT
• Donna E. Maziak, MD, Thomas R. J. Todd, MD, F. Griffith Pearson,
MD ( Toronto General) J Thorac Cardiovasc Surg 1998;115:53-62
• N = 97 ( 50% patients with organo-axial volvulus)
• Left thoracotomy, Collis gastroplasty in 80%, Belsey 270
fundopliclaiton. Used 48F bougie.
• 2 deaths due to leak. Median follow up 72 months.
• 2 recurrences ( 2 %). Both with unrecognized short
esophagus –both treated with re-op and lengthening
• Overall: 91 % with good results at long term follow up
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Best Laparoscopic Surgery Results
• Outcomes after a decade of laparoscopic
giant paraesophageal hernia repair
James D. Luketich, , et al. J Thorac Cardiovasc Surg 2010;139:395-404
• N=662 ( Median age 70). 75% female patients.
• Esophageal lengthening in 63% overall, but early experience, 86%
lengthening.
• Mesh crural reinforcement in 17% initially. Then decreased to 12%
• Median follow up 30 months ( N = 489 patients)
• 30 day mortality 1.7 %
• Complications: Most common was pneumonia in 4%, enteric leak in 2.5 %
• Good to excellent functional results in 90%.
• Recurrence noted in 15% (Radiologic) but without symptom recurrence
• Reoperation in 3.2 %.
Conclusions
• Don’t assume a hiatial hernia on a radiology report is
benign
• If large portion of stomach is migrated, ie, > 50%, almost
all patients have symptoms, they adapt their lifestyles
• Laparoscopic repair can be done in > 95% of patients with
good to excellent results short and long term
• Recurrence rates are declining as greater surgical
experience is gained ( identification of shortened
esophagus).
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