Paraesophageal Hernia

Author: Stephanie Worrell, MD
Institution: University of Arizona
Date Reviewed: 2023
Original Case: Robert  B. Yates, MD; Edward Verrier, MD / University of  Washington
Learning Domain: General Thoracic
Learning Objective: Benign Esophageal Disease
PowerPoint File: File 2023 Paraesophageal Hernia.pptx

 

The Problem

  • GERD is the most common foregut disease in the world and accounts for ~75% of all esophageal pathology
  • Progression of the disease occurs in 13% of patients over 5 years (while on acid suppressive meds)
    • Severe erosive esophagitis
    • Barrett’s esophagus

 

  • Patients at risk for progression:
    • family history of GERD
    • esophagitis on baseline endoscopy
    • failure of esophagitis to heal with acid suppression therapy
    • the need to escalate the dose of acid suppression therapy to achieve symptomatic relief
    • complete dependence on daily proton pump inhibitors (PPIs) to control symptoms

 

Background

  • Nissen has the most effective anti-reflux control
  • Identification of the proper surgical candidate leads to a successful outcome in nearly all patients
  • Dependent on appropriate technique
    • To decrease side effects
    • To decrease risk of slippage/recurrence    
  • Nissen associated with reliable long-term outcomes
  • If concern about motility (i.e., IEM) or pre-operative dysphagia, a partial fundoplication may provide similar outcomes although some long-term data suggests inferiorly acid suppression

 

Identification of the proper surgical candidate

Comprehensive pre-operative work-up:

  • Video esophagram
  • Upper gastrointestinal endoscopy
  • High resolution esophageal motility study
  • Esophageal pH monitoring (off PPI in patients without Barrett's or LA Grade C/D erosive esophagitis)

 

Case

65yoF presents with a Type III hiatal hernia and occasional post prandial chest pain. She denies any dysphagia.

  • PMH: HTN, DM, Chronic anemia
  • PSH: none
  • Non smoker
  • PE: BP 123/84 HR 82 RR 17 O2 sat 98% RA BMI 32
    • Chest CTA bilaterally, CV RRR, Abd soft NTND

     

 

Discussion Points

  • Complications of PEH
    • Cameron’s ulcers, volvulus (organoaxial vs mesenteroaxial), gastric outlet obstruction 
    • Incidence of complications if left untreated 1% per year
  • Surgical Approach
    • Laparoscopic vs robotic vs transthoracic
  • Fundoplication
    • Nissen vs Toupet vs other partial
  • Adjuncts
    • Collis, mesh, diaphragm relaxation, gastropexy

 

Operation

Robotic paraesophageal hernia repair with Toupet fundoplication:

  • Given the ineffective esophageal motility on HRM and no evidence of esophagitis/BE on EGD, a partial fundoplication was chosen
  • There was no evidence of a short esophagus with well >3cm of esophagus resting within the abdomen off tension following complete dissection of the paraesophageal hernia

 

Summary of surgical approaches

Fallon, BP & Reddy, RM (2021). Choosing the best approach for paraesophageal hiatal hernia repair: a narrative review. Video-Assisted Thoracic Surgery, 7, 7. https://doi.org/10.21037/vats-21-13

 

Surgical risk of PEH repair increased

  • Non elective PEH repair (OR 2.06)
  • Elderly, particularly >70yo (OR 1.66)
  • Patients with co-morbidities
  • Open approach (6.03)

Wong, Lye-Yeng et al. The Impact of Age and Need for Emergent Surgery in Paraesophageal Hernia Repair Outcomes. The Annals of Thoracic Surgery, Volume 116, Issue 1, 138 - 145