Indications for procedure

The majority of sliding hiatal hernias are asymptomatic. Only when surgical intervention is indicated for GERD should Type I (sliding hiatal hernia) be repaired (see Chapter 3) (2).

The presence of Type II paraesophageal hiatal hernias has traditionally been considered an indication for surgery in a patient who is otherwise fit for surgery. Paraesophageal hiatal hernias have been associated with the risk of strangulation of incarcerated viscera and the potential need for emergency operations. In their classic article from 1967, Skinner and Belsey found that 6 of 21 patients under review for paraesophageal hernias developed gastric volvulus and died of the catastrophic complications of strangulation, perforation, exsanguinating hemorrhage, or acute dilatation of the herniated intratho-racic stomach. Although other series reported similar findings to that of Skinner and Belsey, more recent large series suggest that symptoms associated with paraesophageal

Fig. 3. Type III or mixed sliding and paraesophageal hernias: coronal section.

Herniated Gastric Fundus

Herniated Gastric Fundus

Strangulated Sliding Hernia
Fig. 4. Type IV hiatal hernia: combination of type III with herniation of other viscus (colon).

hernia may develop more gradually. Allen et al. followed 23 patients for a median of 78 mo and found only three cases of gastric strangulation in 735 patient years of follow-up (5).

Although the true incidence of gastric volvulus presenting with strangulation is controversial (ranging from 3-30%), the elective repair of paraesophageal hernia is generally recommended because emergency surgery for acute complications carries a high mortality rate (5,6).

There are two patterns to gastric volvulus, organoaxial and mesenteroaxial (Figs. 6 and 7). Organoaxial volvulus occurs when 180° torsion occurs about the stomach's longitudinal axis. Mesenteroaxial volvulus is less common and occurs with torsion about

Gastric Volvulus

Duodenum

Fig. 6. Paraesophageal hernia: gastric volvulus.

the vertical axis. Thirty percent of patients with paraesophageal hiatal hernia present with hematemesis or exhibit anemia, which is likely caused by mucosal hemorrhage

Fig. 7. Paraesophageal hernia: gastric volvulus. Upper gastrointestinal contrast study.

from venous congestion located at the neck of the hernia. They may also complain of dysphagia, early satiety, referred diaphragmatic pain with postprandial gastric distention, and weight loss (7).

About 30% of patients with paraesophageal hernia have Type 3 hernia and have symptoms of GERD. Many patients with paraesophageal hernia have no serious symptoms or complications of their condition for years. As the hernia progresses, varying degrees of complaints and severity of symptoms will be directly attributable to the configuration of the hiatal hernia (2).

Gastric volvulus presenting with infarction occurs when the stomach dilates and gastric ischemia occurs. Progression of ischemia can lead to perforation. Symptoms of epigastric pain, the inability to vomit, and gastric obstruction on contrast study are indication for emergency intervention (2).

When patients with paraesophageal hiatal hernias are considered for operative repair, diagnostic tests should include upper endoscopy to exclude other significant esophageal mucosal disease, upper gastrointestinal contrast radiographs to classify the type of hiatal hernia and give an indication of the degree of esophageal shortening, and esophageal manometry to assess the adequacy of esophageal peristalsis (2,6).

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