1. Paraesophageal Hiatal Hernias Bradley J. Phillips, MD Burn-Trauma-ICU Adults & Pediatrics

2. 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 6 th ed.

3. 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.

4. 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.

5. Type II & Type III The “Type IV” hernia ?

6. increasingly common with advancing age more often among women than men symptoms are often associated with GERD

7. Relative Frequency According to Age Type I: hatched bars Type II & III: solid bars Basic prevalence of Type I hernias…

8. 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…

9. 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

10. 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…

11. 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

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

13. 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…

14. Post-op C.T.

17. Paraesophageal Hiatal Hernias … questions ?