Paraesophageal Hernias

With the advent of laraposcopy, the treatment of paraesophageal hernias has now been thrust into the limelight. Minimally invasive surgery has resulted in elective treatment that is more tolerable to elderly patients and more enticing to symptomatic patients. Multiple studies have now been reported with results that are comparable to laparotomy and thoracotomy.1-4 In this issue, Hashemi et al. have written an excellent review on the current concepts of paraesophageal hernias.5 Many controversies exist concerning the treatment of paraesophageal hernias. Although there are four classifications of hiatal hernias, no consensus exists on how to diagnose the difference in the three classifications or whether barium esophagram, endoscopy, or surgical exploration should be used as the definitive exam. Hashemi has suggested barium esophagram as the best method. Currently, most paraesophageal hernias are believed to be mixed or type III hernias. However, different tests may reveal conflicting locations of the lower esophageal sphincter in relation to the diaphragm. Despite Hashemis' hypothesis, no proof exists as to whether a sliding hernia progresses to become a paraesophageal or mixed hernia. A patient with a paraesophageal hernia may present with either esophageal reflux disease, regurgitation, or dysphagia. These symptoms may be present together or separately. Many patients deny symptoms; however, when questioned carefully 89% will have some symptoms. As Hashemi explained, patients with paraesophageal hernias were referred for treatment to prevent the 29% incidence of emergent bleeding, strangulation, and gastric volvulus.3,6 It is now believed that the potential for these catastrophic events is minimal, and prior studies indicating the high incidence of these events may no longer be accurate. In contrast to Hashemi's suggestion, only those patients with symptoms should undergo surgery. The acute patient may be treated electively after the stomach is decompressed with an N-G tube. Rarely is surgery necessary if decompression is not possible to prevent impending necrosis of the stomach. Traditionally, paraesophageal hernias were repaired by thoracotomy or laparotomy, and involved a hospital stay of 10 days. A morbidity rate of 19% and a mortality rate of 2.1% was typical.7,8 Recently, thoracoscopy and laparoscopy results have been reported with a lower mortality and quicker recovery with similar recurrence rates. However, these procedures entail a substantial learning curve. Between 30 to 50 laparoscopic fundoplications should be performed prior to attempting the paraesophageal hernia repair. Technical challenges include hernia reduction, sac removal from the chest, and determination of the anatomical structures after hernia reduction. As Hashemi describes, patients who undergo hernia reduction and hiatal closure should undergo a concomitant Nissen fundoplication.5 A partial fundoplication should be performed in patients with poor motility as well as in patients with emergent situations. Most of these patients will have some prior history of esophageal reflux. Those patients who do not have symptomatic reflux may develop reflux after the extensive dissection of the lower esophageal hiatus. Patients with dysphagia may develop reflux after the compression of the lower esophageal sphincter by the hernia is released. Patients who do not receive a concomitant anti-reflux procedure may develop severe reflux. Hashemi et al. consider a Collis-Nissen fundoplication an appropriate procedure, with results indicating 91% of patients symptom free at six years.5 Recently, Swanstrom described a laparoscopic approach for this procedure. Rarely is this procedure necessary, and a major disadvantage is created by placing the gastric mucosal cells above the newly created lower esophageal sphincter. The argument of repair on all patients is still under critical debate. Currently, the trend is toward performing Nissen fundoplication. The results of the laparoscopic procedures are approaching those of the open procedures as surgeons obtain better laparoscopic skills. We are all encouraged by the advancements of laparoscopic surgery in the area of paraesophageal hernia repair, as it is one more treatment that may benefit our patients. Neil Robert Floch, M.D.