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Small Incisions for a Big Problem: ‘Giant’ Paraesophageal Hernia Repair
By Ryan A. Macke, MD
Hiatal hernias (HH) are common and are often associated with gastroesophageal reflux disease (GERD). HHs present in different forms and are typically described as:
Over 90% of HHs are of the Type I variety, which oftentimes are managed with observation and medical therapy to address reflux-associated symptoms. Types II-IV HHs are commonly referred to as paraesophageal hernias (PEHs). “Giant” PEHs are large hernias with 30% or more of the stomach in the chest (Figure 1).
Similar to the more common Type I HHs, patients with PEHs may present with “classic” symptoms of reflux (heartburn, regurgitation, and/or dysphagia). However, these larger hernias can also present with a wider spectrum of symptoms:
PEHs are oftentimes overlooked as a potential cause for symptoms such as cough, recurrent pneumonia, dyspnea, and anemia. For this reason, many patients with PEHs are considered to be asymptomatic and are never referred for surgical consultation.
Indication for surgical consultation
Symptomatic PEHs are a clear indication for consultation. However, controversy exists as to whether or not asymptomatic PEHs should be repaired. Giant PEH may lead to potentially life-threatening complications such as upper GI obstruction, acute dilation, perforation, or bleeding caused by twisting/flipping of the stomach in the chest (gastric volvulus). Risk of complications is significantly increased when PEHs are repaired emergently in the setting of these complications rather than in an elective fashion before these complications occur. Therefore it is recommended that patients with a known PEH be thoroughly worked up and surgical consultation considered.
Workup of patients with incidentally noted or symptomatic PEHs include:
Manometry, pH studies, and impedance studies are typically not needed, as catheter placement can be difficult, risk of esophageal perforation exists, and the results often do not change management.
Historically PEHs were repaired using an open laparotomy or left thoracotomy approach. Like the surgeons at UW, many institutions have adopted a laparoscopic approach for repair given the reported decreases in length of stay, blood loss, and postoperative complications compared to open repair. Despite these results, it is estimated that roughly half of PEHs are still repaired in an open fashion in the United States.
Average hospital stay is approximately three days following laparoscopic PEH repair. Morbidity rates range from 5% to 20% and risk of mortality is approximately 1% to 2% in recent series.
Recurrent PEHs are not uncommon following repair (10-50% in select series). However, the minority of patients develop symptoms significant enough to warrant reoperation (<5%).
For More Information
The Thoracic Surgery doctors at UW Health offer consultation and surgical management for disorders and diseases involving the airway, lung, chest wall, pleura, mediastinum, diaphragm, and foregut. If you would like to refer a patient to our staff, please call Thoracic Surgery at the University of Wisconsin Hospital and Clinics at (608) 263-7502.
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