Transcript Hiatal Hernias

Paraesophageal Hiatal
Hernias
Bradley J. Phillips, MD
Burn-Trauma-ICU
Adults & Pediatrics
In general…
• Optimal management is controversial.
• Points of contention
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Appropriate evaluation of patients
Optimal surgical approach
+/- Antireflux procedure accompanying repair
Option of laparoscopic technique
Ferguson,
Cameron 6th ed.
Types
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.
(1)
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.
Type II & Type III
The “Type IV” hernia ?
• increasingly common with advancing age
• more often among women than men
• symptoms are often associated with GERD
Relative Frequency According to Age
•
Type I: hatched bars
•
Type II & III: solid bars
Basic prevalence of
Type I hernias…
Diagnosis
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Typical symptoms
Suspicious CXR
Chest C.T.
Upper GI Series
Often difficult to assess the
location of the actual
junction…
• In urgent situations:
– Placement of NG tube & subsequent coiling
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
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…
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
Surgical Techniques
• Principles similar to other hernia operations
• Need to anchor the stomach
• Fundoplication is controversial
• Transthoracic vs. Transabdominal…
Results & Outcomes
1. Short-term:
• Mortality less than 1%
•
Major complication rate up to 30%
2. Future role of laparoscopic approach…
Mean duration of follow-up is 1 yr.
Post-op C.T.
Post-op C.T.
Post-op C.T.
Paraesophageal Hiatal
Hernias…
questions ?