Paraesophageal Hernias

Question 1

4 Types of paraesophageal hernia

Answer 1

• Type I: sliding hiatal hernia (MC, ~ 95%)
  
  • enlargment of esophageal hiatus and lengthening of phrenoesophageal ligament
  • GEJ: intrathoracic
  • no hernia sac
• Type II: least common
  
  • enlargement of esophageal hiatus with fundus that has herniated into stomach
  • GEJ: intra-abdominal
  • • hernia sac
• Type III:
  
  • combination of GEJ and >= 30% of stomach intra-thoracic
  • • hernia sac
• Type IV:
  
  • herniation of other organs into the thoracic cavity along with stomach
  • • hernia sac

Question 2

Which types of esophageal hiatal hernias are paraesophageal hernias

Answer 2

Types II-IV

Question 3

Demographics of PEH

Answer 3

• Female predominance (~75%)
• Elderly (50% > 70 years old)
  
  • loss of elasticiy and muscle as people age

Question 4

Proposed risk factors of PEH

Answer 4

• Female
• Elderly
• Obesity
• Chronic constipation
• Abdominal ascites

Question 5

Presentation of PEH

Answer 5

• GERD (40-70%)
• Regurgitation
• Dyspnea
• Chest/abdominal pain
• Chronic anemia (Cameron’s ulcers, ~40%)

Question 6

Urgent/emergent complication of PEH

Answer 6

Gastric volvulus

(acute onset of severe abdominal pain)

Tx: Emergent operative intervention

(reduction and repair vs. subtotal gastrectomy)

Question 7

First diagnostic study in evaluation of PEH

Answer 7

UGI series

• Define position of stomach in relationship to diaphragm and degree of herniation
• ID organoaxial rotation
• May provide insight into esophageal motility

Question 8

Diagnostic studies used in eval of PEH

Answer 8

• UGI series
• CXR
• Endoscopy
  
  • evaluation for strangulation
  • evauation for stricture, malignancy
• Esophageal manometry +/- pH testing

Question 9

PFTs can be expected to improve by __% once a PEH is repaired and abodminal contents are no longer in the thoracic cavity

Answer 9

~ 15%

Question 10

Important operative detail to know for evaluation of a PEH that had been previously repaired

Answer 10

Status of vagus nerves (have they been injured)

• Obtain gastric emptying studies

Question 11

2 goals of PEH surgical repair

Answer 11

1. Restore normal anatomy by returning the GEJ into the abdomen
2. Correct the condition that contributed to the development of the anatomic problem (i.e. GERD)

Question 12

Major surgical steps in PEH repair

Answer 12

• Reduction of herniated contents
• Restoration of normal, tension-free intra-abdominal location of GEJ (2.5 cm of esophagus in abdomen)
• Removal of hernia sac
• Closure of esophageal hiatus (56-F Bougie)
• Anti-reflux procedure (fundoplication)
• Operative approaches: transthoracic (Belsy), trans-abdominal, laparoscopic

Question 13

Expected outcomes and LOS for PEH repair

Answer 13

• Postop complication rate: 20-25%
• Average LOS: 4-5 days

Similar between transthoracic and transabdominal

Question 14

Reported PEH recurrence rates

Answer 14

2-18% overall

laparoscopic (~15%)

Question 15

Options for esophageal lengthing if unable to obtain 2-2.5 cm tension-free, intra-abdominal esophagus

Answer 15

• Collis gastroplasty
• Laparoscopic wedge fundectomy

*Both performed over 56-F Bougie

Question 16

PEH in the urgent/emergent setting increases complication rate __-fold compared to PEH performed in the elective setting

Answer 16

2-fold (doubles complication rate)

Question 17

Initial approach to incarcerated and possibly strangulated PEH

Answer 17

Early endoscopy

• May also for decompression and placement of NGT with subsequent resuscitiation, stabilization, and optimization and allow for elective repair the following day

Question 18

Surgical approach for emergent PEH

Answer 18

• PEH reduction and primary repair (if stomach not grossly ischemic)
• PEH reduction + Gastropexy + jejunostomy tube:
  
  • hemodynamic instability
  • poor UOP
  • Inotrope use
  • EKG changes
  • Persistently elevated lactate
• Esophageal exclusion with NGt decompression + subtotal gastrectomy + jejunostomy + resuscitiatoin + 2nd look operation and reconstruction (RNY E-J)
  
  • gross ischemic changes

Question 19

2 most dreaded complications due to technical error following PEH repair

Answer 19

Recurrence

Gastroparesis (vagus nerve injury)

Question 20

RF for PEH recurrence

Answer 20

• Failure to have tension-free, 2.5 cm of intra-abdominal esophagus.
• Failure to perform esophageal lengthing procedure

Question 21

Results in poor crural appoximation and eventual PEH repair failure

Answer 21

Damage to peritoneal lining over the crux

Question 22

Potential complication of Collis gastroplasty

Answer 22

Staple line leak (leave drain)

Question 23

Dysphagia after PEH repair due to

Answer 23

• Fundoplication too tight
  
  • Peform over 56-60F bougie
  • Dilation: if not resolved by 1st postop visit
• Postoperative swelling (transient)

Question 24

First step to evaluate postoperative complaints of recurrent heartburn, dysphagia, regurgitation

Answer 24

UGI series

• Assess for recurrence
  
  • If recurrence: medical therapy futile, needs reoperation with esophageal lengthening procedure

Question 25

First step to evaluate postoperative complaints of bloating

Answer 25

• Radionucleotide gastric emptying study
• Endoscopy if UGI and emptying study negative
  
  • Confirm intact wrap
  • Assess for intraluminal mucosal irregularities and/or masses
    
    • long-standing GERD for most all patients increases risk of esophageal adenocarcinoma
  • Assess for gastric or duodenal ulcers