Paraesophageal Hernias Flashcards
4 Types of paraesophageal hernia
- 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
Which types of esophageal hiatal hernias are paraesophageal hernias
Types II-IV
Demographics of PEH
- Female predominance (~75%)
- Elderly (50% > 70 years old)
- loss of elasticiy and muscle as people age
Proposed risk factors of PEH
- Female
- Elderly
- Obesity
- Chronic constipation
- Abdominal ascites
Presentation of PEH
- GERD (40-70%)
- Regurgitation
- Dyspnea
- Chest/abdominal pain
- Chronic anemia (Cameron’s ulcers, ~40%)
Urgent/emergent complication of PEH
Gastric volvulus
(acute onset of severe abdominal pain)
Tx: Emergent operative intervention
(reduction and repair vs. subtotal gastrectomy)
First diagnostic study in evaluation of PEH
UGI series
- Define position of stomach in relationship to diaphragm and degree of herniation
- ID organoaxial rotation
- May provide insight into esophageal motility
Diagnostic studies used in eval of PEH
- UGI series
- CXR
- Endoscopy
- evaluation for strangulation
- evauation for stricture, malignancy
- Esophageal manometry +/- pH testing
PFTs can be expected to improve by __% once a PEH is repaired and abodminal contents are no longer in the thoracic cavity
~ 15%
Important operative detail to know for evaluation of a PEH that had been previously repaired
Status of vagus nerves (have they been injured)
- Obtain gastric emptying studies
2 goals of PEH surgical repair
- Restore normal anatomy by returning the GEJ into the abdomen
- Correct the condition that contributed to the development of the anatomic problem (i.e. GERD)
Major surgical steps in PEH repair
- 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
Expected outcomes and LOS for PEH repair
- Postop complication rate: 20-25%
- Average LOS: 4-5 days
Similar between transthoracic and transabdominal
Reported PEH recurrence rates
2-18% overall
laparoscopic (~15%)
Options for esophageal lengthing if unable to obtain 2-2.5 cm tension-free, intra-abdominal esophagus
- Collis gastroplasty
- Laparoscopic wedge fundectomy
*Both performed over 56-F Bougie
PEH in the urgent/emergent setting increases complication rate __-fold compared to PEH performed in the elective setting
2-fold (doubles complication rate)
Initial approach to incarcerated and possibly strangulated PEH
Early endoscopy
- May also for decompression and placement of NGT with subsequent resuscitiation, stabilization, and optimization and allow for elective repair the following day
Surgical approach for emergent PEH
- 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
2 most dreaded complications due to technical error following PEH repair
Recurrence
Gastroparesis (vagus nerve injury)
RF for PEH recurrence
- Failure to have tension-free, 2.5 cm of intra-abdominal esophagus.
- Failure to perform esophageal lengthing procedure
Results in poor crural appoximation and eventual PEH repair failure
Damage to peritoneal lining over the crux
Potential complication of Collis gastroplasty
Staple line leak (leave drain)
Dysphagia after PEH repair due to
- Fundoplication too tight
- Peform over 56-60F bougie
- Dilation: if not resolved by 1st postop visit
- Postoperative swelling (transient)
First step to evaluate postoperative complaints of recurrent heartburn, dysphagia, regurgitation
UGI series
- Assess for recurrence
- If recurrence: medical therapy futile, needs reoperation with esophageal lengthening procedure
First step to evaluate postoperative complaints of bloating
- 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
