Paraesophageal Hiatal Hernia

Types: 
#1—true sliding hernia; the phrenoesophageal ligament fails to keep the esophagogastric junction below the diaphragm and within the abdomen. The LES is usually inadequate and reflux esophagitis exists 
#2—true paraesophageal hernia with the esophagogastric junction in its normal location below the diaphragm. The fundus/body of the stomach is rotated into the chest with the greater curve as the leading point; usually no esophagitis present. 
#3—combination of upward movement of the esophagogastric junction above the diaphragm and herniation of the stomach into the chest. The patient usually has symptoms of esophagitis. 

Anatomy: 
-Intact posterior fixation of the esophagus to the preaortic fascia and the median arcuate ligament 
-The reason why the greater curve of the stomach herniates is because it is the most mobile portion—gastric cardia is fixed by the left gastric vessels, the gastrosplenic and gastrohepatic ligaments; the pylorus is fixed by the duodenum. 
-As the hernia enlarges the stomach moves upward and to the right utilizing the fixed lesser curve as an axis of rotation—organoaxial rotation. This is the path of least resistance because the aorta lies to the left and the heart lies left and anterior. 
-This is a true anatomic hernia with a sac 

Symptoms: 
-produce few symptoms when small, which is why the defects are large when discovered 
-long history of postprandial distress/discomfort 
-substernal fullness and belching 
-true dysphagia uncommon 
-absence of heartburn/esophagitis 
-pulmonary complications are common: recurrent pneumonia; chronic atelectasis; dyspnea classically after a large meal—from pleural space compression by the huge hernial sac 
-ulceration of the herniated stomach with resultant bleeding and anemia 
-incarceration, obstruction, torsion, gangrene, and perforation 
-most feared and lethal complication is gastric volvulus with strangulation which usually occurs post-prandially—this is a true surgical emergency if the stomach cannot be decompressed. Almost 30% of paraesophageal hernis present in this fashion. The stomach becomes twisted and angulated in its midportion just proximal to the antrum. Most prominent manifestation is the inability to swallow or regurgitate. 
-Borchardt’s triad: chest pain, retching but unable to vomit, and inability to pass a nasogastric tube indicate gastric volvulus 

Diagnosis/Therapy 

 -CXR--retrocardiac air-fluid level 
 -Barium Swallow to show an intrathoracic upside down stomach; look for signs of peptic esophagitis/position of GE junction 
 -Technical points: 
  antireflux procedure—routinely vs. those with signs of peptic esophagitis 
  surgical approach—transthoracic [ease of hernial sac dissection and esophageal mobilization when necessary] vs. abdominal [placement of a gastrostomy tube] 
 -Technique—principals of repair are reduction of the hernia and its contents to the abdominal cavity along with repair of the defect 
  -mobilize esophagus; GE junction below diaphragm 
  -narrow the hiatus posteriorly first until tip of finger can be admitted 
  -fix stomach below the diaphragm (Hill repair—stomach fixed to median arcuate lig) 
  -+/- Nissan fundoplication 
  -gastrostomy 
  -resection for gangrene/perforation 

 -elective repair has ~1%  mortality 
 -emergent procedures (volvulus) has ~15% mortality 
 -long term results are generally excellent whether or not an anti-reflux procedure is performed