Management of Giant Paraesophageal Hiatal Hernia

The survey on management of giant paraesophageal hernia produced more concensus than most prior surveys. The respondents were asked to consider the case of an elderly female who was diagnosed with a large (>50% of stomach in the chest) type III (esophagogastric junction has migrated into the chest) paraesophageal hernia. The patient had early satiety as well as postprandial chest pain and shortness of breath.

Almost all respondents manage patients with such problems, although the total number of respondents was about 50% lower than for some other recent surveys, indicating that many potential respondents didn't reply because they don't manage such problems. Almost all respondents agreed that surgical repair was appropriate in this setting.

Interestingly, about half of respondents favor a laparoscopic approach and only one-third favor an open thoracotomy. Most respondents indicated that an esophageal lengthening procedure and crural reinforcement were not normally necessary. The vast majority of respondents anchor the stomach in the abdomen, usually by performing a fundoplication after the repair.

1. Do you manage patients with paraesophageal hiatal hernia?
		Response Percent	Response Count
Yes		95.4%	83
No		4.6%	4
	answered question		87
	skipped question		1

2. Do you believe definitive management of the hernia in this patient is appropriate?
		Response Percent	Response Count
Yes		97.7%	85
No		2.3%	2
	answered question		87
	skipped question		1

3. In your practice, which surgical approach do you prefer?
		Response Percent	Response Count
Laparotomy		16.5%	14
Laparoscopy		48.2%	41
Thoracotomy		35.3%	30
	answered question		85
	skipped question		3

4. How often in your practice do such patients require an esophageal lengthening procedure?
		Response Percent	Response Count
10% or fewer		65.5%	55
20%		13.1%	11
30%		9.5%	8
40% or more		11.9%	10
	answered question		84
	skipped question		4

5. Do you find that closure of the hiatal defect is usually accomplished satisfactorily using native tissues?
		Response Percent	Response Count
Yes		75.9%	63
No		24.1%	20
	answered question		83
	skipped question		5

6. Do you routinely reinforce the hiatal closure using artificial material?
		Response Percent	Response Count
Yes		31.7%	26
No		68.3%	56
	answered question		82
	skipped question		6

7. Do you routinely anchor the stomach in the abdomen by performing gastropexy, gastrostomy, or fundoplication?
		Response Percent	Response Count
Yes		85.5%	71
No		14.5%	12
	answered question		83
	skipped question		5

8. Do you routinely perform a fundoplication to prevent reflux?
		Response Percent	Response Count
Yes		78.8%	67
No		21.2%	18
	answered question		85
	skipped question		3

9. In what region is your surgical practice based?
		Response Percent	Response Count
North America		63.5%	54
Europe		20.0%	17
South America		3.5%	3
Asia		11.8%	10
Africa		1.2%	1
	answered question		85
	skipped question		3