Management of large para-esophageal hiatal hernias

Para-esophageal hernias are relatively rare and typically occur in elderly patients. The various presenting symptoms are non-specific and often occur in combination. These include symptoms of gastro-esophageal reflux (GERD) in 26 to 70% of cases, microcytic anemia in 17 to 47%, and respiratory symptoms in 9 to 59%. Respiratory symptoms are not completely resolved by surgical intervention. Acute complications such as gastric volvulus with incarceration or strangulation are rare (estimated incidence of 1.2% per patient per year) but gastric ischemia leading to perforation is the main cause of mortality. Only patients with symptomatic hernias should undergo surgery. Prophylactic repair to prevent acute incarceration should only be undertaken in patients younger than 75 in good condition; surgical indications must be discussed individually beyond this age. The laparoscopic approach is now generally accepted. Resection of the hernia sac is associated with a lower incidence of recurrence. Repair of the hiatus can be reinforced with prosthetic material (either synthetic or biologic), but the benefit of prosthetic repair has not been clearly shown. Results of prosthetic reinforcement vary in different studies; it has been variably associated with four times fewer recurrences or with no measurable difference. A Collis type gastroplasty may be useful to lengthen a foreshortened esophagus, but no objective criteria have been defined to support this approach. The anatomic recurrence rate can be as high as 60% at 12years. But most recurrences are asymptomatic and do not affect the quality of life index. It therefore seems more appropriate to evaluate functional results and quality of life measures rather than to gauge success by a strict evaluation of anatomic hernia reduction.