Esophageal hiatus hernia after fundoplication

The cases of three patients who underwent fundoplication to correct gastroesophageal reflux and who subsequently had herniation above the diaphragm of abdominal contents through the esophageal hiatus are described. In two patients, the fundoplication was performed through a transabdominal approach, and in one patient through a transthoracic approach. The main symptoms were vague but persistent (48 hours) abdominal pain in three, associated with nausea and vomiting in one. The diagnosis was confirmed with an upper GI series in all three; the proximal stomach was displaced in all, the transverse colon in one. Elective reoperation to reduce the displaced abdominal contents and to narrow the esophageal hiatus was done in the three cases. All recovered uneventfully and were relieved of their preoperative symptoms. Eight years later, one patient developed a gastric carcinoma requiring esophagogastrectomy; another patient remained asymptomatic 1 year after operation; the third was lost to follow-up 1 month after his operation. The presence of herniation of abdominal contents through the esophageal hiatus is a rare complication that should be suspected in patients who previously underwent fundoplication, either through the abdominal or thoracic approaches, and who complain of mild but persistent abdominal pain. Narrowing of the esophageal hiatus by approximating with sutures the diaphragmatic crura at the time when the fundoplication is done would appear to be an important technical point to avoid this complication. When it occurs, elective repair is advisable.