Massive hiatus hernia: evaluation and surgical management

Area of Science:

• Gastroenterology
• Surgical Oncology
• Thoracic Surgery

Background:

• Paraesophageal hernias are advanced sliding hiatus hernias with intrathoracic displacement of the esophagogastric junction.
• Gastroesophageal reflux disease (GERD) is common, often leading to acquired short esophagus, influencing surgical repair choices.

Purpose of the Study:

• To analyze the clinical presentation, surgical management, and outcomes of patients with massive, incarcerated paraesophageal hiatus hernia.
• To evaluate the incidence of GERD, esophagitis, and acquired short esophagus in these patients.

Main Methods:

• Retrospective analysis of 94 patients undergoing surgery for massive, incarcerated paraesophageal hiatus hernia between 1960 and 1996.
• Clinical data, endoscopic findings, and esophageal manometry results were reviewed.
• Surgical repair involved transthoracic approach with fundoplication and, in most cases, gastroplasty.

Main Results:

• The majority of patients (91/94) had findings consistent with sliding hiatus hernia.
• High incidence of symptomatic reflux (83%), peptic esophagitis (36%), and acquired short esophagus (80% required gastroplasty).
• At a mean follow-up of 94 months, 80% of patients had excellent outcomes (asymptomatic), and 13% had good outcomes (inconsequential symptoms).

Conclusions:

• Paraesophageal hernias are frequently associated with sliding hiatus hernia, GERD, and acquired short esophagus.
• Transthoracic repair with fundoplication and gastroplasty is effective for managing these complex hernias.
• Acquired esophageal shortening should be recognized and addressed during initial repair to prevent recurrence.