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Hiatal Hernias

Hiatal Hernias. In general…. A hiatus hernia is the protrusion of the upper part of the stomach into the thorax through a tear or weakness in the diaphragm. Ferguson, Cameron 6 th ed. Epidemiology & Demography. The condition spreading estimated from 1-20% of the population.

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Hiatal Hernias

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  1. HiatalHernias

  2. In general… A hiatus hernia is the protrusion of the upper part of the stomach into the thorax through a tear or weakness in the diaphragm. Ferguson, Cameron 6th ed.

  3. Epidemiology & Demography • The condition spreading estimated from 1-20% of the population. • From those, about 9% are symptomatic. • Probability increased with age.

  4. Classification hiatal hernias are classified according to the position of the esophagogastricjuncton • Type I - Sliding hernia (95%) - the LES protrudes above the diaphragm along with the stomach • Type II-III - Paraesophageal (“rolling”) hernia (5%)- the LES remains stationary but the stomach protrudes above the diaphragm

  5. Type I (sliding) • Leading edge of the hernia is the esophagogastric junction, which is displaced into an intrathoracic position. • The longitudinal axis of the stomach is aligned with the esophagus. • There is often no true hernia sac nor is there any paraesophageal component.

  6. Type II/III - paraesophageal • Type II (rolling) • The esophagogastric junction is in its normal intraabdominal location • The hernia sac (containing portions of the gastric fundus and body) develops alongside the esophagus • Type III • The esophagogastric junction is displaced into the thorax and like a Type II, the hernia sac contains portions of the gastric fundus or body.

  7. Type II & Type III The “Type IV” hernia ?

  8. Symptoms • Acid reflux • Vomit • Disphagia • Epigastric or substernalburning pain • postprandial fullness • Anemia and iron deficiency • Many patients are not symptomatic.

  9. increasingly common with advancing age • more often among women than men • symptoms are often associated with GERD

  10. Risk factors • Old people • pregnancy. • Persistent coughing or vomiting • Lifting heavy objects • Western, fiber-depleted diet • Obesity • Chronic esophagitis

  11. Diagnosis • Typical symptoms • Suspicious X-Ray • Chest C.T. • Endoscopy (upper GI series) Often difficult to assess the location of the actual junction…

  12. Evaluation • Endoscopy • Esophageal Motility Studies • Manometry & pH Monitoring • 1/3 of pts will have atypical peristalsis of the esophageal body • ½ of symptomatic pts will have abnormal pH results

  13. Medical Treatment • Antacids - can be used to neutralize stomach acid. • H-2-receptor blockers, • PPIs

  14. Indications for Operation • patient decision: quality of life considerations • Failed medical management • complications of GERD: Barrett’s esophagus • extra-esophageal manifestations: asthma, chest pain, aspiration) • Type II & III • Associated with a high-risk of complications • “catastrophic” in 20 – 30% of pts • Symptoms do not predict risk…

  15. Medical vs. Surgical Seven randomized controlled trials with follow-up of these studies ranging from 1 to 10.6 years have compared treatment of GERD. These studies strongly support surgery both for patients with good symptom control on medical therapy and for those who achieve only partial symptomatic relief from PPIs.

  16. Surgical Techniques • Need to anchor the stomach • Fundoplicationis controversial • Transthoracicvs. Transabdominal

  17. Nissenfunduplication the gastric fundus of the stomach is wrapped, or plicated, around the inferior part of the esophagus (360°funduplication)

  18. Results & Outcomes • Mortality less than 1% • 10-years-after Symptom free patients – 89% • Major complication rate up to 30% Mean duration of follow-up is 1 yr.

  19. reference • http://www.sages.org/publications/guidelines/guidelines-for-surgical-treatment-of-gastroesophageal-reflux-disease-gerd/ • http://www.wikidoc.org/index.php/Hiatus_hernia_surgery • http://www.uptodate.com/contents/hiatus-hernia#H4 • http://emedicine.medscape.com/article/178393-treatment

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