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Paraesophageal Hiatal Hernias

Paraesophageal Hiatal Hernias. Bradley J. Phillips, MD Burn-Trauma-ICU Adults & Pediatrics. In general…. Optimal management is controversial. Points of contention Appropriate evaluation of patients Optimal surgical approach +/- Antireflux procedure accompanying repair

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Paraesophageal Hiatal Hernias

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  1. Paraesophageal Hiatal Hernias Bradley J. Phillips, MD Burn-Trauma-ICU Adults & Pediatrics

  2. In general… • Optimal management is controversial. • Points of contention • Appropriate evaluation of patients • Optimal surgical approach • +/- Antireflux procedure accompanying repair • Option of laparoscopic technique Ferguson, Cameron 6th ed.

  3. Types (1) hiatal hernias are classified according to the position of the esophagogastric junction and the existence of a true hernia sac. • 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.

  4. Types (2) Type II & Type III are referred to as “paraesophageal hernias”. • 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.

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

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

  7. Relative Frequency According to Age • Type I: hatched bars • Type II & III: solid bars Basic prevalence of Type I hernias…

  8. Diagnosis • Typical symptoms • Suspicious CXR • Chest C.T. • Upper GI Series • In urgent situations: • Placement of NG tube & subsequent coiling Often difficult to assess the location of the actual junction…

  9. Management (1) • 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

  10. Management (2) • Indications for Operation • Type I • Type II & III • Associated with a high-risk of complications • “catastrophic” in 20 – 30% of pts • Symptoms do not predict risk…

  11. Management (3) • Findings that may prompt surgery (even in those pts that are “not optimal”) • Symptoms of obstruction • Reflux • Anemia • Trying to avoid: • Further aspiration • Hemorrhage • Transfusion requirements

  12. Surgical Techniques • Principles similar to other hernia operations • Need to anchor the stomach • Fundoplication is controversial • Transthoracic vs. Transabdominal…

  13. Results & Outcomes • Short-term: • Mortality less than 1% • Major complication rate up to 30% • Future role of laparoscopic approach… Mean duration of follow-up is 1 yr.

  14. Post-op C.T.

  15. Post-op C.T.

  16. Post-op C.T.

  17. Paraesophageal Hiatal Hernias…questions ?

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