Esophageal hiatal hernia: risk, diagnosis and management

Abstract

Esophageal hiatal hernia involves abnormal abdominal entry into thoracic cavity. It is classified based on orientation between esophageal junction and diaphragm. Sliding hiatal hernia (Type-I) comprises the most frequent category, emanating from right crus of diaphragm. Type-II esophageal hernia engages both left and right muscular crura. Type-III and IV additionally include the left crus. Age and increased body mass index are key risk factors, and congenital skeletal aberrations trigger pathogenesis through intestinal malrotations. Familiar manifestations include gastric reflux, nausea, bloating, chest and epigastric discomfort, pharyngeal and esophageal expulsion and dysphagia. Weight loss and colorectal bleeding are severe symptoms. Areas covered: This review summarizes updated evidence of pathophysiology, risk factors, diagnosis and management of hiatal hernias. Laparoscopy and oesophagectomy procedures have been discussed as surgical procedures. Expert commentary: Endoscopy identifies untreatable gastric reflux; radiology is better for pre-operative assessments; manometry measures esophageal peristalsis, and CT scanning detects gastric volvulus and associated organ ruptures. Gastric reflux disease is mitigated using antacids and proton pump and histamine-2-receptor blockers. Severe abdominal penetration into chest cavity demands surgical approaches. Hence, esophagectomy has chances of post-operative morbidity, while minimally invasive laparoscopy entails fewer postoperative difficulties and better visualization of hernia and related vascular damages.

Cardiopulmonary arrest secondary to compression of the heart owing to esophageal hiatal hernia: a case report

“…Esophagectomy is associated with postoperative morbidity; by contrast, minimally invasive laparoscopy affords better visualization of the hernia and entails fewer postoperative complications. 1,2 Allen et al 3 have described their observations in a case series wherein 119 of 147 patients with an intrathoracic stomach underwent surgery. They state that patients with an intrathoracic craniocaudal stomach who have obstructive symptoms at the initial presentation should undergo surgical repair and that elective surgery is both safe and effective.…”

The management of hiatal hernia: an update on diagnosis and treatment

“…According to Andolfi et al, esophageal manometry should be performed especially before undergoing surgery, as it can rule out achalasia or other motility disorders. Before performing fundoplication surgery it is also essential to verify the integrity of the peristaltis of the esophagus, which can be done using high resolution manometry (HRM) as it provides real time pressure recording [3,5]. However, placement of the manometry catheter can be rather difficult; Dallemagne et al have reported that the method is completed in less than 50% of cases [17].…”

“…Usually, a Nissen fundoplication (360°) is performed after most hiatal hernia repairs, unless there is a preexisting esophageal dysmotility, in which case the Toupet fundoplication (270°) is preferred [15]. There has been recent evidence that a complete fundoplication might be more beneficial as it has a reduced abnormality in the pH profile and a stronger impact [3]. Laparoscopic surgery provides the advantages of a minimally invasive approach, which consist of: shorter hospital stays, faster time of recovery, reduced post-operative pain and reduced pulmonary complications [1,28].…”

“…Zaman et al have found a decrease in recurrence after laparoscopic paraesophageal hernia repair and mesh reinforcement, with similar results in both syntethic and biologic mesh [24]. Regarding the use of synthetic mesh, concerns have arisen as it has been associated with the development of esophageal erosion, stricture, dysphagia, obstruction and esophageal stenosis [3,24,29]. Zhang et al, Huddy et al and Tam et al have all found a reduced rate of hernia recurrence after mesh reinforcement compared to primary suture repair at short-term follow-up (up to 12 months) [30,31,32].…”

“…It is caused by increased intra-abdominal pressure, which leads to the protrusion of the stomach and other abdominal viscera into the mediastinum [1,2]. Being overweight and elderly are the key risk factors in its development [3,4,5]. Other known risk factors include: multiple pregnancies, history of esophageal surgery, partial or full gastrectomy and certain disorders of the skeletal system associated with bone decalcification and degeneration [3,6].…”