Paraoesophageal Hernias: A Surgical Perspective

Abstract

EditorialHiatal hernias refer to the condition where intra-abdominal structures herniate into the mediastinum through the oesophageal hiatus. They occur in about 10% of the population. Hiatal hernias are classified in 4 types. Type I or sliding hernia represents 85%-90% of all hiatal hernias. It results from laxity and loss of coherence of the phreno-oesophageal membrane. The gastro-oesophageal junction (GOJ) is displaced above the diaphragm while the fundus remains below the GOJ. Hiatal hernias type II, III and IV or collectively known as paraesophageal hernias represent about 10%-15% of hiatal hernias. Type II hernia results from a localized defect in the phrenooesophageal membrane. The gastric fundus herniates into the mediastinum, while the GOJ remains fixed to the preaortic fascia and the median arcuate ligament. Type III paraoesophageal hernias have elements of both types I and II and have both the GOJ and the fundus herniating through the hiatus. Type IV hiatus hernia is associated with a large defect in the diaphragm defined by the presence of organs other than the stomach in the hernia sac commonly being the transverse colon, spleen, pancreas or small bowel.Paraoesophageal hernia is a condition mainly seen in the elderly population. In most large series, presentation with a median age of 65 to 75 years appears to be the rule [1]. Risk factors for developing hiatal hernia include age greater than 50, BMI>25 and male gender [2]. About 50% of cases are asymptomatic and the hernia is an incidental finding on imaging or endoscopy. In sliding hernias reflux symptoms such as heartburn and regurgitation are more frequent; whilst in paraoesophagheal hernias common symptoms include epigastric or substernal pain, postprandial fullness, dysphagia, nausea, vomiting and dyspnoea. Microcytic anaemia can be present secondary to erosions of the gastric mucosa. Acute symptoms due to gastric outlet obstruction/ gastric volvulus, uncontrolled bleeding, strangulation, perforation, and respiratory compromise are indications for urgent surgery.Hiatus hernia can be an incidental finding on a chest X-ray where the gastric bubble can be seen in the chest. On barium swallow the presence of more than 2 cm separation between the B ring (level of squamocolumnar junction) and the diaphragm suggests a sliding hiatus hernia. If a B ring is not evident on barium swallow (absent in 85% of individuals), the demonstration of at least three rugal folds traversing the diaphragm is diagnostic of a sliding hiatus hernia [3]. In paraoesophageal hernias there is evidence of the fundus herniating into the mediastinum. On endoscopy a sliding hernia is defined as a greater than 2 cm distance between the squamocolumnar junction and the diaphragmatic impression on the stomach [3]. In paraoesophageal hernias the hernia can be visualised on retroflexion (J manoeuvre) of the endoscope that reveals a portion of the stomach, herniating upward through the diaphragm, adjacent to the endoscope [3]. Another indirect indicator of paraoesophageal hernia that sh...

Problems and ways of improving the efficiency of surgical treatment of hiatal herniae

“…В в е д е н и е. Грыжи пищеводного отверстия диафрагмы (ГПОД) (хиатальные грыжи) относятся к наиболее распространенным вариантам нарушения висцеральной анатомии. Считается, что у людей моложе 30 лет подобные анатомические изменения отмечаются в 10-15 %, в то время как у индивидуумов старше 50 лет -в 60 % [1][2][3][4][5][6].…”

“…Смешанные грыжи (III тип) сочетают в себе анатомические изменения первых двух вариантов. Хиатальные грыжи (IV тип) -дислокация в грудную полость любых других органов брюшной полости, кроме желудка [1,4,5,7].…”

“…При грыжах пищеводного отверстия диафрагмы II-IV типов нередко создаются условия для нарушения пассажа пищи, обусловленные деформацией, перегибом или заворотом пищевода, желудка или других полых органов брюшной полости. Этими изменениями и определяются клинические проявления и показания к их хирургическому лечению [4,[10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26]. В период с 2010 по 2017 г. в ПСПбГМУ им.…”