Paraoesophageal Hernia

A paraoesophageal hernia is a type II, III or IV hiatus hernia in which a substantial portion of the stomach lies beside or above the oesophagus.

Unlike a simple sliding hernia, the major danger is mechanical. The herniated stomach may twist, obstruct, bleed, aspirate or become strangulated.

Type II has a normally positioned gastroesophageal junction with fundal herniation. Type III contains both the gastroesophageal junction and stomach. Type IV contains additional viscera such as colon or small bowel.

Many large hernias produce vague but significant symptoms:

• Postprandial epigastric or lower chest pressure
• Early satiety
• Dysphagia
• Regurgitation
• Dyspnoea
• Recurrent aspiration
• Iron deficiency anaemia

Acute gastric volvulus presents with severe chest or epigastric pain, retching and inability to vomit effectively. Marked distension, haematemesis, shock or peritonism suggests gastric ischaemia or perforation.

Contrast swallow: clearly demonstrates the position and rotation of the stomach.

Upper gastrointestinal endoscopy: assesses mucosal disease, obstruction, Cameron lesions and gastric viability when safe.

CT chest and upper abdomen: preferred in acute obstruction, suspected volvulus or complex large hernias.

Symptomatic paraoesophageal hernias should usually be repaired electively when operative risk is acceptable.

A completely asymptomatic patient with an incidentally discovered hernia can be considered for surveillance after discussion of age, operative risk, hernia anatomy and the possibility of acute complications.

Elective repair involves complete reduction, mediastinal sac dissection, restoration of adequate intra abdominal oesophageal length and tension free crural closure.

Add fundoplication in most patients undergoing elective repair because repair alone can produce or worsen reflux. A partial wrap may be preferable when preoperative dysphagia or weak oesophageal motility makes postoperative obstruction a concern.

Gastropexy can supplement repair, especially in very large hernias or selected high risk patients.

Acute gastric volvulus requires urgent decompression and surgical assessment.

Endoscopic decompression may temporarily untwist or decompress a viable stomach in a stable high risk patient, but it does not definitively correct the anatomical defect.

Gastric necrosis or perforation requires resection of nonviable stomach in addition to hernia management.

In an unstable patient, the priority is reduction, assessment of viability and control of contamination. A complex elective style reconstruction should not take priority over physiological rescue.