Ciaran O’Hare. A Selective Approach to Type II / III (Paraesophageal) Hiatal Hernia Ciaran M. O’Hare FRCSI FACS Associate Professor OUHSC Chief of Surgery

Ciaran O’Hare

Ciaran O’Hare

A Selective Approach to Type II / III A Selective Approach to Type II / III (Paraesophageal) Hiatal Hernia(Paraesophageal) Hiatal Hernia

Ciaran M. O’Hare FRCSI FACSCiaran M. O’Hare FRCSI FACS

Associate Professor OUHSCAssociate Professor OUHSC

Chief of Surgery VAMCChief of Surgery VAMC

Oklahoma City.Oklahoma City.

Sept 29Sept 29thth 2005 2005

Ciaran O’Hare

Para-esophageal HerniaPara-esophageal Hernia ANATOMYANATOMY

95%95%

1%1%

4%4%

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Type IIIType III Type IVType IVType IIType II

Para-esophageal HerniaPara-esophageal Hernia ANATOMYANATOMY

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Aetiology : Type IIAetiology : Type II

Esophago-phrenic ligamentEsophago-phrenic ligament ((Type II)Type II) Remains strong posteriorlyRemains strong posteriorly Sac is attenuated in ant.Sac is attenuated in ant. and lat. portionsand lat. portions

Para-esophageal HerniaPara-esophageal Hernia

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Levels Of EvidenceLevels Of Evidence

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• AsymptomaticAsymptomatic

• Reflux Type SymptomsReflux Type Symptoms

• Related to Intrathoracic StomachRelated to Intrathoracic Stomach

(Obstructive + Ischemic)(Obstructive + Ischemic)

• Acute / EmergentAcute / Emergent

SymptomsSymptoms


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DiagnosisDiagnosis

Fluid Level Fluid Level On CXROn CXR

BariumBariumMealMeal


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• Elective Elective (Asymptomatic, Minimal)(Asymptomatic, Minimal)

• Acute Acute (Gastric Obstruction or Ischemia)(Gastric Obstruction or Ischemia)

• Emergent Emergent (Gastric Volvulus or Gangrene)(Gastric Volvulus or Gangrene)

Surgery : Surgery : 2001-32001-3


87%87%10%10% 3%3%

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• Reduce HerniaReduce Hernia• Excise SacExcise Sac• (Lengthen Esophagus)(Lengthen Esophagus)• Repair CruraRepair Crura• GastropexyGastropexy• FundoplicationFundoplication• Post-op CXRPost-op CXR

Principles of RepairPrinciples of Repair


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• Through Left Chest Through Left Chest better hiatal access, with ‘short’ esophagus, in fat males vs better hiatal access, with ‘short’ esophagus, in fat males vs morbiditymorbidity

• Via AbdomenVia Abdomenquicker, simple gastropexy in emergencies vs quicker, simple gastropexy in emergencies vs hiatus can be difficulthiatus can be difficult

• LaparoscopicLaparoscopicLess morbid vs Less morbid vs difficult (R side and sac excision), greater recurrencedifficult (R side and sac excision), greater recurrence

Methods of RepairMethods of Repair


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Closing the Large HiatusClosing the Large Hiatus

Create a relaxing incision,Create a relaxing incision,

then close with PTFEthen close with PTFE


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Ciaran O’Hare

As always, when As always, when data are scarce, data are scarce, opinions are opinions are strongly held!strongly held!


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Para-esophageal HerniaPara-esophageal Hernia Levels Of EvidenceLevels Of Evidence

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ControversiesControversies

Acts as a tether promoting recurrenceActs as a tether promoting recurrence

Interferes with esophageal mobilizationInterferes with esophageal mobilization

Can promote a post-op fluid collectionCan promote a post-op fluid collection

““The sac must be completely excised”The sac must be completely excised”


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True!True!

Meta-analysis, Case series Meta-analysis, Case series

““The sac must be completely excised”The sac must be completely excised”


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““Fundoplication must always be performed”Fundoplication must always be performed”

Most have some degree of refluxMost have some degree of reflux

Compression by stomach prevents pre-op evaluationCompression by stomach prevents pre-op evaluation

Esophageal mobilization predisposes to refluxEsophageal mobilization predisposes to reflux


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Probably trueProbably true

Case series, Expert OpinionCase series, Expert Opinion(Best Available Evidence)(Best Available Evidence)

““Fundoplication must always be performed”Fundoplication must always be performed”


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UnprovenUnproven

No controlled studiesNo controlled studies

Laparoscopy associated with greater Laparoscopy associated with greater (asymptomatic) post-op reflux(asymptomatic) post-op reflux

““Laparoscopic (Open, Thoracic) repair is the preferred Laparoscopic (Open, Thoracic) repair is the preferred method”method”


Ciaran O’Hare


Hill 1973 – Because 30% will need emergency surgery, Hill 1973 – Because 30% will need emergency surgery, with a 40% mortality.with a 40% mortality.

Also stated by Nyus in “HERNIA” 1964Also stated by Nyus in “HERNIA” 1964

Quoted in virtually every other paper on the subject till Quoted in virtually every other paper on the subject till 20002000

““All Paraesophageal Hernias must be repaired”All Paraesophageal Hernias must be repaired”


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• Only 29 patientsOnly 29 patients

• Uncontrolled retrospective Uncontrolled retrospective

• Some were watched for 20 yrsSome were watched for 20 yrs

• 6/10 – successfully decompressed6/10 – successfully decompressed

• 4/10 died – 2 before surgery4/10 died – 2 before surgery

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• Degree of herniation varies at any one timeDegree of herniation varies at any one time

• Most (90%) of acute presentations can be Most (90%) of acute presentations can be decompressed by NGdecompressed by NG

• Modern worst case operative mortality is Modern worst case operative mortality is 15%15%


““All Paraesophageal Hernias must be All Paraesophageal Hernias must be repaired…… NO!”repaired…… NO!”

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• Allen 1993 – 1 gastric strangulation/245 pt-yrsAllen 1993 – 1 gastric strangulation/245 pt-yrs (type IV)(type IV)• Treacy – 1987Treacy – 1987

• Hashemi 2000 – 1/54 pts with emergency Hashemi 2000 – 1/54 pts with emergency surgerysurgery

• Pellegrini – 1/45 emergency surgeryPellegrini – 1/45 emergency surgery


““All Paraesophageal Hernias must be All Paraesophageal Hernias must be repaired…… NO!”repaired…… NO!”

Ciaran O’Hare


5m patient computer model based on clinical databases5m patient computer model based on clinical databases

Entered modern data for symptom progression, mortality Entered modern data for symptom progression, mortality (emergency and elective)(emergency and elective)

Compared mandatory surgery vs watchful waiting (with risk Compared mandatory surgery vs watchful waiting (with risk of gangrene) and surgery for symptom progressionof gangrene) and surgery for symptom progression

But no similar study on the strategy for moderately But no similar study on the strategy for moderately symptomatic patientssymptomatic patients

Minimally Symptomatic PatientsMinimally Symptomatic Patients

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Para-esophageal HerniaPara-esophageal Hernia Minimally Symptomatic PatientsMinimally Symptomatic Patients

Annual risk of needing Annual risk of needing emergency surgery is ~ 1.5%emergency surgery is ~ 1.5%

Comparing morb. / mort. of Comparing morb. / mort. of operating on everyone vs a operating on everyone vs a strategy of operating strategy of operating emergently, only 1 / 5 of 65 yr emergently, only 1 / 5 of 65 yr old, and 1 / 10 of 85 yr olds old, and 1 / 10 of 85 yr olds would benefitwould benefit

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Para-esophageal HerniaPara-esophageal Hernia So what’s a fellow to do?So what’s a fellow to do?

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- Even then , carefully weigh the risk v benefit of elective surgery, given - Even then , carefully weigh the risk v benefit of elective surgery, given that emergent surgery remains unusual, and survival is 85% that emergent surgery remains unusual, and survival is 85%

- Difficult hiatal repairs, or with “short” esophagus,- Difficult hiatal repairs, or with “short” esophagus,

may be best approached trans –thoracicmay be best approached trans –thoracic

Minimally Symptomatic PatientsMinimally Symptomatic Patients

RecommendationsRecommendations

- Watch for symptoms showing significant - Watch for symptoms showing significant

episodes of gastric obstruction or ischemiaepisodes of gastric obstruction or ischemia

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- One would assume that the risk of an emergent event would be One would assume that the risk of an emergent event would be greater, though there is no datagreater, though there is no data

- Perhaps the subset of patients with occasional gastric obstructivePerhaps the subset of patients with occasional gastric obstructive

symptoms could be watched, while those with gastric ischemis symptoms symptoms could be watched, while those with gastric ischemis symptoms (ulcers, anemia) should be electively operated on(ulcers, anemia) should be electively operated on

Assess individually and carefully weigh the risk v benefit of Assess individually and carefully weigh the risk v benefit of elective surgeryelective surgery

RecommendationsRecommendations

Symptomatic PatientsSymptomatic Patients

Ciaran O’Hare


Any Any Questions?Questions?

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Ciaran O’Hare. A Selective Approach to Type II / III (Paraesophageal) Hiatal Hernia Ciaran M. O’Hare FRCSI FACS Associate Professor OUHSC Chief of Surgery