1. science
2. medicine
3. surgery

Patients with Hiatal Hernias/ Reflux
Director Metabolic Medicine and Surgery Institute
Florida Hospital Celebration Health
Overview
Consequence of hiatal hernia
Treatment
Method of repair: anterior vs posterior
Laparoscopic vs robotic
Technique
Special scenarios
Consequence of hiatal hernia after foregut
surgery
medical vs surgical management
Surg Endosc. 2011 Aug;25(8):2547-54. Epub 2011 Apr 22.
A randomized controlled trial of laparoscopic Nissen fundoplication versus proton pump
inhibitors for the treatment of patients with chronic gastroesophageal reflux disease
(GERD): 3-year outcomes.
Anvari M, Allen C, Marshall J, Armstrong D, Goeree R, Ungar W, Goldsmith C.
104 pts randomized
93 pts available for analysis at 3 years
surgical pts:
more heartburn free days
improved quality of life
treatment failures: 11.8% surgery vs 16% medical
24 hour pH monitoring at 3 years: no difference
conclusion: no difference in objective measures but statistically significant
difference in subjective measures and quality of life scores
surgical technique
Ann Surg. 2011 Jul;254(1):39-47.
Laparoscopic anterior versus posterior fundoplication for gastroesophageal reflux disease:
systematic review and meta-analysis of randomized clinical trials.
Broeders JA, Roks DJ, Ahmed Ali U, Draaisma WA, Smout AJ, Hazebroek EJ
meta-analysis of randomized clinical trials
7 eligible studies 683 patients: posterior vs
anterior fundoplication
Short term: reflux and symptomatic heartburn less
for posterior repair, but dysphagia score higher
long term: dysphagia scores become comparable
but difference in reflux and symptomatic
heartburn persist
conclusion: posterior fundoplication is superior for
symptom control and there is no difference in
dysphagia in the long term
Laparoscopic vs robotic approach
Br J Surg. 2006 Nov;93(11):1351-9.
Randomized clinical trial of standard laparoscopic versus robot-assisted laparoscopic Nissen
fundoplication for gastro-oesophageal reflux disease.
Draaisma WA, Ruurda JP, Scheffer RC, Simmermacher RK, Gooszen HG, Rijnhart-de Jong HG, Buskens E, Broeders IA
50 patients randomized to laparoscopic (LNF) vs
robotic nissen fundoplication (RNF)
no difference in operative time, blood loss, perioperative complications, post-operative pain
scores, hospital stays
no difference in reduction of esophageal acid
exposure and increase in LES sphincter tone
conclusion: no benefits of robotic vs laparoscopic
approach in terms of clinical outcomes (small series)
Trocar Placement
5 mm
8mm
Assistant
Camera
5mm
technique
special scenarios
large/giant/intrathoracic
somewhat synonymous for type III hiatal hernia
herniation of >30% of stomach (no uniform
definition)
incidence unclear
management debatable
elective vs observation
mesh vs no mesh
Large intrathoracic hernias
Surg Endosc. 2010 Jun;24(6):1250-5. Epub 2009 Dec 24.
A population-based analysis of emergent vs. elective hospital admissions for an intrathoracic stomach.
Polomsky M, Hu R, Sepesi B, O'Connor M, Qui X, Raymond DP, Litle VR, Jones CE, Watson TJ, Peters JH.
Source
The New York Statewide Planning and Research Cooperative System
(SPARCS) administrative database over 5 year period (53 per 1 million
people)
data supports early elective repair
Approx 1000 pts admitted each year with primary diagnosis of
intrathoracic stomach
53% coded as emergent admissions
66% of the emergent admissions discharged without surgical intervention
emergent admissions vs elective admissions
higher mortality (5.1% vs 1.1%)
higher cost
longer length of stay
giant hiatal hernias
J Thorac Cardiovasc Surg. 2010 Feb;139(2):395-404, 404.e1. Epub 2009 Dec 11.
Outcomes after a decade of laparoscopic giant paraesophageal hernia repair.
Luketich JD, Nason KS, Christie NA, Pennathur A, Jobe BA, Landreneau RJ, Schuchert MJ.
retrospective review 662 pts laparoscopic repair
mean age: 70
mean percent of stomach herniation: 70%
giant hiatal hernias
radiographic recurrence: 15.7%
reoperations: 3.2%
30 day mortality: 1.7%
quality of life scores: excellent in 90%
giant hiatal hernia
giant hiatal hernia
giant hiatal hernia
42 yo female
BMI 43
GERD, asthma
gastric bypass after repair of giant
hiatal hernia
hiatal hernia
patient information
52 yo female
45 kg
progressive dysphagia for solids and now
sometimes liquids
has had multiple prior endoscopic interventions
achalasia
heller myotomy with Dor
fundoplication
post-op x-ray
clinical significance after foregut
surgery
case study
58 yo female with h/o gastric bypass
severe epigastric pain with eating
extensive workup negative for possible etiology
gastric bypass reversed secondary to severe pain
with eating
pain intermittent after reversal, then became
chronic again
endoscopy and barium studies unremarkable
Obesity Surg. 2010 Mar;20(3):386-92. Epub 2009 Oct 24.
Diagnosis and treatment of atypical presentations of hiatal hernia following bariatric surgery.
Flanagin BA, Mitchell MT, Thistlethwaite WA, Alverdy JC.
Pritzker School of Medicine, The University of Chicago, Chicago, IL60637, USA.
Abstract
Bariatric surgery dramatically alters the normal stomach anatomy resulting in a significant incidence of hiatal hernia and gastroesophageal reflux
disease. Although the majority of patients remain asymptomatic, many complain of severe heartburn refractory to medical management and additional
highly atypical symptoms. Here, we describe the diagnosis and treatment regarding four cases of symptomatic hiatal hernia following bariatric surgery
presenting with atypical symptoms in the University Hospital, USA. Four patients presented following laparoscopic Roux-en-Y gastric bypass or
duodenal switch/pancreaticobiliary bypass (DS) with disabling and intractable midepigastric abdominal pain characterized as severe and radiating to
the jaw, left shoulder, and midscapular area. The pain in all cases was described as paroxysmal and not necessarily associated with eating. All four
patients also experienced nausea, vomiting, and failure to thrive at various intervals following laparoscopic bariatric surgery. Routine workup failed to
produce any clear mechanical cause of these symptoms. However, complimentary use of multidetector CT and upper gastrointestinal contrast studies
eventually revealed the diagnosis of hiatal hernia. Exploration identified the presence of a type I hiatal hernia in all four patients, with the stomach staple
lines densely adherent to the diaphragm and parietal peritoneum. Operative intervention led to immediate and complete resolution of symptoms. The
presence of a hiatal hernia following bariatric surgery can present with highly atypical symptoms that do not resolve without operative intervention.
Recognition of this problem should lead to the consideration of surgery in cases where patients are dependent on artificial nutritional support and
whose symptoms are poorly controlled with medication alone.
atypical symptoms
debilitating epigastric pain unrelated to eating
other symptoms included nausea and vomiting
comprehensive evaluation negative for obvious
mechanical cause
symptoms immediately and completely resolved after
hiatal hernia repair
consequence
Obesity Surg. 2010 Jun;20(6):702-8. Epub 2009 Sep 12.
Clinical utility of endoscopy and barium swallow X-ray in the diagnosis of sliding hiatal hernia in morbidly obese patients: a study before and after
gastric bypass.
Fornari F, Gurski RR, Navarini D, Thiesen V, Mestriner LH, Madalosso CA.
GASTROBESE, Rua Uruguai, 1555, 99010112, Passo Fundo, Rio Grande do Sul, Brazil. [email protected]
Abstract
BACKGROUND: The main clinical consequence of sliding hiatal hernia (SHH) is gastroesophageal reflux disease (GERD). Endoscopy and barium
swallow X-ray are commonly used to diagnose SHH. We aimed to assess the clinical utility of endoscopy and X-ray in the diagnosis of SHH in morbidly
obese patients before and after gastric bypass (GBP).
METHODS: Ninety-two patients underwent reflux symptoms evaluation, upper gastrointestinal endoscopy, and barium swallow X-ray before and 6
months after banded GBP. The performance of endoscopy in diagnosing SHH was assessed, taking X-ray as reference. Endoscopy and X-ray were
tested as predictors of SHH with GERD.
RESULTS: SHH was more prevalent when characterized by X-ray than endoscopy either before (33% vs. 17%; P = 0.017) or after GBP (26% vs. 7%; P
= 0.001). Endoscopy showed low sensitivity (<or=40%) and high specificity (>or=94%) in diagnosing SHH. Before GBP, more patients with SHH had
GERD compared to patients without SHH using either X-ray (83% vs. 58%; P = 0.016) or endoscopy (94% vs. 61%; P = 0.009). After GBP, only patients
with radiologic evidence of SHH showed higher prevalence of GERD compared to patients without SHH (50% vs. 26%; P = 0.037). SHH patients also
reported weekly or daily vomit more often than patients without SHH (59% vs. 32%; P = 0.026).
CONCLUSIONS: In morbidly obese patients, X-ray is superior to endoscopy in diagnosing SHH either before or after banded GBP. In patients treated
with this technique, the utilization of X-ray may help in the management of reflux symptoms and frequent vomit.
hiatal hernia in bariatric patients
33% of patients found to have hiatal hernia on barium
swallow pre-op
26% of patients found to have persistent hiatal hernia
on barium swallow 6 months postop
these patients had greater frequency of vomiting
summary
consequence of hiatal hernia is reflux and surgery is an
effective treatment option
robotic approach shows no clinical outcomes advantages
versus laparoscopic approach, but studies are limited and
there are obvious technical advantages to the surgeon
giant hiatal hernias should be electively repaired
one must consider the whole patient and all of the
variables in choosing the appropriate intervention
hiatal hernias can have a far greater clinical consequence
after foregut surgery, and therefore, one should be more
aggressive in repairing hiatal hernias in this setting
thank you