Operating on Recurring Paraesophageal Hernia

Case Presentation

A 78-year-old woman presents to clinic with a history of significant dysphagia associated with pain and emesis. These symptoms have persisted for several weeks, and she has tolerated only a liquid diet since their onset. Although she has maintained her hydration, she reports a 10- to 15-lb weight loss in the interim.

She has a history of a paraesophageal hernia, which was repaired laparoscopically approximately 5 months ago. A biological mesh was used at the hiatus and a Nissen fundoplication performed. Her preoperative symptoms were early satiety and heartburn. These resolved immediately after her operation.

An upper gastrointestinal contrast study in this patient demonstrated recurrence of a paraesophageal hernia (Figure 1).

Figure 1. Posterior/anterior (left) and lateral (right) films of an upper gastrointestinal contrast study. There is focal narrowing of the stomach at the level of the diaphragm, representing recurrence of the paraesophageal hernia.

Recurrence Remains a Challenge

The esophageal hiatus is a dynamic center that is stressed by constant motion. It represents a barrier between the high pressures of the abdomen and the negative pressures in the chest. Therefore, it is no surprise that although the key principles of repair have been extensively described,^[1,2,3] recurrence remains common.

A wide range of recurrence rates have previously been reported for paraesophageal hernia. However, more recent analyses that have used routine evaluation with upper gastrointestinal contrast studies have demonstrated more consistent recurrence rates of 15.7%-27% in short-term follow-up.^[4,5] Historically, it was believed that that the majority of recurrences occurred in the first year,^[6] yet the latest studies suggest that recurrence rates and median follow-up are directly proportional,^[7,8,9] with an incidence of 57% described in a recent multi-institutional, randomized study.^[10]

The clinical significance of these recurrences is greatly reduced by the fact that most are relatively small and asymptomatic.^[7] No repair is needed in these instances.^[11] However, larger recurrences are often symptomatic. If symptoms are not related to gastroesophageal reflux disease or are uncontrollable with medical therapy, operative intervention should be considered. The altered geometry around the gastroesophageal junction often leads to dysphagia and varied degrees of obstruction, because the recurrent anatomy is often complicated by a displaced fundoplication.

Risk Factors

Although many of the risk factors for recurrence would seem intuitive, they have proven equally difficult to quantify as they are to mitigate.

Recently, Lidor and colleagues^[4] attempted to identify risk factors for recurrence in 111 patients with type III hiatal hernias. No significant differences were found related to comorbid conditions or preoperative clinical and radiologic findings. Obesity and pulmonary disease led to increased intra-abdominal pressures, and decreased esophageal length and incomplete sac reduction led to increased caudal traction on the hiatus.

Although the use of biological mesh has shown good results in the short term, its durability remains to be demonstrated,^[10] whereas the risks of prosthetic mesh at the hiatus are well documented.^[12]

Preoperative Evaluation

Symptoms of a paraesophageal hernia are typically caused by either intermittent obstruction (eg, nausea, vomiting, dysphagia, early satiety) or gastroesophageal reflux (eg, heartburn, regurgitation).^[10]

We use a standard work-up to evaluate patients for recurrent paraesophageal hernia. Upper gastrointestinal endoscopy is used to evaluate for mucosal disease, including Cameron ulcers and Barrett esophagus. It is useful to gain perspective on the distance between the gastroesophageal junction and the diaphragm.

High-resolution manometry should be performed to evaluate the effectiveness of esophageal peristalsis. The quality of esophageal peristalsis is important when deciding what type of fundoplication to perform. We opt for partial fundoplication in patients with ineffective esophageal motility.

A barium swallow is performed to assess the morphology of the hernia and, again, to estimate the size of the hernia orifice.

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