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20 Cards in this Set

  • Front
  • Back
Symptome
Etwa jeder fünfte ältere Erwachsene entwickelt eine so genannte axiale Hiatushernie (mit 70 Jahren zu 70%).
Symptome werden meist durch eine begleitende Refluxerkrankung hervorgerufen.
Diagnostik
• Diagnostiziert werden Hernien durch die Röntgenuntersuchung mit oraler Kontrastmittelgabe.
• Kleine axiale Hernien kommen manchmal erst in Kopftieflage und Valsalva-Versuch zur Darstellung.
• Manchmal deutet sich die paraösophageale Hernie bereits auf der Thoraxübersichtsaufnahme durch eine mediastinale Flüssigkeits- oder Luftansammlung an.
• Die Endoskopie ist für die Diagnose der Hiatushernie meist ohne Bedeutung,
Therapie
• Die Therapie der axialen Hiatushernie richtet sich nach der in mehr als 50% gleichzeitig auftretenden Refluxkrankheit.
• Ohne diese Begleiterkrankung muss sie nicht therapiert werden.
• Die paraösophageale und die gemischte Hernie stellen aufgrund ihres Beschwerdebildes und ihres Komplikationsrisikos immer eine Operationsindikation dar.
• zwei Ziele verfolgen:
• den sicheren Verschluss des teilweise erheblich erweiterten Hiatus (Hiatoplastik)
• Fixierung des Magenfundus an das Zwerchfell (Fundophrenikopexie).
• die simultane Durchführung einer zusätzlichen Fundoplikatio ist umstritten.
INTRODUCTION
• Hiatus hernia is a frequent finding by both radiologists and gastroenterologists.
ANATOMY AND PHYSIOLOGY OF THE GASTROESOPHAGEAL JUNCTION
• The distal end of the esophagus is anchored to the diaphragm by the phrenoesophageal membrane, formed by the fused endothoracic and endoabdominal fascia.

• The repetitive stress of swallowing as well as that associated with abdominal straining and episodes of vomiting subject the phrenoesophageal membrane to substantial wear and tear, making it a plausible target of age-related degeneration.
• Another potential source of stress on the phrenoesophageal membrane is tonic contraction of the esophageal longitudinal muscle induced by gastroesophageal reflux and mucosal acidification
• gastroesophageal junction also serves to minimize gastroesophageal reflux.
• complex valvular mechanism,
• The proximal margin of the LES extends up to and a short distance proximal to the squamocolumnar junction.
• The distal margin of the LES is more difficult to define but careful anatomic studies suggest that it is composed of elements of the gastric musculature, the opposing clasp, and sling fibers of the gastric cardia (figure 3) [6].
• Surrounding the LES at the level of the squamocolumnar junction is the crural diaphragm, composed mainly of the right diaphragmatic crus [7].
TYPES OF HIATAL HERNIA
Type I: Sliding hernia — Type I or sliding hiatal hernia accounts for more than 95 percent of cases. This type of hernia is characterized by widening of the muscular hiatal tunnel and circumferential laxity of the phrenoesophageal membrane, allowing a portion of the gastric cardia to herniate upward.

• In marginal instances, type I hiatal hernia is simply an exaggeration of the normal phrenic ampulla,
• Hiatal hernias that are larger than 2 cm in axial span can be diagnosed easily by barium swallow radiography, endoscopy, or esophageal manometry.
• By contrast, endoscopy and radiography are much less accurate for defining smaller hernias.
• most small hiatal hernias are asymptomatic and, even with larger type I hernias, the main clinical implication is the propensity to develop gastroesophageal reflux disease (GERD).
Type II, III, and IV: Paraesophageal hernias —
• The less common types of hiatal hernia, types II, III, and IV, are varieties of "paraesophageal" hernias which account for about 5 percent of all hiatal hernias [3,12].
• recognized complication of surgical dissection of the hiatus as occurs during antireflux procedures, esophagomyotomy, or partial gastrectomy.
• abnormal laxity of structures normally preventing displacement of the stomach — the gastrosplenic and gastrocolic ligaments.
• herniated stomach tends to rotate around its longitudinal axis, resulting in an organoaxial volvulus

• Infrequently, rotation occurs around the transverse axis resulting in a mesenteroaxial volvulus (figure 6) [13].
• best diagnosed with a barium swallow,
• Types III and IV hiatal hernias are variants of the type II (purely paraesophageal) hernia:
• Type III hernias have elements of both types I and II.
• Type IV hiatus hernia is associated with a large defect in the phrenoesophageal membrane, allowing other organs, such as the colon, spleen, pancreas, and small intestine, to enter the hernia sac.
SYMPTOMS
• It is usually discovered as a finding on upper gastrointestinal studies or endoscopy.
• type II hernia are either asymptomatic or have only vague, intermittent symptoms.
• The most common symptoms are
• epigastric or substernal pain,
• postprandial fullness,
• substernal fullness,
• nausea, and
• retching.
• An upright radiograph of the thorax may be diagnostic,
• Barium contrast studies are almost always diagnostic.
• Most complications of a type II hernia are reflective of the mechanical problem caused by the hernia.
• Gastric volvulus can cause dysphagia, while postcibal pain is usually related to gastric torsion.
• Bleeding, although infrequent, occurs from gastric ulceration, gastritis, or erosions (Cameron lesions) within the incarcerated hernia pouch
• Respiratory complications
o mechanical compression of the lung
• Association of type I hiatus hernia with gastroesophageal reflux
• 50 to 94 percent of patients with GERD have a type I hiatal hernia
• Hiatus hernia and the diaphragmatic sphincter
• both the LES and the crural diaphragm encircling the LES serve a sphincteric function
• neither hiatus hernia nor a hypotensive LES alone results in severe gastroesophageal junction incompetence
• Compromise of esophageal emptying related to hiatus hernia.
TREATMENT
• Repair of an isolated, asymptomatic type I hiatal hernia is rarely indicated.
• If symptoms of GERD occur in association with a large hiatus hernia, either medical or surgical treatment is indicated to control the reflux.
• In contrast, the enlarging types II, III, and IV hernias pose a constant risk of serious complications.
• These hernias never regress and progressively enlarge.
• hernia eventually reaches the stage of the giant intrathoracic stomach, at which point the prognosis is poor and the complication rate is high
• Some advocate surgical treatment even in the absence of symptoms
• mortality rate from elective paraesophageal hernia repair is reportedly 1.4 percent,
• probability of developing acute symptoms requiring emergent surgery is reportedly 1.1 percent
• The lifetime risk of developing acute symptoms requiring emergency surgery decreases exponentially with age after 65 years.
• Surgical approaches to type II hiatal hernias can be divided into five components, not all of which are required in each case:
• Reduction of the herniated stomach into the abdomen
• Herniotomy (excision of the hernia sac)
• Herniorrhaphy (closure of the hiatal defect)
• An antireflux procedure
• Gastropexy (attachment of the stomach subdiaphragmatically to prevent reherniation)
• Opinion varies as to whether or not an antireflux procedure is necessary if concomitant pathologic reflux has not been demonstrated.
• The most common antireflux procedure is a Nissen fundoplication.
• Gastropexy is performed if the stomach is unusually mobile after reduction.
• The prognosis is excellent following surgical repair of a type II hiatal hernia (which accounts for 95 percent of paraesophageal hernias). The recurrence rate for type II hernias is higher than for type I hernias presumably because the tissues of the hiatus are more compromised [7].
SUMMARY AND RECOMMENDATIONS
• In general terms, hiatus hernia refers to herniation of elements of the abdominal cavity through the esophageal hiatus of the diaphragm. The most comprehensive classification scheme recognizes four types of hiatal hernia.
• Type I or sliding hiatal hernia accounts for more than 95 percent of cases. This type of hernia is characterized by widening of the muscular hiatal tunnel and circumferential laxity of the phrenoesophageal membrane, allowing a portion of the gastric cardia to herniate upward. The phrenoesophageal membrane remains intact and the hernia is contained within the posterior mediastinum (figure 4).
• The less common types of hiatal hernia, types II, III, and IV, are varieties of "paraesophageal" hernias which account for about 5 percent of all hiatal hernias.
• Hiatal hernia is not a diagnosis that is pursued in and of itself. It is usually discovered as a finding on upper gastrointestinal studies or endoscopy.
• Repair of an isolated, asymptomatic type I hiatal hernia is rarely indicated. If symptoms of GERD occur in association with a large hiatus hernia, either medical or surgical treatment is indicated to control the reflux.
The enlarging types II, III, and IV hernias pose a risk of serious complications. However, prophylactic paraesophageal hernia repair is rarely performed, as the mortality rate from elective paraesophageal hernia repair is 1.4 percent, while the probability of developing acute symptoms requiring emergent surgery is 1.1 percent
Paraesophageal hernia

INTRODUCTION
uncommon type of hiatal hernia.
Surgical management is indicated when medical management fails to control symptoms of gastroesophageal reflux that may be related to the paraesophageal hernia, or when there is an emergent complication [1-5].
Paraesophageal hernia

DEFINITION
Hiatal hernias are classified by type:
type I is a sliding hernia and
types II, III, and IV are paraesophageal hernias.
Paraesophageal hernias account for approximately 5 percent of all hiatal hernias and frequently are asymptomatic or associated with vague and intermittent symptoms of gastroesophageal reflux
Paraesophageal hernia

CLINICAL FEATURES
• Most patients with a paraesophageal hernia are asymptomatic
• one-third of patients have endoscopic evidence of
• gastritis,
• gastric ulceration
• esophageal reflux.
• Serious complications
• gastric volvulus,
• gastric outlet obstruction,
• hemorrhage, and rarely,
• respiratory distress secondary to tracheobronchial compression of the left main stem bronchus.
Paraesophageal hernia

DIAGNOSIS
• chest x-ray,
• upper endoscopy
• hernia can be visualized on a retroflexion maneuver
• video barium swallow .
• Prior to surgical repair, all patients diagnosed with a paraesophageal hernia should undergo endoscopic evaluation to rule out other esophageal or gastric pathology.
• A barium swallow can provide information regarding gastric anatomy, the length of the esophagus, and the presence of organoaxial rotation.
Paraesophageal hernia

INDICATIONS FOR SURGICAL REPAIR
• There is no medical treatment for a paraesophageal hernia.
• Treatment is directed towards symptoms of gastroesophageal reflux (GER).
• Indications for an elective repair of a paraesophageal hernia include
• failed medical management of GER,
• dysphagia,
• early satiety,
• postprandial pain,
• anemia, and
• vomiting that is associated with a paraesophageal hernia.
• Indications for an emergent repair include a
• gastric volvulus,
• bleeding,
• obstruction,
• strangulation,
• perforation, and
• respiratory compromise secondary to a paraesophageal hernia.
• prophylactic paraesophageal hernia repair is rarely performed, as the mortality rate from elective repair is estimated to be 1.4 percent, while the probability of developing acute symptoms requiring emergent surgery is 1.1 percent
• For symptomatic patients who are too frail to undergo a formal paraesophageal hernia repair, we perform a laparoscopic assisted endoscopic hernia reduction with placement of two percutaneous endoscopic gastrostomy (PEG) tubes to secure the stomach to the anterior abdominal wall
Paraesophageal hernia

TECHNICAL INSIGHTS
Dissection of the hernia sac
The following principles are followed when performing the dissection [10]:
• An incarcerated stomach, if present, can be friable and should be handled with care.
• The dissection is performed within the plane between the hernia sac and the adjacent tissues.
• The peritoneal covering of the abdominal side of the crus for the repair is preserved when dividing the gastrohepatic omentum from the right crus of the diaphragm (picture 4).
• A Penrose drain is placed around the esophagus to facilitate the dissection of the posterior wall of the hernia sac. Using gentle upward traction on the Penrose drain, the dissection begins at the right crus and proceeds posteriorly to the left crus (picture 5).
• The hernia sac must be completely removed from the mediastinum.
• Dividing the short gastric vessels will increase mobilization of the stomach. This will facilitate a fundoplication and improve exposure of the operative site.
• The esophagus must be mobilized to the level of the aortic arch or until at least 4 cm of intra-abdominal esophagus is mobilized without tension (picture 6).
• The amount of electrocautery should be limited when mobilizing the esophagus, since the potential risk of damage to the esophagus is high. An esophageal lengthening procedure is rarely required for an initial repair.
• Injury or transection of the vagal nerves should be avoided to reduce the risk of delayed gastric emptying.
• Closure of hiatal defect
• The repair must be tension-free and can be performed as a primary suture repair or, if the defect is large, using mesh.
• Fundoplication —
• a fundoplication benefits patients who have symptomatic gastroesophageal reflux disease (GERD)
• Anterior gastropexy — permanent gastric fixation in the abdominal cavity. An anterior gastropexy can be used to reduce the risk of gastric reherniation into the thoracic cavity by fixing the stomach to the abdominal wall. Fixation can be achieved using primary sutures between the stomach and abdominal wall or by a percutaneous endoscopic gastrostomy (PEG) tube.
Paraesophageal hernia

POSTOPERATIVE MANAGEMENT
• if laparoscopic repair is performed, most are discharged on the second postoperative day.
• Patients managed with an open repair remain hospitalized until bowel function returns, which occurs at approximately five days
• Delayed gastric emptying is generally self-limiting, but can result in postoperative emesis, disruption of the hernia repair, and early hernia recurrence
• anti-nausea medication for the first 24 hours postoperatively.
• A barium swallow is performed on the first postoperative day to assess for possible esophageal leak and early hernia recurrence, and to evaluate gastric emptying and motility.
• If the barium swallow study shows an adequate repair, patients are started on a clear liquid diet and advanced to soft solids as tolerated.
• Patients are instructed to follow a low residue diet for two to three weeks following discharge from the hospital.
Paraesophageal hernia

PATIENT OUTCOMES
Laparoscopic versus open repair Data are limited
Mesh repairs —
• mesh repair reduces the rate of recurrence,
• serious complications (eg, intraluminal mesh erosion, esophageal stenosis, dense fibrosis) and
• reoperations (eg, esophagectomies, partial and total gastrectomies, esophageal stent placement)
Paraesophageal hernia

Mortality and morbidity
• mortality rate of 1.7 percent and 0.8 percent,
• The major adverse morbidity outcomes included
• pneumonia (4.0 percent),
• pulmonary embolism (3.4 percent),
• heart failure (2.6 percent), and
• postoperative leak (2.5 percent) [31].
REOPERATIVE CONSIDERATIONS
• Patients requiring reoperation for a symptomatic paraesophageal hernia recurrence present a significant technical challenge.
• Asymptomatic recurrences identified by an esophagram do not require a reoperation.
Paraesophageal hernia

SUMMARY AND RECOMMENDATIONS
— A paraesophageal hernia is an uncommon type of hiatal hernia with a peritoneal layer that forms a true hernia sac. The management of paraesophageal hernias has changed significantly over the last few decades. Surgical management is indicated when medical management fails to control gastroesophageal reflux disease (GERD) associated with a paraesophageal hernia, or in the presence of a gastric volvulus, uncontrollable bleeding, or respiratory compromise secondary bronchial compression. (See 'Introduction' above.)
• Indications for an emergent repair of a paraesophageal hernia include gastric volvulus, bleeding, obstruction, strangulation, perforation, and respiratory compromise secondary to the hernia. (See 'Indications for surgical repair' above.)
• An elective paraesophageal hernia repair is reserved for symptomatic patients (eg, dysphagia, early satiety, postprandial pain). (See 'Indications for surgical repair' above.)
• Elective repairs are offered to symptomatic patients and can be performed laparoscopically or by an open technique. (See 'Laparoscopic versus open repair' above.)
• Regardless of the approach, the basic tenets of mediastinal hernia sac reduction, esophageal mobilization, stable crural closure, antireflux procedure, and intra-abdominal gastric fixation are all important aspects of the procedure. (See 'Technical insights' above.)
• The role of mesh in the paraesophageal repair should be considered for large diaphragmatic defects or defects that cannot be closed without tension using a primary suture repair. While there is a lower rate of recurrence with mesh, there are serious risks with mesh repairs (eg, intraluminal mesh erosion and esophageal stenosis). (See 'Mesh repairs' above.)
• For patients who are elderly or frail, we perform a laparoscopic assisted endoscopic hernia reduction with double PEG tube placement to serve as an anterior gastropexy. A formal paraesophageal repair can be performed later as indicated by the patient’s condition. (See 'Anterior gastropexy' above.)
• For elderly patients, the mortality rate for an emergent repair is higher than an elective repair. However, those who are entirely asymptomatic can be observed. (See 'Mortality and morbidity' above.)
• A barium swallow should be performed on the first postoperative day to assess for a possible esophageal leak, early hernia recurrence, and assess gastric motility. (See 'Postoperative management' above.)
• An anti-emetic should be administered for the first 24 postoperative hours to reduce the risk of postoperative emesis that may result in disruption of the repair and early recurrence. (See 'Postoperative management' above.)
• Operative management of recurrent paraesophageal hernias is reserved for symptomatic patients and needs to be tailored to the individual setting. (See'Reoperative considerations' above.