From the Guidelines
Treatment for hiatal hernia should prioritize a personalized approach, considering symptom severity, and may include lifestyle modifications, medications, and in some cases, surgery, with laparoscopic fundoplication being a viable option for non-obese patients, as suggested by the most recent study 1.
Overview of Treatment Options
When considering treatment for hiatal hernia, it's essential to evaluate the severity of symptoms and the presence of any complications. The goal is to alleviate symptoms, prevent further complications, and improve quality of life.
Lifestyle Modifications
For mild symptoms, the first line of treatment includes lifestyle changes:
- Elevate the head of the bed 6-8 inches
- Avoid lying down within 3 hours after eating
- Lose weight if overweight
- Eat smaller meals
- Avoid trigger foods like spicy or fatty items, chocolate, caffeine, and alcohol
Medications
Medications commonly prescribed for hiatal hernia symptoms include:
- Antacids (like Tums or Rolaids) for immediate relief
- H2 blockers (such as famotidine 20mg twice daily or ranitidine 150mg twice daily) to reduce acid production
- Proton pump inhibitors (like omeprazole 20mg daily or pantoprazole 40mg daily) for more severe symptoms, as supported by 1
Surgical Options
For severe cases or when conservative treatments fail, surgical options are considered, particularly for large hernias, severe persistent symptoms, or complications like strangulation.
- Laparoscopic fundoplication is often utilized in non-obese patients, with the type of fundoplication tailored to the patient's needs, as discussed in 1
- Magnetic sphincter augmentation and transoral incisionless fundoplication are other options for carefully selected patients
- In patients with proven GERD, Roux-en-Y gastric bypass is an effective primary anti-reflux intervention in obese patients, and a salvage option in non-obese patients, while sleeve gastrectomy has potential to worsen GERD, as noted in 1
Recent Guidelines and Recommendations
The most recent study 1 highlights the importance of minimally invasive surgery for managing complicated diaphragmatic hernias, with laparoscopic or thoracoscopic approaches being the most used and having shorter hospital stays and less morbidity compared to open surgery. However, the treatment of hiatal hernia should be guided by the most recent and highest quality evidence, which suggests a personalized approach to management, including lifestyle modifications, medications, and surgical options, with a focus on symptom severity and patient selection, as emphasized in 1.
From the Research
Hiatal Hernia Treatment Options
- Asymptomatic hiatal hernias can be managed with watchful waiting, as they become symptomatic and necessitate repair at a rate of 1% per year 2
- Symptomatic hiatal hernias and those with confirmed reflux disease require operative repair with an anti-reflux procedure 2
- Key operative steps for hiatal hernia repair include reduction and excision of hernia sac, 3 cm of intraabdominal esophageal length, crural closure with mesh reinforcement, and an anti-reflux procedure 2
Surgical Techniques
- Laparoscopic Nissen fundoplication is often considered the standard for treating gastroesophageal reflux disease-related hiatal hernias due to its effectiveness 3
- Other procedures, such as Toupet and Dor fundoplications, may be suited for patients with specific conditions, such as impaired esophageal motility 3
- Newer approaches, including magnetic sphincter augmentation (MSA) and mesh repair, focus on patient-specific treatments to achieve the best outcomes 3
Management Guidelines
- The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has released guidelines for the surgical treatment of hiatal hernias, including recommendations for asymptomatic patients and the use of mesh 4
- The guidelines suggest routinely performing a fundoplication in the repair of hiatal hernias, though this is based on low certainty evidence 4
- Expert opinions are offered for select asymptomatic patients who may be offered surgical repair, and for conversion to Roux-en-Y gastric bypass (RYGB) for management of recurrent hiatal hernias 4
Controversies and Future Research
- High recurrence rates after surgical treatment of hiatal hernias and antireflux surgery have led to a discussion about diaphragm closure with or without mesh augmentation 5
- Data seem to indicate that hiatal mesh augmentation reduces recurrence, but more research is needed to confirm this 5
- Future research should focus on randomized studies of subsets of patients, stratified by age, gender, symptoms, and comorbidities, to provide stronger recommendations for the treatment of hiatal hernias 6, 4