What is the management of a large hiatus hernia?

From the Guidelines

The management of a large hiatus hernia should prioritize a multidisciplinary approach, focusing on lifestyle modifications, medical therapy, and surgical intervention, with the goal of alleviating symptoms, preventing complications, and improving quality of life, as supported by the most recent evidence from 2023 1.

Initial Management

Initial management of a large hiatus hernia involves lifestyle modifications, including:

• Weight loss
• Avoiding large meals
• Not lying down after eating
• Elevating the head of the bed, as recommended by the 2022 AGA clinical practice update 1 Medical therapy focuses on acid suppression with proton pump inhibitors (PPIs) like omeprazole 20-40mg daily or pantoprazole 40mg daily, which reduce reflux symptoms and prevent esophagitis.

Surgical Intervention

Surgical intervention is recommended for patients with:

• Persistent symptoms despite medical therapy
• Complications such as strictures or Barrett's esophagus
• Paraesophageal hernias due to their risk of incarceration or strangulation The standard surgical approach is laparoscopic Nissen fundoplication, which involves reducing the hernia, closing the hiatal defect, and wrapping the fundus of the stomach around the lower esophagus to create an anti-reflux barrier, as supported by the 2023 WSES position paper 1.

Additional Considerations

For very large defects, mesh reinforcement may be necessary, and anti-reflux procedures combined with TDH repair may be performed successfully in patients with a history of gastroesophageal reflux, as reported in the literature 1. In critical patients, Damage Control Surgery (DCS) can be life-saving, and should be considered when the diaphragm cannot be closed, as recommended by the 2023 WSES position paper 1.

From the Research

Management of Large Hiatus Hernia

The management of large hiatus hernia involves a combination of surgical and medical approaches.

• Surgical repair is the primary treatment for large hiatus hernia, with laparoscopic surgery being a commonly used method 2, 3.
• Laparoscopic repair with crura mesh augmentation and Toupet fundoplication has been shown to be safe and effective in improving quality of life and reducing symptoms in patients with large hiatus hernia 2.
• The use of prosthetic material to reinforce the repair of the hiatus has been shown to be effective in reducing the incidence of recurrence, but the benefit of prosthetic repair has not been clearly shown 4.

Surgical Approaches

• Transthoracic repair with fundoplication is another surgical approach used to treat large hiatus hernia, particularly in patients with acquired short esophagus 5.
• A Collis type gastroplasty may be useful to lengthen a foreshortened esophagus, but no objective criteria have been defined to support this approach 4.
• Laparoscopic surgery has been shown to be a simple and effective approach for patients with gastroesophageal reflux symptoms due to diaphragmatic esophageal hiatus hernia, with a lower number of complications compared to open operations 3.

Medical Management

• Medical management of large hiatus hernia includes the use of proton-pump inhibitors (PPIs) to reduce acid reflux symptoms 6.
• Reflux inhibitors, such as baclofen, have been shown to be effective in reducing reflux episodes in patients with large hiatus hernia, but may not change the number of acid reflux episodes or total acid exposure time 6.

Outcomes and Recurrence

• The anatomic recurrence rate after surgical repair of large hiatus hernia can be as high as 60% at 12 years, but most recurrences are asymptomatic and do not affect the quality of life index 4.
• Functional results and quality of life measures are more important than a strict evaluation of anatomic hernia reduction in evaluating the success of surgical repair 4.