What is the next step in managing a hiatal hernia?

Management of Hiatal Hernia

The next step in managing a hiatal hernia should be optimization of lifestyle modifications and PPI therapy, with consideration for surgical repair if symptoms persist despite medical management or if complications are present. 1, 2

Initial Management Approach

Medical Management

1. Lifestyle Modifications:

   • Weight management for obese patients
   • Elevation of head of bed
   • Avoidance of meals within 3 hours of bedtime
   • Elimination of trigger foods (spicy, fatty, acidic)
   • Smoking cessation
   • Alcohol reduction

2. PPI Optimization:

   • Ensure proper timing (30 minutes before meals)
   • Consider escalation to double dose if symptoms persist
   • Switch to more potent PPI if inadequate response
   • Add alginate antacids for breakthrough symptoms, particularly useful in patients with hiatal hernia 1
   • Consider H2-receptor antagonists for nighttime symptoms

3. Adjunctive Therapy based on symptom pattern:

   • Baclofen for regurgitation or belch-predominant symptoms
   • Prokinetics if gastroparesis is present
   • Neuromodulators (low-dose antidepressants) if esophageal hypersensitivity is suspected 1

When to Consider Surgical Management

Surgical repair should be considered in the following scenarios:

1. Persistent symptoms despite optimized medical therapy 2
2. Paraesophageal hernias (types II, III, IV) even if minimally symptomatic, due to risk of complications 2, 3
3. Emergency situations including:
   • Strangulation
   • Incarceration
   • Perforation
   • Gastric volvulus 2
4. Regurgitation-predominant GERD (responds particularly well to surgical repair) 2

Pre-Surgical Evaluation

Before proceeding with surgical management, the following diagnostic workup is essential:

1. Upper GI Endoscopy: To assess for esophagitis, Barrett's esophagus, and hernia characteristics 2
2. Double-contrast Upper GI Series: Most useful test for diagnosing hiatal hernia (80% sensitivity) 2
3. High-resolution Manometry: To exclude achalasia and evaluate esophageal motility 2
4. 24-hour pH Monitoring: To confirm pathologic GERD 2
5. CT Scan: Gold standard for diagnosing diaphragmatic hernias (sensitivity 14-82%, specificity 87%) 2

Surgical Options

1. Laparoscopic Fundoplication with Hiatal Hernia Repair:

   • Standard approach with type of fundoplication tailored to esophageal motility
   • Partial fundoplication preferred in patients with esophageal hypomotility 1, 2

2. Magnetic Sphincter Augmentation:

   • Combined with crural repair for hiatal hernia 1, 2

3. Roux-en-Y Gastric Bypass:

   • For obese patients with proven GERD 2
   • Avoid sleeve gastrectomy as it may worsen GERD

4. Transoral Incisionless Fundoplication (TIF):

   • For carefully selected patients with small hiatal hernias 2

Key Surgical Principles

Successful repair requires:

• Reduction of hernia contents
• Removal of hernia sac
• Closure of hiatal defect (often with mesh reinforcement)
• Addition of an antireflux procedure 3, 4

Common Pitfalls to Avoid

1. Inadequate preoperative evaluation: Failure to diagnose achalasia or unrecognized esophageal hypomotility 2
2. Improper patient selection: Not all hiatal hernias require surgical repair
3. Inadequate mobilization of esophagus: Can lead to recurrence 2
4. Overlooking small paraesophageal hernias: These can lead to serious complications if untreated 2, 5
5. Relying solely on chest X-rays: Normal chest radiographs occur in 11-62% of diaphragmatic injuries or uncomplicated hernias 2

Follow-up Management

After surgical repair, patients should be monitored for:

• Recurrent symptoms (can occur weeks to years after surgery) 6
• Dysphagia (common early postoperative symptom)
• Weight loss
• Deteriorating quality of life

If symptoms recur, repeat evaluation with esophagram, endoscopy, and possibly CT scan is warranted to assess for recurrent hernia or slipped/migrated wrap 6.