What is the guideline for managing hiatal hernia?

Guidelines for Hiatal Hernia Management

The management of hiatal hernias should follow a stepwise approach, beginning with medical therapy for asymptomatic or mildly symptomatic cases, progressing to surgical intervention for symptomatic cases or those with complications, with laparoscopic repair being the preferred surgical approach. 1

Classification and Diagnosis

• Hiatal hernias are classified into four types:

  • Type I (sliding): Most common (90% of cases)
  • Type II (paraesophageal)
  • Type III (combined)
  • Type IV (complex)

• Diagnostic workup should include:

  • CT scan with IV contrast and neutral oral contrast (water or dilute barium)
  • Upper GI series (barium swallow) for structural and functional evaluation
  • Chest radiography as first-line imaging 1

Medical Management

Asymptomatic Hiatal Hernias

• Watchful waiting is appropriate for asymptomatic hernias 2
• Annual risk of asymptomatic hiatal hernias becoming symptomatic is approximately 1% 2

Symptomatic Hiatal Hernias with GERD

1. Initial treatment:

   • Lifestyle modifications (weight management, dietary changes)
   • Proton pump inhibitors (PPIs) as first-line medication 1
   • Start with single daily dose taken 30-60 minutes before first meal
   • Initial trial period of 4-8 weeks 1

2. For breakthrough symptoms:

   • Alginate antacids (particularly effective for hiatal hernia)
   • H2-receptor antagonists for nighttime symptoms 1

3. Long-term management:

   • Continue single-dose PPI therapy for patients with erosive esophagitis, Barrett's esophagus, or peptic stricture 1

Surgical Management

Indications for Surgery

• Symptomatic hiatal hernias not responding to medical therapy
• Confirmed reflux disease
• Complications (incarceration, volvulus) 2

Key Operative Steps

1. Reduction and excision of hernia sac
2. Establishment of at least 3 cm of intra-abdominal esophageal length
3. Crural closure with mesh reinforcement
4. Anti-reflux procedure 2

Types of Surgical Approaches

• Laparoscopic approach: Preferred due to safety and improved outcomes 2
• Fundoplication options:
  • Nissen fundoplication (360° wrap): Most commonly performed
  • Toupet fundoplication (270° posterior wrap): May have lower recurrence rates 1
  • Dor fundoplication: Alternative for specific cases 3

Mesh Selection

• Biosynthetic, biologic, or composite meshes are preferred
• Benefits include lower recurrence rates and higher resistance to infections 1

Special Considerations

• For patients with oral intake difficulties: Consider percutaneous endoscopic gastrostomy (PEG) or jejunostomy 1
• For obese patients: Consider concomitant weight loss surgery
  • Roux-en-Y gastric bypass offers better symptom control for GERD
  • Sleeve gastrectomy may induce or worsen GERD 4

Post-Surgical Management

• Continue PPI therapy after repair in patients with Barrett's esophagus to control symptoms and potentially reduce disease progression 1
• Monitor for potential complications including:
  • Pulmonary complications
  • Surgical site infection
  • Bleeding
  • Respiratory failure
  • Hernia recurrence (occurs in 3-5% of cases) 1

Common Pitfalls and Caveats

• Missed diagnosis of short esophagus may require additional procedures like Collis gastroplasty
• Inadequate mobilization of the esophagus can lead to tension and complications
• Inadequate mesh fixation can lead to mesh migration and recurrence 1
• Higher recurrence risk in elderly patients and with larger defects 1
• Combined sleeve gastrectomy and paraesophageal hiatal hernia repair may worsen GERD symptoms 4

By following these guidelines, clinicians can optimize the management of patients with hiatal hernias, minimizing complications and improving quality of life.