Is aerophagia an indication for repair of hiatal hernia?

Aerophagia is Not an Indication for Hiatal Hernia Repair

Aerophagia is not an established indication for hiatal hernia repair according to current clinical guidelines. 1 Surgical repair of hiatal hernia should be based on confirmed pathologic gastroesophageal reflux disease (GERD), anatomical considerations, and failure of optimized medical therapy rather than aerophagia alone.

Established Indications for Hiatal Hernia Repair

• Surgical repair is indicated for complicated hiatal hernias, particularly paraesophageal hernias (types II, III, and IV) due to the risk of severe complications 2
• Confirmed pathologic GERD with inadequate response to optimized medical therapy is an established indication for surgical intervention 1
• Laparoscopic repair is recommended for stable patients with hiatal hernia, while open repair may be necessary for unstable patients 3
• Candidacy for invasive anti-reflux procedures requires confirmatory evidence of pathologic GERD, exclusion of achalasia, and assessment of esophageal peristaltic function 1

Preoperative Assessment Requirements

• High-resolution manometry to assess esophageal peristaltic function and exclude achalasia is recommended before considering surgical intervention 4
• Complete endoscopic evaluation is necessary to document the severity of any esophagitis 4
• Ambulatory 24-hour pH-impedance monitoring should be considered to determine the mechanism of persistent symptoms and confirm PPI-refractory GERD 1
• Objective reflux testing should be offered to establish a diagnosis of GERD before planning long-term management 1

Surgical Approach Considerations

• Type of fundoplication should be tailored based on esophageal motility findings 4
• Partial fundoplication (Toupet) is preferred in patients with esophageal hypomotility or impaired peristaltic reserve when there is concern for postoperative dysphagia 4
• Nissen fundoplication (360° wrap) remains the gold standard for durable relief of GERD symptoms but carries a higher risk of postoperative dysphagia 4
• For larger defects (>8 cm or >20 cm²), mesh reinforcement may be necessary to prevent recurrence 3

Potential Complications and Side Effects

• Patients who undergo fundoplication experience more dysphagia and gas bloat than controls and patients with untreated hiatal hernia 5
• Postoperative complications can include atelectasis, surgical site infection, bleeding, respiratory insufficiency, ileus, chronic pain, hernia recurrence, and cardiac injury 6
• Recurrence rates may be related to surgical technique, including the use of absorbable sutures, suture tension, inadequate fixation of prosthetic material, increased intra-abdominal pressure, poor thoracic cleaning, and intra-abdominal sepsis 6

Special Considerations for Obese Patients

• Roux-en-Y gastric bypass is the preferred primary anti-reflux intervention in obese patients with hiatal hernia 4
• Sleeve gastrectomy has the potential to worsen GERD and should be avoided in patients with significant reflux symptoms 1
• When sleeve gastrectomy is performed with concurrent hiatal hernia repair, a posterior repair approach is recommended over anterior repair to minimize worsening GERD symptoms 7

In conclusion, while aerophagia may be present in patients with hiatal hernia, it is not considered a primary indication for surgical repair. The decision for surgical intervention should be based on confirmed pathologic GERD, anatomical considerations, and failure of optimized medical therapy, with appropriate preoperative assessment to guide the surgical approach.