What is the management of a sliding hiatus hernia?

Management of Sliding Hiatus Hernia

The management of sliding hiatus hernia should begin with lifestyle modifications, proton pump inhibitor (PPI) therapy, and adjunctive pharmacotherapy, with surgical intervention reserved for cases with inadequate response to medical management or complications. 1

Classification and Pathophysiology

• Sliding hiatus hernia (Type I) is the most common type, representing about 90% of all hiatal hernias, where the gastroesophageal junction and part of the stomach slide into the chest through the esophageal hiatus 2
• Sliding hiatus hernia disrupts normal antireflux mechanisms by reducing lower esophageal sphincter length and pressure, impairing diaphragmatic crus function, and creating a reservoir for acid reflux 3
• The presence of a hiatus hernia is associated with increased prevalence and severity of reflux esophagitis, Barrett's esophagus, and reduced efficacy of PPI therapy 3

Diagnostic Approach

• Complete endoscopic evaluation should include inspection for erosive esophagitis (graded according to Los Angeles classification), diaphragmatic hiatus, axial hiatal hernia length, and Barrett's esophagus 1
• High-resolution manometry is the most reliable method for detecting subtle disruption of the esophagogastric junction and can help exclude achalasia before considering surgical intervention 4, 5
• Ambulatory 24-hour pH-impedance monitoring should be considered in patients with persistent symptoms despite therapy to determine the mechanism of ongoing symptoms 1

Medical Management

First-Line Approach

• Provide standardized educational material on GERD mechanisms, weight management, lifestyle modifications, and dietary behaviors 1
• Initiate a 4-8 week trial of single-dose PPI therapy for patients with troublesome heartburn, regurgitation, or non-cardiac chest pain without alarm symptoms 1
• If inadequate response, increase PPI dosing to twice daily or switch to a more effective acid suppressive agent 1
• When symptoms are adequately controlled, taper PPI to the lowest effective dose 1

Adjunctive Therapy

• Personalize adjunctive pharmacotherapy based on symptom pattern 1:
  • Alginate antacids for breakthrough symptoms, particularly useful for post-prandial symptoms and in those with hiatal hernia 1
  • Nighttime H2 receptor antagonists for nocturnal symptoms (limited by tachyphylaxis) 1
  • Baclofen for regurgitation or belch predominant symptoms 1
  • Prokinetics for coexistent gastroparesis 1

Surgical Management

Indications for Surgery

• Inadequate response to optimized medical therapy (lifestyle modifications, optimized PPI therapy, and adjunctive pharmacotherapy) 2, 5
• Presence of complications such as severe GERD requiring long-term therapy 2
• Large hiatal hernia with significant symptoms 2

Preoperative Assessment

• Confirm pathologic GERD with objective testing (endoscopy, pH monitoring) 5
• Exclude achalasia and assess esophageal peristaltic function with high-resolution manometry 5
• Consider ambulatory 24-hour pH-impedance monitoring to confirm PPI-refractory GERD 5

Surgical Approaches

• Laparoscopic approach is preferred in stable patients due to lower morbidity (5-6%) compared to open surgery (17-18%) 2
• Surgical repair typically involves 2:
  • Reduction of hernia contents
  • Excision of hernia sac
  • Crural repair with non-absorbable sutures
  • Antireflux procedure (fundoplication)

Types of Fundoplication

• Nissen fundoplication (360° wrap) is the most common technique 2
• Toupet fundoplication (270° wrap) may be preferred in patients with esophageal hypomotility to reduce risk of postoperative dysphagia 2, 1

Special Considerations for Obese Patients

• Roux-en-Y gastric bypass is the preferred anti-reflux intervention in obese patients with hiatal hernia 5
• Sleeve gastrectomy should be avoided as it has potential to worsen GERD 5

Monitoring and Follow-up

• Monitor patients for at least 2 hours in recovery after any endoscopic or surgical procedure 1
• Provide clear written instructions with advice on fluids, diet, and medications after procedures 1
• Routine imaging and contrast studies are not required post-procedure unless patients develop persistent chest pain, fever, breathlessness, or tachycardia 1

Potential Complications of Surgery

• Postoperative complications include atelectasia, surgical site infection, bleeding, respiratory insufficiency, ileus, persistent GERD, chronic pain, and hernia recurrence 2
• Recurrence may be related to use of absorbable sutures, suture tension, inadequate fixation of prosthetic material, increased intra-abdominal pressure, or intra-abdominal sepsis 2