How to approach hiatal hernia repair in patients with Barrett’s esophagus and dysplasia?

Hiatal Hernia Repair in Barrett's Esophagus with Dysplasia

Hiatal hernia repair should not be performed for the purpose of preventing cancer progression in patients with Barrett's esophagus and dysplasia; instead, prioritize endoscopic eradication therapy (radiofrequency ablation, photodynamic therapy, or endoscopic mucosal resection) as the primary treatment for dysplasia, with hiatal hernia repair reserved only for severe reflux symptoms unresponsive to medical therapy. 1

Primary Management Strategy

The treatment approach must be driven by the grade of dysplasia, not the presence of hiatal hernia:

For High-Grade Dysplasia

• Endoscopic eradication therapy is the definitive treatment, with strong evidence supporting radiofrequency ablation (RFA), photodynamic therapy (PDT), or endoscopic mucosal resection (EMR) over surveillance alone 1
• Perform EMR first for any visible mucosal irregularity to determine T stage before proceeding with ablation 1, 2
• Offer endoscopic ablation of residual Barrett's tissue after endoscopic resection 2, 3

For Low-Grade Dysplasia

• Confirm the diagnosis with at least two expert GI pathologists from biopsy samples taken at two separate endoscopies, as low-grade dysplasia is frequently overcalled by community pathologists 4, 2, 3
• Offer radiofrequency ablation as primary treatment once diagnosis is confirmed 4, 2
• If ablation is declined, perform surveillance endoscopy every 6-12 months with high-resolution white light endoscopy and Seattle protocol biopsies 4, 3

Role of Antireflux Surgery

Antireflux surgery is explicitly not recommended for cancer prevention in Barrett's esophagus with dysplasia:

• The American Gastroenterological Association provides a strong recommendation against attempts to eliminate esophageal acid exposure through antireflux surgery for the prevention of esophageal adenocarcinoma (moderate-quality evidence) 1
• Antireflux surgery is not more effective than medical GERD therapy for cancer prevention 1, 2, 3
• Do not offer anti-reflux surgery specifically to prevent progression to dysplasia or cancer 2, 3

When Hiatal Hernia Repair May Be Considered

Hiatal hernia repair should only be considered in the following specific clinical scenarios:

• Severe reflux symptoms refractory to maximal medical therapy (proton pump inhibitors) that significantly impair quality of life 2, 3
• Large fixed hiatal hernia causing mechanical symptoms such as dysphagia or obstruction 5
• After completion of endoscopic eradication therapy if reflux symptoms persist despite medical management 6

Critical Clinical Algorithm

1. Confirm dysplasia grade with two expert GI pathologists from two separate endoscopies 4, 2, 3

2. Treat the dysplasia endoscopically first:

   • High-grade dysplasia: EMR for visible lesions, then RFA/PDT for residual Barrett's 1, 2
   • Low-grade dysplasia: RFA as primary treatment 4, 2

3. Optimize acid suppression with once-daily proton pump inhibitors for symptom control (not for cancer prevention) 4, 3

4. Assess need for hiatal hernia repair only after dysplasia management:

   • If severe reflux symptoms persist despite maximal medical therapy, consider surgical consultation 2
   • If symptoms are controlled medically, continue medical management 3

Evidence Regarding Hiatal Hernia as Risk Factor

While hiatal hernia size is associated with increased risk of progression to cancer (particularly hernias ≥3 cm), this association does not translate into a recommendation for surgical repair as a preventive measure 7, 8:

• Hiatal hernia presence and size are independent predictors of progression to multifocal high-grade dysplasia or adenocarcinoma 7
• However, surgical correction of the hernia does not prevent neoplastic progression better than medical therapy 1

Common Pitfalls to Avoid

• Do not delay endoscopic eradication therapy to perform hiatal hernia repair first, as this delays definitive cancer-preventive treatment 1, 2
• Do not recommend hiatal hernia repair based solely on hernia size without considering symptom severity and response to medical therapy 2, 3
• Do not proceed with ablation therapy until dysplasia is confirmed by two expert pathologists, as false-positive rates are extremely high in community practice 4, 3
• Do not use increased PPI dosing or pH monitoring to titrate therapy for cancer prevention purposes 1

Post-Treatment Surveillance

After endoscopic eradication therapy, regardless of hiatal hernia status:

• Continue endoscopic follow-up to monitor for recurrence of Barrett's esophagus or dysplasia 2
• Continue proton pump inhibitor therapy for symptom control, not cancer prevention 4, 2
• If hiatal hernia repair was performed, long-term outcomes show 79% remain symptom-free at 5 years, though recurrent hernias occur in approximately 22% of patients 6