From the Research
The most feared complication of a paraesophageal hernia is strangulation, which can lead to tissue necrosis, perforation, and potentially life-threatening sepsis if not treated promptly. This complication is a surgical emergency that requires immediate attention to prevent severe morbidity and mortality 1. Other serious complications include gastric volvulus (stomach rotation), bleeding from mucosal tears, obstruction preventing food passage, and respiratory compromise due to compression of the lungs. These complications typically present with severe chest or abdominal pain, difficulty swallowing, vomiting, and respiratory distress. The risk of these complications is why large paraesophageal hernias often warrant surgical repair, even in asymptomatic patients, particularly in those who are good surgical candidates.
The underlying mechanism involves the stomach herniating through the diaphragmatic hiatus alongside the esophagus while the gastroesophageal junction remains in its normal position, creating a potential space where the stomach can twist upon itself and compromise its blood supply. According to a recent study published in 2024, acute gastric volvulus presents with the classic triad of severe epigastric pain, vomiting, and difficulty or inability to pass a nasogastric tube, and can be complicated by strangulation and perforation which are associated with high mortality rates 1.
Some key points to consider in the management of paraesophageal hernias include:
- Quick diagnosis and attempt at decompression is paramount
- Computer-aided tomography is an important diagnostic step, and findings such as gastric wall thickening, extraluminal gas, and mediastinal fluid should prompt urgent surgical intervention
- Approaches can include minimally invasive or open operations and in general should include reduction of the hernia, resection of devitalized tissue, and in some cases esophageal exclusion with delayed reconstruction 1. The most recent and highest quality study available, published in 2024, provides the most relevant guidance on the management of complications in paraesophageal hernia repair, and should be consulted for further information 2.