From the Guidelines
In a patient with a paraesophageal hernia, the most concerning complication is incarceration, which can rapidly progress to strangulation, and therefore, it is the complication that should be most feared due to its high risk of morbidity and mortality. Incarceration occurs when the herniated stomach becomes trapped in the chest cavity, leading to compromised blood supply. This is particularly dangerous because it can quickly evolve into strangulation, where blood flow is completely cut off, resulting in tissue necrosis and perforation 1. While obstruction is also a significant concern as the twisted stomach can block food passage, and irreducibility can complicate management, the risk of strangulation makes incarceration the most feared acute complication. Perforation is a late consequence of untreated incarceration and strangulation. The danger lies in the high mortality rate associated with strangulation, as it can lead to sepsis, mediastinitis, and shock if emergency surgery is not performed promptly 1.
Some key points to consider in the management of paraesophageal hernias include:
- Early detection of complications is crucial to prevent high morbidity and mortality rates
- Patients should undergo emergency hernia repair immediately when intestinal strangulation is suspected, as recommended by the WSES guidelines 1
- Systemic inflammatory response syndrome (SIRS), contrast-enhanced CT findings, as well as lactate, serum creatinine phosphokinase (CPK), and D-dimer levels are predictive of bowel strangulation 1
- The elapsed time from onset to surgery is the most important prognostic factor, and delayed diagnosis can lead to septic complications and high mortality rates 1
Patients with large paraesophageal hernias should be educated about warning symptoms such as severe chest pain, persistent vomiting, and inability to pass nasogastric tubes, which may indicate incarceration requiring immediate medical attention. A high index of suspicion and prompt surgical intervention are essential to prevent the high morbidity and mortality associated with strangulation and perforation in patients with paraesophageal hernias 1.
From the Research
Common Complications of Paraesophageal Hernia
The common complications of paraesophageal hernia include:
- Irreducability
- Obstruction
- Incarceration
- Perforation
Risk of Complications
According to the studies, patients with paraesophageal hernia are at risk of developing these complications, which can lead to severe consequences such as respiratory failure, systemic sepsis, and even death 2. The risk of complications is higher in patients who undergo emergent repair compared to those who undergo elective repair 3.
Comparison of Complications
The studies suggest that:
- Perforation is a serious complication that can occur in patients with paraesophageal hernia, and it requires prompt surgical intervention 4, 2.
- Incarceration is a feared complication that can lead to increased morbidity and mortality, and it is more common in patients who undergo emergent repair 3.
- Obstruction is a potential complication that can occur in patients with paraesophageal hernia, and it can lead to severe consequences such as acute dilatation and bleeding of the gastric mucosa 5.
- Irreducability is a complication that can occur in patients with paraesophageal hernia, and it can lead to increased morbidity and mortality 6.
Management of Complications
The management of complications in paraesophageal hernia repair is crucial to prevent severe consequences. The studies suggest that:
- Early identification and expeditious intervention are paramount in the overall management of complications 4.
- Laparoscopic repair of acute paraesophageal hernia is safe and feasible with low morbidity and mortality, and it is recommended for patients with no obvious perforation 2.
- Elective repair is recommended for patients with paraesophageal hernia, especially in younger patients who are otherwise good operative candidates, to prevent the risk of complications 3.