Management of Complex Paraesophageal Hernias

Paraesophageal hernias are complex and challenging when they
occur with acute symptoms, in malnourished patients, or when there is gastric
ischemia. Treatment should be individualized based on each patient’s clinical
characteristics.

Medical treatment is often offered to most patients without
chronic symptoms. In elective patients with good preoperative performance,
surgical repair should be performed to resolve potential gastric or esophageal
problems. In emergent cases, initial resuscitation and decompression may allow
the patient to stabilize, especially when they can be endoscopically
decompressed. This may allow patients additional time to recover before a
surgical repair is performed prior to discharge. Surgical repair is often the
best answer, but patients presenting for reoperation should only undergo reoperation
if they have severe symptoms. The viability of the stomach and imaging,
especially 3D imaging, can greatly influence what type of repair is needed, the
repair timing, and whether or not adjunctive surgeries, such as a feeding tube
placement, are required. Tenets of a good repair include: no mesh against the
esophagus, crural closure, fundoplication in good candidates, gastropexy, and
cruropexy. The video above reviews each step of a complex patient management
algorithm (shown below) that guides the surgeon and team through the difficult
decisions of managing paraesophageal hernias.Learn more and find a list of additional resources at: https://www.ctsnet.org/article/management-complex-paraesophageal-hernias

食管旁疝在急性症状、营养不良患者或胃缺血的情况下出现时，往往复杂且极具挑战性。治疗应根据每位患者的临床特征进行个体化调整。对于多数无慢性症状的患者，通常提供药物治疗。在术前表现良好的择期患者中，应进行手术修复以解决潜在的胃或食管问题。在紧急情况下，初步的复苏和减压可能使患者稳定下来，特别是在他们可以通过内镜减压的情况下。这可能会为患者提供更多时间恢复，从而在出院前进行手术修复。手术修复通常是最佳选择，但对于需要再次手术的患者，只有在出现严重症状时才应进行再次手术。胃的存活性和影像学检查，尤其是三维影像，可以极大地影响所需修复的类型、修复时机以及是否需要辅助手术，如放置喂养管。良好的修复原则包括：食管无网状结构、裂孔闭合、适合的胃底折叠、胃固定和裂孔固定。上述视频回顾了复杂患者管理算法的每个步骤（如下所示），该算法指导外科医生和团队通过管理食管旁疝的困难决策。更多信息和附加资源列表请访问：https://www.ctsnet.org/article/management-complex-paraesophageal-hernias