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