Continuing Education Activity

A hiatal hernia is a condition in which the upper part of the stomach or other internal organ bulges through the hiatus of the diaphragm. When there is laxity in this hiatus, gastric content can back up into the esophagus and is the leading cause of gastroesophageal reflux disease (GERD). This activity reviews the evaluation and treatment of hiatal hernias and highlights the role of the interprofessional team in the care of patients with this condition.

Objectives:

• Identify the etiology of hiatal hernias.
• Describe the appropriate evaluation procedures for assessing potential hiatal hernias.
• Outline the management options available for hiatal hernias.
• Summarize interprofessional team strategies for improving care coordination and communication to advance the treatment of hiatal hernias.

Introduction

A hiatal hernia is a medical condition in which the upper part of the stomach or other internal organ bulges through an opening in the diaphragm. The diaphragm is a muscular structure that assists in respiration and has a small opening, a hiatus, through which the esophagus passes prior to connecting to the stomach. This is called the gastroesophageal junction (GEJ). In a hiatal hernia, the stomach pushes through that opening and into the chest and compromises the lower esophageal sphincter (LES). This laxity of the LES can allow gastric content and acid to back up into the esophagus and is the leading cause of gastroesophageal reflux disease (GERD). While small hiatal hernias are often asymptomatic and can typically be managed medically, large hiatal hernias often requires surgery.[1]

Classification of hiatal hernias are divided into 4 types:

• Type I (sliding type), which represents more than 95% of hiatal hernias, occurs when the GEJ is displaced upwards towards the hiatus.
• Type II is a paraesophageal hiatal hernia, which occurs when part of the stomach migrates into the mediastinum parallel to the esophagus.
• Type III is both a paraesophageal hernia and a sliding hernia, where both the GEJ and a portion of the stomach have migrated into the mediastinum.
• Type IV is when the stomach, as well as an additional organ such as the colon, small intestine, or spleen, also herniate into the chest.

Etiology

Hiatal hernias may be congenital or acquired. There is an increased prevalence in older people. It is believed that muscle weakness with loss of flexibility and elasticity with age predisposes to the development of a hiatal hernia. This may cause the upper part of the stomach to not return to its natural position below the diaphragm during swallowing. Other predisposing factors have been identified, such as elevated intraabdominal pressure. This typically is a result of obesity, pregnancy, chronic constipation, and chronic obstructive pulmonary disease (COPD). Trauma, age, previous surgeries, and genetics can also play a role in the development of a hiatal hernia.[2]

Epidemiology

The incidence of hiatal hernias increases with age. Approximately 55%-60% of individuals over the age of 50 have a hiatal hernia. However, only about 9% have symptoms, and it depends on the type and competency of the lower esophageal sphincter. The vast majority of these hernias are type I sliding hiatal hernias. Type II, paraesophageal hernias, only make up about 5% of hiatal hernias where the LES remains stationary, but the stomach protrudes above the diaphragm. There is also an increased prevalence in women, which could be attributed to increased intraabdominal pressure during pregnancy. Hiatal hernias are most common in Western Europe and North America and are rare in rural Africa.[3]

History and Physical

The typical presentation leading to an evaluation for a hiatal hernia is gastroesophageal reflux disease (GERD). Patients typically complain of heartburn and sometimes regurgitation. While heartburn is the most common complaint, some patients will present with extra-esophageal symptoms such as a chronic cough or asthma. The presentation of regurgitation or extra-esophageal symptoms typically is a sign of disease progression. However, not all patients with regurgitation have GERD, and it is important to note if the regurgitated food is digested or undigested.

Undigested food may represent another pathology such as achalasia or a diverticulum. Dysphagia is another problem seen with advanced disease. This is typically secondary to a mechanical obstruction. When this is encountered, it could represent additional pathology such as a peptic stricture, tumor, diverticula, or primary motor disorder. Physical examination in patients with a hiatal hernia and GERD rarely helps confirm the diagnosis. The presence of abnormal supraclavicular lymph nodes in patients with heartburn and dysphasia may suggest esophageal or gastric cancer and is an important part of the evaluation.[4][5]

Evaluation

The preoperative work-up in a patient being considered for operative treatment will help confirm the diagnosis, exclude other pathologic entities, and direct the operative intervention.

• Endoscopy: This is an essential step in the evaluation of patients with GERD and a suspected hiatal hernia who are being considered for surgery. This study can exclude other diseases, such as tumors, and can document the presence of esophageal injury.

• Manometry: This study is used to rule out primary motility disorders such as achalasia, which can mimic the symptoms of reflux. Patients with primary motility disorders often require a partial fundoplication as opposed to a Nissen.

• pH monitoring: The 24-hour pH test is the gold standard for diagnosing acid reflux. In this study, a probe is placed 5cm above the GE junction and measures the amount of acid to which it is exposed. This data is then quantified into a number called the DeMeester score. A score of 14.7 or above indicates significant gastroesophageal reflux.[6]

• Esophagography: The esophagogram provides valuable information in terms of the anatomy of the esophagus and proximal stomach. Anatomic abnormalities such as tumors or strictures may also be discovered during this study.

Treatment / Management

Management for hiatal hernias depends on the type of hernia and severity of symptoms. Initial management of a patient presenting with typical symptoms of GERD in an outpatient setting includes a double dose of a proton pump inhibitor (PPI). This can be both therapeutic and diagnostic in that persistent symptoms often require a more extensive evaluation. Since the advent of PPIs, the indication for surgical therapy has changed. Patients with evidence of severe esophageal injury such as ulcer, stricture, or Barrett's mucosa should be considered for surgical treatment. Other patients, such as those with a long duration of symptoms or those with incomplete resolution of symptoms while on medical therapy, should also be considered for surgical intervention. With advancements in minimally invasive techniques for the treatment of GERD, the cost of surgery has decreased. Patients who have more than 8 years of life expectancy and are in need of lifelong therapy because of a mechanically defective LES, surgical therapy may be considered the treatment of choice.[7][8][9] 

Paraesophageal hernias can present with a gastric volvulus due to the laxity of the stomach's peritoneal attachments and subsequent rotation of the gastric fundus. This is considered a surgical emergency. Current recommendations are for operative repair of all symptomatic paraesophageal hernias as well as completely asymptomatic large hernias in patients less than 60 years old and otherwise healthy.[10]

Nissen fundoplication (360-degree wrap): This involves completely wrapping the GEJ using the fundus of the stomach. This is usually done with a 52 french bougie in place to ensure appropriate approximation without the wrap being too tight. The initial steps involve dissection of the short gastric vessels off the greater curvature of the stomach to mobilize the fundus. The phrenoesophageal membrane over the left crus is fully dissected, and the crural fibers are identified. For the right crural dissection, the lesser omentum must be opened, and the right phrenoesophageal membrane mobilized. It is important to preserve the anterior and posterior vagi during this dissection. A Penrose drain is typically placed around the esophagus to assist in mobilization and creation of the wrap. The wrap is created over a length of 2.5 to 3 cm using 3-4 interrupted permanent sutures. Once the wrap is complete, the 52 french bougie is removed, and the wrap is anchored to the esophagus and hiatus. This helps prevent herniation and slippage.[11]

Partial fundoplication (Dor and Toupet): When esophageal motility is poor, a partial fundoplication is typically the procedure of choice. The two most common partial fundoplications are the Dor procedure, which is an anterior wrap, and the Toupet procedure, which is a posterior wrap.  As opposed to the complete 360-degree wrap performed with a Nissen, these two procedures involve creating a 180 to 250-degree wrap. The thought is that a partial wrap will help prevent obstruction in the esophagus when motility is a concern. 

Dor procedure: This is performed by folding the fundus over the anterior aspect of the esophagus and then anchoring it to the hiatus and esophagus as is done in the 360-degree wrap. This wrap has been limitedly used for the treatment of GERD and is more commonly used to treat patients with achalasia who have undergone an anterior myotomy. 

Toupet procedure: The entire esophageal dissection for this procedure is the same as that of a Nissen, with mobilization of the esophagus. As opposed to the Nissen, this procedure creates a 220 to 250-degree wrap around the posterior aspect of the esophagus and is the procedure of choice if motility is a concern.[12]

Differential Diagnosis

The differential diagnosis of a patient presenting with GERD can be quite extensive and is the reason for such a thorough work-up prior to operative therapy. Typical heartburn is described as an epigastric caustic or burning sensation. This does not typically radiate to the back or be described as a sensation of pressure. This is an important part of the history and physical as it can distinguish GERD from other pathologies such as pancreatitis or acute coronary syndrome.[13]

Extra-esophageal symptoms of GERD arise from the respiratory tract and manifests as laryngeal or pulmonary symptoms. It can be difficult to distinguish the etiology of such symptoms, and it is important to have a high suspicion for primary esophageal motility disorders, gastric or esophageal cancer, and primary lung disease. If a patient presents with such symptoms and the primary work-up is negative, it is important to explore other etiologies. Often times consultation to a pulmonologist is warranted.[14]

Prognosis

The success of hiatal hernia surgery can be measured by relief of symptoms, improvement in esophageal acid exposure, complications, and need for reoperation. One prospective study followed 100 patients who underwent antireflux surgery over 10 years. They found a 90% reduction in symptoms at 10 years. Over the past 2 decades, the collective experience with operative management has continued to improve outcomes. With increased experience, symptom improvement has increased while perioperative complications have decreased. This is especially true in high-volume centers.[15]

Complications

Complications from surgery are typically minor and not directly related to the surgery itself. It is estimated that the overall 30-day mortality rate associated with antireflux surgery is 0.19%. Complications that are specific to antireflux surgery include the following: 

• Pneumothorax: This is the most common intraoperative complication. However, this is reported to occur in less than 2% of patients. 
• Gastric and esophageal injuries: Reported to occur in approximately 1% of patients undergoing Nissen fundoplication. 
• Splenic and liver injuries: This can result in bleeding and occurs in about 2.3% of patients. Major injury is rare.
• Dysphasia: This typically resolves without further intervention and is most commonly caused by postoperative edema.[16]

Deterrence and Patient Education

Deterrents of hiatal hernias are often unavoidable. However, patients should be adherent to their medications and follow post-operative instructions closely. This often includes modification of diet in the postoperative period.

Enhancing Healthcare Team Outcomes

Managing hiatal hernias and reflux requires an interprofessional team approach. The team should include primary care clinicians, radiologists, gastroenterologists, and surgeons. Diagnostic studies are required for both diagnosis and operative planning. This requires endoscopy, pH monitoring, and esophagography, which is a coordinated effort between multiple teams. This ultimately results in more accurate diagnoses, better surgical outcomes, and more patient satisfaction.