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Management of Paraesophageal Hernias

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Title: Management of Paraesophageal Hernias


1
Management of Paraesophageal Hernias
2
Paraesophageal Management
  • Define Paraesophageal Hernia
  • Management Options
  • Intervention vs. Natural History
  • Interventional Techniques
  • Surgery vs. Endoscopy
  • Results

3
Definition
  • Type 1
  • Sliding hernia GEJ migrates through hiatus
  • Type 2
  • True paraesophageal, GEJ within the abdomen with
    herniation of fundus
  • Type 3
  • GEJ intrathoracic as well component of stomach
  • Type 4
  • GEJ intrathoracic with complete herniation of
    stomach or associated with other intra-abdominal
    viscera (spleen, colon)

4
Who Requires Treatment?
  • Symptomatic
  • Reflux Regurgitation
  • Chest pain SOB
  • Aspiration
  • Bleeding
  • Dysphagia
  • N/V Obstruction

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Who Requires Treatment?
  • Asymptomatic
  • Historical dictum
  • Repair due to 20 mortality associated with
    obstruction or perforation

Hill. Am J Surg 126 1973 Ozdemir. Ann Thorac
Surg 16 1973
7
Asymptomatic Treatment
  • Operation or Observation?
  • Ann Surg 236(4) 492-501, 2002
  • Pooled data from 1964-2000
  • Results
  • Annual risk of acute sxs requiring urgent
    surgery 1.16 per year
  • 5 yrs-5.5 10 yrs-11, 20-20 of urgent surgery.

8
Asymptomatic Treatment
  • Cont Ann Surg 236 (4) 492-501, 2002
  • Results
  • Waiting effective 83 of patients
  • Emergent surgery assoc 5.4 mortality
  • Elective Lap repair assoc 1.4 mortality

9
Asymptomatic Treatment
  • Cont Ann Surg 236 (4) 492-501, 2002
  • Conclusions
  • Non-operative therapy is acceptable
  • In Asymptomatic
  • Laparoscopic Repair has an acceptable mortality

10
Pre-operative Workup
  • pH monitoring
  • 60 of all paras 100 with Type IIIGERD
  • Esophageal manometry
  • Difficult to pass catheter interpret results
  • Do results alter management?
  • Endoscopy and UGI
  • Exclude related pathology (Cancer, stricture,
    Barretts)
  • Identify GEJ location

Am J Surg 147111-116,1984 Am J Gastroenterol
91914-916, 1996
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Barium Enema
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Goals of Management
  • Reduction of intrathoracic contents
  • Closure of Esophageal Defect
  • Buttress Closure with Absorbable Mesh
  • Anti-reflux valve (wrap)

16
Endoscopic management
  • Reserved for elderly patients with significant
    comorbidities
  • Am J Surg 182(5), 2001
  • 11 patients, ASA 3, CAD, mean 78.3 yrs
  • All got 2 PEG tubes, 9/11 additional laparoscopic
    assistance for reduction and gastropexy
  • PEGs removed at two months

17
Endoscopic Management
  • Cont Am J Surg 182(5), 2001
  • Results
  • 1 TIA, 1 A-fib with PE, 1 transverse colon hernia
  • 4 month F/U all eating normally, 3 residual Type
    I hernias
  • Conclusions
  • Effective treatment for debilitated patients, but
    convert Type II IIIs into 1s

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Laparoscopic Ports
5
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5
5
10
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Enter Lesser Sac
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Caudate Lobe/Vena Cava
CAUDATE
VENA CAVA
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Right Crural Dissection
HERNIA SAC
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Left Crus
33
Left and Right Crural Junction
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L
R
38
Retroesophageal Dissection
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40
Crural Repair
Position of AORTA
41
AORTA
42
Mesh?
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Mesh Placement
  • Type I evidence to support Absorbable mesh to
    buttress repair
  • Reduces Recurrence rate from 24 to 9

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Toupet
48
NISSEN
49
GASTROPEXY
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POD 1
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Results
  • Conversions
  • Low (Below 5 in all studies)
  • Recurrences
  • Follow-up Yearly UGI
  • Symptomatic vs. Asymptomatic
  • Median Laparoscopic Recurrence rate approximately
    7 (0-42)

58
Recurrence
  • Esophageal Length
  • Collis-Nissen ??Neoesophagus
  • Convert II IIIs in elderly into Is
  • Resolve Obstruction Bleeding
  • Strictures Long Segment Barretts
  • Poor crural closure
  • Tissue integrity
  • Add mesh

59
Bochdalek Hernia
60
HERNIA
E
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64
Conclusions
  • Asymptomatic paraesophageal hernias do not
    necessarily require treatment
  • Endoscopic intervention for debilitated patients
    is acceptable
  • Mesh for crural defects is standard of care
  • Lengthening procedure is rare
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