Esophagus—Hiatal Hernia
Concept
Four types:
I Sliding hernia, GEJ in chest II Paraesophageal, GEJ in abdomen
III Type II with shortening of esophagus and GEJ in chest
IV Additional abdominal organs (spleen, colon) in hernia defect
Oral Exam questions seem to be surrounding the treat- ment of Type II and III paraesophageal hernias that are symptomatic.
Way Question May be Asked?
“53 y/o female presents to the office complaining of full- ness in her chest immediately after eating and associated weight loss.” May also have postprandial pain, may not be related to any specific solid or liquid foods. Pain likely epi- gastric.
How to Answer?
Complete history and physical exam (may have been given all this already):
History
Character of pain Relation to meals Relation to solids/liquids
Previous esophageal problems/diagnoses Heartburn
Dysphagia Vomiting Anemia Early satiety
Physical Exam
Abdominal masses Lymphadenopathy
Diagnostic Tests
Usual labs (check H/H as often pts are anemic) CXR (may see gastric bubble behind heart shadow) Barium Swallow
Upper endoscopy (examine for ulcerations, malignan- cies, diverticula)
Manometry (helpful when deciding what degree of wrap to perform)
Indications for surgery: (all paraesophageal hernias get surgery)
Volvulus Ulcerations Anemia
Surgical Treatment
Abdominal incision (can consider thoracic if believe shortened esophagus or prior abdominal operations) Reduction of stomach (herniated contents) and
inspection
Excision of hernia sac
Closure of diaphragmatic defect (interrupted, non- absorbable sutures +/− mesh)
Anchoring stomach (Stamm gastrostomy or gastropexy to abdominal wall or to arcuate ligament)
“Floppy” Nissen (unless severely abnormal manometry)
Common Curveballs
Pt has a malignancy on endoscopy
Pt will have shortened esophagus ( →Collis gastroplasty) Pt will have esophageal/gastric mass on UGI
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Incarcerated contents (stomach) will be strangulated and need resection
Can’t close crura without the use of a mesh
Abnormal manometry so can’t do 360 degree Nissen wrap
Being asked if it is necessary to perform anti-reflux procedure
Pt will have pneumothorax from dissection of adhe- sions from sac to pleura
Post-op recurrence of hernia
Being asked how tight to reapproximate the crura Injury to stomach or esophagus during procedure
(change scenario!)
Strikeouts
You forget the UGI or EGD
You forget to anchor the stomach or perform a wrap You try to treat the pt medically/non-operatively once
you’ve diagnosed a paraesophageal hernia
You treat your pt with strangulation in the hernia sac as having angina or an MI
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