1. Ciaran O’Hare

2. A Selective Approach to Type II / III (Paraesophageal) Hiatal Hernia Ciaran M. O’Hare FRCSI FACS Associate Professor OUHSC Chief of Surgery VAMC Oklahoma City. Sept 29 th 2005

3. Ciaran O’Hare Para-esophageal Hernia ANATOMY 95% 1% 1% 4% 4%

4. Ciaran O’Hare Type III Type IV Type II Para-esophageal Hernia ANATOMY

5. Ciaran O’Hare Aetiology : Type II Esophago-phrenic ligament ( Type II) ( Type II) Remains strong posteriorly Remains strong posteriorly Sac is attenuated in ant. Sac is attenuated in ant. and lat. portions and lat. portions Para-esophageal Hernia

6. Ciaran O’Hare Levels Of Evidence

7. Ciaran O’Hare Levels Of Evidence

8. Ciaran O’Hare Levels Of Evidence

9. Ciaran O’Hare Asymptomatic Asymptomatic Reflux Type Symptoms Reflux Type Symptoms Related to Intrathoracic Stomach Related to Intrathoracic Stomach (Obstructive + Ischemic) (Obstructive + Ischemic) Acute / Emergent Acute / Emergent Symptoms Para-esophageal Hernia

10. Ciaran O’Hare Diagnosis Fluid Level On CXR BariumMeal Para-esophageal Hernia

11. Ciaran O’Hare Elective (Asymptomatic, Minimal) Elective (Asymptomatic, Minimal) Acute (Gastric Obstruction or Ischemia) Acute (Gastric Obstruction or Ischemia) Emergent (Gastric Volvulus or Gangrene) Emergent (Gastric Volvulus or Gangrene) Surgery : 2001-3 Para-esophageal Hernia 87%10% 3% 3%

12. Ciaran O’Hare Reduce Hernia Reduce Hernia Excise Sac Excise Sac (Lengthen Esophagus) (Lengthen Esophagus) Repair Crura Repair Crura Gastropexy Gastropexy Fundoplication Fundoplication Post-op CXR Post-op CXR Principles of Repair Para-esophageal Hernia

13. Ciaran O’Hare Through Left Chest Through Left Chest better hiatal access, with ‘short’ esophagus, in fat males vs morbidity Via Abdomen Via Abdomen quicker, simple gastropexy in emergencies vs hiatus can be difficult Laparoscopic Laparoscopic Less morbid vs difficult (R side and sac excision), greater recurrence Methods of Repair Para-esophageal Hernia

14. Ciaran O’Hare Closing the Large Hiatus Create a relaxing incision, then close with PTFE then close with PTFE Para-esophageal Hernia

15. Ciaran O’Hare Para-esophageal Hernia

16. Ciaran O’Hare As always, when data are scarce, opinions are strongly held! Para-esophageal Hernia

17. Ciaran O’Hare Para-esophageal Hernia Levels Of Evidence

18. Ciaran O’Hare Controversies Acts as a tether promoting recurrence Interferes with esophageal mobilization Can promote a post-op fluid collection “The sac must be completely excised” Para-esophageal Hernia

19. Ciaran O’Hare Controversies True! Meta-analysis, Case series “The sac must be completely excised” Para-esophageal Hernia

20. Ciaran O’Hare Controversies “Fundoplication must always be performed” Most have some degree of reflux Compression by stomach prevents pre-op evaluation Esophageal mobilization predisposes to reflux Para-esophageal Hernia

21. Ciaran O’Hare Controversies Probably true Case series, Expert Opinion (Best Available Evidence) “Fundoplication must always be performed” Para-esophageal Hernia

22. Ciaran O’Hare Controversies Unproven No controlled studies Laparoscopy associated with greater (asymptomatic) post-op reflux “Laparoscopic (Open, Thoracic) repair is the preferred method” method” Para-esophageal Hernia

23. Ciaran O’Hare Controversies Hill 1973 – Because 30% will need emergency surgery, with a 40% mortality. Also stated by Nyus in “HERNIA” 1964 Quoted in virtually every other paper on the subject till 2000 “All Paraesophageal Hernias must be repaired” Para-esophageal Hernia

24. Ciaran O’Hare Para-esophageal Hernia Only 29 patients Only 29 patients Uncontrolled retrospective Uncontrolled retrospective Some were watched for 20 yrs Some were watched for 20 yrs 6/10 – successfully decompressed 6/10 – successfully decompressed 4/10 died – 2 before surgery 4/10 died – 2 before surgery

25. Ciaran O’Hare Degree of herniation varies at any one time Degree of herniation varies at any one time Most (90%) of acute presentations can be decompressed by NG Most (90%) of acute presentations can be decompressed by NG Modern worst case operative mortality is 15% Modern worst case operative mortality is 15% Para-esophageal Hernia “All Paraesophageal Hernias must be repaired…… NO!”

26. Ciaran O’Hare Allen 1993 – 1 gastric strangulation/245 pt-yrs Allen 1993 – 1 gastric strangulation/245 pt-yrs (type IV) (type IV) Treacy – 1987 Treacy – 1987 Hashemi 2000 – 1/54 pts with emergency surgery Hashemi 2000 – 1/54 pts with emergency surgery Pellegrini – 1/45 emergency surgery Pellegrini – 1/45 emergency surgery Para-esophageal Hernia “All Paraesophageal Hernias must be repaired…… NO!”

27. Ciaran O’Hare Para-esophageal Hernia 5m patient computer model based on clinical databases Entered modern data for symptom progression, mortality (emergency and elective) Compared mandatory surgery vs watchful waiting (with risk of gangrene) and surgery for symptom progression But no similar study on the strategy for moderately symptomatic patients Minimally Symptomatic Patients

28. Ciaran O’Hare Para-esophageal Hernia Minimally Symptomatic Patients Annual risk of needing emergency surgery is ~ 1.5% Comparing morb. / mort. of operating on everyone vs a strategy of operating emergently, only 1 / 5 of 65 yr old, and 1 / 10 of 85 yr olds would benefit

29. Ciaran O’Hare Para-esophageal Hernia So what’s a fellow to do?

30. Ciaran O’Hare Para-esophageal Hernia - Even then, carefully weigh the risk v benefit of elective surgery, given that emergent surgery remains unusual, and survival is 85% - Difficult hiatal repairs, or with “short” esophagus, may be best approached trans –thoracic may be best approached trans –thoracic Minimally Symptomatic Patients Recommendations - Watch for symptoms showing significant episodes of gastric obstruction or ischemia

31. Ciaran O’Hare Para-esophageal Hernia - One would assume that the risk of an emergent event would be greater, though there is no data - Perhaps the subset of patients with occasional gastric obstructive symptoms could be watched, while those with gastric ischemis symptoms (ulcers, anemia) should be electively operated on symptoms could be watched, while those with gastric ischemis symptoms (ulcers, anemia) should be electively operated on Assess individually and carefully weigh the risk v benefit of elective surgery Recommendations Symptomatic Patients

32. Ciaran O’Hare Para-esophageal Hernia Any Questions?