Complications
The patient complains of abdominal distension, typically in association with meals.
This is a common complaint in the first several months after an anti-reflux procedure. Bloating is attributed to the decreased ability to belch secondary to the valve mechanism of the anti-reflux procedure.
Bloating usually resolves without specific intervention.[50]
Dietary modifications are recommended such as avoiding carbonated beverages and gas-producing food. Drugs such as simethicone can be used to reduce flatulence and bloating.
In rare circumstances, a takedown or repeat fundoplication may be necessary to treat severe, unrelenting, and debilitating bloating.
This rare but potentially deadly complication occurs in patients with type II or III hernias.[1]
Typically, the stomach rotates around its long axis (from the gastro-oesophageal junction to the pylorus, also known as organoaxial volvulus) as it herniates into the chest. The fundus and antrum exchange relative positions, resulting in a condition sometimes called upside-down stomach.
A less common type of volvulus is the mesentericoaxial, in which the stomach twists around a transverse axis (such as the pedicle of the left gastric artery).
Gastric volvulus can produce strangulation, necrosis, and fulminant mediastinitis requiring urgent surgery.
Asymptomatic or minimally symptomatic gastric volvulus should usually be surgically corrected if the patient can tolerate a general anaesthetic.
Occurs in the setting of type II and III hernias and is typically associated with a gastric volvulus. Patients have bloody or non-bilious emesis, or both, and passage of a nasogastric tube is usually difficult.
Obstruction with suspected strangulation is a surgical emergency. Non-strangulated obstruction also is a surgical condition, although not as urgent. It may be difficult to differentiate strangulated from non-strangulated obstruction, so resuscitation with urgent surgery is usually prudent.
Most commonly occurs because of breakdown of the hiatus hernia repair and is usually the result of disruption of the sutured cruroplasty in patients who did not have a mesh repair.
Recurrence can occur in the early postoperative period in association with severe increases in intra-abdominal pressure, such as from coughing or vomiting.
Recurrent hernia is usually best treated by reoperation (either open or laparoscopic) with a repeat hiatus hernia repair. To minimise further recurrence, a mesh repair can be considered. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) suggests considering conversion to Roux-en-Y gastric bypass in select patients without obesity and with recurrent type II, III, or IV hiatus hernia as it may reduce the need for re-intervention.[47]
The patient experiences difficulty swallowing, typically with solids.
This usually occurs from a fundoplication that wraps around the oesophagus too tightly, or from a hiatus closure that is too narrow.
A patient with underlying oesophageal dysmotility may be predisposed to developing postoperative dysphagia. Many patients do experience some degree of postoperative dysphagia that lasts for several months and requires no specific intervention other than patient education and reassurance.[50]
Mild-to-moderate postoperative dysphagia should be observed initially because it will usually resolve without specific intervention other than avoiding certain foods, such as coarse bread and steak, that tend to get stuck.
Severe, unrelenting, and debilitating dysphagia may require early surgical intervention to correct the tight fundoplication or crural closure, but this is an uncommon indication for reoperation.
In patients who have undergone a hiatus hernia repair, post-operative haemorrhage is a rare complication that usually occurs along the greater curve of the stomach or in the hilum of the spleen, at the site where the short gastric vessels have been transected and ligated. Other, less common sites of postoperative haemorrhage include small vessels in the mediastinum and a replaced left hepatic artery in the gastrohepatic omentum.
Surgical versus non-surgical management of postoperative haemorrhage depends on the clinical scenario.
This is a rare complication that is more liable to occur in patients who have undergone ligation of the short gastric vessels and the branches of the left gastric artery along the lesser curve of the stomach.[51] Care should be taken to preserve the blood supply to the lesser curve, if possible.
Fundal necrosis is a surgical emergency. Typically, the patient will require a major gastric resection with closure of the distal stomach, gastrostomy, oesophageal stapling, cervical oesophagostomy, and drainage.
This is a rare complication of hiatus repair that can range in severity from mild to debilitating. The aetiology is obscure but may be secondary to vagal injury incurred during mobilisation of the gastro-oesophageal junction.
Treatment is mostly symptomatic, consisting of antidiarrhoeal drugs and dietary modifications.
Mesh-associated infection that occurs early in the postoperative period after a mesh repair of hiatus hernia usually indicates an undiagnosed iatrogenic gastro-oesophageal perforation.[40] Patients typically present with signs and symptoms of an intra-abdominal abscess. The diagnosis is usually made with a gastrointestinal (GI)-contrasted computed tomography scan or Gastrografin upper GI series.
Because early mesh infection is associated with a perforation, early reoperation is advised to remove the mesh, drain the abscess, and close the perforation. In this situation, definitive repair of the hiatus hernia may have to be deferred for a future elective procedure.
Hiatus hernias associated with gastro-oesophageal reflux disease are at risk of oesophagitis and subsequent chronic blood loss. Cameron lesions (erosions or ulcerations of the stomach mucosa at the diaphragmatic hiatus) in patients with hiatus hernia can present with overt or occult gastrointestinal bleeding.[6][49]
Sliding (but not para-oesophageal) hiatus hernias are always associated with gastro-oesophageal reflux disease and consequently are at risk of Barrett's oesophagus.
Includes mesh erosion into the gastro-oesophageal lumen, mesh migration, and mesh infection.[40] If a patient has a late mesh complication, surgical removal of the mesh is indicated in most cases.
The experience from centres that have done a relatively large number of mesh hiatus herniorrhaphies suggests that, at least in experienced hands, the long-term risk with the use of modern prosthetic mesh as the oesophageal hiatus is vanishingly small.[29][30][31][32][33][34]
Late hernia recurrence after hiatus herniorrhaphy continues to be an issue with this area of surgery. Late recurrence appears to be minimised with the use of mesh for specific indications.
Whether patients with a recurrent hiatus hernia should undergo a repeat repair is a decision that should be individualised based on the patient's symptoms and comorbidities.
A repeat hiatus hernia repair should ideally be performed in a high volume referral centre by a surgeon experienced in these procedures. The operative approach could be transabdominal, transthoracic, open, laparoscopic, or robotic. The SAGES suggests considering conversion to Roux-en-Y gastric bypass in select patients without obesity and with recurrent type II, III, or IV hiatus hernia as it may reduce the need for re-intervention.[47]
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