Approach
The main goal of treatment for hiatus hernia is to alleviate the patient's symptoms. A secondary goal is to move the displaced intra-abdominal organ(s) from the chest back into the abdomen; this is not necessary in all patients.
Lifestyle changes
Lifestyle modifications may be helpful for some symptomatic patients, although evidence is limited.[6][12] These changes include:
losing weight
elevating the head of the bed
avoiding large meals
avoiding meals just before bedtime
avoiding alcohol
avoiding acidic foods.
Substances suspected to inhibit the lower oesophageal sphincter should also be avoided. These include nicotine, chocolate, peppermint, caffeine, fatty foods, and drugs such as calcium-channel blockers, nitrates, and beta-blockers.
Medical therapy
Patients with symptoms of gastro-oesophageal reflux disease (GORD) are treated medically with a proton-pump inhibitor (PPI).[6][12] See Gastro-oesophageal reflux disease.
Surgical correction, general considerations
Controlled studies suggest that open surgical therapy is better than medical therapy, but the advantage decreases with time.[22][23]
One meta-analysis comparing surgical (laparoscopic or open) options versus medical management to treat Cameron lesions (erosions or ulcerations of the stomach mucosa at the diaphragmatic hiatus) in patients with hiatus hernia, found that surgery significantly increased resolution of these lesions compared with PPI treatment.[24]
The principles of hiatus hernia repair are reduction of hernia contents, excision of the hernia sac, lengthening of the intra-abdominal oesophagus to reach a minimum of 3 cm intra-abdominal length, a tension-free closure of the hiatus by primary cruroplasty with or without mesh reinforcement, and an anti-reflux procedure or gastropexy. Most surgical procedures for hiatus hernia now are performed with a minimally invasive (laparoscopic or robotic) approach.[13]
The robotic approach may offer improved visualisation, ergonomics, and improved mobility with the use of articulating instruments. There is a lack of randomised surgical outcome data to support the use of the robotic surgical technique. However, evidence from retrospective and prospective uncontrolled trials suggests that robotic surgery is safe, feasible, and effective, with no difference in operative times, rate of re-admissions, acute complications, and with potentially lower recurrence rates compared with traditional laparoscopic surgery.[25][26][27] Further advantages may be seen in reoperative surgery, but more studies are needed.[28]
Both controlled and uncontrolled data indicate that the durability of a hiatus hernia repair is better if the repair is performed with prosthetic mesh.[29][30][31][32][33][34] For large hiatus defects (generally >5 cm transverse dimension), the use of mesh can be considered in the repair. Laparoscopic repair of hiatus hernia without mesh can result in an anatomic recurrence rate of 15% to 30%, although not all of these recurrences are symptomatic or require reoperation.[35][36][37] One systematic review and meta-analysis found that mesh use was associated with fewer symptomatic recurrences.[38]
Mesh-related complications such as mesh erosion or oesophageal fibrosis have been reported and appear to be more common with non-absorbable mesh compared with absorbable mesh.[39][40][41] Biological (absorbable) mesh is associated, however, with a higher recurrence rate.[34][41] With respect to non-absorbable mesh only, there is no apparent relationship between mesh type and configuration and the complications.[40][41] The controversies over which type of mesh to utilise in hiatus hernia repair, the details of mesh implantation, and the general indications for mesh usage are ongoing, and will require further study to resolve. At this point in the evolution of hiatus hernia surgery there may be a trade-off in the choice of prosthetic mesh for the repair: choose permanent mesh and there is the risk of erosion; choose biological mesh and there is the risk of recurrence. Good scientific data to support a specific choice of mesh for the repair are currently lacking.[42][43]
Caution should be exercised when performing a laparoscopic repair of a large hiatus hernia to avoid injury to the heart or the aorta. Such injuries have occurred secondary to suture or tacker use to anchor the mesh to the diaphragm, and may have catastrophic consequences.[44][45]
If expertise in minimally invasive surgery is not available, open repair is an acceptable alternative. Surgical correction of GORD and hiatus hernia can be performed with a combined anti-reflux procedure and hiatus herniorrhaphy.[13][46]
In asymptomatic patients, a shared decision-making approach should be followed to decide between surgery and observation as evidence for superiority of one over another is lacking.[38][47]
Urgent indications for surgery
Surgical repair is indicated urgently in patients who have life-threatening complications of obstruction, volvulus, or upper gastrointestinal haemorrhage. These patients will need resuscitation and stabilisation before surgical repair.[1]
Surgical resection is urgently indicated for patients with irreversible ischaemia, or necrosis of the stomach or other herniated organs, such as small intestine or colon.[1] Gastrointestinal continuity may be temporarily interrupted in these patients if a major oesophagogastric resection is performed. An intrathoracic anastomosis should be avoided in frail patients who have evidence of mediastinitis. In such cases, the stomach should be stapled off and decompressed with a gastrostomy tube, and the proximal oesophagus should be diverted with a cervical oesophagostomy.
Surgical repair, indications (type I)
Referral and consideration for surgical correction is indicated in patients who have not had a satisfactory response to medical therapy.[1] This includes patients who are non-adherent with drugs, have persistent regurgitation, have reflux-induced asthma, or who simply choose to have surgical therapy.
A loose Nissen fundoplication (i.e., 360° wrap) should generally be used whenever feasible, even in patients without GORD. This practice is based on the observation that the dissection performed during a hiatus hernia repair typically destroys all of the tissue relationships that make up the physiological anti-reflux mechanism.
Surgical repair, indications (types II, III, and IV)
Patients with a hiatus hernia of types II to IV should be considered for surgical repair. The patient's age, comorbidities, and the long-term risk of strangulation and mediastinitis should all considered.[1] Surgical repair is not routinely recommended in asymptomatic patients.[1]
The routine use of an anti-reflux procedure in association with the hiatus hernia repair is controversial, especially in patients who do not have signs or symptoms of GORD preoperatively. Guidelines suggest performing surgical fundoplication over no fundoplication, as the benefits outweigh the harms.[47] As for patients with type I hiatus hernia, a loose Nissen fundoplication (i.e., 360° wrap) should generally be used whenever feasible, even in patients without GORD.
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