Management of Complex Paraesophageal Hernias

Paraesophageal hernias are complex and challenging when they occur with acute symptoms, in malnourished patients, or when there is gastric ischemia. Treatment should be individualized based on each patient’s clinical characteristics.

Medical treatment is often offered to most patients without chronic symptoms. In elective patients with good preoperative performance, surgical repair should be performed to resolve potential gastric or esophageal problems. In emergent cases, initial resuscitation and decompression may allow the patient to stabilize, especially when they can be endoscopically decompressed. This may allow patients additional time to recover before a surgical repair is performed prior to discharge. Surgical repair is often the best answer, but patients presenting for reoperation should only undergo reoperation if they have severe symptoms. The viability of the stomach and imaging, especially 3D imaging, can greatly influence what type of repair is needed, the repair timing, and whether or not adjunctive surgeries, such as a feeding tube placement, are required. Tenets of a good repair include: no mesh against the esophagus, crural closure, fundoplication in good candidates, gastropexy, and cruropexy. The video above reviews each step of a complex patient management algorithm (shown below) that guides the surgeon and team through the difficult decisions of managing paraesophageal hernias.

Additional Resources

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Dr Blackmon holds a patent for an anastomotic esophageal device. She is a speaker/advisor for Medtronic, Ethicon, Boston-Scientific, and Olympus. She runs clinical trials sponsored by TruFreeze and Medtronic.