Hiatal Hernia Management Guidelines Issued

Laurie Barclay, MD

June 24, 2013

The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has issued evidence-based guidelines for the diagnosis and management of hiatal hernia. The new recommendations should help facilitate decision-making by clinicians and patients regarding the appropriate use of laparoscopic surgery.

"Hiatal hernia is a common disorder," write Geoffrey P. Kohn, MBBS(Hons), MSurg, FRACS, and colleagues from the SAGES Guidelines Committee, who included all 4 types of hiatal hernias in their review. Based on current anatomic classification, "[g]reater than 95% of hiatal hernias are Type I," explain the authors. "Types II – IV hernias as a group are referred to as paraesophageal hernias...and are differentiated from Type I hernias by relative preservation of posterolateral phrenoesophageal attachments around the gastroesophageal junction."

"A large body of literature exists on the management of hiatal hernia," the authors continue. "These guidelines are specific for each type of hiatal hernia since the implications of a hiatal hernia and the indications for repair differ between the sliding (Type I) hernias and for the paraesophageal hernias (Type II, III and IV)." Recurrent hiatal hernias are included in the review, but other diaphragmatic hernias are not.

A systematic literature search of PubMed in February 2011 and a pediatric literature search in February 2013 identified 392 relevant articles in the last 5 years. Of these, 153 articles were reviewed by the guidelines authors, including randomized controlled trials, meta-analyses, systematic reviews, and prospective and retrospective studies enrolling at least 20 patients.

Topics reviewed included definitions, classification, pathophysiology, diagnosis, natural history, indications for surgery, preoperative evaluation, outcomes, predictors of success, revisional surgery, and pediatric considerations.

Technical considerations reviewed included a transthoracic vs transabdominal approach, hernia sac excision vs simple reduction, laparoscopic vs open surgery, mesh cruroplasty vs no reinforcement, fundoplication vs no antireflux procedure, and gastropexy vs no gastric fixation.

Using the GRADE system, the guidelines authors rated the quality of the evidence and the strength of the recommendations. When current literature evidence did not support a conclusion, they relied on expert opinion.

Highlights of Strong Recommendations

  • Various tests can diagnose hiatal hernia but should be done only if they will change clinical management.

  • In the absence of reflux disease, repair of a type I hernia is unnecessary.

  • All symptomatic paraesophageal hiatal hernias (types II - IV) should be repaired, especially in the presence of acute obstructive symptoms or volvulus.

  • Acute gastric volvulus requires stomach reduction, with limited resection if needed.

  • To minimize poor outcomes, postoperative nausea and vomiting should be treated aggressively.

  • A transabdominal or transthoracic approach can effectively repair hiatal hernia.

  • The laparoscopic approach is as effective as and has markedly less morbidity than the open approach and is preferred for most hiatal hernias.

  • During paraesophageal hiatal hernia repair, the hernia sac should be dissected away from mediastinal structures.

  • Use of mesh for reinforcement of large hiatal hernia repairs is linked to lower short-term recurrence rates.

  • Hiatal hernia repair must return the gastroesophageal junction to an infradiaphragmatic position.

  • When repair is complete, the intraabdominal esophagus should measure 2 to 3 cm or more (weak evidence), which can be achieved by mediastinal dissection of the esophagus and/or gastroplasty (strong evidence).

  • Gastropexy may safely be used in addition to hiatal repair.

  • In selected patients, gastrostomy tube insertion may facilitate postoperative care.

  • As early postoperative dysphagia is common, adequate caloric and nutritional intake are important.

  • In asymptomatic patients, routine postoperative contrast studies are unnecessary.

  • Experienced surgeons can safely perform laparoscopic revisional surgery.

Highlights of Pediatric Considerations (Weak Recommendations)

  • Symptomatic hiatal hernias should be surgically repaired.

  • A laparoscopic approach is feasible.

  • Hernia age or size is not an absolute contraindication to laparoscopy.

  • Gastroesophageal reflux should be addressed by a concomitant antireflux procedure.

  • The current standard of care is either hernia sac excision or disconnection from the crura.

  • Hiatal dissection should be minimal to reduce the risk for postoperative paraesophageal hernia after fundoplication.

  • Plication of the esophagus to the crura may reduce recurrence in children.

"Guidelines for the Management of Hiatal Hernia." SAGES. Full text

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