Controversies regarding the management of hiatus hernia

Abstract

Herniation through the esophageal hiatus is a controversial and complex matter as regards both the underlying pathophysiology and appropriate therapy. Such hernias are best divided into the paraesophageal and sliding varieties. In a paraesophageal hiatus hernia, the fundus and body of the stomach migrate into the chest, the esophagogastric junction usually remaining more or less in its normal position and maintaining normal function. The condition is potentially life-threatening because of the hazards of incarceration and strangulation. Accordingly, surgical treatment is indicated once the diagnosis has been made. Restoration of normal anatomy is the goal of therapy. An antireflux procedure is included only in those rare instances in which hypotension of the lower esophageal sphincter coexists. A sliding esophageal hiatus hernia is a relatively common condition, particularly in older persons, and is often asymptomatic. When symptoms do occur, they are the result of hypotension of the lower esophageal sphincter, which results in gastroesophageal reflux and its complications. Treatment, whether medical or surgical, must be directed toward restoring gastroesophageal competence and minimizing the deleterious effects of regurgitating acid gastric contents. Most patients can be successfully managed medically, only a small portion requiring surgical therapy. A variety of antireflux procedures are now available to achieve this goal. Because reflux is more effectively controlled after the Nissen fundoplication than after the other procedures, I consider it the procedure of choice. Potential complications can be avoided by attention to the technical performance of the procedure.