Natural history and non-operative treatment of paraesophageal hernias

Abstract

: Paraesophageal hernias (PEHs) are a commonly encountered, anatomical process that result from enlargement of the diaphragmatic hiatus. PEHs are characterized by projection of abdominal organs into the mediastinum. They may be asymptomatic and noted incidentally on imaging studies or present with a variety of symptoms, such as reflux, post-prandial fullness or discomfort, dysphagia, vomiting, regurgitation, cough or shortness of breath. The main components of a diagnostic work-up and characterization of PEHs are a contrast swallow study and esophagogastroduodenoscopy (EGD). Modern treatment paradigms involve surgical repair for symptomatic hernias or large asymptomatic hernias in those without significant operative risk. Asymptomatic patients require no specific treatment but are at risk for progression over time. Lifestyle modifications and medical treatment of reflux are important for management of mild to moderate symptoms. While the risk of acute symptom development is low, volvulus/obstruction is associated with significant worsening morbidity and mortality. Although surgical correction is the optimal treatment, when indicated, conservative or endoscopic management in high-risk surgical patients may be options. This, however, has a likely high rate of recurrent symptoms. Non-operative approaches include symptom control and watchful waiting in those without severe symptoms or high-risk surgical candidates. In severe cases, obstruction and organ ischemia from volvulus can occur, which require urgent intervention and surgery. Patients who present with these symptoms have a high rate of recurrence with non-operative management.