Giant paraesophageal hernia: What do we really know?

Abstract

Feature Editor Note-The management of giant paraesophageal hernias remains challenging. In this invited expert opinion article, Bhargava and Andrade provide an in-depth discussion of the controversies surrounding repair of giant paraesophageal hernias, including management of recurrent hiatal hernias, esophageal-lengthening procedures, and the use of mesh. Based on their own practice, they suggest performing an extensive mediastinal dissection to achieve adequate intra-abdominal esophageal length, gastroplasty when needed for esophageal shortening, and the avoidance of mesh due to the risk of erosion, cost, and lack of clear data supporting its use. Other practices are more controversial, such as placement of a gastrostomy tube for recurrent hernias in the hopes of preventing recurrence, avoidance of a fundoplication in patients with morbid obesity, and usage of a pharyngostomy tube for decompression, which is considered a legacy procedure by most surgeons.Recurrent paraesophageal hernias in particular require a thoughtful approach, including obtaining the operative report from the initial operation when possible, considering the severity of the patient's symptoms, and careful review of objective data from current studies. Patients with multiple previous repairs are unlikely to benefit from a repeat repair, and partial gastrectomy with Roux-en-Y esophagojejunostomy or esophagectomy should be reserved for those with severe symptoms such as the inability to tolerate an oral diet.The authors emphasize the importance of clearly defining what constitutes a giant paraesophageal hernia, the natural history, and an objective assessment of short-and long-term outcomes. While there have been substantial advances, repair of a giant paraesophageal hernia continues to be a challenging procedure, particularly redo repair, and should be performed in experienced, high-volume centers.Giant paraesophageal hernia characterization remains a challenging concept. CENTRAL MESSAGELaparoscopic giant paraesophageal hernia repair remains in evolution. We use extensive mediastinal dissection to achieve intra-abdominal esophageal length, gastroplasty as needed, and avoid mesh.See Commentary on page 373.

Intraesophageal Migration of a Paraesophageal Hernia Mesh: A Case Report

“…When considering the type of mesh, synthetic meshes like polypropylene and polytetrafluoroethylene (PTFE)-based mesh can lead to more frequent erosions [ 2 ], but this can be explained by the fact that synthetic meshes are simply more frequently used as argued by Antoniou et al. [ 7 ].…”

“…Reoperating a recurrent PEH may not benefit the patient, that is why we must consider the severity of the symptoms and also consider other alternatives to simple repair such as esophageal lengthening and mesh use (even if it is controversial) [ 2 ].…”

Commentary: A century of giant paraesophageal hernia (GPEH) repair: A century of controversy!

“…Given that elective repair is associated low mortality and morbidity and contrasting it with the low risk of obstructive and gangrenous complications per year, the lifetime risk of developing complications needs to be taken into account before considering repair. 3 In their article by Bhargava and Rafael, 4 the authors identify knowledge gaps and describe a systematic approach to evaluation, management, and follow-up of patients with GPEH. They note that despite the long history of treating GPEH, there is still no consensus about its definition.…”

“…In their article by Bhargava and Rafael, 4 the authors identify knowledge gaps and describe a systematic approach to evaluation, management, and follow-up of patients with GPEH. They note that despite the long history of treating GPEH, there is still no consensus about its definition.…”

“…The 2 controversial elements highlighted in this paper are the need for esophageal lengthening and the use of mesh. 4 There have been few, if any, long-term series with results as good as the one by Maziak and colleagues 6 when a Collis gastroplasty was liberally used along with a fundoplication. Some surgeons question the existence of the entity of a shortened esophagus entirely.…”