Hiatal hernia controversies ‐ a review of pathophysiology and treatment options

Abstract

Hiatal hernia is not completely understood in humans or animals. It has a complex multifactorial aetiology and pathophysiology. A primary disturbance of the lower oesophageal sphincter has not been shown in humans or animals. Knowledge of pathophysiology is necessary to institute appropriate treatment. Medical and/or surgical therapy is not indicated in asymptomatic cases. Medical treatment should be used for up to 1 month in stable cases of sliding hiatal hernia. Paraoesophageal hiatal hernias and any large sliding hiatal hernia should be considered for prompt surgical treatment. Surgical techniques used depend on the type of hiatal hernia present. Surgical treatment of hiatal hernia cases should be performed by experienced surgeons, and must include hiatal closure and gastropexy. The Nissen fundoplication procedure has been discontinued in the veterinary field due to poor success rates, coupled with the published view that there is a marked difference in pathophysiology between humans and dogs. Reported complications associated with the original Nissen fundoplication technique are identical in the human and veterinary literature. There have been no complications reported with use of the modified or 'floppy' Nissen fundoplication in dogs. Both oesophagopexy and Nissen fundoplication require further evaluation in small animals.

Combined surgical and endoscopic approach for the reduction of a congenital hiatal hernia in a cat: a case report

“…Congenital hiatal hernia, as other congenital malformations (Pisoni et al 2012;Tremolada et al 2013) is an uncommon abnormality in dogs and rare in cats, but various reports are available in the literature (Gaskell et al 1974;Teunissen et al 1978;Peterson 1983;Ellison et al 1987;Miles et al 1988;Prymak et al 1989;Bright et al 1990;Williams 1990;Brinkley 1990;White 1993;Callan et al 1993;Auger and Riley1997;Hardie et al 1998;Lorinson and Bright 1998;Sivacolundhu et al 2002;Rahal et al 2003;Kirkby et al 2005;Owen et al 2005;Ardnt et al 2006;Baig et al 2006;Keeley et al 2008;DeSandre-Robinson et al 2011), most of which are congenital, such as, apparently, the case described in the present report. Despite the several cases reported, the pathogenesis is not completely understood and, similarly, the therapeutic protocol has not been standardised.…”

“…A prokinetic agent can improve the LES pressure and accelerate gastric emptying. The diet is also important; reducing the fat content, changing the consistency of the food, giving small amounts of food frequently and keeping the animal in a vertical position for some minutes after the meal can help oesophageal transit and gastric emptying (Sivacolundhu et al 2002). Usually surgery is suggested only after failure to alleviate the symptoms by medical therapy.…”

“…Congenital hiatal hernia (HH) is considered an unusual disease in dogs and is also rare in cats (Sivacolundhu et al 2002;Hunt and Johnson 2003). Different types of HH have been described in veterinary medicine: type I, sliding hiatal hernia, type II or paraoesophageal hernia, type III, which is a combination of types I and II, and type IV, a mix of I and II complicated by the herniation of other abdominal organs (Miles et al 1988;Williams 1990;Auger and Riley 1997;Rahal et al 2003;Kirkby et al 2005;Owen et al 2005;Baig et al 2006).…”

“…These symptoms are considered to be connected with the frequent gastrooesophageal reflux leading from the hernia (Hunt and Johnson 2003). The reflux is probably caused by the reduction in muscular tone of the lower oesophageal sphincter (LES) that moves from the abdomen to the thorax through the diaphragm (Sivacolundhu et al 2002).…”

“…Clearer indications can be deduced about surgical intervention in types II, III and IV, where surgical therapy is advised even in the absence of clinical signs, but, as already reported, the incidence of these types of hernia is low (Miles et al 1988). Usually for symptomatic type I hernia medical therapy should be attempted, even if the success rate is low (Ellison et al 1986), and surgery is usually proposed only after failure of the medical therapy (Lorinson et al 1998;Sivacolundhu et al 2002).…”