The natural course of giant paraesophageal hernia and long‐term outcomes following conservative management

Abstract

Background Accurate information on the natural course of giant paraesophageal hernia is scarce, challenging therapeutic decisions whether or not to operate. Objective We aimed to investigate the long-term outcomes, including hernia-related deaths and complications (e.g. volvulus, gastrointestinal bleeding, strangulation) of patients with giant paraesophageal hernia that were conservatively managed, and to determine factors associated with clinical outcome. Methods We retrospectively analysed charts of patients diagnosed with giant paraesophageal hernia between January 1990 and August 2019, collected from a university hospital in The Netherlands. Included patients were subdivided into three groups based on primary therapeutic decision at diagnosis. Radiological, clinical and surgical characteristics, along with long-term outcomes at most recent follow-up, were collected. Results We included 293 patients (91 men, mean age 70.3 ± 12.4 years) with a mean duration of follow-up of 64.0 ± 58.8 months. Of the 186 patients that were conservatively treated, a total hernia-related mortality of 1.6% was observed. Hernia-related complications, varying from uncomplicated volvulus to strangulation, occurred in 8.1% of patients. Only 1.1% of patients included in this study required emergency surgery. Logistic regression analysis revealed the presence of symptoms (odds ratio (OR) 4.4, 95% confidence interval (CI) 1.8–20.6), in particular obstructive symptoms (vomiting, OR 15.7, 95% CI 4.6–53.6; epigastric pain, OR 4.4, 95% CI 1.2–15.8 and chest pain, OR 6.1, 95% CI 1.8–20.6) to be associated with the occurrence of hernia-related complications. Conclusions Hernia-related death and morbidity is low in conservatively managed patients. The presence of obstructive symptoms was found to be associated with the occurrence of complications during follow-up. Conservative therapy is an appropriate therapeutic strategy for asymptomatic patients.

Minimally Invasive Abdominal Repair of a Giant Paraesophageal Hiatal Hernia with Occupation of the Right Thorax in a 53-Year-Old Man

“…The gastric volvulus of paraesophageal HH is an emergency pathology that must be resolved quickly, due to the risk of necrosis of the stomach or other organs that are in the hernia sac, which presents a high morbidity and mortality [6][7][8][9]. The patient's symptoms, characterized by weight loss, epigastric pain, and upper gastrointestinal bleeding, should lead to suspicion of cancer, so the study in the emergency room should be efficient in order to reach a precise diagnosis.…”

UEGWeek: The modern School of Athens

“…21 Concerning benign, yet scary diseases, about rare giant paraesophageal hernias a retrospective study on 186 treated conservatively reported a mortality rate of 1.6% and a complication rate of 8.1%; presence of symptoms (vomiting, epigastric pain and chest pain) were associated with the occurrence of complications. 22 Lastly, with the Hp-EuReg, a large prospective multicenter registry investigated on 2100 patients the effectiveness of singlecapsule bismuth quadruple therapy for H.P., with eradication being around 90% both when used as first, second and up to the sixth line of therapy. 23…”

“…Concerning benign, yet scary diseases, about rare giant paraesophageal hernias a retrospective study on 186 treated conservatively reported a mortality rate of 1.6% and a complication rate of 8.1%; presence of symptoms (vomiting, epigastric pain and chest pain) were associated with the occurrence of complications 22 …”

“…Among the almost 6000 abstracts submitted to 2019 and 2020 UEGWeek editions, 32 were then accepted as full‐text publication to UEG Journal 1–31 . Here we will summarize these “hot” papers (see also Figure 3).…”

Impact of surgical repair on type IV paraesophageal hernias (PEHs)

“…On the other hand, symptomatic patients, and mainly those presenting with obstructive symptoms such as vomiting, epigastric and chest pain are more prone to hernia-related complications. As a result, they should be strongly considered for surgical therapy [6].…”