Treatment Guidelines for Large Paraesophageal Hernia

Diagnostic Evaluation

CT scanning is the most useful diagnostic method to detect complications such as bowel strangulation, with reduced wall enhancement being the most significant independent predictor (56% sensitivity and 94% specificity) in patients with suspected bowel strangulation 1
Elevated white blood cell count can be moderately predictive of complications in patients with incarcerated hernias, indicating the need for close monitoring and potential intervention 1
Water-soluble contrast swallow may be performed after repair to screen for perforation, though it is not essential, as part of the postoperative management protocol 2

Consider partial fundoplication (Toupet or Dor) in patients with esophageal hypomotility or impaired peristaltic reserve to reduce risk of postoperative dysphagia, as recommended by the American Gastroenterological Association 3
Type of fundoplication may be tailored based on preoperative manometry findings, allowing for a more personalized approach to surgical repair 3

Proton pump inhibitor (PPI) therapy should be offered after repair to reduce risk of reflux symptoms (which occur in 10-40% of patients) and promote healing and prevent recurrence, as suggested by the European Society of Gastrointestinal Endoscopy 2
Provide patients with contact information for the on-call team in case they experience chest pain, breathlessness, or become unwell, to ensure prompt recognition and management of potential complications 5
Monitor for potential complications, including perforation (suspect when patients develop persistent pain, breathlessness, fever, or tachycardia), and take prompt action to address these issues 5

Patients with symptoms of gastroesophageal reflux disease (GORD) should receive PPI therapy as this has been shown to reduce the need for subsequent interventions, according to the American College of Gastroenterology 2
For obese patients with proven GERD, Roux-en-Y gastric bypass may be considered as an effective primary anti-reflux intervention, while sleeve gastrectomy has potential to worsen GERD, as noted by the American Society for Metabolic and Bariatric Surgery 3
Placement of a feeding jejunostomy tube may be considered for patients with gastroduodenal motility disorders, gastric outlet stenosis, or high risk of aspiration, to ensure adequate nutrition and minimize complications 4