Hiatal Hernia Management

Introduction

Hiatal hernias can be classified into different types, including Type I (sliding), Type II (paraesophageal), Type III (combined), and Type IV, with Type I being the most common, accounting for approximately 90% of all cases 1

A CT scan with IV contrast should be performed with neutral oral contrast (water or dilute barium) for diagnostic imaging of hernias 2
An upper GI series (barium swallow) is helpful for evaluating structural and functional abnormalities in patients with suspected hernias 2
Chest radiography is recommended as the first-line imaging for suspected diaphragm dysfunction, with the American College of Radiology suggesting a right interlobar artery measurement of >15 mm in women or >16 mm in men may indicate associated pulmonary hypertension 3, 4, 5, 6
The sensitivity and specificity of diagnostic tests for hiatal hernias are as follows:
Diagnostic Test Sensitivity Specificity
CT scan 14-82% 87%
Chest X-ray 2-60% (left-sided), 17-33% (right-sided) -
3

Diagnostic Test	Sensitivity	Specificity
CT scan	14-82%	87%
Chest X-ray	2-60% (left-sided), 17-33% (right-sided)	-

Primary repair with non-absorbable sutures is used for small defects, while mesh reinforcement is used for larger defects that cannot be closed with direct suture, as recommended by the World Journal of Emergency Surgery guidelines 1
Biosynthetic, biologic, or composite meshes are preferred due to lower recurrence rates and higher resistance to infections, according to the World Journal of Emergency Surgery guidelines 1
Nissen fundoplication (360° wrap) is the most commonly performed type of fundoplication, while Toupet fundoplication (270° posterior wrap) may have lower recurrence rates, and patients with gastroesophageal reflux history should include fundoplication as part of the repair 1, 7
The initial treatment for gastroesophageal reflux disease (GERD) caused by hiatal hernia should include lifestyle modifications, weight management, and proton pump inhibitor (PPI) therapy optimized to control symptoms, as recommended by the American Gastroenterological Association and American Society for Gastrointestinal Endoscopy 7
PPI therapy should be started with a single daily dose taken 30-60 minutes before the first meal of the day, with an initial trial of 4-8 weeks 7

A 4-8 week trial of single-dose PPI therapy should be initiated before considering invasive procedures, and continuing proton pump inhibitor (PPI) therapy after hiatal hernia repair in patients with Barrett's esophagus is recommended for symptom control and to potentially reduce the risk of disease progression, with a Grade A recommendation, according to the American Gastroenterological Association 7, 8, 9
Alginate antacids may be used for breakthrough symptoms, particularly in patients with hiatal hernia, and H2-receptor antagonists (H2RAs) may be used for nighttime symptoms 7
For patients with erosive esophagitis, Barrett's esophagus, or peptic stricture, long-term PPI therapy should be continued at least at a single-dose level 7

Consider percutaneous endoscopic gastrostomy (PEG) or jejunostomy in patients with oral intake difficulties, as suggested by the World Journal of Emergency Surgery guidelines 1
Missed diagnosis of short esophagus may require additional procedures like Collis gastroplasty, and inadequate mobilization of the esophagus can lead to tension and other complications, emphasizing the importance of proper surgical technique and postoperative care 1

The recurrence risk is higher in elderly patients and with larger defects, but mesh reinforcement reduces this risk, as reported by the World Journal of Emergency Surgery guidelines 1
Hernia recurrence is reported in 3-5% of cases, and inadequate mesh fixation can lead to mesh migration and recurrence, with potential complications of surgical repair including pulmonary complications, surgical site infection, bleeding, respiratory failure, ileus, chronic pain, hernia recurrence, and cardiac injury, according to the World Journal of Emergency Surgery 1