Background:Historically, the pathophysiology of Hiatal Hernias (HH) has not been
fully understood. As a result, the surgical therapy of HH has focused primarily
on gastrointestinal symptoms and Gastroesophageal Reflux (GERD). This
treatment strategy has been associated with poor relief of symptoms and poor long-term outcomes. In fact,
until recently, most
patients with HH have been watched and referred for surgery as a last resort.
Recent experience has shown that a large (giant) Hiatal Hernia (GHH) is a
common problem known to impact adjacent
organs such as the hearts and lungs. Those referred for surgical repair often complain of
dyspnea, which is erroneously attributed to pulmonary compression or aspiration, but has been shown to be from tamponade caused from compression of the heart by herniated abdominal contents.
This article reviews the present understanding of GHH, the cardiac
complications which result from GHH, and the
most advanced robotic minimally invasive surgical approach to the
anatomic and physiologic repair of GHH. Methods: In a prospective cohort
study, we evaluated patients undergoing RRHH with at least a 2-year follow-up. All patients undergoing elective (RRHH)
were identified preoperatively and
enrolled prospectively in this study. Preoperative characteristics, medical
comorbidities, and clinical information were all recorded prospectively and recorded into a secure surgical
outcomes database. All patients received
the previously validated Gastroesophageal Reflux Disease-Health-Related
Quality of Life (GERD-HRQL) questionnaire preoperatively and at postoperative time points of 1 month,1 year, and 2 years. Patients routinely had a barium
swallow
References
[1]
Kahrilas, P.J., Kim, H.C. and Pandolfino, J.E. (2008) Approaches to the Diagnosis and Grading of Hiatal Hernia. Best Practice and Research in Clinical Gastroenterology, 22, 601-616.
[2]
Altorki, N.K., Yankelevitz, D. and Skinner, D.B. (1998) Massive Hiatal Hernias: The Anatomical Basis of Repair. The Journal of Thoracic and Cardiovascular Surgery, 115, 828-835. https://doi.org/10.1016/S0022-5223(98)70363-0
[3]
Luketich, J.D, Raja. S., Fernando, H.C., Campbell, W., Christie, N.A., Buenaventura, P.O., Weigel, T.L., Keenan, R.J. and Schauer, P.R. (2000) Laparoscopic Repair of Giant Paraesophageal Hernia: 100 Consecutive Cases. Annals of Surgery, 232, 608-618. https://doi.org/10.1097/00000658-200010000-00016
[4]
Gharagozloo, F., Meyer, M., Atiquzzaman, B., Maqsood, K., Abukharah, R., Rahal, F., Baskar, S., et al. (2021) Robotic Anatomic and Physiologic Reconstruction of Paraeso- phageal Hiatal Hernias: Combining Lessons from a Century of Discovery and Controversy. In: Gharagozloo, F., Patel, V., Giulianotti, P., Poston, R., Gruessner, R. and Meyers M., Eds., Robotic Surgery, Second Edition, Springer, Cham, 621-657. https://doi.org/10.1007/978-3-030-53594-0_50
[5]
Gharagozloo, F., Soberman, M., DuBree, K., Tempesta, B. and Gurfinchel, G. (1999) Correlation of a Hiatal Hernia and Gastroesophageal Reflux Disease: A Prospective Blinded Study in Patients Undergoing Laparoscopy. Chest, 116, 371s.
[6]
Maziak, D.E., Todd, T.R. and Pearson, F.G. (1998) Massive Hiatus Hernia: Evaluation and Surgical Management. The Journal of Thoracic and Cardiovascular Surgery, 115, 53-60. https://doi.org/10.1016/S0022-5223(98)70442-8
[7]
Andolfi, C., Jalilvand, A., Plana, A. and Fisichella, P.M. (2016) Surgical Treatment of Paraesophageal Hernias: A Review. Journal of Laparoendoscopic and Advanced Surgical Techniques: Part A, 26, 778-783. https://doi.org/10.1089/lap.2016.0332
[8]
Gagliardi, D., Makihara, S., Corsi, P.R., De Toledo Viana, A., Wiczer, M.V.F.S., Naka- kubo, S. and Mimica, M.J. (1998) Microbial Flora of the Normal Esophagus. Diseases of the Esophagus, 11, 248-250. https://doi.org/10.1093/dote/11.4.248
[9]
Pajecki, D., Zilberstein, B., dos Santos, M.A.A., Ubriaco, T.A., Quintanilba, A.G., Cecco- nello, I. and Gama-Rodrigues, T. (2002) Megaesophagus Microbiota: A Qualitative and Quantitative Analysis. Journal of Gastrointestinal Surgery, 6, 723-729.
[10]
Pei, Z.H, Bini, E.J., Yang, L.Y., Zhou, M.S., Francois, F. and Blaser, M.J. (2004) Bacterial Biota in the Human Distal Esophagus. Proceedings of the National Academy of Sciences of the United States of America, 101, 4250-4255. https://doi.org/10.1073/pnas.0306398101
[11]
Pei, Z.H., Yang, L.Y., Peek, R.M., Jr. Levine, S.M., Pride, D.T. and Blaser, M.J. (2005) Bacterial Biota in Reflux Esophagitis and Barrett’s Esophagus. World Journal of Gastroenterology, 11, 7277-7283. https://doi.org/10.3748/wjg.v11.i46.7277
[12]
Liu, N., Ando, T., Ishiguro, K., Maeda, O., Watanabe, O., Funasaka, K., Nakamura, M., Miyahara, R., Ohmiya, N. and Goto, H. (2013) Characterization of Bacterial biota in the Distal Esophagus of Japanese Patients with Reflux Esophagitis and Barrett’s Esophagus. BMC Infectious Diseases, 13, Article No: 130. https://doi.org/10.1186/1471-2334-13-130
[13]
Johnston, N., Knight, J., Dettmar, P.W., Lively, M.O. and Koufman, J. (2004) Pepsin and Carbonic Anhydrase Isoenzyme III as Diagnostic Markers for Laryngopharyngeal Reflux Disease. The Laryngoscope, 114, 2129-2134. https://doi.org/10.1097/01.mlg.0000149445.07146.03
[14]
Samuels, T.L. and Johnston, N. (2009) Pepsin as a Causal Agent of Inflammation during Nonacidic Reflux. Otolaryngology-Head and Neck Surgery, 141, 559-563. https://doi.org/10.1016/j.otohns.2009.08.022
[15]
Havemann, B.D., Henderson, C.A. and El-Serag, H.B. (2007) The Association between Gastro-Oesophageal Reflux Disease and Asthma: A Systematic Review. Gut, 56, 1654-1664. https://doi.org/10.1136/gut.2007.122465
[16]
Zhu, J.C., Becerril, G., Marasovic, K., Ing, A.J. and Falk, G.L. (2011) Laparoscopic Repair of Large Hiatal Hernia: Impact on Dyspnoea. Surgical Endoscopy, 25, 3620- 3626. https://doi.org/10.1007/s00464-011-1768-0
Chau, A.M.T., Ma, R.W.L and Gold, D. (2011) Massive Hiatus Hernia Presenting as Acute Chest Pain. Internal Medicine Journal, 41, 704-705. https://doi.org/10.1111/j.1445-5994.2011.02551.x
[19]
Milito, P., Lombardi, M., Asti, E., Bonitta, G., Fina, D., Bandera, F., et al. (2018) Influence of Large Hiatus Hernia on Cardiac Volumes. A Prospective Observational Cohort Study by Cardiovascular Magnetic Resonance. International Journal of Cardiology, 268, 241-244. https://doi.org/10.1016/j.ijcard.2018.05.016
[20]
Lim, H.S., Leong, D.P. and Alasady, M. (2013) Massive Hiatus Hernia Mimicking a Left Atrial Mass. Heart, Lung and Circulation, 22, 875-876. https://doi.org/10.1016/j.hlc.2013.01.001
[21]
Sahin, C., Akin, F., Cullu, N., Ozseker, B., Kirli, I. and Altun, I. (2015) A Large Intra-Abdominal Hiatal Hernia as a Rare Cause of Dyspnea. Case Reports in Cardiology, 2015, Article ID: 546395. https://doi.org/10.1155/2015/546395
[22]
Naoum, C., Falk, G.L., Ng, A.C.C., et al. (2011) Left Atrial Compression and the Mechanism of Exercise Impairment in Patients with a Large Hiatal Hernia. Journal of the American College of Cardiology, 58, 1624-1634. https://doi.org/10.1016/j.jacc.2011.07.013
[23]
Raza, S.T., Mukherjee, S.K., Danias, P.G., et al. (1995) Hemodynamically Significant Extrinsic Left Atrial Compression by Gastric Structures in the Mediastinum. Annals of Internal Medicine, 123, 114-116. https://doi.org/10.7326/0003-4819-123-2-199507150-00006
[24]
Devbhandari, M.P., Khan, M.A. and Hooper, T.L. (2007) Cardiac Compression Following Cardiac Surgery Due to Unrecognised Hiatus Hernia. The European Journal of Cardio-Thoracic Surgery, 32, 813-815. https://doi.org/10.1016/j.ejcts.2007.08.002
[25]
Neumann, L., Poulton, B. and Ridley, S. (1999) Life-Threatening Complications of Hiatus hernia. Anaesthesia, 54, 93-94. https://doi.org/10.1046/j.1365-2044.1999.0759o.x
[26]
Oishi, Y., Ishimoto, T., Nagase, N., et al. (2004) Syncope upon Swallowing Caused by an Esophageal Hiatal Hernia Compressing the Left Atrium: A Case Report. Echocardiography, 21, 61-64. https://doi.org/10.1111/j.0742-2822.2004.03005.x
[27]
Maekawa, T., Suematsu, M., Shimada, T. and Go, M. (2002) Unusual Swallow Syncope Caused by Huge Hiatal Hernia. Internal Medicine, 41,199-201. https://doi.org/10.2169/internalmedicine.41.199
[28]
Park, S.M., Shim, C.Y., Choi, D., et al. (2010) Coronary Sinus Obstruction by Primary Cardiac Lymphoma as a Cause of Dyspnea Due to Significant Diastolic Dysfunction and Elevated Filling Pressures. Journal of the American Society of Echocardiography, 23, 682. https://doi.org/10.1016/j.echo.2009.10.008
[29]
Miura, T., Hiramatsu, T., Forbess, J.M. and Mayer, J.E.J. (1995) Effects of Elevated Coronary Sinus Pressure on Coronary Blood Flow and Left Ventricular Function: Implications after the Fontan Operation. Circulation, 92, II298-II303. https://doi.org/10.1161/01.CIR.92.9.298
[30]
Gaasch, W.H., Bing, O.H., Franklin, A., Ng, A.C.C., Lu, T., Ridley, L., et al. (1978) The Influence of Acute Alterations in Coronary Blood Flow on Left Ventricular Diastolic Compliance and Wall Thickness. European Journal of Cardiology, 7, 147-161.
[31]
Vogel, W.M., Apstein, C.S., Briggs, L.L., Gaasch, W.H. and Ahn, J. (1982) Acute Alterations in Left Ventricular Diastolic Chamber Stiffness: Role of the “Erectile” Effect of Coronary Arterial Pressure and Flow in Normal and Damaged Hearts. Circulation Research, 51, 465-478. https://doi.org/10.1161/01.RES.51.4.465
[32]
Marwick, T.H. (2011) When the Stomach Rules the Heart: Dyspnea as a Neglected Complication of a Large Hiatal Hernia. Journal of the American College of Cardiology, 58, 1635-1636. https://doi.org/10.1016/j.jacc.2011.07.011
[33]
Asti, E., Bonavina, L., Lombardi, M., Bandera, F., Secchi, F. and Guazzic, M. (2015) Reversibility of Cardiopulmonary Impairment after Laparoscopic Repair of Large Hiatal Hernia. International Journal of Surgery Case Reports, 14, 33-35. https://doi.org/10.1016/j.ijscr.2015.07.005
[34]
Stavi, D., Sztarkier, I., Chudakov, G. and Kalchiem-Dekel, O. (2014) Ascites Worsening Due to a Large Hiatal Hernia Compressing Hepatic Venous Outflow: A Case Report. Journal of Medical Cases, 5, 573-575. https://doi.org/10.14740/jmc1559w
[35]
Roy, R.R., Sagar, S., Bunch, T.J., Aman, W., Daniel, J., Crusan, D.J., Srivathsan K., Asir- vatham, S.J., Shen, W.K. and Jahangir, A. (2013) Hiatal Hernia Is Associated with an Increased Prevalence of Atrial Fibrillation in Young Patients. Journal of Atrial Fibrillation, 6, 11-15.
[36]
Weston, A.P. (1996) Hiatal Hernia with Cameron Ulcers and Erosions. Gastrointestinal Endoscopy Clinics of North America, 6, 671-679. https://doi.org/10.1016/S1052-5157(18)30334-9
[37]
Maganty, K. and Smith, R.L. (2008) Cameron Lesions: Unusual Cause of Gastrointestinal Bleeding and Anemia. Digestion, 77, 214-217. https://doi.org/10.1159/000144281
[38]
Haurani, C., Carlin, A.M., Hammoud, Z.T. and Velanovich, V. (2012) Prevalence and Resolution of Anemia with Paraesophageal Hernia Repair. Journal of Gastrointestinal Surgery, 16, 1817-1820. https://doi.org/10.1007/s11605-012-1967-6
[39]
Pauwelyn, K.A. and Verhamme, M. (2005) Large Hiatal Hernia and Iron Deficiency Anemia: Clinico-Endoscopical Findings. Acta Clinica Belgica, 60,166-172. https://doi.org/10.1179/acb.2005.030
[40]
Hayden, J.D. and Jamieson, G.G. (2005) Effect on Iron Deficiency Anemia of Laparoscopic Repair of Large Paraesophageal Hernias. Diseases of the Esophagus, 18, 329- 331. https://doi.org/10.1111/j.1442-2050.2005.00508.x
[41]
Bonrath, E.M. and Grantcharov, T.P. (2015) Contemporary Management of Paraeso- phaegeal Hernias: Establishing a European Expert Consensus. Surgical Endoscopy, 29, 2180-2195. https://doi.org/10.1007/s00464-014-3918-7
[42]
Linke, G.R., Borovicka, J., Schneider, P., Zerz, A., Warschkow, R., Lange, J. and Müller- Stich, B.P. (2008) Is a Barium Swallow Complementary to Endoscopy Essential in the Preoperative Assessment of Laparoscopic Antireflux and Hiatal Hernia surgery? Surgical Endoscopy, 22, 96-100. https://doi.org/10.1007/s00464-007-9379-5
[43]
Sfara, A. and Dumitrascu, D.L. (2019) The Management of Hiatal Hernia: An Update on Diagnosis and Treatment. Medicine and Pharmacy Reports, 92, 321-325. https://doi.org/10.15386/mpr-1323
[44]
Wolf, P.S. and Oelschlager, B.K. (2007) Laparoscopic Paraesophageal Hernia Repair. Advances in Surgery, 41, 199-210. https://doi.org/10.1016/j.yasu.2007.05.013
[45]
Fuller, C.B., Hagen, J.A., DeMeester, T.R., Peters, J.H., Ritter, M. and Bremmer, C.G. (1996) The Role of Fundoplication in the Treatment of Type II Paraesophageal Hernia. The Journal of Thoracic and Cardiovascular Surgery, 111, 655-661. https://doi.org/10.1016/S0022-5223(96)70319-7
[46]
Gharagozloo, F. (2021) Laparoscopic Modified Fundoplasty (Gastroesophageal Valvulo- plasty) for Relief of Gastroesophageal Reflux Disease: Review of Technique and Results. Gastroenterology Medicine & Research, 6, 488-493. https://doi.org/10.31031/GMR.2021.06.000627
[47]
Gharagozloo, F., Atiquzzaman, B., Tempesta, B., Tolboom, R.C., Meyer, M. and Gruess- ner, S. (2019) Long Term Results of Robotic Modified Belsey (Gastroesophageal Val- vuloplasty) Fundoplication. Surgical Technology International, 34, 121-127.
[48]
Perdikis, G., Hinder, R.A., Filipi, C.J., Walenz, T., McBride, P.J., Smith, S.L., et al. (1997) Laparoscopic Paraesophageal Hernia Repair. The Archives of Surgery, 132, 586-589. https://doi.org/10.1001/archsurg.1997.01430300028005
[49]
El Khoury, R., Ramirez, M., Hungness, E.S., Soper, N.J. and Patti, M.G. (2015) Symptom Relief after Laparoscopic Paraesophageal Hernia Repair without Mesh. Journal of Gastrointestinal Surgery, 19, 1938-1942. https://doi.org/10.1007/s11605-015-2904-2
[50]
Lebenthal, A., Waterford, S.D. and Fisichella, P.M. (2015) Treatment and Controversies in Paraesophageal Hernia Repair. Frontiers in Surgery, 2, Article 13. https://doi.org/10.3389/fsurg.2015.00013
[51]
Horgan, S., Eubanks, T.R., Jacobsen, G., Omelanczuk, P. and Pelligrini, C.A. (1999) Repair of Paraesophageal Hernias. The American Journal of Surgery, 177, 354-358. https://doi.org/10.1016/S0002-9610(99)00061-6
[52]
Floch, N.R. (1999) Paraesophageal Hernias: Current Concepts. Journal of Clinical Gastroenterology, 29, 6-7. https://doi.org/10.1097/00004836-199907000-00004
[53]
Oelschlager, B.K., Yamamoto, K., Woltman, T. and Pelligrini, C.A. (2008) Vagotomy during Hiatal Hernia Repair: A Benign Esophageal Lengthening Procedure. Journal of Gastrointestinal Surgery, 12, 1155-1162. https://doi.org/10.1007/s11605-008-0520-0
[54]
Horvath, K.D., Swanstrom, L.L. and Jobe, B.A. (2000) The Short Esophagus: Pathophysiology, Incidence, Presentation, and Treatment in the era of Laparoscopic Antire- flux Surgery. Annals of Surgery, 232, 630-640. https://doi.org/10.1097/00000658-200011000-00003
[55]
Stylopoulos, N., Gazelle, G.S. and Rattner, D.W (2002) Paraesophageal Hernias: Operation or Observation? Annals of Surgery, 236, 492-501. https://doi.org/10.1097/00000658-200210000-00012
[56]
Morrow, E.H., Chen, J., Patel, R., Bellows, B., Nirula, R., Glasgow, R. and Nelson, R.E. (2018) Watchful Waiting Versus Elective Repair for Asymptomatic and Minimally Symptomatic Paraesophageal Hernias: A Cost-Effectiveness Analysis. The Ameri- can Journal of Surgical Pathology, 216, 760-763. https://doi.org/10.1016/j.amjsurg.2018.07.037
[57]
Carrott, P.W., Hong, J., Kuppusamy, M., Koehler, R.P. and Low, D.E. (2012) Clinical Ramifications of Giant Paraesophageal Hernias Are Underappreciated Making the Case for Routine Surgical Repair. Annals of Thoracic Surgery, 94, 421-122. https://doi.org/10.1016/j.athoracsur.2012.04.058
[58]
Hong, J., Kuppusamy, M., Kirtland, S., Koehler, R.P. and Low, D.E. (2012) Repair of Giant Paraesophageal Hernias Routinely Produces Improvement in Respiratory Function. The Journal of Thoracic and Cardiovascular Surgery, 143, 398-404. https://doi.org/10.1016/j.jtcvs.2011.10.025
[59]
Fullum, T.M., Oyetunji, T.A., Ortega, G., et al. (2013) Open Versus Laparoscopic Hiatal Hernia Repair. Journal of the Society of Laparoendoscopic Surgeons, 17, 23-29. https://doi.org/10.4293/108680812X13517013316951
[60]
Zehetner, J., Demeester, S.R., Ayazi, S., Kilday, P., Augustin, F., Hagen, J.A., et al. (2011) Laparoscopic versus Open Repair of Paraesophageal Hernia: The Second De- cade. Journal of the American College of Surgeons, 212, 813-820. https://doi.org/10.1016/j.jamcollsurg.2011.01.060
[61]
Chen, S.W., Brody, F., Lee, K.B., Walters, J. and Randall, J.A. (2021) Outcomes of Paraesophageal Hernia Repair: Analysis of the Veterans Affairs Surgical Quality Improvement Program Database. Journal of Gastrointestinal Surgery, 25, 593-602. https://doi.org/10.1007/s11605-020-04650-2
[62]
Seetharamaiah, R., Romero, R.J., Kosanovic, R., Gallas, M., Verdeja, J.C., Rabaza, J., et al. (2013) Robotic Repair of Giant Paraesophageal Hernia. Journal of the Society of Laparoendoscopic Surgeons, 17, 570-577. https://doi.org/10.4293/108680813X13654754534594
[63]
Tam, V., Winger, D.G. and Nason, K.S. (2016) A Systematic Review and Meta-Ana- lysis of Mesh vs Suture Cruroplasty in Laparoscopic Large Hiatal Hernia Repair. The American Journal of Surgical Pathology, 211, 226-238. https://doi.org/10.1016/j.amjsurg.2015.07.007
[64]
Watson, D.I., Thompson, S.K., Devitt, P.G., et al. (2015) Laparoscopic Repair of Very Large Hiatus Hernia with Sutures versus Absorbable Mesh versus Nonabsorbable Mesh: A Randomized Controlled Trial. Annals of Surgery, 261, 282-289. https://doi.org/10.1097/SLA.0000000000000842
[65]
Wilson, L.J., Ma, W. and Hirschowitz, B.I. (1999) Association of Obesity with Hiatal hernia and Esophagitis. The American Journal of Gastroenterology, 94, 2840-2844. https://doi.org/10.1111/j.1572-0241.1999.01426.x
[66]
Luketich, J.D., Nason, K.S., Christie, N.A., Pennathur, A., Jobe, B.A., Landreneau, RJ, et al. (2010) Outcomes after a Decade of Laparoscopic Giant Paraesophageal Hernia Repair. The Journal of Thoracic and Cardiovascular Surgery, 139, 395-404. https://doi.org/10.1016/j.jtcvs.2009.10.005
[67]
Anvari, M., Allen, C., Marshall, J., Armstrong, D., Goeree, R., Ungar, W. and Goldsmith, C. (2006) Randomized Controlled Trial of Laparoscopic Nissen Fundoplication versus Proton Pump Inhibitors for Treatment of Patients with Chronic Gastroeso- phageal Reflux Disease: One-Year Follow-Up. Surgical Innovation, 13, 238-249. https://doi.org/10.1177/1553350606296389
[68]
Merchant, A.M., Cook, M.W., Srinivasan, J., Davis, S.S., Sweeney, J.F. and Lin, E. (2009) Comparison between Laparoscopic Paraesophageal Hernia Repair with Sleeve Gastrec- tomy and Paraesophageal Hernia Repair Alone in morbidly Obese Patients. The American Surgeon, 75, 620-625. https://doi.org/10.1177/000313480907500716
