A hiatal hernia occurs when a portion of the stomach pushes upward through the diaphragm, the muscular sheet separating the chest and abdomen. Most are sliding hiatal hernias, which typically cause symptoms like heartburn due to acid reflux. The paraesophageal hernia (PEH) is a specific and far less common variation. PEH is considered a more serious medical concern compared to the sliding variety because the unique way the stomach herniates creates a potential for acute, life-threatening complications.
Defining the Paraesophageal Hernia
Hiatal hernias are categorized into four types based on the portion of the stomach that moves into the chest cavity. Type I, the sliding hernia, is the most prevalent form, where the gastroesophageal junction (GEJ) and the upper stomach slide through the diaphragm opening. Types II, III, and IV are collectively classified as paraesophageal hernias (PEH).
The Type II PEH involves the fundus, the upper part of the stomach, rolling up into the chest cavity alongside the esophagus. A key distinction from the sliding type is that the GEJ, the connection point between the esophagus and the stomach, remains in its fixed, normal position within the abdomen. This arrangement gives the hernia its name, meaning “beside the esophagus.”
Type III hernias combine both the upward displacement of the GEJ and the herniation of the stomach fundus into the chest. Type IV hernias are the most complex, involving a large defect in the diaphragm that allows the stomach and other abdominal organs, such as the colon or spleen, to enter the chest cavity. All PEH types share a potential for mechanical complications because the stomach becomes trapped and contorted.
PEH is further differentiated from the sliding type by the existence of a peritoneal sac (a true hernia sac). This sac allows the stomach to be trapped in the chest, where it is subjected to compression and twisting. Since the stomach rolls into a confined space, the risk of serious mechanical issues is elevated compared to the movement seen in a sliding hernia.
The Primary Risks: Why PEH is Serious
The seriousness of a paraesophageal hernia lies in its potential to cause acute, life-threatening events requiring immediate surgical intervention. While a sliding hernia primarily causes chronic acid reflux, the danger in PEH is the mechanical trapping and damage to the stomach tissue. Elective repair is often recommended for symptomatic patients and those with high-risk anatomy to mitigate this risk.
One immediate concern is incarceration, which occurs when the stomach tissue trapped in the chest cavity becomes tightly wedged and cannot be easily pushed back down. Incarceration can lead to gastric obstruction, preventing the passage of food or fluid into the digestive tract. This blockage causes severe pain, vomiting, and a rapid decline in the patient’s condition.
The most feared complication is gastric volvulus, the abnormal rotation or twisting of the stomach on its axis. This twisting can happen in two ways: organoaxial (rotation along the long axis) or mesenteroaxial (rotation along the short axis). A sudden, complete twist can abruptly cut off the blood supply to the stomach, creating a surgical emergency.
The loss of blood flow, known as ischemia, quickly leads to tissue death, or necrosis, in the affected stomach wall. This condition is termed strangulation and is associated with a high mortality rate if not promptly addressed. If necrotic tissue is not removed, it can progress to perforation, spilling stomach contents and bacteria into the chest cavity and causing life-threatening sepsis.
Patients experiencing acute complications often present with severe, sudden symptoms demanding immediate medical attention. These symptoms include the classic Borchardt’s triad: sudden, severe pain in the chest or upper abdomen, an inability to vomit despite retching, and difficulty passing a tube into the stomach. These warning signs indicate the trapped stomach may be twisting or losing its blood supply, necessitating an emergency operation.
The mortality rate for patients requiring emergency surgery for complications like strangulation and perforation is significantly higher than for those undergoing planned, elective repair. This difference drives the recommendation for surgical correction in symptomatic patients. Elective repair allows for a controlled environment and a safer recovery, mitigating the risk of a fatal complication.
Managing PEH: Treatment and Monitoring
The clinical approach to PEH differs substantially from the conservative management of a Type I sliding hernia. While Type I hernias are managed with medication and lifestyle changes to control reflux, PEH often requires a more definitive intervention. The decision to proceed with surgery is based on the patient’s symptoms and overall health status.
For asymptomatic patients or those with co-existing medical conditions that make surgery risky, a strategy of watchful waiting may be employed. However, for symptomatic patients or those with a very large herniation, surgical repair is generally recommended to prevent acute, life-threatening complications. The operation’s goal is to restore the normal anatomy of the upper gastrointestinal tract.
The standard procedure is typically performed using a minimally invasive laparoscopic approach (keyhole surgery). Through small incisions, the surgeon first pulls the herniated portion of the stomach back into the abdominal cavity (reduction). The hernia sac, the thin lining of tissue that contained the stomach, is usually removed to prevent recurrence.
Following reduction, the surgeon addresses the widened opening in the diaphragm, known as the crural defect or hiatus. The enlarged opening is closed by bringing the diaphragm muscle edges together with sutures (crural repair). Sometimes, biological or synthetic mesh is used to reinforce this repair, especially in cases of large or recurrent hernias.
The final step involves an anti-reflux procedure, most commonly a fundoplication, where the upper part of the stomach is wrapped around the lower esophagus. This wrap creates a new valve to prevent acid reflux and helps anchor the stomach below the diaphragm. Successful management provides symptomatic relief and significantly reduces the lifetime risk of acute incarceration, volvulus, and strangulation.