Paraesophageal hernia

The diaphragm is the muscular sheet that separates the chest from the abdomen. The esophagus has to get from one to the other, and it does so through an opening called the hiatus, formed by the muscular fibers of the diaphragm itself. Around that opening is a thin ligament, the phrenoesophageal ligament, which tethers the esophagus and the top of the stomach in position.

A hiatal hernia is what happens when that opening widens and that tether stretches, allowing part of the stomach to migrate up into the chest.

Not all of these are the same thing, and the distinction matters more than most patients realize.

The four types

Type I, the sliding hernia, is by far the most common and is what most people mean when they say “hiatal hernia.” The gastroesophageal junction, the point where the esophagus meets the stomach, slides upward through the hiatus along with the top of the stomach. The relevance of a Type I hernia is mostly reflux, because the anti-reflux mechanism at that junction depends on it sitting below the diaphragm. Most Type I hernias are managed medically, and surgery is considered based on reflux disease, not on the hernia itself.

Type II is the true paraesophageal hernia, and it is genuinely uncommon. Here the gastroesophageal junction stays anchored where it belongs, and the top of the stomach, the fundus, herniates up alongside the esophagus. The name means exactly that: beside the esophagus.

Type III is a combination of the two, with both the junction and a large portion of the stomach in the chest. Despite Type II having the name, Type III is the most common of the true paraesophageal hernias by a wide margin, so if you have been told you have a paraesophageal hernia, this is most likely what you have.

Type IV means something other than stomach has joined it in the chest — colon, small intestine, spleen, or pancreas. These are large hernias by definition.

What does it feel like?

Some people have no symptoms at all and find out incidentally on a chest x-ray or CT done for something else.

When there are symptoms, they are often not the ones people expect. Reflux may be minimal or absent, especially in a Type II. What patients more often describe is chest or upper abdominal pressure after eating, filling up quickly on small meals, food feeling like it hangs up, and shortness of breath after meals because a stomach in the chest is occupying space the lung would like to use.

There is also a quieter presentation worth knowing about: iron deficiency anemia. Where a large hernia is squeezed by the diaphragm, chronic friction produces linear erosions in the stomach lining, called Cameron lesions, which ooze slowly. A significant number of large paraesophageal hernias are found during a workup for unexplained anemia.

The complication we are actually worried about

The stomach in the chest can rotate on itself. This is called a gastric volvulus, and it can twist either along its long axis or along the axis perpendicular to it. When it twists, it obstructs, and if it obstructs tightly enough, it strangulates and the stomach wall dies. That is a life-threatening emergency with a serious mortality rate.

The classic presentation, described by Borchardt more than a century ago and still accurate, is severe chest or upper abdominal pain, violent retching that produces nothing, and an inability to pass a nasogastric tube because the tube cannot get past the twist. If you have a known large hiatal hernia and you develop that combination, that is an emergency department visit, not a phone call in the morning.

Should an asymptomatic hernia be repaired?

Historically the answer was yes, on the theory that the risk of catastrophe justified pre-emptive surgery. That thinking has been revised. Decision analyses estimating the annual risk of an acute event in a truly asymptomatic large paraesophageal hernia put it around one percent per year, which in an older patient is comparable to or lower than the risk of the operation itself.

So watchful waiting is reasonable for a patient with no symptoms, particularly an elderly one, provided they understand the warning signs above. Symptoms change the calculation, and most patients who are told they have a large paraesophageal hernia turn out on careful questioning to have more symptoms than they had attributed to it.

What does the repair involve?

Almost always minimally invasive now, laparoscopic or robotic. The operation has several distinct steps, and skipping any of them is how repairs fail:

Reduce the stomach back into the abdomen. Excise the hernia sac, which is the peritoneal lining that came up with it. This step is tedious and is one of the more important predictors of durability. Mobilize the esophagus upward in the chest until there is at least two to three centimeters of it sitting comfortably below the diaphragm without tension, because a repair pulled downward under tension will pull apart. Close the crura, the muscular pillars of the hiatus, sometimes reinforced with mesh, though mesh at the hiatus is a genuinely debated topic and carries its own risks. Then usually a fundoplication, wrapping the top of the stomach around the lower esophagus, which both restores the anti-reflux mechanism and helps anchor the stomach below the diaphragm.

Occasionally, when years of scarring have left the esophagus genuinely too short to reach, a small tube of stomach is used to lengthen it, called a Collis gastroplasty.

Recovery, and an honest word about recurrence

The recovery is more about diet than about pain. You will progress from liquids through soft foods over several weeks, because swelling at the repair makes solid food difficult early. Carbonated drinks and anything that causes retching or vomiting are avoided, because a forceful retch is precisely the mechanism that disrupts a fresh repair. Antiemetics are prescribed generously for this reason. Heavy lifting is restricted for the same reason.

Now the part that is often underdiscussed: if you image these patients years later, radiographic recurrence rates for large paraesophageal hernia repair are high, reported in some series at up to half. That number frightens people out of proportion to its meaning. Most of those recurrences are small, asymptomatic, and never require anything. The rate of recurrence that actually requires a second operation is far lower, in the range of a few percent. But I would rather you hear that number from me before the operation than read it on the internet afterward.