Hernia de hiato: little known, but very common

The hiatus hernia involves the passage of elements of the abdominal cavity, especially the stomach, through the esophageal hiatus in the mediastinum. It is a relatively frequent situation and its incidence increases with age and with weight gain. The presence of important deviations of the vertebral column, especially kyphosis and scoliosis, also favor its appearance. The history of major trauma (such as traffic accidents or falls from high altitude) may favor its presentation, as well as the complications of previous surgery in this area (gastro-oesophageal reflux operations or gastric resections).

Hiatus hernia is quite common and in many cases is not accompanied by any symptoms and is only a fortuitous finding. The importance lies in the presentation of symptoms, and the most common are those derived from gastroesophageal reflux.

The four types of hiatal hernia

The most commonly accepted classification of hiatal hernias establishes four different types: 

1. Type I or hiatal hernia by slip : it implies a widening of the hiatus muscle, as well as an increase of laxity of the brainsophageal membrane (that normally maintains these structures in their normal position), which allows the herniation of a part of the high portion from the stomach to the thorax (in the mediastinum). This is the most common type of hiatal hernia and its importance comes from its frequent association with reflux disease. It is also the most difficult type to define objectively and the major focus of controversy in its diagnosis. 
2. Types II, III and IV or less common types of hiatal hernia: All of them are varieties of what are called " paraesophageal hernias " and suppose all hiatal hernias. Although these three types may be associated with gastroesophageal reflux, its greater clinical importance lies in the potential risk of mechanical complications. 

• In type II there is a localized defect that causes herniation of the upper part of the stomach (fundus) while the gastro-esophageal junction remains in its anatomic position. 
• The type III hernia has elements of type I and II, the progressive passage of the stomach through the hiatus displaces the esophagus-gastric junction above the diaphragm. 
• In type IV there is a major defect that allows the passage of the stomach and other organs (such as the colon, spleen, pancreas, small intestine) into the hernia sac in the mediastinum.

Symptoms of hiatal hernia

Hiatal hernia may be accompanied by the presence of gastroesophageal reflux (GERD) , and this may be a chronic digestive tract disease in which the lower esophageal sphincter (SLE) barrier function fails and allows the gastric juice to flow back into of the esophagus causing symptoms and even anatomical lesions.

The typical symptoms of GERD are heartburn, heartburn and regurgitation. And all this can lead to significant complications such as erosive esophagitis, Barrett's esophagus and even adenocarcinoma.

GERD is prevalent in a slight percentage population of Western countries, and can have a profound impact on the quality of life of these patients.

How is a hiatal hernia diagnosed?

Diagnosis of the most common type I sliding hiatus hernia is simple by means of tests such as barium contrast radiographic examination, endoscopy, and manometry, provided the size of the hernia is of, at least 2 cm. Smaller hernias are diagnosed more accurately by means of high resolution manometry.

For the diagnosis of pathological gastro esophageal reflux, the standard tests are endoscopy, radiographic contrast study, and PHmetry.

Surgical treatments and techniques, risks, care and outcomes in hiatal hernia

Initial reflux treatment (GERD) is performed with oral administration of proton pump inhibitors (PPIs) and is generally effective, although some of these patients are not fully satisfied with this treatment and it is considered that almost half do not respond to it or have an incomplete response to this treatment. While these medications may cure esophagitis and control reflux-related symptoms, they are less effective for those with non-esophageal symptoms and those with regurgitant symptoms. These cases may require higher doses of PPIs and other medications. Potential side effects of long-term PPI treatment are increased risk of bone fractures, infectious complications, interference with antiplatelet medication, and absorption of vitamins and minerals (calcium, magnesium, iron, B 12).

Cases that do not respond adequately to PPI, in which this treatment can not or should be used, or that prefer another type of treatment will be the subsidiaries of the surgical treatment, that is to say the anti-reflux surgery, commonly called fundoplication. Today, this surgery, mostly performed by laparoscopy, in cases operated by surgeons experienced in this technique has excellent long-term results, is the first alternative to treatment with PPI, and the rate of complications related to it is minimal. It is a treatment with very good results and perfectly consolidated by the experience accumulated over the years. Although it can present at times collateral symptoms usually passengers and that consist of flatulence, difficulty to burp or to vomit, diarrhea, and sensation of dysphagia (difficulty in swallowing). These side effects are common to all treatments involving the performance of an effective funduplication, be it the fundoplication by the conventional open route, the laparoscopic route, or with other more recent procedures that are currently evaluated. After surgery, the patient should follow simple dietary measures consisting mainly of making frequent and non-copious food intakes, avoiding gas drinks and belching attempts, as well as important physical efforts. Progressively the organism adapts to the new situation and the quality of life is usually excellent.

With laparoscopic funduplication and a surgeon expert in this subject, the results are very good in the long term, with an index of absence of reflux and good quality of life at 10 years.

New treatment alternatives for hiatal hernia

As alternatives to funduplicaura in recent years other procedures have been developed: 

• TIF (EsophyX), an orally endoscopic procedure with an instrument to perform a mechanical repair of the hernia and reflux defect. 
• LINX System which involves the laparoscopic placement of a magnetic ring at the level of the esophagogastric junction. 
• MUSEtm (Medigus Ultrasonic Surgical Endostapler) consisting of anterior fundoplication by oral endoscopy with a flexible instrument using an endo-stapler and ultrasound 
• Stretta that uses radiofrequency therapy to reduce reflux by causing a contraction or increase in the function of the lower esophageal sphincter. 

All these procedures need sufficient time to be accurately evaluated in terms of their effectiveness and the maintenance over time of their effects.

However, the overall impression is that they may be effective in patients with a non-significant reflux disease grade, complicated reflux, and small-sized hiatal hernia.

A different problem is the surgical treatment of large hiatal hernias in which part or all of the stomach ascends to the mediastinum and in which reflux is not usually the predominant symptom but rather the ones derived from the occupation of part of the mediastinum and the possible volvulation or torsion of the herniated stomach on its axis. In these cases, the surgical intervention aims to restore the stomach to its anatomical situation and prevent the hernia from recurring. This surgery has a significantly greater hernia recurrence rate than reflux surgery with fundoplication. It can be performed by conventional open or laparoscopic route. To date, it seems that the use of the laparoscopic route and biological reinforcement mesh provides the best results in terms of the frequency of postoperative complications and the lower incidence of recurrences and complications in the long term.

For more information, consult a specialist in General Surgery .