Hiatal hernia can it get bigger

As such, the authors conclude that cost of initial elective surgery justified the overall improvement in quality of life. One of the major reasons why the study differed so strikingly from the study was that mortality of elective PEH repair has continued to decrease. Thus, just as the sensitivity analysis in the original study predicted that changes in mortality could affect the results of the study, these new statistics altered the best decision course to again favor elective repair.

Given this evidence, it appeared that routine operative intervention for asymptomatic PEHs would again be recommended. However, an additional simulation study published by Jung et al. A Markov model was created based on data collected from a systematic review of studies on type 2 and 3 hiatal hernias. Researchers discovered a difference in QALE of 5 months favoring watchful waiting over elective hernia repair.

Eighty-four percent of their simulations showed a more favorable outcome if patients were initially assigned to watchful waiting. This effect did not change in a sensitivity analysis that increased the maximum age a patient could undergo surgery to 95 years. The same analysis also decreased the amount of years the patient was at risk for recurrence to 5 years and changed the type of closure method from mesh repair to suture only.

It is surprising that two studies with very similar methodology yielded such strikingly different outcomes. Although these studies are simulations and cannot account for every variable as in a randomized controlled trial, they used the same current body of literature and statistical methodology yet arrived at very different conclusions.

This appears to be due to differences in risk percentages used in the simulations. The Jung et al. In the study by Morrow et al. A lower emergency complication rate decreases the risk of needing emergency surgery, favoring watchful waiting.

There were also important differences in the proportion of patients who progressed to a symptomatic hernia 7. Finally, the Jung et al. All told, these studies highlight how interpretation of the literature and how changing the input data can dramatically affect the results of a Markov model. Even a sensitivity analysis will miss important differences unless every variable is examined.

Therefore, without level one evidence, it is difficult to confidently derive conclusions about watchful waiting versus routine repair of asymptomatic PEHs. As such, we agree with the SAGES guidelines that decision-making for the asymptomatic patient should be conducted on a case-by-case basis after discussion of the risks and benefits with the patient Despite the low modern rates of morbidity and mortality, surgical intervention is not without complications.

PEH surgery complications can include visceral injury, vagal nerve injury, pneumothorax, and mediastinal hemorrhage, among others When considering the routine repair of an asymptomatic hernia, it is important to identify important risk factors of the patient. This is both for optimization and for the informed consent discussion.

As was previously mentioned, Jassim et al. Lower rates of complication were significantly associated with female sex, elective and laparoscopic procedures Increasing age was also associated with an increased overall risk of complication and mortality following elective and non-elective PEH repair. Frailty and preoperative sepsis increased the odds of mortality.

The finding from Jassim et al. Management of the recurrent hiatal hernia is also important, given the high overall recurrence rates. Lidor et al. They noticed that those patients who had a return of their symptoms dysphagia, early satiety, bloating, postprandial chest pain and shortness of breath tended to have a recurrent hiatal hernia greater than 2 cm based on upper gastrointestinal barium contrast exam They advocated for repair of all symptomatic recurrent hernias greater than 2 cm.

Jones et al. Seventy-nine percent of these patients had upper GI studies post operatively to screen for radiologic recurrence. These studies were repeated annually until the patients were lost to follow-up. The resultant mean follow-up period was 25 months. The median size of recurrence during this follow-up was 4 cm.

There was no significant difference in post-operative symptoms between patients with or without radiological occurrence. White et al. Eighty percent of these recurrences were sliding hiatal hernias. The authors argue that despite the relatively high rate of recurrence of hernia overall, patients benefit symptomatically following PEH surgery, and that recurrences in the form of type I hiatal hernia do not put the patient at increased risk for volvulus Gangopadhyay et al.

Researchers found that older patients had a significantly higher ASA class, and required significantly longer post-operative length of stays. Older patients ultimately had similar long-term outcomes in terms of post-operative symptomology, recurrence and reoperation. These results suggest that older patients are more vulnerable in the perioperative period, but that they are likely to have similar long-term outcomes. Spaniolas et al.

Interestingly, Gupta et al. They compared outcomes between patients undergoing PEH repair and surgery for GERD to find that differences in mortality are better explained by perioperative pulmonary complications, venous thromboembolic events, and hemorrhage, then they are by age and comorbidities. They made the argument that greater focus should be spent on pulmonary optimization and prophylaxis for thromboembolic events.

El Lakis et al. They found that patients aged 80 years or older had more comorbidities, larger hernias, increased proportion of type IV PEH, and were more likely to present emergently The majority of complications were low grade and did contribute to a longer length of stay in this elderly population. Hernia recurrence was no different in this group compared with the rest of the population. Importantly, after adjustment for comorbidities, age was not a significant factor in predicting severe complications, readmission within 30 days, or early recurrence.

Staerkle et al. Similar studies have also been conducted with smaller cohorts and found similar results 49 , Because these studies have all found excellent or comparable outcomes associated with PEH repair in elderly patients, we believe that age in of itself is not a contraindication for elective surgery. Patients should be evaluated on a case by case basis with optimization of modifiable risk factors. With the innovative robotic-assisted technology at Genesis, incision sites measure less than an inch, compared to the inch long incision from the top to bottom of the abdomen before minimally invasive surgery.

Rothermel reported. A week later she came in for a follow-up, and I was thrilled to hear how her quality of life had improved. Today, Char enjoys a variety of foods.

Recently, she savored biscuits and gravy — a dish she never attempted with her hiatal hernia. Do yourself a favor, and take care of it before it causes an emergency.

Call the Center of Surgical Excellence at to learn more about the services available. Type I hernias, or sliding hiatal hernias, are the smallest and most common variety. These hernias cause your stomach to slide through a small opening in the diaphragm, and up into your chest. These often do not require an operation or treatment. These occur when a part of the stomach protrude into the chest adjacent to the esophagus. While these hernias are far less common, they can be more dangerous, since they cause more serious symptoms, and because the blood flow to your stomach can be compromised.

Those over the age of 50, pregnant women, and the obese are at higher risk. A hiatal hernia can also be triggered by insistent pressure on the hiatus muscles. Hiatal hernias, especially Type I hernias, do not usually cause symptoms.

These can include:. Along with a complete exam and detailed medical history, your surgeon may use one or more diagnostic tests to determine the best course of treatment.

If you have experienced trouble swallowing, this procedure can help to locate any areas in your esophagus that may have narrowed. Ventral hernias.

Ventral hernias occur in the abdomen and also exhibit a bulge and pain. These hernias are more common in people who are obese or have diabetes or chronic smoking habits, but being in good health reduces the chances of those complications. Learn more about vaccine availability.

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