ABCD: Arquivos Brasileiros de Cirurgia Digestiva (Feb 2024)

BRAZILIAN HERNIA AND ABDOMINAL WALL SOCIETY STATEMENT ON LARGE HIATAL HERNIAS MANAGEMENT

  • André BRANDALISE,
  • Fernando Augusto Mardiros HERBELLA,
  • Renato Abrantes LUNA,
  • Sergio SZACHNOWICZ,
  • Rubens Antonio Aissar SALLUM,
  • Carlos Eduardo DOMENE,
  • Paula VOLPE,
  • Leandro Totti CAVAZZOLLA,
  • Marcelo Lopes FURTADO,
  • Christiano Marlo Paggi CLAUS,
  • José Francisco de Mattos FARAH,
  • Eduardo CREMA

DOI
https://doi.org/10.1590/0102-672020230069e1787
Journal volume & issue
Vol. 36

Abstract

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ABSTRACT Large hiatal hernias, besides being more prevalent in the elderly, have a different clinical presentation: less reflux, more mechanical symptoms, and a greater possibility of acute, life-threatening complications such as gastric volvulus, ischemia, and visceral mediastinal perforation. Thus, surgical indications are distinct from gastroesophageal reflux disease-related sliding hiatal hernias. Heartburn tends to be less intense, while symptoms of chest pain, cough, discomfort, and tiredness are reported more frequently. Complaints of vomiting and dysphagia may suggest the presence of associated gastric volvulus. Signs of iron deficiency and anemia are found. Surgical indication is still controversial and was previously based on high mortality reported in emergency surgeries for gastric volvulus. Postoperative mortality is especially related to three factors: body mass index above 35, age over 70 years, and the presence of comorbidities. Minimally invasive elective surgery should be offered to symptomatic individuals with good or reasonable performance status, regardless of age group. In asymptomatic and oligosymptomatic patients, besides obviously identifying the patient’s desire, a case-by-case analysis of surgical risk factors such as age, obesity, and comorbidities should be taken into consideration. Attention should also be paid to situations with greater technical difficulty and risks of acute migration due to increased abdominal pressure (abdominoplasty, manual labor, spastic diseases). Technical alternatives such as partial fundoplication and anterior gastropexy can be considered. We emphasize the importance of performing surgical procedures in cases of large hiatal hernias in high-volume centers, with experienced surgeons.

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