The indications for surgery are controversial. Before the mid-1990s, the mere diagnosis of paraesophageal hiatal hernia was sufficient indication to operate. This was based on the belief that nonsurgical management would result in a 30% risk for acute gastric dilatation, perforation, strangulation, and hemorrhage.10,11 In one series of patients, adverse outcome occurred in as many as 50% of patients treated conservatively,12 and the resulting death rate was reportedly as high as 27%.10 The principle of repairing all paraesophageal hernias was challenged in 1993 by Allen and colleagues, who found that symptoms rarely worsened in 23 patients who were managed nonsurgically for a median of approximately 6½ years, and only 1 patient died from aspiration.1 Whether these findings were the result of improvements in medical management or of observational bias, it challenged the dogma of surgical repair. Moreover, despite the advanced age of most patients with hiatal hernia, improvements in intra- and postoperative management of thoracic surgery patients in the 1980s reduced the likelihood of postoperative death and complications, even after perforation.6 In 1999, without any data to support his claim, Floch stated in an editorial published in the Journal of Clinical Gastroenterology that acutely symptomatic patients should be treated electively with nasoenteric tube decompression and that the likelihood of catastrophic event was “no longer accurate.”2 This article has been quoted or misquoted by others as support for elective management as well. However, it does address the fact that even in cases of acute strangulation, without signs or symptoms of acute perforation, the patient can be decompressed and repaired electively rather than emergently. Further influencing the management of paraesophageal hernia, Stylopoulos and colleagues performed a thorough analysis of the prevailing literature as recently as 2003.3 Using a Markov Monte Carlo analytical model based on the assumption of complete reporting of all paraesophageal hernias and complications thereof, they identified 203 patients who underwent emergent surgical repair from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project. Among these patients, they identified an additional “watchful waiting” group based on six small reports in the literature, five of which were used for their analysis. From this evaluation, they concluded that the “watchful waiting” approach was safe for asymptomatic patients over 65 years of age. Unfortunately, Stylopoulos and colleagues failed to address potentially significant reporting bias because the true prevalence of paraesophageal hernia is unknown, and the risk factors for poor outcome and/or debility or increased cost of care have not been defined. Simply stated, our knowledge of the natural course of these patients is insufficient to support such conclusions, and currently, we lack an evidence-based approach. The elderly with little comorbidity may benefit from surgical repair, if operated early. Moreover, the morbidity associated with worsening herniation and the potential for repeated hospitalizations and cost of care may be reduced with surgical management as opposed to continued observation. Hence the latter analysis raises questions but is not sufficient to set a standard of care.