A multiplicity of terms has been used over the years to describe paraesophageal hernia. These reflect the considerable confusion that persists to this day concerning its pathophysiology and treatment. Terms like up-side-down stomach, rolling hernia, intrathoracic stomach, parahiatal, and paraesophageal hernia have all been used to describe this clinical condition. Any herniation of the fundus and/or body of the stomach into the chest anterior or lateral to the esophagus is considered to be a paraesophageal hernia. Once considered an immediate indication for surgical repair, the role of surgery in this operation is changing and patients receive treatment appropriate to their complaints. Persistent symptoms, in particular, those related to the mechanical effects of paraesophageal hernia, eventually will result in an indication for surgery.
Pathophysiology and Classification
The common classification for paraesophageal hernia distinguishes four types (Table 46-1). The sliding type hiatal hernia (Type I) is the most common. It occurs when the gastroesophageal junction (GEJ), along with a leading portion of the gastric cardia, slides through the esophageal hiatus into the mediastinum. The sliding hernia may progress to a rolling hernia. As the muscles of the hiatus weaken, the hiatus becomes wider, causing an ever increasing portion of the stomach along with the GEJ to slip through the opening, until the entire greater curvature rolls into the posterior mediastinum (hence the name rolling hernia). A rolling hernia is therefore seen as a progression from a small sliding hernia to complete herniation of the greater curvature of the stomach. It is now generally accepted that most paraesophageal hernias begin as sliding hiatal hernias.
++ Table Graphic Jump Location Table 46-1Classification of Hiatal Hernia ||Download (.pdf) Table 46-1Classification of Hiatal Hernia
|I ||Sliding hernia |
|II ||True paraesophageal hernia with the GEJ in place intra-abdominally |
|III ||Organoaxial volvulus of the stomach into the mediastinum |
|IV ||Organoaxial volvulus of the stomach with migration of other abdominal viscera into the mediastinum |
In rare cases, the GEJ may remain in its normal intra-abdominal position. This is called the “true” paraesophageal hernia (Type II). Here a portion of the stomach and sometimes other parts of the abdominal viscera migrate into the mediastinum either through the esophageal hiatus or through an adjacent defect in the diaphragm.
Occasionally, the stomach may further migrate into the chest causing organoaxial volvulus, in which usually more than half the stomach lies in the mediastinum, a condition known as “giant” paraesophageal hernia (Type III). The lesser curvature remains in the abdomen, fixed by the gastrohepatic omentum and the left gastric vessels, which explains the asymmetric displacement of the stomach generally observed. With organoaxial volvulus, the fundus folds over anteriorly to the esophagus and toward the right side of the mediastinum.
Less frequently, if the defect becomes very large, colon together with omentum, spleen, and eventually small bowel may migrate ...