Meckler's Triad

http://www.ncbi.nlm.nih.gov/pubmed/20935623

Upper GI premalignant screening recommendations

American society of gastroenterologists recommendations:

http://www.guideline.gov/summary/summary.aspx?doc_id=9306


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Operative Repair of Hiatal Hernias

Laparoscopic hiatal hernia repair is now considered the standard of care despite the lack of level 1 evidence  to support its use.
Port placement: 
- 10mm umbo camera port
- 10 mm epigastric liver retraction port
- 5mm para-rectus operating ports
- 5mm R ant axill line fundal retraction port

- Description of procedure ...

Controversies:

- Fundoplication? Accepted for type 1 and 3 as they usually have significant reflux symptoms.  Less clear for type 2 .  Technically GE jxn is in abdomen - however, these patients may have subclinical symptoms of reflux.  In general, addition of reflux procedure well accepted because it helps anchor the stomach in the abdomen to prevent hernia recurrence and type 2 pts may have subclinical sx that are unmasked by repair of hernia.

- Use of mesh: not of proven benefit, however with advent of surgisis mesh, risks associated with non-absorbable mesh averted and generally used now.

Hiatal Hernia

Classification: 
- Type 1: Sliding hernia - Laxity of phrenoesophageal ligament allows GE jxn to slide into chest
- Type 2: paraesophageal hernia - fundus of the stomach slides above hiatus, but GE jxn remains in the abdomen
- Type 3: Combination - GE junction above the hiatus AND fundus/body herniated into the thorax
Type 4: advanced type 3 - same but with entire stomach or other organs herniated through hiatus
There is a distinction between the terms hiatal hernia and paraesophageal hernias - all of above are hiatal hernias, however, only type 2 and 3 hernias are truly para's

Presentation:
- true incidence of type 1 hernias unknown because many asymptomatic, type 2 and 3 are very rare (<1% of hiatal hernias are type 2/3)
- often times diagnosed incidentally during investigations for other reasons
- If symptoms are present, may include reflux or mechanical symptoms of esophageal obstruction - pain, fullness, dysphagia, bloating, respiratory sx)
- Anemia: results from chronic GI blood loss in 1/3 of pts.  Caused by linear ulcerations of the gastric cardia and resolves after repair.
- Borchardt's triad: chest pain, retching with inability to vomit and inability to pass NG.  Indicative of an incarcerated hiatal hernia.


Diagnosis:
- barium swallow
- pH, manometry: may be difficult to acquire and interpret due to changes in anatomy.  May not be very useful in type 2 and 3 hernias.
- EGD

Indications for OR:
- Type 1 hernias: leave asymptomatic pts alone.  Symptomatic patients should first have symptom-specific work-up and subsequently be considered for repair.
- Asymptomatic patients: asymptomatic para's historically thought to have 30% mortality rate.  However, more recent series suggest that ~80% of pts will remain asymptomatic.
- Symptomatic patients: all symptomatic patients should be reapired.  This includes patients with esophageal mucosal changes (esophagitis, Barrett's) or anemia.