Hiatal Hernia

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Practice Essentials

A hiatal hernia occurs when a portion of the stomach prolapses through the diaphragmatic esophageal hiatus. Most hiatal hernias are asymptomatic and are discovered incidentally, but rarely, a life-threatening complication may present acutely. The image below depicts a paraesophageal hiatal hernia.



View Image

Hiatal hernia. A paraesophageal hernia is seen on an upper gastrointestinal radiograph series. Note that the gastroesophageal (GE) junction remains be....

Signs and symptoms

Most people with hiatal hernias are asymptomatic. In a minority of individuals, hiatal hernias may predispose to reflux or worsen existing reflux.

Complications of hiatal hernia may include the following:

The physical examination usually is unhelpful. Certain conditions may predispose to the development of hiatal hernia, including the following:

Diaphragmatic hernias may be congenital or acquired. Acquired hiatal hernias are divided further into nontraumatic (more common) and traumatic hernias. Nontraumatically acquired hernias are divided yet further into 2 types: (1) sliding hiatal hernia and (2) paraesophageal hiatal hernia (a mixed variety is also possible).

See Presentation for more detail.

Diagnosis

The typical reason for evaluation is the presence of symptoms of gastroesophageal reflux disease (GERD) or a chest radiograph suggesting a paraesophageal hernia.

A barium upper gastrointestinal series may yield the following findings:

A barium study also helps distinguish a sliding from a paraesophageal hernia.

Upper GI endoscopy may be performed for the following purposes:

See Workup for more detail.

Management

When symptoms are due to GERD, treatment goals include the following:

In the majority of patients, these goals are achieved by means of a combination of the following:

If iron-deficiency anemia occurs, it usually responds well to proton-pump inhibitor (PPI) therapy.

Surgical treatment involves removing the hernia sac and closing the abnormally wide esophageal hiatus. It is necessary only in the very few patients who have complications of GERD despite aggressive PPI treatment. Potential surgical candidates include the following:

The 3 major types of surgical procedures that may be considered are as follows:

See Treatment and Medication for more detail.

Background

A hiatal hernia occurs when a portion of the stomach prolapses through the diaphragmatic esophageal hiatus. Although the existence of hiatal hernia has been described in earlier medical literature, it has come under scrutiny only in the last century or so because of its association with gastroesophageal reflux disease (GERD) and its complications. There is also an association between obesity and the presence of hiatal hernia. By far, most hiatal hernias are asymptomatic and are discovered incidentally. On rare occasion, a life-threatening complication, such as gastric volvulus or strangulation, may present acutely.

Pathophysiology

The esophagus passes through the diaphragmatic hiatus in the crural part of the diaphragm to reach the stomach. The diaphragmatic hiatus itself is approximately 2 cm in length and chiefly consists of musculotendinous slips of the right and left diaphragmatic crura arising from either side of the spine and passing around the esophagus before inserting into the central tendon of the diaphragm. The size of the hiatus is not fixed, but narrows whenever intra-abdominal pressure rises, such as when lifting weights or coughing.[1]

The lower esophageal sphincter (LES) is an area of smooth muscle approximately 2.5-4.5 cm in length. The upper part of the sphincter normally lies within the diaphragmatic hiatus, while the lower section normally is intra-abdominal. At this level, the visceral peritoneum and the phrenoesophageal ligament cover the esophagus. The phrenoesophageal ligament is a fibrous layer of connective tissue arising from the crura, and it maintains the LES within the abdominal cavity. The A-ring is an indentation sometimes seen on barium studies, and it marks the upper part of the LES. Just below this is a slightly dilated part of the esophagus, forming the vestibule. A second ring, the B-ring, may be seen just distal to the vestibule, and it approximates the Z-line or squamocolumnar junction. The presence of a B-ring confirms the diagnosis of a hiatal hernia. Occasionally, the B-ring also is called the Schatzki ring.

Any sudden increase in intra-abdominal pressure also acts on the portion of the LES below the diaphragm to increase the sphincter pressure. An acute angle, the angle of His, is formed between the cardia of the stomach and the distal esophagus and functions as a flap at the gastroesophageal junction and helps prevent reflux of gastric contents into the esophagus (see the image below).



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Hiatal hernia. Figure 1 shows the normal relationship of the gastroesophageal (GE) junction, stomach, esophagus, and diaphragm. Figure 2 shows a slidi....

The gastroesophageal junction acts as a barrier to prevent reflux of contents from the stomach into the esophagus by a combination of mechanisms forming the antireflux barrier. The components of this barrier include the diaphragmatic crura, the LES baseline pressure and intra-abdominal segment, and the angle of His. The presence of a hiatal hernia compromises this reflux barrier not only in terms of reduced LES pressure but also reduced esophageal acid clearance. Patients with hiatal hernias also have longer transient LES relaxation episodes particularly at night time. These factors increase the esophageal mucosa acid contact time predisposing to esophagitis and related complications.

Frequency

United States

Hiatal hernias are more common in Western countries. The frequency of hiatus hernia increases with age, from 10% in patients younger than 40 years to 70% in patients older than 70 years.

International

Burkitt et al suggest that the Western, fiber-depleted diet leads to a state of chronic constipation and straining during bowel movement, which could explain the higher incidence of this condition in Western countries.[2]

Mortality/Morbidity

Paraesophageal hernias generally tend to enlarge with time, and sometimes the entire stomach is found within the chest. The risk of these hernias becoming incarcerated, leading to strangulation or perforation, is approximately 5%. This complication is potentially lethal, and surgical intervention is necessary. Because of the high mortality associated with this condition, elective repair often is advised wherever a paraesophageal hernia is found.[3, 4]

Sihvo et al examined the mortality associated with adult paraesophageal hernia in a Finnish retrospective, population-based study.[3] Five hundred sixty-three patients received surgical intervention and 67 received conservative treatment for paraesophageal hernia. Death occurred in 32 patients, of whom 29 had concomitant diseases.

Of the 563 patients in the surgical group, the overall mortality was 2.7% (15 patients), of whom 3 died following elective repair.[3] Of the 67 patients in the conservative treatment group, 16.4% (11 patients) died; 13% (4 patients) of the deaths might have been avoided with elective surgical intervention. Of the 32 patients who died, over half had type III (16 patients; 50%) or type IV (9 patients; 28.1%) had hiatal hernias; 4 patients (12.5%) had had type II hiatal hernias, with the remaining 3 deceased having an unknown type. The causes of death were primarily from incarceration (24 patients; 75%), followed by surgical complications (6 patients; 18.8%) and bleeding ulcer (2 patients; 6.2%).[3]

Sihvo et al recommended of the paraesophageal hernia, at least in symptomatic patients, except for those at high surgical risk.[3]

In a Swiss study, Larusson et al investigated the predictive factors for postoperative morbidity and mortality in patients undergoing laparoscopic hernia repair.[4] Of 354 laparoscopic paraesophageal hernia repairs, age at 70 years or older was significantly associated with postoperative morbidity (24.4%) and mortality (2.4%) relative to those younger than 70 years (10.1% postoperative morbidity, P = 0.001; 0% mortality, P = 0.045). Similar age findings were noted with gastropexy but not with fundoplication.[4] In addition, high-risk patients had significantly higher morbidity but not mortality.

Larusson et al concluded that age, American Society of Anesthesiologists (ASA) score, and type of operation are significant predictive factors in patients undergoing laparoscopic paraesophageal hernia repair.[4] The investigators advised caution in balancing surgical indications with each patient's comorbidities, age, symptoms, and potentially life-threatening complications.[4]

Cardiac complications such as cardiac tamponade have been reported to occur following laparascopic Nissen repair of large hiatal hernia.[5]

Sex

Hiatal hernias are more common in women than in men. This might relate to the intra-abdominal forces exerted in pregnancy.

Age

Muscle weakening and loss of elasticity as people age is thought to predispose to hiatus hernia, based on the increasing prevalence in older people. With decreasing tissue elasticity, the gastric cardia may not return to its normal position below the diaphragmatic hiatus following a normal swallow. Loss of muscle tone around the diaphragmatic opening also may make it more patulous.

History

Hiatal hernias are relatively common and, in themselves, do not cause symptoms. For this reason, most people with hiatal hernias are asymptomatic. Hiatal hernias may predispose to reflux or worsen existing reflux in a minority of individuals. Physicians should resist the temptation to label hiatal hernia as a disease.

Patients can have reflux without a demonstrable hiatal hernia. When a hernia is present in a patient with symptomatic GERD, the hernia may worsen symptoms for several reasons, including the hiatal hernia acting as a fluid trap for gastric reflux and increasing the acid contact time in the esophagus. In addition, with a hiatal hernia, episodes of transient relaxation of the LES are more frequent and the length of the high-pressure zone is reduced. The main symptoms of a sliding hiatal hernia are those associated with reflux and its complications.

No clear correlation exists between the size of a hiatal hernia and the severity of the symptoms. A very large hiatal hernia may be present with no symptoms at all. Some complications are specific for a hiatal hernia.

Physical

The physical examination usually is unhelpful. Certain conditions predispose to the development of hiatus hernia. These include obesity, pregnancy, and ascites.

Causes

See the list below:

Laboratory Studies

The typical reasons for evaluation are symptoms of GERD or a chest radiograph suggesting a paraesophageal hernia.

Imaging Studies

Barium upper gastrointestinal series

Although a chest radiograph may reveal a large hiatal hernia (see the first image below), and many incidentally diagnosed hiatal hernias are discovered in this manner, a barium study of the esophagus helps establish the diagnosis with greater accuracy (see the second image below).



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Hiatal hernia. These anteroposterior (left) and lateral views (right) on a chest radiograph showing a large hiatal hernia. Courtesy of David Y Graham,....



View Image

Hiatal hernia. This barium study shows a sliding hiatal hernia: The gastric folds can be seen extending above the diaphragm. GE = gastroesophageal. C....

Typical findings include an outpouching of barium at the lower end of the esophagus, a wide hiatus through which gastric folds are seen in continuum with those in the stomach, and, occasionally, free reflux of barium.

A barium study helps distinguish a sliding from a paraesophageal hernia (see the images below).



View Image

Hiatal hernia. A paraesophageal hernia is seen on an upper gastrointestinal radiograph series. Note that the gastroesophageal (GE) junction remains be....



View Image

Hiatal hernia. A paraesophageal hernia is seen on a barium upper gastrointestinal radiograph series. The mucosal folds are seen going up into the ches....



View Image

Hiatal hernia. This image is a barium radiograph view of a large paraesophageal hernia. GE = gastroesophageal. Courtesy of David Y Graham, MD.

In rare cases, the entire stomach may herniate into the chest (see the image below).



View Image

Hiatal hernia. This barium radiograph shows a large paraesophageal hernia in which the entire stomach is seen in the chest cavity. Courtesy of David Y....

The stomach may then undergo volvulus (see the image below) and subsequent incarceration and strangulation.



View Image

Hiatal hernia. These barium studies show gastric volvulus as the herniated stomach undergoes rotation. This situation requires surgical intervention. ....

Procedures

Endoscopy

Hiatal hernia is diagnosed easily using upper gastrointestinal endoscopy.

The diagnosis of a hiatal hernia actually is incidental, and endoscopy is used to diagnose complications such as erosive esophagitis, ulcers in the hiatal hernia, Barrett esophagus, or tumor.

A hiatal hernia is confirmed when the endoscope is about to enter the stomach or on retrograde view once inside the stomach (see the image below). If any doubt remains, the patient may be asked to sniff through the nose, which causes the diaphragmatic crura to approximate, seen as a pinch, closing the lumen.



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Hiatal hernia. A retrograde view of a hiatal hernia seen at endoscopy shows the gastric folds to the left of the scope shaft extending up into the her....

Endoscopy also permits biopsy of any abnormal or suspicious area.

Esophageal manometry

Traditionally, esophageal manometry has had a low sensitivity for diagnosing hiatal hernia, as compared to endoscopy, and was therefore not appropriate in helping to establish a diagnosis.[6]

More recent studies with esophageal high-resolution manometry (HRM) appear to be more accurate for detecting hiatal hernias. In one study that evaluated the HRM recordings, endoscopy reports, and barium esophagograms of 90 patients, HRM had a 92% sensitivity and 95% specificity for identifying hiatal hernias compared with a 73% sensitivity each for endoscopy and radiography.[7]

Approach Considerations

In June 2013, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) issued guidelines for the diagnosis and management of hiatal hernia.[8, 9]

Strong recommendations include the following:

Weak recommendations for pediatric patients include the following:

Medical Care

When hiatal hernias are symptomatic, acid reflux usually produces the symptoms. If the hernia itself is causing chest discomfort or other symptoms, surgery may be necessary.

When symptoms are due to GERD, the goals of treatment include prevention of reflux of gastric contents, improved esophageal clearance, and reduction in acid production. This is achieved in the majority of patients by a combination of the following:

The treatment of GERD is beyond the scope of this article and is discussed in Gastroesophageal Reflux Disease.

Large hiatal hernias may cause iron deficiency anemia regardless of whether Cameron ulcers are present. This anemia responds well to PPI therapy with surgery offering no clear advantage over medical therapy.

Surgical Care

The goal of surgery is to remove the hernia sac and close the abnormally wide esophageal hiatus.

Surgery is necessary only in the minority of patients with complications of GERD despite aggressive treatment with proton pump inhibitors (PPIs). Because only a minority of patients with hiatal hernia have any problems, this represents a very small proportion of patients with sliding hiatal hernia; most patients with problems are managed medically.

By far, the majority of patients who would have undergone surgery in the past are managed successfully today with PPIs. However, young patients with severe or recurrent complications of GERD, such as strictures, ulcers, and bleeding, who cannot afford lifelong PPI treatment or would prefer to avoid taking medications long term, may be surgical candidates. Another group of patients who are surgical candidates are those with pulmonary complications, in particular, asthma, recurrent aspiration pneumonia, chronic cough, or hoarseness linked to reflux disease.

Most patients with a paraesophageal hernia remain asymptomatic. In this type of hernia, symptoms from acid reflux usually do not occur. Instead, the most common symptom is epigastric or substernal pain. Some patients complain of substernal fullness, nausea, and dysphagia. A significant proportion of patients with this type of hernia develop incarceration of the hernia and possible gastric volvulus, which can lead to perforation. If perforation occurs, the mortality rate is high. Because of this, many surgeons advise elective repair when the diagnosis is made.

A patient with a large hiatal hernia may experience vague intermittent chest discomfort or pain. The paraesophageal hernia may strangulate and frequently is operated on prophylactically to prevent this complication. Paraesophageal hernias may present in infants or adults as a potentially life-threatening complication of strangulation, and prompt surgical repair is key. When found in asymptomatic individuals, laparoscopic repair is often undertaken, with large defects in the diaphragm being closed with mesh.[10, 11, 12, 13]

Three major types of surgical procedures correct gastroesophageal reflux and repair the hernia in the process. They can be performed by open laparotomy or with laparoscopic approaches, which currently are being employed more frequently. These procedures offer relief of symptoms in 80-90% of patients.

In most cases, the procedure of choice is the one with which the surgeon is most familiar. These procedures carry low mortality and morbidity rates, lower than 15-20%.

A systematic review and meta-analysis of 4 trials comprising 406 patients found comparable results and outcomes between suture cruroplasty and prosthetic hiatal herniorrhaphy for large hiatal hernia closure.[14]  In another study consisting of data from 65 patients over nearly 2 decades, left thoracoscopic Collis gastroplasty-laparoscopic Nissen (Collis-Nissen) procedure and conventional laparoscopic Nissen fundoplication yielded similarly satisfactory results in uncomplicated patients with true short esophagus in the setting of gastroesophageal reflux disease and type III-IV hiatal hernia.[15]

In another systematic study and meta-analysis of mesh (n = 673) versus suture (n = 521) cruroplasty during laparoscopic large hiatal hernia repair, data from 13 studies consisting of 1194 patients showed symptomatic improvement in most studies, with fewer odds of recurrence but not need for reoperation with mesh cruroplasty.[16] However, the quality of the evidence for supporting routine use of mesh cruroplasty was low.

DeMeester et al found the Nissen procedure superior to the Belsey and Hill repairs with regard to symptom relief and prevention of reflux postoperatively (as judged by pH monitoring). Good long-term results have been reported for antireflux surgery, with adequate control of reflux in the range of 80% at 10 years.

See the video below for a discussion of surgical options for paraesophageal hernia repair.



View Video

Hiatal hernia. Inderpal S Sarkaria, MD, discusses the options for paraesophageal hernia repair. Courtesy of Memorial Sloan-Kettering Cancer Center.

Recurrent paraesophageal hernia (PEH) repair is performed for symptomatic recurrent hiatal hernia and/or reflux and appears to have similar outcomes to those of initial PEH, although increased operative time, blood loss, persistent symptoms, and need for Collis gastroplasty occurred more often in those who underwent revisional repair.[17]

Nissen fundoplication

The Nissen fundoplication performed laparoscopically has gained popularity because of its lower morbidity and shorter hospital stay compared to the open procedure performed previously. Although a relatively high incidence of postoperative complications, such as dysphagia and gas bloating, are reported, DeMeester and Peters[18] have shown that placing a larger bougie in the esophagus during this procedure, along with a shorter wrap and more complete mobilization of the stomach, have markedly reduced postoperative complications.[19, 20]

This procedure involves a 360° fundic wrap around the gastroesophageal junction. The diaphragmatic hiatus also is repaired.

A transthoracic approach may be used in patients who have had a previous Nissen wrap or those who have an irreducible hernia.

In a study involving 26 patients who underwent Nissen fundoplication, the use of permanent mesh following fundoplication resulted in symptom improvement in 23 patients (88.5%), with hernia recurrence reported by the remaining three patients (11.5%). No mesh erosions occurred during the mean 65-month follow-up period.[21]

The Toupet procedure is a variant of the Nissen wrap and involves a 180° wrap in an attempt to lessen the likelihood of postoperative dysphagia.

Belsey fundoplication

This operation involves a 270° wrap in an attempt to reduce the incidence of gas bloating and postoperative dysphagia. It also is preferred when minimal esophageal dysmotility is suspected. To complete this operation, the left and right crura of the diaphragm are approximated.

Hill repair

In this procedure, the cardia of the stomach is anchored to the posterior abdominal areas, such as the medial arcuate ligament. This also has the effect of augmenting the angle of His and thus strengthening the antireflux mechanism.

Some surgeons then tack the stomach down in the abdomen to prevent it from migrating upwards again, or, they perform a temporary gastrostomy to help decompress the stomach and anchor it in place in the abdominal cavity.

Diet

An appropriate diet maintains an ideal body mass index. Obesity predisposes to reflux disease.

Burkitt et al suggest that the Western, fiber-depleted diet leads to a state of chronic constipation and straining during bowel movement, which would explain the higher incidence of this condition in Western countries.[2]

Medication Summary

Symptomatic acid reflux can be treated medically, either by neutralizing acid with antacids or blocking acid secretion with H2-receptor blocking drugs or the more potent PPIs. The treatment of GERD is discussed in Gastroesophageal Reflux Disease. Hiatal hernias, per se, only require attention if they are causing symptoms because of their size or if the patient is at risk of strangulation, in which case surgery may be indicated.

Follow-up

Patient Education

See the list below:

Author

Waqar A Qureshi, MD, FRCP(UK), FACP, FACG, FASGE, Professor of Medicine, Chief of Endoscopy, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

Disclosure: Nothing to disclose.

Specialty Editors

Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Philip O Katz, MD, FACP, FACG, Chairman, Division of Gastroenterology, Albert Einstein Medical Center; Clinical Professor of Medicine, Jefferson Medical College of Thomas Jefferson University

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Medtronic<br/>Received income in an amount equal to or greater than $250 from: Torax medical: pfizer consumer, .

Additional Contributors

Vivek V Gumaste, MD, Associate Professor of Medicine, Mount Sinai School of Medicine of New York University; Adjunct Clinical Assistant, Mount Sinai Hospital; Director, Division of Gastroenterology, City Hospital Center at Elmhurst; Program Director of GI Fellowship (Independent Program); Regional Director of Gastroenterology, Queens Health Network

Disclosure: Nothing to disclose.

References

  1. Polomsky M, Peters JH, Schwartz SI. Hiatal hernia and disorders of the spine: a historical perspective. Dis Esophagus. 2011 Oct 25. [View Abstract]
  2. Burkitt DP, James PA. Low-residue diets and hiatus hernia. Lancet. 1973 Jul 21. 2(7821):128-30. [View Abstract]
  3. Sihvo EI, Salo JA, Rasanen JV, Rantanen TK. Fatal complications of adult paraesophageal hernia: a population-based study. J Thorac Cardiovasc Surg. 2009 Feb. 137(2):419-24. [View Abstract]
  4. Larusson HJ, Zingg U, Hahnloser D, Delport K, Seifert B, Oertli D. Predictive factors for morbidity and mortality in patients undergoing laparoscopic paraesophageal hernia repair: age, ASA score and operation type influence morbidity. World J Surg. 2009 May. 33(5):980-5. [View Abstract]
  5. Fernandez Mdel C, Diaz M, Lopez F, Marti-Obiol R, Ortega J. Cardiac complications after laparoscopic large hiatal hernia repair. Is it related with staple fixation of the mesh? -Report of three cases. Ann Med Surg (Lond). 2015 Dec. 4 (4):395-8. [View Abstract]
  6. Salvador R, Dubecz A, Polomsky M, Gellerson O, Jones CE, Raymond DP, et al. A new era in esophageal diagnostics: the image-based paradigm of high-resolution manometry. J Am Coll Surg. 2009 Jun. 208(6):1035-44. [View Abstract]
  7. Weijenborg PW, van Hoeij FB, Smout AJ, Bredenoord AJ. Accuracy of hiatal hernia detection with esophageal high-resolution manometry. Neurogastroenterol Motil. 2015 Feb. 27 (2):293-9. [View Abstract]
  8. Barclay L. Hiatal hernia management guidelines issued. Medscape Medical News. June 24, 2013;. Available at http://www.medscape.com/viewarticle/806792. Accessed: October 21, 2014.
  9. Kohn GP, Price RR, Demeester SR, et al. Guidelines for the management of hiatal hernia. Available at http://www.sages.org/publications/guidelines/guidelines-for-the-management-of-hiatal-hernia/. Accessed: October 21, 2014.
  10. Hazebroek EJ, Leibman S, Smith GS. Erosion of a composite PTFE/ePTFE mesh after hiatal hernia repair. Surg Laparosc Endosc Percutan Tech. 2009 Apr. 19(2):175-7. [View Abstract]
  11. Soricelli E, Basso N, Genco A, Cipriano M. Long-term results of hiatal hernia mesh repair and antireflux laparoscopic surgery. Surg Endosc. 2009 Apr 3. [View Abstract]
  12. Wassenaar EB, Mier F, Sinan H, Petersen RP, Martin AV, Pellegrini CA, et al. The safety of biologic mesh for laparoscopic repair of large, complicated hiatal hernia. Surg Endosc. 2011 Nov 16. [View Abstract]
  13. Diaz DF, Roth JS. Laparoscopic paraesophageal hernia repair with acellular dermal matrix cruroplasty. JSLS. 2011 Jul-Sep. 15(3):355-60. [View Abstract]
  14. Memon MA, Memon B, Yunus RM, Khan S. Suture cruroplasty versus prosthetic hiatal herniorrhaphy for large hiatal hernia: a meta-analysis and systematic review of randomized controlled trials. Ann Surg. 2015 Oct 1. [View Abstract]
  15. Lugaresi M, Mattioli B, Perrone O, Daddi N, Di Simone MP, Mattioli S. Results of left thoracoscopic Collis gastroplasty with laparoscopic Nissen fundoplication for the surgical treatment of true short oesophagus in gastro-oesophageal reflux disease and Type III-IV hiatal hernia. Eur J Cardiothorac Surg. 2016 Jan. 49 (1):e22-30. [View Abstract]
  16. Tam V, Winger DG, Nason KS. A systematic review and meta-analysis of mesh vs suture cruroplasty in laparoscopic large hiatal hernia repair. Am J Surg. 2016 Jan. 211 (1):226-38. [View Abstract]
  17. Wennergren J, Levy S, Bower C, et al. Revisional paraesophageal hernia repair outcomes compare favorably to initial operations. Surg Endosc. 2015 Dec 10. [View Abstract]
  18. DeMeester TR, Peters JH. Surgical treatment of gastroesophageal reflux disease. In: DO Castell, ed. The Esophagus. Boston, Mass:. Little, Brown and Company. 1995:577-617.
  19. Frantzides CT, Madan AK, Carlson MA, Zeni TM, Zografakis JG, Moore RM, et al. Laparoscopic revision of failed fundoplication and hiatal herniorraphy. J Laparoendosc Adv Surg Tech A. 2009 Apr. 19(2):135-9. [View Abstract]
  20. Cai W, Watson DI, Lally CJ, Devitt PG, Game PA, Jamieson GG. Ten-year clinical outcome of a prospective randomized clinical trial of laparoscopic Nissen versus anterior 180( degrees ) partial fundoplication. Br J Surg. 2008 Dec. 95(12):1501-5. [View Abstract]
  21. Petersen LF, McChesney SL, Daly SC, et al. Permanent mesh results in long-term symptom improvement and patient satisfaction without increasing adverse outcomes in hiatal hernia repair. Am J Surg. 2014 Mar. 207(3):445-8; discussion 448. [View Abstract]
  22. Hashmi S, Rao SS, Summers RW, Schulze K. Esophageal pressure topography, body position, and hiatal hernia. J Clin Gastroenterol. 2014 Mar. 48 (3):224-30. [View Abstract]

Hiatal hernia. A paraesophageal hernia is seen on an upper gastrointestinal radiograph series. Note that the gastroesophageal (GE) junction remains below the diaphragm. Courtesy of David Y Graham, MD.

Hiatal hernia. Figure 1 shows the normal relationship of the gastroesophageal (GE) junction, stomach, esophagus, and diaphragm. Figure 2 shows a sliding hiatal hernia, in which the stomach immediately below the GE junction is seen to prolapse through the diaphragmatic hiatus into the chest. Figure 3 shows a paraesophageal hernia in which the cardia or fundus of the stomach prolapses through the diaphragmatic hiatus, leaving the GE junction within the esophageal cavity.

Hiatal hernia. Figure 1 shows the normal relationship of the gastroesophageal (GE) junction, stomach, esophagus, and diaphragm. Figure 2 shows a sliding hiatal hernia, in which the stomach immediately below the GE junction is seen to prolapse through the diaphragmatic hiatus into the chest. Figure 3 shows a paraesophageal hernia in which the cardia or fundus of the stomach prolapses through the diaphragmatic hiatus, leaving the GE junction within the esophageal cavity.

Hiatal hernia. These anteroposterior (left) and lateral views (right) on a chest radiograph showing a large hiatal hernia. Courtesy of David Y Graham, MD.

Hiatal hernia. This barium study shows a sliding hiatal hernia: The gastric folds can be seen extending above the diaphragm. GE = gastroesophageal. Courtesy of David Y Graham, MD.

Hiatal hernia. A paraesophageal hernia is seen on an upper gastrointestinal radiograph series. Note that the gastroesophageal (GE) junction remains below the diaphragm. Courtesy of David Y Graham, MD.

Hiatal hernia. A paraesophageal hernia is seen on a barium upper gastrointestinal radiograph series. The mucosal folds are seen going up into the chest, next to the esophagus. GE = gastroesophageal. Courtesy of David Y Graham, MD.

Hiatal hernia. This image is a barium radiograph view of a large paraesophageal hernia. GE = gastroesophageal. Courtesy of David Y Graham, MD.

Hiatal hernia. This barium radiograph shows a large paraesophageal hernia in which the entire stomach is seen in the chest cavity. Courtesy of David Y Graham, MD.

Hiatal hernia. These barium studies show gastric volvulus as the herniated stomach undergoes rotation. This situation requires surgical intervention. Courtesy of David Y Graham, MD.

Hiatal hernia. A retrograde view of a hiatal hernia seen at endoscopy shows the gastric folds to the left of the scope shaft extending up into the hernia. Courtesy of David Y Graham, MD.

Hiatal hernia. Inderpal S Sarkaria, MD, discusses the options for paraesophageal hernia repair. Courtesy of Memorial Sloan-Kettering Cancer Center.

Hiatal hernia. Figure 1 shows the normal relationship of the gastroesophageal (GE) junction, stomach, esophagus, and diaphragm. Figure 2 shows a sliding hiatal hernia, in which the stomach immediately below the GE junction is seen to prolapse through the diaphragmatic hiatus into the chest. Figure 3 shows a paraesophageal hernia in which the cardia or fundus of the stomach prolapses through the diaphragmatic hiatus, leaving the GE junction within the esophageal cavity.

Hiatal hernia. These anteroposterior (left) and lateral views (right) on a chest radiograph showing a large hiatal hernia. Courtesy of David Y Graham, MD.

Hiatal hernia. This barium study shows a sliding hiatal hernia: The gastric folds can be seen extending above the diaphragm. GE = gastroesophageal. Courtesy of David Y Graham, MD.

Hiatal hernia. A paraesophageal hernia is seen on an upper gastrointestinal radiograph series. Note that the gastroesophageal (GE) junction remains below the diaphragm. Courtesy of David Y Graham, MD.

Hiatal hernia. A paraesophageal hernia is seen on a barium upper gastrointestinal radiograph series. The mucosal folds are seen going up into the chest, next to the esophagus. GE = gastroesophageal. Courtesy of David Y Graham, MD.

Hiatal hernia. This image is a barium radiograph view of a large paraesophageal hernia. GE = gastroesophageal. Courtesy of David Y Graham, MD.

Hiatal hernia. This barium radiograph shows a large paraesophageal hernia in which the entire stomach is seen in the chest cavity. Courtesy of David Y Graham, MD.

Hiatal hernia. These barium studies show gastric volvulus as the herniated stomach undergoes rotation. This situation requires surgical intervention. Courtesy of David Y Graham, MD.

Hiatal hernia. A retrograde view of a hiatal hernia seen at endoscopy shows the gastric folds to the left of the scope shaft extending up into the hernia. Courtesy of David Y Graham, MD.

Hiatal hernia. Inderpal S Sarkaria, MD, discusses the options for paraesophageal hernia repair. Courtesy of Memorial Sloan-Kettering Cancer Center.