SAGES Surgical Treatment of Hiatal Hernias Guideline Summary

Summary of Recommendations

The expert panel has decided not to make an evidence-based recommendation for or against the use of mesh in hiatal hernia repair. (, )

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The management of the patient with an asymptomatic type II, III, or IV hiatal hernia is challenging given the poor evidence base. The first step is to ensure the patient is truly asymptomatic; many patients referred for an “asymptomatic” hiatal hernia are suffering from non-gastrointestinal symptoms which could be secondary to the hiatal hernia, including but not limited to shortness of breath, exercise intolerance, or abnormal echocardiogram findings.

One study of 270 patients undergoing hiatal hernia repair demonstrated presenting symptoms to include anemia in 24-57% of patients, dyspnea in 21-67%, and chest pain in 40-60% [21]. In instances when these symptoms cannot be reasonably attributed to a comorbid disease process, such patients can be considered symptomatic and offered repair if medically fit.

In cases where the patient is confirmed to have a true asymptomatic hiatal hernia, it is important to discuss the potential benefits of further workup. There is often discordance between patient symptoms and objective evidence of reflux. The Lyon consensus noted that a history taken by a gastroenterologist has a sensitivity of 70% and a specificity of 67% for GERD when compared against GERD defined by pH monitoring or endoscopy [22,23]. Surgical repair can potentially prevent progression and/or complications of their reflux disease and/or hiatal hernia. Micro-aspiration is another potential sequela of an untreated hiatal hernia. Endoscopy is a good diagnostic test for both. Patients with objective evidence of reflux or findings of micro-aspiration can be offered repair if medically fit. Certain patient populations are so high-risk for complications of micro-aspiration that they can be offered repair even in the absence of objective findings, such as lung transplant patients.

The management of patients without any objective evidence of reflux or micro-aspiration is controversial and unfortunately there is no strong data on which to base decision-making. A thorough discussion of the potential to develop an acute gastric volvulus is essential to allow the patient to make an informed decision. It is also important to have a frank discussion about our inability to predict which patients are high risk for gastric volvulus, though the panel does consider pre-existing organo-axial rotation a concerning feature.

Several studies have tried to model the risk for progression to gastric volvulus compared to the benefits and risks of an elective hernia repair in the minimally symptomatic patient population. Two studies found the overall benefits in favor of the watchful waiting arm, acknowledging that a certain number of patients will electively cross over into the operative arm, while the third study found quality of life favored operative intervention [24-26]. These studies did not weight significantly in our discussion because they are models, and they are based on a symptomatic patient population. However, if the models are accurate, the theoretical benefits of watchful waiting are likely even greater in an asymptomatic patient population.

If the diagnostic workup is unrevealing and the patient understands and accepts the risk of developing gastric volvulus, it is reasonable to pursue a strategy of watchful waiting. Shared decision-making and thorough discussion are essential at all decision points of the evaluation for optimal outcomes.

Despite a paucity of high-quality comparative data, the panel of experts agreed that conversion to RYGB may be considered an appropriate treatment option in select patients without obesity and with recurrent type II, III, or IV hiatal hernia. In a patient with a recurrent hiatal hernia after a previous uncomplicated hiatal hernia repair with fundoplication, redo hiatal hernia repair and fundoplication is appropriate. Greater consideration for RYGB would be made in the following circumstances: patients with diabetes mellitus, severe esophageal dysmotility, short esophagus, or gastroparesis, patients with previous complicated hiatal hernia repair with fundoplication who now have poor quality tissue of the fundus, and lastly patients who have undergone multiple recurrent hiatal hernia failures by an expert. Such patients should be evaluated in a multidisciplinary fashion prior to proceeding with RYGB.

Surgical Treatment of Hiatal Hernias