Clinical Ramifications of Giant Paraesophageal Hernias Are Underappreciated: Making the Case for Routine Surgical Repair

Background. We propose that the symptoms associated with paraesophageal hernia (PEH) are more diverse than previously suggested, and symptoms and clinical manifestations correlate to the anatomy of the hernia. Methods. Patients undergoing surgery for PEH were reviewed from a prospective, institutional review board-approved, single-center database. Presenting symptoms, anatomy of the PEH, demographics, and outcomes were analyzed from 2000 to 2010. Presenting symptoms were assessed for incidence and improvement after surgery. Size and configuration of the PEH were assessed with respect to presenting symptoms. Results. The study included 270 consecutive patients, 63% were female, and the median age was 70 years (range, 39 to 94 years). The most common presenting symptoms were heartburn in 175 patients (65%), early satiety in 136 patients (50%), chest pain in 130 patients (48%), dyspnea in 130 patients (48%), dysphagia in 129 patients (48%), regurgitation in 128 patients (47%), and anemia in 112 patients (41%). Two hundred sixty-nine patients (99.6%) had at least one symptom; the median number of symptoms was 4 (range, 0 to 10). The type of PEH was II (n = 10), III (n = 206), and IV (n = 54), and the percent intrathoracic stomach was less than 50% (n = 33), 50% to 74% (n = 86), 75% to 99% (n = 55), and 100% (n = 96). Paraesophageal hernia type was significantly associated with heartburn (type II/III; p = 0.005) and dyspnea (type IV; p = 0.007). Significant associations included lower percent intrathoracic stomach with regurgitation (p = 0.04); higher percent intrathoracic stomach with early satiety (p = 0.02), decreased meal size (p = 0.007), and dyspnea (p < 0.001); and 50% to 74% intrathoracic stomach with anemia (p = 0.001). With a median postoperative follow-up of 103 days, symptoms were subjectively better in patients with dyspnea (67%), early satiety (79%), regurgitation (92%), dysphagia (81%), chest pain (76%), and heartburn (93%). Conclusions. Paraesophageal hernia is associated with a greater diversity of symptomatic presentation than previously thought. Asymptomatic patients are rare, and size and configuration of the hernia are associated with specific symptoms. Patients with large PEHs should be assessed by an experienced surgeon for elective repair. (Ann Thorac Surg 2012;94:421-8) (c) 2012 by The Society of Thoracic Surgeons