A paraesophageal hernia (PEH) occurs when a portion of the stomach, and sometimes other abdominal organs, moves through the diaphragm and into the chest cavity. This differs from a standard hiatal hernia because the stomach can rotate or become entrapped within the diaphragmatic opening, known as the hiatus. Surgical repair, often performed laparoscopically, involves a fundoplication to anchor the stomach and create a new valve mechanism. Repair is typically recommended due to the risk of life-threatening complications like strangulation. Although the operation is generally successful, it is a complex procedure with a range of possible adverse outcomes.
Acute and General Surgical Risks
Any major abdominal surgery carries a baseline risk for complications related to general anesthesia, such as cardiac or respiratory issues. Immediate risks during PEH repair relate to the proximity of the repair site to delicate structures. One acute risk is hemorrhage from injury to blood vessels or organs, though significant bleeding is uncommon.
Injury to surrounding organs is a specific concern during the dissection and reduction of the hernia sac. The spleen, which lies close to the stomach, may be injured, sometimes requiring its removal (splenectomy). There is also a risk of perforation or laceration to the esophagus or stomach wall. Furthermore, the manipulation of the diaphragm and the use of carbon dioxide gas for laparoscopic viewing can lead to a pneumothorax, where air enters the chest cavity. This complication is usually managed immediately by the surgical team.
Specific Functional Complications
The fundoplication, where the stomach is wrapped around the lower esophagus to prevent reflux, is the source of many functional complications. Dysphagia, or difficulty swallowing, is the most common issue in the immediate postoperative period, affecting many patients temporarily. This temporary difficulty often results from swelling at the surgical site and typically resolves within a few weeks as the tissue heals and the patient progresses through a modified diet.
Persistent dysphagia, lasting longer than three months, can occur if the fundoplication wrap is constructed too tightly or if the esophagus has underlying motility issues. A tight wrap creates a mechanical obstruction, making it difficult for food to pass into the stomach.
Another functional concern is Gas Bloat Syndrome, characterized by the inability to belch or vomit effectively. This inability to vent swallowed air occurs because the newly created valve mechanism is too competent, trapping air in the stomach and leading to uncomfortable abdominal distension and pain. Delayed gastric emptying, or gastroparesis, is a potential problem where the stomach takes too long to empty its contents. This complication can be caused by injury to the vagus nerve during the extensive dissection required to mobilize the stomach and esophagus, resulting in post-operative nausea, vomiting, and early satiety.
Long-Term Structural Failure and Recurrence
The most significant long-term challenge is the structural failure of the repair, known as recurrence. Anatomical recurrence occurs when the stomach or other abdominal contents migrate back into the chest. This is a time-dependent phenomenon, and while reported rates vary widely, many anatomical recurrences are small and do not cause symptoms.
Recurrence can happen due to factors like excessive tension on the sutures used to close the diaphragmatic opening, or an esophagus that is too short to remain anchored without tension. The use of surgical mesh to reinforce the closure of the hiatus is a strategy used by some surgeons to reduce recurrence rates.
Another form of long-term failure involves the fundoplication wrap, which can loosen or slip out of position over time. This wrap failure often leads to a return of original symptoms, such as severe gastroesophageal reflux disease (GERD). Symptomatic recurrence, or recurrence causing acute complications like obstruction, typically prompts a re-operation, which occurs in a small percentage of patients (3.8% to 15%). The size of the original hernia and patient factors like obesity also contribute to the risk of the repair failing.
Recognizing and Addressing Complications
Prompt recognition of postoperative issues is necessary for successful management following paraesophageal hernia repair. Patients should contact their healthcare provider immediately if they experience signs of infection, such as fever, chills, redness, warmth, or pus draining from the incision site. Severe, unrelenting abdominal or chest pain, persistent vomiting, or the inability to keep down liquids or food require urgent medical evaluation.
For the most common functional complication, dysphagia, initial management involves strict adherence to the prescribed modified liquid or soft diet, which allows the surgical site to heal without strain. Persistent difficulty swallowing may require an endoscopic procedure called dilation, where a balloon or tube is used to gently stretch the narrowed area of the esophagus. If imaging confirms a structural failure, such as a large symptomatic recurrence or a migrated wrap, a revisional operation may be necessary to correct the anatomical defect. This re-operation is more complex than the initial repair but can successfully resolve debilitating symptoms.