Para-oesophageal hernias (POH), or rolling hernias, are an uncommon type of hiatal hernia representing ~10% of all hiatal hernias. The majority of the hiatal hernias being of the sliding type.
Can vary and can include:
- gastro-oesophageal reflux disease (mainly hiatus hernia)
- substernal, post-prandial chest pain
- epigastric pain
- diaphragmatic impingement on the stomach
- gastric volvulus
- compression of the oesophagus by the intrathoracic stomach
- respiratory complications
- associated with a large POH
- recurrent aspiration, pneumonia, and chronic cough
A para-oesophageal hernia includes a peritoneal layer that forms a true hernia sac, distinguishing it from the more common sliding hiatal hernia.
In POH, there is an upward dislocation of the gastric fundus alongside a normally positioned gastroesophageal junction. The gastric fundus and sometimes abdominal viscera protrude into the mediastinum through the defect in the diaphragm.
In contrast, a sliding hernia does not have a hernia sac and slides into the chest since the gastro-oesophageal junction (GOJ) is not fixed inside the abdomen.
Generally, a hiatus hernia is classified into four types.
- type I - sliding hernia: GOJ migrates into the posterior mediastinum through the oesophageal hiatus
type II-IV - para-oesophageal hernias
- type II: occurs when the fundus herniates through the hiatus alongside a normally positioned GOJ
- type III: is a combination of types I and II hernias with a displaced GOJ as well as hernia sac containing portions of the fundus/body of stomach protruding through the hiatus
- type IV: characterised by displacement of the stomach along with other organs (colon, spleen, pancreas and small bowel) into the thorax
Treatment and prognosis
Surgical management is indicated when medical management fails to control symptoms of gastro-oesophageal reflux that may be related to the POH, or when there is an emergent complication.
According to the Society of American Gastrointestinal and Endoscopic Surgeons 2013 guidelines:
- in the absence of reflux disease, repair of a type I hernia is unnecessary
- all symptomatic paraoesophageal hiatal hernias (types II-IV) should be repaired, especially in the presence of acute obstructive symptoms or volvulus
On a chest radiograph, possible considerations include:
- 1. Kahrilas PJ, Kim HC, Pandolfino JE. Approaches to the diagnosis and grading of hiatal hernia. Best Pract Res Clin Gastroenterol. 2008;22 (4): 601-16. doi:10.1016/j.bpg.2007.12.007 - Free text at pubmed - Pubmed citation
- 2. Skinner DB. Hernias (hiatal, traumatic, and congenital) In: Berk JE, editor. Gastroenterology. Vol. 4. W. B. Saunders; Philadelphia: 1985. pp. 705–716. Chapter 53.
- 3. Coughlin M, Fanous M, Velanovich V. Herniated pancreatic body within a paraesophageal hernia. World J Gastrointest Surg. 2011;3 (2): 29-30. doi:10.4240/wjgs.v3.i2.29 - Free text at pubmed - Pubmed citation
- 4. Dunn DB, Quick G. Incarcerated paraesophageal hernia. Am J Emerg Med. 1990;8 (1): 36-9. Pubmed citation
- 5. 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 July 9, 2013.
- 6. Diaphragm. In: Surgical Foundations: Essentials of thoracic surgery, Kaiser, LR, Singal, S. (Eds), Elsevier Mosby, Philadelphia 2004. p.294. Kaiser L, Singhal S. Surgical foundations. Mosby. ISBN:0815126131. Read it at Google Books - Find it at Amazon
- 7. Miller, JI, Jr. Chapter 89. Bacterial infections of the lungs and bronchial compressive disorders. In: General thoracic surgery. Lippincott Williams & Wilkins. ISBN:0781779820. Read it at Google Books - Find it at Amazon
- 8. Stylopoulos N, Gazelle GS, Rattner DW. Paraesophageal hernias: operation or observation?. Ann. Surg. 2002;236 (4): 492-500. Free text at pubmed - Pubmed citation
- 9. Skinner DB, Belsey RH. Surgical management of esophageal reflux and hiatus hernia. Long-term results with 1,030 patients. J. Thorac. Cardiovasc. Surg. 1967;53 (1): 33-54. Pubmed citation
- 10. Hill LD. Incarcerated paraesophageal hernia. A surgical emergency. Am. J. Surg. 1973;126 (2): 286-91. Pubmed citation
- 11. Terrence M. Fullum. Surgical Approach, Risks, and Outcomes Of Paraesophageal Hiatal Hernia Repair: An Analysis Of The National Inpatient Sample Database [Internet]. Charlotte,NC: Surgical Section of the National Medical Association July 26, 2011. Available from: http://www.nma-surgical.org/files/Annual_Scientific_Symposium_2011/Fullum_SSNMA_2011.pdf