Paraoesophageal
(‘rolling’) hiatus hernia
Rolling
hiatus hernias are dangerous
Unlike
sliding hiatus hernia a rolling hiatus hernia is a true hernia that is prone to
complications. True paraoesophageal hernias in which the cardia remains in its
normal anatomical position are very rare and confined to museum exhibits and
personal collections of interesting cases. The vast majority of rolling hernias
is mixed hernias in which the cardia is displaced into the chest and the greater
curve of the stomach rolls into the mediastinum (Fig.
50.42). Sometimes the whole of the stomach lies in the chest (Fig.
50.43) and may undergo
The symptoms of rolling hernia are
mostly due to twisting and distortion of the oesophagus and stomach. Dysphagia
is common.
Chest pain may occur due to distension of an obstructed stomach. Classically the
pain is relieved by a loud
The hernia may be visible on a plain X-ray of the chest as a gas bubble, often with a fluid level behind the heart (Fig. 50.44). Fluid levels are not seen in sliding hernias. A barium meal is the best method of diagnosis. The endoscopic appearances may be confusing, especially in large hernias when the endoscopist feels as if they have lost their sense of direction.
Rolling hernias always require surgical repair as they are potentially dangerous. However, major surgery may not be an attractive prospect in frail elderly patients or in someone who has few symptoms. Patients who present as an emergency with acute chest pain may be treated initially by nasogastric tube to relieve the distension that causes the pain, followed by operative repair. If the pain is not relieved or perforation is suspected immediate operation is mandatory.
The type of operation that is done is somewhat controversial because of the variable occurrence of GORD. A thoracic or abdominal approach is equally acceptable. The essential part of the operation is reduction of the hernia and some form of gastropexy. Some surgeons perform a fundoplication arguing that this is a very effective means of maintaining reduction and that it deals with the associated GORD. Others argue that a fundoplication should only be done if reflux can be conclusively demonstrated beforehand. Surprisingly, both philosophies achieve good results. Laparosopic repair has recently become popular. Full anatomical repair of a large rolling hernia can be tedious and difficult by the laparoscopic approach and it is more common simply to reduce the hernia and perform a gastropexy. Some surgeons lay a sheet of prosthetic mesh across the hiatal opening to stop the bowel entering it.