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 volvulus with perforation or gangrene. Colon or small intestine may sometimes lie in the hernia sac, but rarely causes additional complications. The hernia is commonest in the elderly, but may occur in young fit people.
 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   belch. Symptoms of GORD are variable. They may be present in the early stages of evolution of the hernia, but disappear as distortion of the cardia increases.

    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.