Slipped fundoplication and hiatal hernia
Malpositioned fundoplication and hiatal hernia
Hiatal hernia alone
Despite having been recognized over two centuries ago particularly by the work of Bochdalek and Morgagni, pathophysiology of the hiatal hernia still remains to be elucidated . Limited data in the literature suggest; (a) unrelenting motion of the diaphragm, (b) increased intraabdominal pressure, (c) esophageal shortening and (d) structural changes in the diaphragm and adjacent ligaments as three main pathophysiologic mechanisms leading to hiatal hernia (Table 13.2) [7–12].
Pathophysiologic mechanisms and etiology of hiatal hernia
Increased intraabdominal pressure
Congenital short esophagus
Chronic vagal stimuli
Tight esophageal longitudinal muscle
Structural changes in the diaphragm
Reduced matrix metalloproteinases
Defective collagen formation
Structural changes in the crura
Dilatation of the myofibrillar spaces
Swelling of sacrotubular structures
Degeneration of myofibrils
Disruption of the muscles
Decreased elastin in the ligaments
In phrenoesophageal ligament
In gastrohepatic ligament
Technical reasons and mesh related complications may be added to this list as other contributing factors in the patients with previous repairs. Pathophysiologic mechanisms leading to recurrence act by interfering with antegrade pumping of the bolus, wound healing and principle of tension-free hernia repair.
13.3 Clinical Presentation
According to traditional understanding a recurrent hiatal hernia may or may not be symptomatic, and asymptomatic cases are usually discovered incidentally during a work-up for another reason. However, recent reports challenge this notion by suggesting that symptoms associated with silent hernias are much broader than previously thought and truly asymptomatic patients are rare [13–15]. Symptoms like insidious alterations in eating habits, early satiety and postprandial dyspnea that gradually increase over time—particularly in the elderly population—may in fact be related with a recurrent hiatal hernia and should not be assumed to arise due to aging . Moreover, pulmonary symptoms in the patients with hiatal hernia may also remain underappreciated likely because in elderly population symptoms such as dyspnea is often attributed to arise from other comorbidities . Therefore a careful history taking is necessary in the patients that are assumed to be asymptomatic. In the more symptomatic group, complaints are mostly mechanical symptoms due to gastroesophageal obstruction, gastroesophageal reflux, strangulation and incarceration (Table 13.3). While in the cases with slipped fundoplication reflux symptoms are the main components of the clinical picture, obstructive symptoms including anorexia, early satiety, dysphagia, postprandial bloating, regurgitation and weight loss become more prominent in the cases with intact fundoplication. Incarceration and partial strangulation of displaced abdominal organs may cause chest or abdominal pain in addition to other specific symptomology depending on the herniated structures. Venous congestion of the mucosa due to chronic external pressure may result in gastric ulceration ( Cameron’s ulcer ) and postprandial pain  (Fig. 13.1).
The most common chief complaints of the patients with recurrent hiatal hernia 
Cameron’s ulcer may cause occult bleeding and iron deficiency anemia both resolve typically after herniorraphy. Respiratory tract symptoms secondary to chronic aspiration or intrathoracic displacement of the abdominal organs can also be seen and may include postprandial dyspnea, chronic cough, asthma, otitis media, sleep apnea, globus sensation, hoarseness, recurrent upper respiratory tract infections and recurrent pulmonary infections. In addition, patients may present with urgent signs and symptoms of acute conditions such as gastric volvulus, colopleural fistula or gastropericardial fistula [21–23].
Gastropericardial fistula may appear as a rare complication of penetrating peptic or neoplastic ulcers of the stomach within the recurrent hiatal hernia. Diagnosis should be suspected when a patient with an history of hiatal hernia repair present with chest/shoulder pain, dyspnea, atrial fibrillation, pericardial tamponade, pyrexia and upper gastrointestinal symptoms [23, 24]. Dyspnea and coughing with purulent sputum discharge accompanied by with pyrexia, and sepsis should raise suspicion of a colopleural fistula especially in the patients with history of mesh repair of an hiatal hernia [22, 25]. Hemoptysis may add to these symptoms if the recurrence is complicated with gastrobronchial fistula .The classic presentation for acute gastric volvulus is severe epigastric pain, retching without vomiting and inability to pass a nasogastric tube ( Borchardt’s triad ).
Symptom assessment should be standardized by using questionnaires both for follow-up and the quality of life measurement purposes [27–29]. However, it should be remembered that the positive predictive value of the symptoms is limited and the preoperative assessment should be supported by other methods .
In addition to symptomology, patient’s past medical history should be questioned for the presence of chronic immunosuppression, ongoing steroid treatment, diabetes, morbid obesity and smoking as the other factors that may adversely influence the wound healing and increase the probability of a re-recurrence. Obesity in particular is a risk factor for failed antireflux procedure . Nicotine addiction should also be questioned preoperatively. Tobacco usage has a well-known relation with herniations and wound healing similar to its detrimental effect on the lungs which may appear as a systemic spillover reflected in the herniation sites namely metastatic emphysema .
Evaluation of the former surgery is also essential. If available, previous operative report should be reviewed—for information about the diameter of hiatal hernia, management of the sac, preservation of the vagus nerves, post-operative length of the abdominal esophagus, type of the fundoplication and use of a mesh—to get an opinion on the anatomy prior to the initial operation.
13.4 Radiologic Studies
Plain chest radiographs may reveal a mediastinal mass with or without an air-fluid level. In the latter case fundus air is absent. Although the mass is predominantly retrocardiac and located to the left of the spine it may be large enough to even mimic a cardiomegaly. In the absence of gas within the hernia sac plain chest radiograph has a limited value in the differential diagnosis (Fig. 13.2). However in the presence of these findings, particularly in elderly patients with multiple comorbidities which may lead to diagnostic uncertainty, surgeon must maintain high index of suspicion for the presence of recurrent hiatal hernia .
Recurrent hiatal hernia on the PA (a) and lateral plain (b) chest radiographs with air-fluid levels (on the left), and with bowel gas in the mediastinum (on the right)
A barium swallow or videoesophageal study may be useful in demonstrating the position of the hernia, location of the gastroesophageal junction, esophageal motility and is the preferred examination for the investigation of hiatal hernia recurrence under elective conditions (Fig. 13.3). Radiologic diagnosis of a sliding hiatal hernia can be made if more than four mucosal folds are recognizable 2 cm above the diaphragm in an upper gastrointestinal barium swallow series in a prone oblique position. Esophagus may appear tortuous and may become aperistaltic above the hiatus suggesting supradiaphragmatically positioned esophagogastric junction. Under subacute conditions barium swallow may reveal complications like gastric volvulus (Fig. 13.4). On a dynamic study if the hernia is not reducible with the patient in an erect position and persistent within the thorax then it is considered to be an incarcerated diaphragmatic hernia .
Hiatal hernia on barium swallow
Gastic volvulus . Note the supradiaphragmatic position of the stomach
Gastric emptying study should also be obtained in patients who had retained barium in the stomach 2 h after the end of barium swallow and on those who had food in the stomach during gastroscopy after overnight fasting .
Computerized tomography (CT) is not routinely used. But it may be useful in the elective cases without an air-fluid level in direct radiographs or with a neoplasia which requires staging and in urgent cases in which a barium swallow study is contraindicated. Presence of an hernia sac in CT examination which is greater than 2 cm is radiologically accepted as a recurrent hiatal hernia (Fig. 13.5). In urgent cases, CT should be preferred to determine the size of the hernia, width of the hiatal defect, presence of the other intra-abdominal organs in the mediastinum and to rule out complications such as gastric volvulus or hollow organ perforation. Pneumatosis of the gastric wall, free gas and fluid outside the gastric wall within the hernia sac, and lack of contrast enhancement of the gastric wall are the CT findings suggestive of a gastric necrosis .