Thoracic: Giant Paraesopageal Hernia
Giant paraesophageal hernia: What do we really know?
Feature Editor Note—The management of giant paraesophageal hernias remains challenging. In this invited expert opinion article, Bhargava and Andrade provide an in-depth discussion of the controversies surrounding repair of giant paraesophageal hernias, including management of recurrent hiatal hernias, esophageal-lengthening procedures, and the use of mesh. Based on their own practice, they suggest performing an extensive mediastinal dissection to achieve adequate intra-abdominal esophageal length, gastroplasty when needed for esophageal shortening, and the avoidance of mesh due to the risk of erosion, cost, and lack of clear data supporting its use.Commentary: A century of giant paraesophageal hernia (GPEH) repair: A century of controversy!
Giant paraesophageal hernias (GPEHs) can range from an asymptomatic, incidentally detected paraesophageal hernias to an emergent gastric volvulus with concern for ischemia.1 For many decades, the fear of gastric volvulus and its associated risk of mortality (29%), noted in the 1967 work by Drs Skinner and Belsey, has driven the paradigm of urgent repair of GPEH.2 We now know that there are many patients with GPEH who are incidentally diagnosed and have minimal symptoms. Given that elective repair is associated low mortality and morbidity and contrasting it with the low risk of obstructive and gangrenous complications per year, the lifetime risk of developing complications needs to be taken into account before considering repair.
