Hiatal Hernias or Paraesophageal Hernias?

Dear Editor,

Braghetto and Csendes are two prestigious authors in the world of esophagogastric surgery. They have recently published in your journal an article about when and why hiatal hernias (HH) should be treated surgically.¹ Their results are from a prospective study of 121 patients who had undergone HH hernias, who were divided into 2 groups according to age (younger and older than 70). Their conclusions support an interventionist approach to HH, and they believe that all patients should be treated surgically as soon as they are diagnosed. Elderly patients do not need to be excluded from surgery due to the low mortality rate (<1.5%) of elective laparoscopic procedures compared with the mortality rate in cases requiring urgent surgery (>5%).

Although they present a complete series of patients operated on for HH with a predominance of type I HH with gastroesophageal reflux, I believe the article and the final conclusions mainly refer to HH in seniors, which are usually paraesophageal hernias (PH). In 2002, Stylopoulos published an article in Annals of Surgery that had a thought-provoking title: “Paraesophageal hernias: operation or observation?”.² They concluded that the initial treatment for asymptomatic PH patients, or those with few symptoms, should be conservative and non-surgical. To this end, they designed a study with 2 cohorts of patients with PH. The first group was treated surgically and the second group was not. According to the results, the “observation without surgery” strategy was the optimal treatment for 87% of patients.

In the decade that has passed since this publication, laparoscopic repair of esophageal hiatal hernias has advanced immensely. Today, very good results are obtained in elderly patients. I completely agree with Braghetto and Csendes that, if these HH patients are interviewed in depth, most will report having had symptoms that have progressed for several years. As for the controversial topic of when to treat PH surgically in senior patients, I also am in agreement with them, based on reports in the literature and my own personal experience. Patients with complicated PH are sometimes difficult to diagnose, and transmural gastric necrosis is unpredictable. When this happens, patient mortality is very high. Therefore, I believe that all PH patients should be operated on after diagnosis, but not all HH patients. In my opinion, international recommendations for the surgical treatment of gastroesophageal reflux, such as those by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES),³ are still valid today.