TITLE:
Cardiovascular Complications of Large Hiatal Hernias: Expanding the Indications for Robotic Surgical Anatomic and Physiologic Repair: A Review
AUTHORS:
Farid Gharagozloo, Mark Meyer, Robert Poston
KEYWORDS:
Hiatal Hernia, GERD, Paraesophageal Hernia, Robotic Surgery, Laparoscopic Repair, Nissen, Belsey, Gastroesophageal Valvuloplasty
JOURNAL NAME:
World Journal of Cardiovascular Surgery,
Vol.12 No.3,
March
18,
2022
ABSTRACT: Background: Historically, the pathophysiology of Hiatal Hernias (HH) has not been
fully understood. As a result, the surgical therapy of HH has focused primarily
on gastrointestinal symptoms and Gastroesophageal Reflux (GERD). This
treatment strategy has been associated with poor relief of symptoms and poor long-term outcomes. In fact,
until recently, most
patients with HH have been watched and referred for surgery as a last resort.
Recent experience has shown that a large (giant) Hiatal Hernia (GHH) is a
common problem known to impact adjacent
organs such as the hearts and lungs. Those referred for surgical repair often complain of
dyspnea, which is erroneously attributed to pulmonary compression or aspiration, but has been shown to be from tamponade caused from compression of the heart by herniated abdominal contents.
This article reviews the present understanding of GHH, the cardiac
complications which result from GHH, and the
most advanced robotic minimally invasive surgical approach to the
anatomic and physiologic repair of GHH. Methods: In a prospective cohort
study, we evaluated patients undergoing RRHH with at least a 2-year follow-up. All patients undergoing elective (RRHH)
were identified preoperatively and
enrolled prospectively in this study. Preoperative characteristics, medical
comorbidities, and clinical information were all recorded prospectively and recorded into a secure surgical
outcomes database. All patients received
the previously validated Gastroesophageal Reflux Disease-Health-Related
Quality of Life (GERD-HRQL) questionnaire preoperatively and at postoperative time points of 1 month, 1 year, and 2 years. Patients routinely had a barium
swallow postoperatively before discharge but did not undergo a barium swallow, an endoscopy, or a CT scan study at
the 1-month time point unless indicated by symptoms. At 6 months, 1 year, and yearly
intervals thereafter, all patients received an endoscopy study to ascertain the presence
of a recurrence, regardless of symptoms. Recurrence was defined as over 2 cm or
10% of the stomach above the diaphragm detected by CT, esophagogram or
endoscopy. In addition, an extensive search was conducted using Pub Med in order to extract references to the cardiovascular complications of HH. Results: 423 patients underwent RRHH. With a long-term follow-up, there was a significant
decrease in the Median Symptom Severity Score from 42.0 preoperatively, to 3.0 postoperatively. Recurrence was seen in 5
patients (5/423) for a recurrence rate of 1.1%. Conclusion: This
experience has been the basis of two
important realizations: 1) all patients with GHH have at least some degrees of
clinically relevant compression of the inferior vena cava and the left atrium which causes tamponade and cardiogenic dyspnea which completely
resolves after successful surgical repair; and 2) primary care providers and
gastroenterologists who usually treat patients for GHH repair rarely recognize cardiac compression and tamponade as the
cause of the shortness of breath and gradual increase in dyspnea on
exertion and progressive fatigability in these patients. This article reviews
the present understanding of GHH, the
cardiac complications which result from GHH and the most advanced robotic minimally invasive surgical approach to the
anatomic and physiologic repair of GHH.