General Surgery · Year 3 · from General Surgery
Case 3: Paraesophageal Hernia
Patient Demographics
- Age: 71 years
- Sex: Female
- Occupation: Retired librarian
Chief Complaint
"I get short of breath after eating and sometimes feel like my heart is racing."
History of Present Illness
The patient presents with a 6-month history of postprandial dyspnea and early satiety. She reports feeling "full" after eating small amounts and often experiences shortness of breath when lying down after meals. She has occasional palpitations, particularly after large meals. She admits to mild dysphagia to solids and episodic substernal chest discomfort. She has had one episode of acute severe chest pain 2 months ago that brought her to the ED, where cardiac workup was negative. She was found to have a large hiatal hernia on chest X-ray during that visit.
Past Medical History
- Type 2 diabetes
- Hypertension
- Osteoarthritis
- History of sliding hiatal hernia (diagnosed 10 years ago)
- Prior cardiac workup negative
Medications
- Metformin 500 mg BID
- Lisinopril 20 mg daily
- Omeprazole 20 mg daily
- Acetaminophen as needed
Physical Examination
- Vitals: BP 148/82 mmHg, HR 78 bpm, SpO2 96% on room air
- General: Elderly female, mildly overweight
- Chest: Bowel sounds auscultated in left lower chest
- Cardiovascular: Regular rhythm, no murmurs
- Abdomen: Soft, non-distended
Diagnostic Workup
Chest X-ray:
- Large retrocardiac air-fluid level
- Gastric bubble visible in the chest
CT Chest/Abdomen:
- Large Type III (mixed) paraesophageal hernia
- Majority of stomach herniated into the chest
- Organoaxial rotation of the stomach
- No evidence of volvulus or ischemia currently
- GE junction above diaphragm
Upper Endoscopy:
- Large hiatal hernia with stomach in chest
- GE junction located at 35 cm (above diaphragm)
- Cameron erosions (linear ulcers at diaphragmatic hiatus)
- No stricture or malignancy
Barium Swallow:
- Large paraesophageal hernia with most of stomach intrathoracic
- No obstruction
- Delayed gastric emptying
Diagnosis
Type III (mixed) paraesophageal hernia with Cameron erosions
Surgical Indication
- Symptomatic large paraesophageal hernia
- Risk of acute incarceration/volvulus
- Cameron erosions causing chronic anemia (hemoglobin 10.8 g/dL)
Preoperative Optimization
- Cardiac clearance obtained
- Hemoglobin optimized with iron supplementation
- Nutritional counseling
- Risks discussed: 30-day mortality ~1% in elderly, recurrence risk
Operative Procedure
Laparoscopic paraesophageal hernia repair:
- Hernia sac dissected and reduced
- Stomach reduced to abdomen
- Crural repair with primary sutures (posterior cruroplasty)
- Bio-absorbable mesh reinforcement of crural repair
- Nissen fundoplication (360-degree wrap)
- Gastropexy to prevent recurrence
Postoperative Course
- Swallow study POD 1: No leak, wrap intact
- Clear liquid diet, advanced over 2 weeks
- Discharged POD 2
- Dysphagia expected initially (edema); resolved by 4 weeks
Follow-up
- 2 weeks: Tolerating soft diet, no dyspnea
- 6 weeks: Regular diet, no reflux symptoms, off PPI
- 3 months: Hemoglobin improved to 12.4 g/dL (Cameron erosions healed)
- 1 year: Chest X-ray normal, patient asymptomatic
Teaching Points
- Paraesophageal hernias: stomach herniates alongside (not through) GE junction
- Can cause cardiopulmonary symptoms due to mediastinal compression
- Risk of gastric volvulus, incarceration, strangulation (surgical emergency)
- Cameron erosions cause chronic GI blood loss and anemia
- Surgical repair recommended for symptomatic or large paraesophageal hernias
- Laparoscopic repair preferred with fundoplication and crural reinforcement
- Recurrence rate significant (10-30%), higher in elderly
Clinical Image
Image Description: CT scan of the chest demonstrating a large paraesophageal hernia with the majority of the stomach herniated into the thoracic cavity. The intrathoracic stomach is seen as a large soft tissue mass with air-fluid level posterior to the heart.
Attribution: Image from Wikimedia Commons. Source: https://commons.wikimedia.org/wiki/Category:Hiatal_hernia