HERNIAS • SENIOR RESIDENT / SURGEON

Paraesophageal Hernia

Chronic dysphagia and early satiety can become an acute gastric-volvulus emergency when obstruction or strangulation develops.

PROTOTYPE REVIEW REQUIRED

The Call

54-year-old man

Two months of dysphagia, chest discomfort and early satiety. Imaging demonstrates a large paraesophageal hernia with much of the stomach above the diaphragm.

Stable

The key decision is whether this is elective mechanical disease or an acutely obstructed/strangulated stomach.

Read the Image • Clinical DataACS VISUAL

Paraesophageal hernia image from the ACS image archive.

Make the Decision • Commit to a Plan

An older patient with known paraesophageal hernia develops acute epigastric pain, retching and inability to pass an NG tube. CT suggests organoaxial gastric volvulus. Best next step?

Paraesophageal Hernia

54-year-old man

An older patient with known paraesophageal hernia develops acute epigastric pain, retching and inability to pass an NG tube. CT suggests organoaxial gastric volvulus. Best next step?

After reduction the fundus is dusky but improves with warming; the hiatus is large. Best principle?

Postoperatively the patient develops tachycardia, chest pain and rising lactate. Best next concern?

Reduce, assess viability, restore anatomy.

Watch for dysphagia, leak and thoracic complications.

Surgical Pearls

Pitfalls

A paraesophageal hernia patient has severe chest/epigastric pain, unproductive retching and inability to pass an NG tube. What changes?