Hiatal (Diafragmatik) Hernilerde Tanı ve Tedavi
Özet
Hiatal herniler, abdominal organların mediastene yer değiştirmesiyle oluşan ve yaşla sıklığı artan hastalıklardır. En sık görülen ve genellikle asemptomatik seyreden Tip I (Sliding) dışında, morbidite ve mortalite riski yüksek olan Tip II, III ve IV (paraözofageal) herniler olmak üzere dört tipe ayrılır. Semptomatik hastalarda epigastrik ağrı, gastroözofageal reflü (GÖRH) ve anemiye yol açan Cameron ülserleri görülebilirken; gastrik volvulus ve strangülasyon gibi acil durumlar Borchardt triadıyla prezente olur. Tanıda akciğer grafisi, baryumlu pasaj grafisi, BT ve preoperatif gastroskopi kullanılır. Medikal tedavi semptomları rahatlatsa da kesin tedavi cerrahidir. Özellikle paraözofageal herniler, hayati komplikasyon riskleri nedeniyle tanı anından itibaren elektif cerrahiye alınmalıdır. Altın standart olan laparoskopik fundoplikasyonda herni kesesinin redüksiyonu, vagus sinirlerinin korunması, hiatal defektin gerilimsiz kapatılması ve nüksü önlemek için fundoplikasyon eklenmesi kritik adımlardır; mesh kullanımı ve krural gevşetme insizyonları ise tartışmalı veya gerekliliğe bağlı cerrahi stratejiler arasındadır.
Hiatal hernias are conditions characterized by the migration of abdominal organs into the mediastinum, with their incidence increasing with age. They are classified into four types: the most common and usually asymptomatic Type I (sliding) hernia, and Type II, III, and IV (paraesophageal) hernias, which carry significant risks of morbidity and mortality. Symptomatic patients often present with epigastric pain, gastroesophageal reflux disease (GERD), and Cameron ulcers causing anemia, while catastrophic complications like gastric volvulus and strangulation manifest through the Borchardt triad. Diagnosis relies on chest X-rays, barium swallow studies, CT scans, and preoperative gastroscopy. Although medical therapies alleviate symptoms, the definitive treatment is surgical; paraesophageal hernias, in particular, necessitate prompt elective surgery upon diagnosis due to life-threatening complications. Laparoscopic fundoplication is the gold standard, where crucial steps include herniated sac reduction, preservation of the vagal nerves, tension-free closure of the hiatal defect, and concomitant fundoplication to prevent recurrence, while mesh reinforcement and diaphragmatic relaxing incisions remain selective or debated strategies.
Referanslar
Shahid Z, Burns B. Anatomy, Abdomen and Pelvis, Diafragm. Statpearls Publishing. August 11, 2021.
Hyun JJ, Bak YT. Clinical significance of hiatal hernia. Gut Liver. 2011 Sep;5(3):267-77.
Richter JE, Rubenstein JH. Presentation and Epidemiology of Gastroesophageal Reflux Disease. Gastroenterology. 2018 Jan;154(2):267-276.
Che F, Nguyen B, Cohen A, Nguyen NT. Prevalence of hiatal hernia in the morbidly obese. Surg Obes Relat Dis. 2013;9(6):920-924.
Hashemi M, Sillin LF, Peters JH. Current concepts in the management of paraesophageal hiatal hernia. J Clin Gastroenterol. 1999;29:8-13.
Von Diemen V, Trindade EN, Trindade MR. Hiatal hernia and gastroesophageal reflux: study of collagen in the phrenoesophageal ligament. Surg Endosc. 2016;30(11):5091-5098.
Melvin WS, Perry KA. Paraesophageal hernia-open repair. In: Fischer JE, ed.Fischer’s Mastery of Surgery. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2012:760.
Hashemi M, Sillin LF, Peters JH. Current concepts in the management of paraesophageal hiatal hernia. J Clin Gastroenterol. 1999;29(1):8-13.
Mori T, Nagao G, Sugiyama M. Paraesophageal hernia repair. Ann Thorac Cardiovasc Surg. 2012;18(4):297-305. doi: 10.5761/atcs.ra.12.01882. Epub 2012 Jul 31.
Maganty K, Smith RL. Cameron lesions: unusual cause of gastrointesinal bleeding and anemia. Digestion 2008; 77(3-4):214-7.
Chang CC, Tseng CL, Chang YC. A surgical emergency due to an incarcerated paraesophageal hernia. Am J Emerg Med. 2009;27:134.
Ghosh RK, Fatima K, Ravakhah K, Hassan C. Gastric volvulus: an easily missed diagnosis of chest pain in the emergency room. BMJ Case Rep. 2016;2016:pii: bcr2015213888.
Skinner DB, Belsey RH. Surgical management of esophageal reflux and hiatus hernia. Long-term results with 1030 patients. J Thorac Cardiovasc Surg. 1967;53:33.
Larusson JH, Zingg U, Hahnloser D, Delport K, Seifert B, Oertli D. Predictive factors for morbidity and mortality in patients undergoind laparoscopic paraesophageal hernia repair: age, ASA score and operation type influence morbidity. World J Surg. 2009;33:980.
Stylopoulos N, Gazelle GS, Rattner DW. Paraesophageal hernias: operation or observation? Ann Surg. 2002;236(4):492-500, discussion 500-501.
Oelschlager BK, Petersen RP, Brunt LM, et al. Laparoscopic paraesophageal hernia repair: defining long-term clinical and anatomic outcomes. J Gastrointest Surg. 2012;16(3):453-459.
Fuller CB, Hagen JA, DeMeester TR, Peters JH, Ritter M, Bremmer CG. The role of funduplication in the treatment of type II paraesophageal hernia. J Thorac Cardiovasc Surg. 1996;111:655-661.
De Moor V, Zalcman M, Delhaye M, El Nakadi I. Complications of mesh repair in hiatal surgery: about 3 cases and review of the literature. Surg Laparosc Endosc Percutan Tech. 2012; 22(4):e222-225
Acin-Gandara D, Miliani-Molina C, Carneros-Martin J, Martinez-Pineiro J, Vega MD, Pereira-Perez F. Transmural gastric migration of dual-sided PTFE/ePTFEE mesh after laparoscopic surgery for a recurrent hiatal hernia with dysphagia:case report. Chirurgia(Bucur). 2014; 109(4): 538-541.
Oelschlager BK, Pellegrini CA, Hunter JG, Brunt ML, Soper NJ, Sheppard BC, et al. Biologic prosthesis to prevent recurrence after laparoscopic hernia repair: long term follow-up from a multicenter, prospective, randomized trial. J Am Col Surg. 2011;213(4):461-468.
Bradley DD, Louie BE, Faricar AS, Wilshire CL, Baik PU, Aye RW. Assessment and reduction of diaphragmatic tension during hiatal hernia repair. Surg Endosc. 2015;29(4): 796-804.
