Alternatives to hiatal hernia repair for the high-risk patient

Abstract

Hiatal hernia is a common problem affecting the comorbid elderly patients who are not always the best candidates for traditional hiatal hernia repair, which requires general anesthesia and relatively long periods of pneumoperitoneum with mediastinal dissection. This review article explores existing evidence and discusses alternative management and interventional strategies in treating hiatal hernia in the highrisk patients. In addition to discussion of non-operative management of hiatal hernia in these patients, we explore the roles of endoscopic, surgical, and combined endoscopic and laparoscopic interventions as alternatives to the traditional hiatal hernia repair. Given that gastric volvulus is one of the few complications from hiatal hernia that would require urgent operative intervention, we focus on acute gastric volvulus specifically with a proposed management algorithm in the high-risk patient population. While there is no consensus in the literature on the optimal alternative management to definitive hiatal hernia repair, we favor a patient-centered approach with goals of adequate symptom control as well as prevention and treatment of any potential life-threatening complications. It is important for surgeons and gastroenterologists alike to be familiar with the alternative management options for hiatal hernia in order to take care of patients who are otherwise too high risk to undergo traditional laparoscopic or open hiatal hernia repair.