Nonetheless, the authors suggest that patients with paraesophageal hernias are often labeled as asymptomatic or minimally symptomatic, because the hernia has been present for years in an older patient and the gradual alterations in eating and postprandial symptoms are attributed to aging. repair have changed, and currently symptomatic paraesophageal hernias are recommended for repair. In addition, it is important not to overlook iron-deficiency anemia and pulmonary complaints, which tend to improve with repair. Current practice favors a laparoscopic approach, complete sac excision, primary crural repair with or without use of mesh, and a routine fundoplication. strong class=”kwd-title” Keywords: hiatal hernias, paraesophageal hernias, gastroesophageal reflux disease, iron-deficiency anemia, mesh repair Introduction Paraesophageal hernia comprises 5% of all hiatal hernias. While historically all paraesophageal hernias were surgically repaired, intervention is now reserved for symptomatic paraesophageal hernias. In this review, we describe the indications for repair of paraesophageal hernia repair. Next we explore the controversies in paraesophageal hernia repair, which include a comparison of open to laparoscopic paraesophageal hernia repair, the necessity of complete sac excision, the routine performance of fundoplication, and the use of mesh for hernia repair. Methods We searched Pubmed for papers published between 1980 and 2015 using the following keywords: hiatal hernias, paraesophageal hernias, regurgitation, dysphagia, gastroesophageal reflux disease, aspiration, GERD, endoscopy, manometry, pH monitoring, proton pump inhibitors, anemia, iron-deficiency anemia, Nissen fundoplication, sac excision, mesh, and mesh repair. We found a total of 5743 papers. As we were not performing a meta-analysis of all clinical results in paraesophageal hernia, but rather providing an experience-based review of the most impactful contributions to the literature, we selected 36 papers for inclusion in our review. These represent substantial contributions to the field of paraesophageal hernia repair. Incidence and Clinical Presentation Paraesophageal hernia presents at a median age of 65C75?years, based on several large series in the literature (1C3). It is believed that most patients with paraesophageal hernia are asymptomatic. Symptoms can arise from obstruction, reflux, or bleeding. Obstruction at the gastroesophageal junction (GEJ) or at the level of the pylorus can occur from intermittent twisting of the stomach along its long axis while herniating into the chest. If the GEJ is obstructed, the patient will complain of dysphagia and regurgitation, while gastric outlet obstruction produces nausea, vomiting, and epigastric or chest pain. Gastroesophageal reflux disease (GERD) is more common in sliding hiatal hernia, but can occur in Chrysophanol-8-O-beta-D-glucopyranoside paraesophageal hernia as well. In a series of 95 consecutive patients with GERD, those with a sliding hiatal hernia over 3?cm had a significantly shorter lower esophageal sphincter (LES) and greater reflux on pH monitoring compared to those with no sliding hiatal hernia or a sliding hiatal hernia 3?cm (4). Bleeding from the herniated fundus of the Chrysophanol-8-O-beta-D-glucopyranoside stomach owing to mucosal ulcers, known as Cameron lesions, can produce iron-deficiency anemia. Regardless of mechanism, many patients with paraesophageal hernia have other non-specific symptoms, such as postprandial chest pain, postprandial fullness, and shortness of breath. Finally, patients can present acutely with strangulation of the stomach from acute gastric volvulus, which constitutes a Chrysophanol-8-O-beta-D-glucopyranoside surgical emergency. These patients retch but cannot vomit, and a nasogastric tube cannot be passed into the stomach (5). Diagnosis An essential diagnostic test for paraesophageal hernia is a barium swallow, which demonstrates the amount and position of Mouse monoclonal to GATA4 stomach within the thorax. We have found these images to be critical because they demonstrate the location of the GEJ, distinguishing a type II from a type III paraesophageal hernia (5). Hiatal hernias are classified into four types (5) and type III, known as a mixed paraesophageal hernia, is a true paraesophageal hernia and results from a combination of sliding type I and rolling type Chrysophanol-8-O-beta-D-glucopyranoside II hernia, with the stomach migrated into the chest and rolled over the stomach, with concomitant migration of the GEJ into the chest (Figure ?(Figure1).1). In the evaluation of paraesophageal hernia, upper endoscopy is performed to demonstrate the presence of mucosal lesions, as well as to determine whether esophagitis and Barretts esophagus are present. Finally, esophageal manometry is used to assess esophageal motility, which influences selection of the type of fundoplication (partial or total). Placement of a manometry catheter can be difficult in the setting of paraesophageal hernia, and can be guided by endoscopy if necessary. Esophageal pH monitoring is usually performed in the presence of GERD symptoms to document the presence of abnormal esophageal acid exposure. However, if a patient has.