Hiatal Hernia and Gastroesophageal Reflux
A hiatal hernia is a partial gastric pull-up across the hiatal orifice. Gastroesophageal reflux (GER) is frequently associated. On the contrary, a GER disease can exist without anatomical hiatal hernia. In many instances, a small hiatal hernia and slight
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Philippe Montupet and Reva Matta
12.1 Introduction A hiatal hernia is a partial gastric pull-up across the hiatal orifice. Gastroesophageal reflux (GER) is frequently associated. On the contrary, a GER disease can exist without anatomical hiatal hernia. In many instances, a small hiatal hernia and slight or transient GER are asymptomatic or well tolerated. There is a broad spectrum of symptoms related to hiatal hernia and GER. Postprandial regurgitations and failure are suggestive, although upper respiratory or pulmonary symptoms can prevail. In addition, ENT and allergic manifestations, or a failure to thrive, can be the main consequences in terms of symptomatology. Diagnostic techniques are required to confirm GER and associated hiatal hernia and also to assess its repercussions. Although the X-ray barium meal suffers from numerous limitations, it remains a useful tool. The pHmetry has gained popularity, performed over a 24-h period in ambulatory conditions. The P. Montupet (*) Hôpitaux Universitaires Paris-Sud, Bicêtre Hospital, Université Paris XI, 78 avenue du Général Leclerc, 94275, Le Kremlin-Bicêtre Cedex, France e-mail: [email protected]
endoscopy allows a simple and fast evaluation of the possible repercussions of reflux on the esophageal mucosa and may show a cardial gaping openness or a hiatal malposition. The manometry goes further since it is also a mean to investigate possible motor troubles and abnormalities of the lower esophageal sphincter (LES) pressure. Newly the impedancemetry [1–3] combines 24-h records of pH, motility, and pressures – an alkaline GER may be detected as well. Many children who suffer from a GER disease remain under-investigated. When a GER induces severe complications or escapes a prolonged medical treatment, surgical indications have to be considered. That is always the case for a large hiatal hernia. Surgery could also be more frequently indicated since advanced laparoscopic techniques and skill have improved dramatically surgical results [4]. All the techniques performed prior to the era of minimally invasive surgery (MIS) are reproducible under laparoscopy. However, the surgeon’s skill is related to a solid training, and as a matter of fact any surgeon is faithful to a favored technique. Thus, this chapter describes various approaches and also current trends.
R. Matta Assistant Professor of Clinical Surgery, University of Balamand, El-Koura, Lebanon
12.2 Pathophysiology
Division of Pediatric Surgery, Department of Surgery, Saint George Hospital University Medical Center, Beirut, Lebanon e-mail: [email protected]
The esophagogastric junction is an anatomical functional system anchored by anatomical elements which create an antireflux barrier. The fac-
© Springer International Publishing Switzerland 2017 M. Lima (ed.), Pediatric Digestive Surgery, DOI 10.1007/978-3-319-40525-4_12
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tors of anchorage are intrinsic (sphincter and His angle) and extrinsic (crura, membrane of Laimer, gastrophrenic ligament). The LES extends for about 1–2 cm abo
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