Occult Hiatal Hernia in Achalasia Patients: Its Incidence and Treatment Options

Background: Achalasia patients occasionally coexist with esophageal hiatal hernias. The purpose of this study was to clarify the incidence and clinical features of achalasia cases concomitant with hiatal hernia, and to investigate whether our surgical technique was appropriate. Methods: Consecutive achalasia patients who underwent laparoscopic Heller myotomy with Dor fundoplication (LHD) were extracted from the prospectively compiled surgical database, and the perioperative outcomes and the presence rate of hiatal hernia were obtained. Results: We enrolled 58 patients with LHD from 2005 to 2016. Hiatal hernia was seen in 12 patients (20.7%) without preoperative diagnosis. There was no significant difference in preoperative symptoms between patients with and without hiatal hernia. In 6 patients with trivial hiatal hernia, we did not perform hernia repair. In 6 cases with large hiatal hernia, cruroplasty was added. No serious postoperative complications were observed in either of the groups and no patient required reoperation. Symptoms were improved in all patients postoperatively. Residual symptoms were successfully treated with medication, and no patient experienced severe reflux esophagitis or required hiatal hernia repair after surgery. Conclusion: Hiatal hernia was found in 20.7% of patients who received surgical treatment for achalasia, but no cases were diagnosed prior to surgery.