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. 2026 Jan 23;49(1):46–52. doi: 10.1097/SGA.0000000000000926

Review of Perioperative Care in Elderly Patients With Esophageal Hiatal Hernia and Cardiopulmonary Disease

Haibin Zhang 1, Fangyan Lu 1,✉, Di Meng 1
Editor: Cathleen Shellnutt
PMCID: PMC12829495  PMID: 40910797

ABSTRACT

This article aims to explore the clinical characteristics and corresponding nursing points of elderly patients with massive hiatal hernia. A case study of an elderly patient with massive hiatal hernia and severe cardiopulmonary disease was reviewed, along with relevant literature. Nursing points are the following: multidisciplinary team to estimate surgical risks and develop individualized pre-rehabilitation management strategies; assessment and intervention for thrombosis and bleeding risks; postoperative hemodynamic monitoring and precise fluid management; dynamic observation of inflammatory indicators and infection prevention and care; and follow-up visits and health guidance after discharge. Hiatal hernia is common clinically, but it is rare in elderly patients with severe cardiopulmonary disease. Thorough literature review, familiarity with the characteristics of this condition in elderly patients, and proper perioperative nursing management and guidance are crucial for the successful recovery of elderly patients with massive hiatal hernia.

Esophageal hiatal hernia (HH) is a common digestive system disease characterized by the temporary or persistent herniation of intra-abdominal tissues and organs into the thoracic cavity through the esophageal hiatus (Kim et al., 2021; Roman & Kahrilas, 2014; Siegal et al., 2017). Clinical cases of sliding HH are the most common, accounting for over 95% of all HH. The incidence of HH increases significantly with age, reaching nearly 60% in individuals over 60 years old. In elderly patients, the esophageal ligament is lax, and sphincter function is weakened. Early reflux symptoms may be atypical or less noticeable, often leading to treatment for related conditions such as heart and lung diseases. By the time of diagnosis, a large HH (giant hiatal hernia [GHH]) may already be present (Banki, 2017; Duranceau, 2016; Li et al., 2022). GHH is clinically rare, but its risk is extremely high. Besides causing cardiac and respiratory complications due to compression of the heart and lungs, GHH is more prone to gastrointestinal volvulus and organ necrosis.

Currently, there are few case reports of GHH combined with severe cardiopulmonary diseases both domestically and internationally. This article presents the case of an elderly patient with a GHH complicated by severe cardiopulmonary disease, along with a review of relevant literature. The aim is to enhance the early recognition of atypical clinical manifestations of GHH in elderly patients, and improve perioperative care management and guidance for these patients.

Clinical Data

The patient is a male, 86 years old, with a height of 5 ft., 2 in. and a weight of 108 lbs. He has experienced symptoms which worsened over the past week leading to hospitalization. Three weeks prior, he developed chest tightness and coughing without any obvious trigger, along with acid reflux, hiccups, and poor appetite, despite taking stomach-protecting medication. One week prior to hospitalization, his chest tightness and hiccups worsened, accompanied by chest pain, difficulty breathing, and swallowing difficulties.

He was admitted to a local hospital where an electrocardiogram (ECG) showed “sinus tachycardia, ST- and T- wave changes,” myocardial enzyme levels were significantly elevated (details unknown), and fecal occult blood was positive. A lung computed tomography (CT) scan revealed 2 pneumonia lesions and HH. Endoscopy showed: gastric body ulcer, HH, and reflux esophagitis with Los Angeles classification grade D (LA-D) and bleeding (Figure 1). Symptomatic treatment at the local hospital was ineffective, so he was transferred to our hospital.

FIGURE 1.

FIGURE 1.

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Endoscopy suggested cardia relaxation, HH; congestion and erosion of the lower esophagus, large ulcer formation, and spontaneous bleeding were observed.

He has a history of rib deformity, scoliosis, and osteoporosis for over 7 years, taking alendronate sodium tablets 1# QW. He has had poor sleep for a long time, taking diazepam 1# QD, and underwent internal fixation surgery for patellar fracture and lumbar vertebrae fracture 10 years ago.

Treatment and Outcome

Upon admission on March 12, 2024, the patient had a tender point at the level of the xiphoid process with a score of 2, anemic appearance, chest tightness, orthopnea, and a respiratory rate of 26 breaths per minute. Laboratory tests showed: hemoglobin concentration 109 g/L, serum albumin 34.4 g/L, serum prealbumin 14.2 mg/dL, serum troponin I 0.021 ng/mL, lactate dehydrogenase 328 U/L, pyruvate dehydrogenase 259 U/L, creatine kinase 56 U/L, creatine kinase isoenzyme 12 U/L, B-type urinary natriuretic (precursor) quantified 793 pg/mL, D-dimer 1807 μg/L FEU (Fibrinogen Equivalent Units), and a nutritional risk score of 5 (NRS2002) (Zhang et al., 2020). Admission diagnoses were massive HH (i.e., GHH), heart failure, pneumonia, and hypoalbuminemia. The patient was given oxygen, ECG monitoring, total parenteral nutrition, anti-infection treatment, and proton pump inhibitor therapy for 3 days, during which symptoms improved.

On March 15, 2024, under general anesthesia, the “laparoscopic repair of esophageal hiatal hernia” was performed, lasting 90 min with approximately 50 mL of intraoperative bleeding. A nasogastric tube and a right-sided abdominal drainage tube were placed postoperatively. Postoperative treatments included anti-inflammatory medication, nutritional support, analgesics, expectorants, and acid suppression.

On the fifth day after surgery, multiple Candida infections were observed on the oral mucosa, palate, and tongue. The patient received oral care and topical application of nystatin tablets, controlling the oral infection symptoms. On the sixth day post-surgery, rapid atrial fibrillation occurred, and the patient was treated with diuretics, anti-inflammatory drugs, and precise fluid management, leading to gradual improvement in symptoms.

After meticulous care, the patient was discharged 11 days post-surgery. At the 3- and 6-month follow-up, the patient had no chest tightness, chest pain, dyspnea, acid reflux, or hiccups and his quality of life was satisfactory.

Nursing Experience

Multidisciplinary Team Estimates the Surgical Risk

Based on clinical manifestations and auxiliary examinations, the elderly patient was diagnosed upon admission with GHH complicated by severe cardiopulmonary insufficiency, gastric ulcer, anemia, and hypoalbuminemia. A multidisciplinary team comprising surgeons specializing in HH surgery, cardiology, pulmonology, radiology, intensive care, anesthesiology, nutrition, and rehabilitation was formed to implement both online and offline diagnostic and therapeutic models, with responsible nurses participating in disease discussions and treatments.

Using the commonly used physiological and surgical severity score, (Physiological and Operative Severity Score [POSSUM] for the enumeration of Mortality and Morbidity, (Burtin et al., 2023; Meshikhes, 2020) as a tool to predict surgical risks, a comprehensive assessment of the patient’s physical condition, medical history, and surgical tolerance was conducted. The preoperative patient’s physiological factor variable score was 49 points, the surgical severity factor variable score was 17 points, the mortality rate (R1) was 3.81%, and the complication rate (R2) prediction was 24.79%. An individualized pre-rehabilitation management strategy was then formulated.

Develop Individualized Pre-rehabilitation Management Strategies

Pre-rehabilitation of Exercise Focusing on Cardiopulmonary Rehabilitation

Sports training is the core content of pre-rehabilitation. In this case, due to a GHH, more than half of the gastric tissue herniated into the mediastinum, and the patient developed severe heart failure and refractory pneumonia. The patient was determined to be Grade III using the New York Heart Association (NYHA) cardiac function classification (Caraballo et al., 2019). On the basis of drug therapy, an individualized exercise training list was developed including: ① Implement graded exercise rehabilitation training: After admission, provide adequate bed rest, with responsible nurses assisting in standing and walking beside the bed, 3–4 times/day, each session lasting 5–10 min. Based on the patient’s condition, attempt indoor or bedside walking until the patient can complete it independently, and assist in practicing self-care for bowel and bladder functions until he can do so independently. ② The patient should perform pursed-lip abdominal breathing (Haruyama et al., 2022): Inhale while expanding the abdomen, exhale slowly by drawing in the lips, ensuring a slow exhalation. The inhalation-to-exhalation ratio should be ≥1:2: Breathing rate of 6–8 times/min, training twice daily, each session lasting 10–20 min. ③ The patient should use a breathing trainer to train respiratory function: Set training goals, with 5 breaths per set, 3 sets per session, 3 times daily. He should be able to demonstrate the correct method for using the breathing trainer: hold the trainer’s mouthpiece after a normal exhalation and then slowly inhale deeply. When the yellow float of the trainer reaches the preset target position, he should hold his breath for 2–3 s at the end of inhalation, then release the mouthpiece and exhale slowly to complete the exercise. The patient should adjust his breathing before proceeding with the next respiratory function training session.

After personalized guidance, the patient’s lung capacity increased from 1800 to 2500 mL, as measured by the 6-min walk test (6MWT) on the day before surgery (Agarwala & Salzman, 2020; Halliday et al., 2020). His preoperative 6MWT distance improved from 150 ± 12.63 to 400 ± 55.89 m post-prehabilitation, reflecting enhanced cardiopulmonary capacity.

Nutritional Pre-rehabilitation

The nutritional assessment score (NRS2002) of the patient at admission was 5, indicating moderate nutritional risk (Zhang et al., 2021). Hemoglobin concentration was 109 g/L and serum albumin was 34.4 g/L, indicating malnutrition. The patient had a gastric body ulcer with bleeding, and preoperative fasting was required. A nasogastric tube was placed. Major surgery is associated with high metabolism and emergency conditions, so ensuring adequate nutritional intake is crucial for preoperative rehabilitation.

Total parenteral nutrition was initiated with a target protein supply of 1.5 g/kg/day and caloric supply of 126 kJ/kg/day, along with fluid replacement of 1550 mL (including 250 mL of medium- and long-chain fat emulsion, 250 mL of compound amino acid (18AA-2), and 40 mL of multiple trace elements), and albumin at 10 g/d. After 3 days, the patient’s hemoglobin concentration was 91 g/L, serum albumin increased to 38.9 g/L, and there was no change in weight.

Psychological Pre-rehabilitation

Negative psychological states can lead to disorders in the physiological, mental, and immune systems. After admission, the patient exhibited negative emotions such as anxiety and fear. Cognitive intervention using acceptance and commitment therapy was conducted, guiding the patient and family to express their true thoughts through core processes including relationship building, acceptance, cognitive disassociation, experiencing the present moment, and committing to action (Towey-Swift et al., 2023).

The patient expressed a desire for a complete cure through surgery but was afraid of age-related organ dysfunction and various postoperative complications. By using images and videos, it was explained that the surgery would be performed laparoscopically, which has the advantages of minimal trauma and faster recovery. Early surgery can prevent serious consequences caused by complications.

Additionally, foot soaking with warm water combined with Wu Zhu Yu An Shen Ointment applied to the Yongquan acupoint was used. The patient’s lower limbs (below the knees) were soaked in warm water (39 ℃~41 ℃) for 20–30 min, followed by applying a patch made from Wu Zhu Yu An Shen Ointment (containing 4 ingredients: Wu Zhu Yu, Rhodiola rosea, Poria, and Jujube Seed) to the Yongquan acupoint (located at the intersection of the anterior one-third and posterior two-thirds of the line connecting the head of the second and third metatarsophalangeal crease to the heel). With this treatment, the patient should apply moderate pressure to stimulate the acupoint until a feeling of soreness and distension is felt, once every night, and remove it upon waking.

Through various intervention methods, anxiety and depression levels were measured using anxiety scales and depression scales (Teymoori et al., 2020), with anxiety evaluation. Scores dropped from 69 to 56, depression scores dropped from 60 to 58, and patients slept well.

After cardiopulmonary exercise, nutrition, psychological, and other rehabilitation interventions, the patient’s POSSUM physiological factor score decreased to 39 points, the mortality rate (R1) was 1. 18%, and the predicted incidence of complications (R2) was 7.04%. The predicted mortality rate and complication incidence decreased by 30.97% and 28.39%, respectively.

Assessment and Intervention of Thrombosis and Bleeding Risk

The patient’s gastroscopy revealed an ulcer in the gastric body, GHH, and reflux esophagitis at stage LA-D with symptoms of bleeding. Hemoglobin concentration was 109 g/L, and the fecal occult blood test was positive, indicating gastrointestinal bleeding. Additionally, plasma D-dimer levels were 1807 µg/L FEU, suggesting a hypercoagulable state. The Caprini ThromboRisk Assessment Scale (Caprini scale) was used (He et al., 2022) and the patient scored: 1 point for central venous catheter placement, 1 point for having suffered from severe pulmonary disease within the past month, 2 points for laparoscopic surgery (or planned) >45 min, and 3 points for age factors, totaling 7 points, indicating a high risk of thrombosis. The patient also faces dual risks of bleeding and thrombosis.

A multidisciplinary team developed a comprehensive treatment and care plan. While actively maintaining stable vital signs through fluid replacement, anticoagulation therapy was selected. Protamine sulfate injection at 4100 U was administered subcutaneously once daily. During the patient’s bed rest, it was recommended to elevate both legs by 20°~30° to promote venous return. Additionally, ankle pump exercises and quadriceps muscle function exercises were performed as basic preventive measures. The patient performed flexion and extension movements of both feet, quadriceps muscle contractions, and straight leg raises, performing 20~30 sets each time, 3~4 times daily. Continuous use of graduated compression stockings for physical prevention as required, with daily wear exceeding 18 hs and no more than 30 min off.

During anticoagulation therapy, the patient’s vital signs and hemoglobin concentration changes were closely monitored. Based on dynamic monitoring results, the patient’s ambulation activity was gradually increased. After comprehensive preventive measures, the patient’s vital signs, hemoglobin concentration, and imaging results of both lower limbs and lungs showed no signs of active bleeding or thrombosis.

Postoperative Care

Strengthen Hemodynamic Monitoring and Accurate Volume Management

The patient was an elderly patient with grade III heart function. Metabolic changes caused by surgery are often accompanied by electrolyte disturbances such as water, sodium, and potassium requiring “goal-directed fluid therapy (goal directed fluid therapy, GDFT)” (Teja & Mazer, 2021; Zampieri et al., 2023). Individualized fluid therapy can reduce the incidence of postoperative complications and mortality, as well as shorten hospital stays.

Before fluid replacement, a comprehensive assessment of the patient’s overall condition is conducted, including fluid loss, electrolyte balance, renal function, and cardiac function. The total fluid volume is set at approximately 30–35 mL/kg body weight, with an initial infusion rate not exceeding 60 drops per minute (about 250 mL/hr). During the fluid administration, heart rate, blood pressure, and respiration are monitored every 2 hs, urine output is recorded every 4–6 hs, and central venous pressure (CVP) is measured every 24 hs to ensure timely adjustments to the fluid strategy.

On the sixth day post-surgery, the patient developed rapid atrial fibrillation with a heart rate of 101–142 beats per minute, blood pressure of 101/60 mmHg, oxygen saturation of 95%, CVP 9 cmH2O, and B-type natriuretic peptide levels of 517 pg/mL. The patient was switched to mask oxygen at 5 L/min, received dobutamine for cardiac support, and was also given diuretics and anti-inflammatory agents to maintain fluid balance. Three days later, B-type natriuretic peptide levels decreased to 82.70 pg/mL, and the patient’s symptoms gradually improved.

Dynamic Observation of Inflammatory Indicators, and Infection Prevention and Care

Postoperative infections in elderly patients are common, including wound infections, lung infections, urinary tract infections, and oral infections. Dynamic monitoring of inflammatory indicators is essential, with temperature changes monitored every 4 hs. White blood cells, C-reactive protein, and calcitonin levels are also dynamically tracked to assess the progression of infection. The patient’s plan of care relevant to minimizing post-operative infection focused on 4 common sources.

① Wound Infection: For laparoscopic surgery using the 5-port technique (1 observation port and 4 operation ports), dressings are changed regularly to keep the wound clean and dry. In this case, no drainage tube or incision infection occurred postoperatively.

② Lung Infection: Patients are instructed to cough and expel phlegm correctly, observing the color and nature of the sputum, and auscultating for wet rales in the lungs. Postoperatively, the patient received self-administered analgesia pump (PCA) pain control, with a pain NRS score of ≤3. Nebulized inhalation of diluted phlegm and anti-inflammatory agents (0.5 mg of ipratropium bromide solution + 2 mg of budesonide suspension) was administered 3 times daily for 15 min each time. The patient was also assisted in turning over and back tapping to facilitate sputum expulsion. With active anti-infection treatment, CT scans showed relief of pulmonary inflammation, and the patient could cough up yellowish-white phlegm on their own.

③ Urinary Tract Infection: The patient has benign prostatic hyperplasia, making postoperative indwelling urinary catheterization highly susceptible to urinary tract infections. During catheter placement, the urethral opening was disinfected twice daily with iodine tincture. Bladder function training began on the first postoperative day, and the catheter was removed on the third day. The patient could urinate spontaneously without experiencing increased frequency or urgency pain symptoms.

④ Oral infection: The patient had a nasogastric tube placed perioperatively and was fasting for nearly a week. Antibiotics were administered immediately upon admission, along with hypoproteinemia and nutritional deficiencies leading to vitamin deficiencies. On the fifth day post-surgery, multiple white patches were observed on the palate and tongue mucosa, some of which could be wiped away, with no significant tenderness upon palpation. The dental department considered Candida infection. Oral care was provided twice daily, using sodium bicarbonate mouthwash and Kangfuxin solution alternately, tid. Clotrimazole tablets (5 tablets) + glycerin (30 g) were applied orally and topically tid. After 3 days of anti-infective treatment, the patient’s oral infection symptoms were controlled, allowing for a semi-liquid diet without pain.

Postoperatively, the patient’s temperature fluctuated between 38 ℃ and 39 ℃, with intravenous infusion of 2 g of cefoperazone sulbactam (Shupu) every 8 hs. The white blood cell count decreased from 14.43 × 109/L to 8.16 × 109/L, C-reactive protein from 243.68 to 85.78 mg/L, and calcitonin levels from 1.05 to 0.32 ng/mL. The temperature gradually returned to normal.

Follow-Up and Health Guidance After Discharge

In the early postoperative period for HH repair, patients often experience mild to moderate dysphagia, belching, and belching symptoms after eating. These symptoms generally improve significantly within 2–4 weeks and eventually return to normal. Patients should be educated on maintaining a healthy lifestyle after discharge, gradually increasing their food intake with a focus on high-protein, high-energy, easily digestible foods. Food intake can also be supplemented with nutritional supplements. In daily life, they should avoid factors that may trigger HH recurrence, such as eating too quickly, overeating, eating before bedtime, frequently bending over or lying down after meals, and prolonged sitting, which may increase intra-abdominal pressure. After discharge, patients should continue with follow-up visits at 3 and 6 months post-surgery, during which their diet should be recovered and their weight increased compared to when they were discharged.

Discussion

Esophageal HH is a special type of hernia, often presenting with nonspecific symptoms such as acid reflux, belching, and upper abdominal fullness. A large esophageal HH (i.e., GHH) is typically defined as a hernia where more than 30% of the stomach protrudes into the chest cavity or through the esophageal hiatus, with a diameter of >6 cm. This type is considered a high-risk subtype of HH and can lead to severe complications such as gastric volvulus, gastrointestinal obstruction, strangulation, bleeding, and compression (Ardu et al., 2022).

Currently, the clinical diagnosis and treatment of GHH combined with cardio-pulmonary diseases lack a standardized approach. In this case, the elderly patient was initially diagnosed with cardio-pulmonary and other related diseases and was managed by internal medicine. Following referral to our hospital, through multidisciplinary discussions, the team formulated and implemented individualized preoperative rehabilitation management strategies for the patient’s poor overall nutritional status and poor cardio-pulmonary function. Postoperatively, we managed fluid volume, identified complications, and provided early enteral nutrition support. The patient smoothly transitioned into a liquid diet post-surgery, and both pulmonary infection and cardiac function showed significant improvement.

Individualized perioperative nursing management and guidance are essential components in the successful recovery of elderly patients with GHH, playing a crucial role in perioperative care. Nursing, as an important part of multidisciplinary efforts, plays a vital role in safeguarding patient.

Footnotes

THE OFFICIAL JOURNAL OF THE SOCIETY OF GASTROENTEROLOGY NURSES AND ASSOCIATES, INC.

DEDICATED TO THE SAFE AND EFFECTIVE PRACTICE OF GASTROENTEROLOGY AND ENDOSCOPY NURSING

Haibin Zhang is the first author, and Fangyan Lu is the corresponding author.

F.L. contributed to the conception/design of the research. D.M. contributed to the acquisition, analysis, or interpretation of the data. H.Z. drafted the manuscript. All authors approved the final manuscript and agree to be fully accountable for ensuring the integrity and accuracy of the work.

The authors thank Professor Lisong Teng and Professor Jun Lu, Department of Surgical Oncology, the First Affiliated Hospital of Zhejiang University School of Medicine, for their guidance in the preparation of this manuscript.

The data that support the findings of this study are available from the corresponding author upon reasonable request.

This case study was approved by the clinical research ethics committee of the First Affiliated Hospital of Zhejiang University School of Medicine (No. IIT20241020A).

The authors declare to have the written informed consent of the son of the patient involved in the reported case to prepare and publish the case report. The patient himself could not give his consent for obvious reasons.

This study was not funded.

The authors report no conflicts of interest in this work.

No other relevant content was reproduced in this study.

Contributor Information

Haibin Zhang, Email: 1192069@zju.edu.cn.

Fangyan Lu, Email: 2196032@zju.edu.cn.

Di Meng, Email: 2843994578@qq.com.

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