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Background:
Giant Paraesophageal hiatal hernias (PEH) are most commonly associated with symptoms of chest pain, early satiety and GERD. However, Iron-deficiency anemia is an under-appreciated condition associated with giant PEH. The aim of this study was to evaluate the incidence of iron-deficiency anemia in a cohort of patients with giant PEH and assess the incidence of resolution associated with operative PEH repair.
Methods:
Between 2000 and 2010, 270 patients underwent operative repair of PEH and were prospectively entered into an IRB-approved database. From this cohort, 123 (45.6%) patients demonstrated a pre-existing diagnosis of iron-deficiency anemia. 77 patients had a documented pre-operative hemoglobin level (Hb) consistent with iron-deficiency anemia and a follow-up Hb level at least 3 months following surgery and constituted the study population.

Results:
From the cohort of 77 patients with documented pre-operative iron-deficiency anemia, 72 (94%) underwent elective PEH repair, with a median age was 75 (range 39-91). Cameron erosions were endoscopically documented preoperatively in 25 patients (32%). The average preoperative Hb value was 11.8 (7.6 - 16). Postoperatively at 3 - 12 month follow-up, the average Hb level was 13.2 (10.7 - 17), and at more than 1 year follow-up it was 13.6 (9.2 - 17.2) (P < 0.05). Furthermore 90% of patients had a rise in post-operative hemoglobin level by at least 1g/dL. Anemia was fully resolved postoperatively (Hb≥12.0 in females, ≥14.0 in males) in 55 (71%) patients. This resolution was observed more commonly in women (40/50, 80%) than men (15/27, 56%, P < 0.05). Also younger patients (<70 years) were more likely to resolve their anemia (29/33 vs. 26/44; P < 0.05) and have a greater post-operative Hb (14.0 vs. 13.0 g/dL; P < 0.05) than older patients. 40 patients required preoperative iron supplementation, 29 (73%) were able to discontinue iron following surgery. There was no significant difference in the resolution of anemia in patients with or without Cameron erosions (19/25 vs. 36/52, p=0.54).

Conclusion:
This single institution study shows a high incidence of iron-deficiency anemia (45.6%) in patients with giant PEH. Elective repair results in resolution of the anemia and discontinuation of iron supplementation therapy, in more than 70% of patients. This improvement in Hb is independent of the presence of pre-operative Cameron erosions. This study demonstrates the clinical and potential economic benefits of elective PEH repair of patients with Giant PEH and iron-deficiency anemia.