Ann Thorac Surg 2002;74:333-337
© 2002 The Society of Thoracic Surgeons
Original article: general thoracic
Effect of paraesophageal hernia repair on pulmonary function
Donald E. Low, MD*a,
Eric J. Simchuk, MDa
a Section of General Thoracic Surgery, Virginia Mason Medical Center, Seattle, Washington, USA
* Address reprint requests to Dr Low, Section of General Thoracic Surgery, Virginia Mason Medical Center, 1100 Ninth Ave, Seattle, WA 98101 USA
e-mail: donald.low{at}vmmc.org
Presented at the Poster Session of the Thirty-eighth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28–30, 2002.
 |
Abstract
|
|---|
Background. Paraesophageal hernias classically present in elderly patients with symptoms of postprandial pain, bloating, dysphagia, and anemia. Most surgeons would advocate repairing paraesophageal hernias whenever they are encountered, however, significant levels of dyspnea or pulmonary dysfunction could previously have led to concerns regarding individual patient suitability for repair. We have noted that patients complaining of dyspnea prior to paraesophageal hernia repair often noted significant improvement following surgery.
Methods. Between 1995 and 2001, 45 patients (mean age 71.5 years) presented with paraesophageal hernias. Patients had preoperative investigations including chest roentgenogram and barium swallow, 100%; upper endoscopy, 96%; manometry, 89%; and 24-hour pH studies, 27%. Operative repair was accomplished with an open Hill repair with intraoperative manometrics. All patients had assessment of pre- and postoperative spirometry, diffusion capacity, dyspnea index, and quality of life assessment.
Results. Presenting symptoms included dyspnea, 84%; heartburn, 71%; dysphagia, 67%; regurgitation, 64%; and anemia, 47%. Type II hernias were found in 2 patients, type III in 33 patients, and type IV in 10 patients. Complications were minimal; mortality was zero. Mean length of stay was 4.7 days (range 3 to 9). Significant improvement in spirometry levels were noted in mean forced expiratory volume in 1 second (FEV1) (preop, 1.87 liters; postop, 2.17 liters; percent improvement, 16%), p < 0.0001; mean forced vital capacity (FVC) (preop, 2.52 liters; postop, 2.89 liters; percent improvement, 14.7%), p < 0.0001; mean percent predicted FEV1 (preop, 75.8%; postop, 88.6%), p < 0.0001; and mean percent predicted FVC (preop, 78.8%; postop, 91.5%), p < 0.0001. An improvement trend was noted in diffusing capacity, which did not reach statistical significance. The degree of improvement was seen to correlate with the size of the hernia. When hernias involved 100% of the stomach, percent improvement in FEV1 of 19.6% and FVC of 19.7% were noted. Two patients who required home oxygen were able to discontinue therapy following surgery. Significant improvements in quality of life scores and dyspnea index were documented.
Conclusions. Elderly patients with paraesophageal hernias are occasionally considered inappropriate candidates for surgical repair on the basis of coexistent medical problems including pulmonary dysfunction. Paraesophageal hernia repair is routinely associated with significant improvement in spirometry values, dyspnea index, and quality of life scores.
|
Introduction
|
|---|
Paraesophageal hiatal hernias (type II, III, IV) are much less common than the standard sliding hiatal hernia (type I) often associated with gastroesophageal reflux disease. These hernias classically present in the older patient population (age 60 to 90), and associated symptoms most commonly involve dysphagia, regurgitation, chest pain, and microcytic anemia.
Paraesophageal hernias can reach massive proportions in certain patients producing profound attenuation of the esophageal hiatus and can volumetrically displace components in the inferior chest, mediastinum, and retrocardiac area.
Patients with paraesophageal hernias are often considered to be poor operative risks due to advanced age and impaired pulmonary function. We have noted that a significant component of patients will note increasing levels of dyspnea over the years prior to their presentation and that they will routinely report an improvement in breathing and exercise capacity following surgery. We hypothesize that the presence of paraesophageal hernias impairs respiratory function and that by restoring normal anatomy within the chest and the esophageal hiatus, respiratory parameters will improve.
|
Material and methods
|
|---|
The study included patients presenting with type II, III, and IV paraesophageal hernias to Virginia Mason Medical Center between 1995 and 2001. All patients were reviewed to document preoperative symptoms. Preoperative studies included chest roentgenogram (100%), barium swallow (100%), endoscopy (96%), manometry (89%), and 24-hour pH study (27%).
Basic spirometry studies and diffusion capacity measurements were carried out 1 to 4 weeks preoperatively and repeated 1 to 6 months following surgery. All patients underwent reconstruction of the gastroesophageal junction (Hill repair) done through an upper midline incision with an epidural catheter in place. The procedure included reduction of the paraesophageal hernia, complete removal of the paraesophageal hernia sac, primary closure of the esophageal hiatus, and Hill repair. Selected patients also underwent gastrostomy.
Additional postoperative assessment involved documentation in changes in dyspnea index, quality of life parameters, and assessment of postoperative symptoms. Statistical analysis was carried out with Student’s t test.
|
Results
|
|---|
Patients were studied between 1995 and 2001. These included 45 patients, 16 males and 29 females, mean age 71.5 years (range 46 to 91). Presenting symptoms are shown in Table 1.
Over 50% of patients presented with symptoms of gastroesophageal reflux disease, dysphagia, and regurgitation. However, 84% complained of some degree of dyspnea preoperatively. Two patients (5%) were on home oxygen preoperatively. Three patients underwent urgent operations following hospitalization for what was thought to be transient incarceration of the paraesophageal hernias. Mean preoperative American Society of Anesthesiology score was 2.32.
The type of paraesophageal hernia was assessed preoperatively at the time of barium swallow. Type II hernias were found in 2 patients (Fig 1).
Type III hernias were seen in 33 patients (Fig 2),
and 10 patients presented with type IV paraesophageal hernia (Fig 3).
Manometry studies were carried out in 40 patients (89%). Peristalsis was found to be intact in 32 patients; 8 patients were found to have nonspecific motility disorders. Preoperative endoscopy demonstrated callous ulceration in 15 patients (33%).
View larger version (134K):
[in this window]
[in a new window]
|
Fig 1. Type II paraesophageal hernia—esophagogastric junction (arrow) remains in normal subdiaphragmatic position.
|
|
View larger version (122K):
[in this window]
[in a new window]
|
Fig 2. Type III paraesophageal hernia—combined sliding and paraesophageal hernia with intrathoracic air fluid level in stomach.
|
|
View larger version (132K):
[in this window]
[in a new window]
|
Fig 3. Type IV paraesophageal hernia—combined hernia with other abdominal viscera within the hernia sac. This radiograph of the delayed portions of a barium swallow shows small bowel located alongside paraesophageal hernia.
|
|
All patients underwent Hill procedure utilizing intraoperative manometrics. All patients were extubated immediately postoperatively, and postoperative pain was managed with patient-controlled epidural anesthesia. Other procedures performed at the same time included gastrostomy, 4; cholecystectomy, 3; resection of gut stromal tumor, 1; pelvic lymph dissection, 1; and coronary artery bypass grafts, 1. All 4 patients undergoing gastrostomy had very large type IV hernias.
Mean length of stay was 4.7 days (range 3 to 9 days) and mean follow-up was 19 months (range 2 months to 6 years). Postoperative complications and symptoms are shown in Table 2.
In-hospital and 30-day mortality was zero.
Comparisons of pre- and postoperative forced expiratory volume in 1 second (FEV1), FVC, percent predicted FEV1 and FVC, and diffusion capacity is demonstrated in Tables 3 and 4.
Significant improvements were documented with FEV1, FVC, and percent predicted FEV1 and FVC. There was a trend toward improvement with DLCO, although it did not reach statistical significance. A decrease in postoperative FEV1 was noted in only 3 patients, whereas only 1 patient failed to show an increase in FVC.
Table 5
examines the effect on pre- and postoperative spirometry values depending on the size of the paraesophageal hernia. Paraesophageal hernias that encompassed 75% to 100% of the stomach showed percent improvements ranging from 13.2% to 19.7% after paraesophageal hernia repair. Improvements in quality of life score and dyspnea index are shown in Table 6.
The two patients who required home oxygen prior to surgery were able to discontinue this therapy following surgical repair.
|
Comment
|
|---|
There is a significant body of literature suggesting a relationship between pulmonary symptoms and gastroesophageal reflux disease [1–3]. However, there is very little assessment of the potential ramifications of large hiatal hernias and pulmonary function.
Sliding (type I) hiatal hernias can become very large, but do not often reach the proportions seen with paraesophageal hernias (type II, III, and IV). Patients who present with these hernias are typically elderly and often present with other complex medical problems. These patients usually demonstrate symptoms of postprandial pain and bloating, dysphagia, and anemia [4, 5]. It is clear, however, that a significant component will present with an evolving problem with dyspnea over the previous decade prior to their surgery. These symptoms are often ascribed to chronic obstructive pulmonary disease, "heart problems," or simply the patient’s advanced age. We have observed that the majority of patients will note an improvement in the level of dyspnea following paraesophageal hernia repair. Senyk and colleagues have previously reported changes in basic spirometry values [6] and ventilation studies [7] following repair of a variety of hiatal hernias. They have noted that the dimensions of the effect varied with the size of the hernia. We have documented a very similar relationship in patients with paraesophageal hernias demonstrating dramatic improvements in basic spirometry values in the range of 14% to 16% increases in FEV1 and FVC. These improvements become more prominent as the size of the hiatal hernia increases. Objective findings are mirrored in improvements in dyspnea index and quality of life parameters.
The explanation of these findings has previously been thought to be secondary to improvement in diaphragmatic function [8–10] or decreasing levels of atelectasis [11]. Considering the dimensions of the diaphragmatic defects encountered in many of these patients, the reestablishment of normal diaphragmatic contour and configuration is potentially a major factor. It may also be one of the most important reasons to provide an anatomic primary closure of the hiatus rather than using prosthetic material. Some of these hernias will contain not only the entire stomach, but occasionally components of colon, omentum, and small bowel (type IV paraesophageal hernias). Previous reports in patients with hiatal hernias have documented ventilation abnormalities involving upper as well as lower pulmonary zones [7] supporting the hypothesis that dyspnea may be secondary to transient changes in ventilation and perfusion. It is also feasible that in this elderly population, acute distention may have a temporary impact on cardiac function contributing to symptoms of dyspnea and changes in exercise capability.
Historical reports of open repairs have established the importance of hernia reduction, sac removal, secure closure of the esophageal hiatus, and anchoring the repair (usually in association with an antireflux procedure) in the abdominal cavity. There have been a large number of recent publications reporting the feasibility of laparoscopic paraesophageal hernia repair. Unfortunately, many of the basic tenets of the operation needed to be "relearned" during this process [12–14]. In addition, some recent publications have demonstrated the technical feasibility of paraesophageal hernia repair, but with the recognition that the approach is challenging and in some cases raising concerns regarding rates of recurrence and complications [4, 15–17]. There is also increasing recognition of the requirements for an esophageal lengthening procedure (Collis operation) in a proportion of these patients secondary to coexistent esophageal shortening [18, 19].
The current series reports the outcomes in patients having an open Hill repair in these technically challenging patients. This repair has the advantage of firmly anchoring the esophagogastric junction in the abdominal cavity. No patients required lengthening procedures and all patients had primary closure of the hiatus. Complications were minimal. No patients died. The mean length of hospital stay was 4.7 days and short-term follow-up demonstrated minimal problems with symptom recurrence and dramatic improvement in quality of life parameters.
In conclusion, the presence of paraesophageal hernias can significantly impair respiratory function. Following surgical repair, improvement can be expected in spirometry values, subjective levels of dyspnea, and quality of life. As a result, significant respiratory embarrassment heretofore thought to be a relative contraindication for esophageal surgery may, in fact, be an indication for repair in patients with large paraesophageal hernias.
|
References
|
|---|
- Iverson L.I.G., May I.A., Samson P.C. Pulmonary complications in benign esophageal disease. Am J Surg 1973;126:223-228.[Medline]
- Belsey R. The pulmonary complications of oesophageal disease. Br J Dis Chest 1960;54:342-348.
- Selmonosky C.A., Blanc J.S., Byrd R. Hiatal hernia and pulmonary function impairment: incidence or coincidence?. South Med J 1980;73:1234-1236.[Medline]
- Oddsdottir M. Paraesophageal hernia. Surg Clin North Am 2000;80:1243-1252.[Medline]
- Wo J.M., Branum G.D., Hunter J.G., et al. Clinic features of type III paraesophageal hernia. Am J Gastroenterol 1996;91:914-916.[Medline]
- Senyk J., Arborelius M., Lilja B., et al. Respiratory function in esophageal hiatus hernia. I. Spirometry, gas distribution, and arterial blood gases. Respiration 1975;32:93-102.[Medline]
- Senyk J., Arborelius M., Lilja B., et al. Respiratory function in esophageal hiatus hernia. II. Regional lung function. Respiration 1975;32:103-111.[Medline]
- Marchand P. Hiatal hernia. Its varying modes of presentation and frequent early misdiagnosis. SAfr Med J 1965;39:448-453.
- Harrington S.W. Various types of diaphragmatic hernia treated surgically. Report of 430 cases. Surg Gynecol Obstet 1948;86:735-755.[Medline]
- Hill L.D., Tobias J.A. Paraesophageal hernia. Arch Surg 1968;96:735-744.[Medline]
- Malm A., Svanberg L. Synpunkter pa operationsindikationerna vid hiatusbrackk. Nord Med 1958;60:961-962.
- van der Peet D.L., Klinkenberg-Knol E.C., Poza A.A., et al. Laparoscopic treatment of large paraesophageal hernias. Both excision of the sac and gastropexy are imperative for adequate surgical treatment. Surg Endosc 2000;14:1015-1018.[Medline]
- Watson D.I., Davies N., Devitt P.G., et al. Importance of dissection of the hernial sac in laparoscopic surgery for large hiatal hernias. Arch Surg 1999;134:1069-1073.[Abstract/Free Full Text]
- Edye M., Salky B., Posner A., et al. Sac excision is essential to adequate laparoscopic repair of paraesophageal hernia. Surg Endosc 1998;12:1259-1263.[Medline]
- Hashemi M., Peters J.H., DeMeester T.R., et al. Laparoscopic repair of large type III hiatal hernia: objective followup reveals high recurrence rate. J Am Coll Surg 2000;190:553-561.[Medline]
- Dahlberg P.S., Deschamps C., Miller D.L., et al. Laparoscopic repair of large paraesophageal hiatal hernia. Ann Thorac Surg 2001;72:1125-1129.[Abstract/Free Full Text]
- Trus T.L., Bax T., Richardson W.S., et al. Complications of laparoscopic paraesophageal hernia repair. J Gastrointest Surg 1997;1:221-228.[Medline]
- Mittal S.K., Awad Z.T., Tasset M., et al. The preoperative predictability of the short esophagus in patients with stricture or paraesophageal hernia. Surg Endosc 2000;14:464-468.[Medline]
- Urbach D.R., Khajanchee Y.S., Glasgow R.E., et al. Preoperative determinants of an esophageal lengthening procedure in laparoscopic antireflux surgery. Surg Endosc 2001;15:1408-1412.[Medline]
This article has been cited by other articles:
|
|
|
|
 
D. E. Low and T. Unger
Open Repair of Paraesophageal Hernia: Reassessment of Subjective and Objective Outcomes
Ann. Thorac. Surg.,
July 1, 2005;
80(1):
287 - 294.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
E. M. Targarona, G. Bendahan, C. Balague, J. Garriga, and M. Trias
Mesh in the Hiatus: A Controversial Issue
Arch Surg,
December 1, 2004;
139(12):
1286 - 1296.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
