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Ann Thorac Surg 2002;74:337
© 2002 The Society of Thoracic Surgeons

Invited commentary

^a Sharp Memorial Hospital, San Diego, CA, USA

e-mail: gstilesl{at}san.rr.com

These authors found preoperative dyspnea in 84% of their patients with paraesophageal hernia. This is higher than reported in most series and raises questions. Did these authors look more intensively for this symptom? Or, have previous studies not recognized dyspnea as a function of the hernia and gastroesophageal reflux but, rather, considered it a comorbidity related to primary pulmonary pathology?

From a purely mechanical standpoint the concept of impaired respiratory function due to a paraesophageal hernia is logical. Returning herniated abdominal contents from the chest to the abdomen restores the total lung capacity to normal and would, therefore, be expected to improve respiratory function; the larger the volume of the intrathoracic hernia, the greater the expected improvement in function. This is confirmed by the work of these authors, but the mechanism of improvement doesn’t seem so simple.

Other potential mechanisms, such as returning the diaphragm to its normal contour and function, as suggested by these authors and others, are less intuitive but likely have merit. Senyk and associates. (references 6 and 7 in article by Low and Simchuk) long ago reported similar findings with all types of hiatal hernias. Senyk did not find an association with size of the thoracic hernia and spirometric or arterial oxygen findings. He did, however, find a correlation of lung volume and regional ventilation/perfusion abnormalities with the roentgenographic transverse diameter of the hernia. He suggested that herniated contents compressing lung parenchyma might cause regional ventilation/perfusion mismatch as a possible source of spirometric and arterial oxygen saturation abnormalities.

All these proposed mechanisms, however, may be overlooking a potentially greater contributing factor; that is the well-established improvement in respiratory symptoms after surgical treatment of gastroesophageal reflux regardless of the type of hernia. Although this aspect of respiratory dysfunction is usually described as cough, asthma, pulmonary fibrosis or recurrent pneumonia and not distinctly dyspnea, this certainly may be a contributing factor as well.

Regardless of the mechanism, these authors convincingly demonstrate overall respiratory improvement after surgical repair of paraesophageal hernias when accompanied by an anti-reflux procedure. They importantly point out that respiratory symptoms and findings of impaired respiratory function on diagnostic evaluations should not necessarily be contraindications to, and may even be indications for surgery in these patients.

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