THE ROLE OF FUNDOPLICATION IN THE TREATMENT OF TYPE-II PARAESOPHAGEALHERNIA

Objectives: The role of fundoplication in patients with pure type II p araesophageal hiatal hernia remains controversial, Conventional thinki ng suggests that because the lower esophageal sphincter is located wit hin the abdomen, it is competent, and fundoplication is unnecessary, F ew studies have used objective evaluation to guide the addition of an antireflux procedure, Methods: Fifteen consecutive patients with type II paraesophageal hernia were treated between May 1991 and July 1994, All had radiographic criteria of pure type II hernias, Preoperative ev aluation included upper intestinal endoscopy, esophageal manometry, an d 24-hour ambulatory pH monitoring, The lower esophageal sphincter was considered incompetent if any of the following criteria were present: a resting pressure less than 7 mm Hg, an overall sphincter length les s than 2 cm, or an intraabdominal length less than 1 cm, Primary sympt oms responsible for surgery were related to the hernia in 73% of patie nts: dysphagia or postprandial abdominal pain in six patients, abdomin al distension or vomiting in four patients, and bleeding in one patien t, Symptoms typical of gastroesophageal reflux were present in four pa tients: heartburn and regurgitation in two each, Results: Objective ev idence of gastroesophageal reflux was present in the majority of patie nts, Five patients (31%) had evidence of esophageal injury: esophagiti s in three patients, stricture in one, and esophageal ulcer in one, In 11 of 15 patients (69%), pathologic esophageal acid exposure was dete cted by 24-hour pH monitoring, Twelve patients (75%) had a defective l ower esophageal sphincter, usually the result of an inadequate intraab dominal length (8/12, 66%), Hernia reduction, crural closure, and Niss en fundoplication were performed in 14 patients (one patient awaits su rgery), Symptomatic relief was excellent in all cases, No patient has had hernia recurrence at an average of 14 months' follow-up (range 2 t o 39 months), Conclusion: Objective evaluation reveals that gastroesop hageal reflux accompanies type II paraesophageal hernia in a high prop ortion of patients, usually because of an incompetent lower esophageal sphincter, Appropriate treatment includes reduction of the hernia, cr ural closure, and fundoplication in most, if not all, patients.