MANAGEMENT OF PARAESOPHAGEAL HERNIA WITH A SELECTIVE APPROACH TO ANTIREFLUX SURGERY

BACKGROUND: The role of an antireflux procedure in the management of p araesophageal hernia is controversial. To address this issue, we revie wed our experience with selective use of antireflux procedures in pati ents with pure paraesophageal hernia (type II; n = 26) and those with a partial sliding component (type III; n = 11). PATIENTS AND METHODS: Surgical repair was performed on diagnosis in all 37 patients. Compete ncy of the lower esophageal sphincter was evaluated on the basis of re flux symptoms, and objectively, with endoscopy in 21 patients and 24-h our esophageal pH studies in 17 patients. Repair included an antireflu x procedure in 11 patients, as indicated by reflux disease. RESULTS: P reoperatively, 80% of both type II and type III patients reported obst ructive symptoms. Reflux symptoms were present in 27% of patients-19% of type II and 45% of type III patients. Endoscopy revealed esophagiti s in 5 cases, and 24-hour pH studies indicated significant reflux in 3 of 17 patients. There were no operative deaths and 1 recurrence. Symp toms improved in 92% of patients after surgery. Medically manageable r eflux was identified in 2 patients. CONCLUSIONS: Frequent obstructive symptoms and the potential for gastric volvulus indicate elective repa ir of paraesophageal hernia on diagnosis. Significant gastroesophageal reflux is less common, especially in type II patients, and excellent symptomatic results are obtained with selective application of an anti reflux procedure.