MASSIVE HIATUS-HERNIA - EVALUATION AND SURGICAL-MANAGEMENT

Objective: Paraesophageal hernias represent advanced degrees of slidin g hiatus hernia with intrathoracic displacement of the intraesophageal junction. Gastroesophageal reflux disease occurs in most cases, resul ting in acquired short esophagus, which should influence the type of r epair selected. Methods: Between 1960 and 1996, 94 patients with massi ve, incarcerated paraesophageal hiatus hernia were operated on at the Toronto General Hospital. The mean age was 64 years (39 to 85 years), with a female to male ratio of 1.8:1. Organoaxial volvulus was present in 50% of cases. Clinical presentation in these patients included pos tprandial pain in 56%, dysphagia in 48%, chronic iron deficiency anemi a in 38%, and aspiration in 29%. Symptomatic reflux, either present or remote, was recorded in 83% of cases. All patients underwent endoscop y by the operating surgeon. In 91 of 94 patients, the esophagogastric junction was found to be above the diaphragmatic hiatus, denoting a sl iding type of hiatus hernia. Gross, endoscopic peptic esophagitis was observed in 36% of patients: ulcerative esophagitis in 22% and peptic esophagitis with stricture in 14%. A complete preoperative esophageal motility study was obtained for 41 patients. The lower sphincter was h ypotensive in 21 patients (51%), and the amplitude of peristalsis in t he distal esophagus was diminished in 24 patients (59%). These abnorma lities are both features of significant gastroesophageal reflux diseas e. In 13 recent, consecutive patients with paraesophageal hernia, the distance between the upper and lower esophageal sphincters was measure d during manometry. The average distance was 15.4 +/- 2.33 cm (11 to 2 0 cm), which is consistent with acquired short esophagus. The normal d istance is 20.4 cm +/- 1.9 (p < 0.0001). Results: All 94 patients were treated surgically: 97% had a transthoracic repair with fundoplicatio n. A gastroplasty was added in 75 cases (80%) because of clearly defin ed or presumed short esophagus. There were two operative deaths, and t wo patients were never followed up. Among the 90 available patients, t he mean follow-up was 94 months; median follow-up aas 72 months. Seven ty-two patients (80%) are free of symptoms (excellent result); 13 (13% ) have inconsequential symptoms requiring no therapy (good result); an d three patients (4%) are improved but have symptoms requiring medical therapy or interval dilatation (fair result). Two patients had poor r esults because of recurrent hernia and severe reflux. Both were succes sfully treated by reoperation with the addition of gastroplasty becaus e of acquired shortening, which was not recognized at the first operat ion. Conclusions: Most of these 94 patients had symptoms or endoscopic , manometric, and operative findings that were consistent with a slidi ng hiatus hernia. There was a high incidence of endoscopic reflux esop hagitis and of acquired short esophagus. True paraesophageal hernia, w ith the esophagogastric junction in a normal abdominal location, appea rs rare. Our observations were supported by measurements obtained at p reoperative endoscopy and manometry, and by findings at the time of su rgical repair. These observations support the choice of a transthoraci c approach for repair in most patients.