MASSIVE HIATAL-HERNIAS - THE ANATOMIC BASIS OF REPAIR

Objectives: In the repair of giant hiatal hernias, controversy persist s as to whether an antireflux repair is required and whether a Collis gastroplasty is necessary. This study was undertaken to determine the location of the gastroesophageal junction in giant hiatal hernias with an intrathoracic stomach. as well as the outcome after repair without a Collis gastroplasty, Methods: Fifty-two patients were evaluated for a giant hiatal hernia, of whom 47 underwent surgical correction. Preo perative evaluation included esophagoscopy (n = 45), gastrointestinal series (n = 40), esophageal manometry (n = 20), and 24-hour pH testing (n = 13), The dominant clinical features were acute chest or abdomina l pain (72%), heartburn (53%), and gastrointestinal bleeding (49%). Th e gastroesophageal junction was located in the mediastinum in 77% of p atients, in the abdomen in 17%, and was not determined in 6%. Twenty-e ight patients (59%) had clinical or objective evidence of reflux. Redu ction with an antireflux repair without a gastroplasty was done in 47 (Belsey, n = 28; Nissen, n = 19), An excellent or good result a as ach ieved in 38 patients (90%) with a median follow-up of 45 months. Concl usions: These results, obtained without a Collis gastroplasty, are equ ivalent to those obtained by an antireflux: repair with an esophageal lengthening procedure. The frequent location of the gastroesophageal j unction in the mediastinum suggests that these massive hernias often a re the result of progressive enlargement of a sliding component. An an tireflux repair is therefore necessary in the majority of patients.