Clinical Ramifications of Giant Paraesophageal Hernias Are Underappreciated: Making the Case for Routine Surgical Repair

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1 Clinical Ramifications of Giant Paraesophageal Hernias Are Underappreciated: Making the Case for Routine Surgical Repair Philip W. Carrott, MD, Jean Hong, ARNP, MadhanKumar Kuppusamy, MD, Richard P. Koehler, MD, FACS, and Donald E. Low, MD, FACS Section of General Thoracic Surgery, Virginia Mason Medical Center, Seattle, Washington GENERAL THORACIC Background. We propose that the symptoms associated with paraesophageal hernia (PEH) are more diverse than previously suggested, and symptoms and clinical manifestations correlate to the anatomy of the hernia. Methods. Patients undergoing surgery for PEH were reviewed from a prospective, institutional review board approved, single-center database. Presenting symptoms, anatomy of the PEH, demographics, and outcomes were analyzed from 2000 to Presenting symptoms were assessed for incidence and improvement after surgery. Size and configuration of the PEH were assessed with respect to presenting symptoms. Results. The study included 270 consecutive patients, 63% were female, and the median age was 70 years (range, 39 to 94 years). The most common presenting symptoms were heartburn in 175 patients (65%), early satiety in 136 patients (50%), chest pain in 130 patients (48%), dyspnea in 130 patients (48%), dysphagia in 129 patients (48%), regurgitation in 128 patients (47%), and anemia in 112 patients (41%). Two hundred sixty-nine patients (99.6%) had at least one symptom; the median number of symptoms was 4 (range, 0 to 10). The type of PEH was II (n 10), III (n 206), and IV (n 54), and the percent intrathoracic stomach was less than 50% (n 33), 50% to 74% (n 86), 75% to 99% (n 55), and 100% (n 96). Paraesophageal hernia type was significantly associated with heartburn (type II/III; p 0.005) and dyspnea (type IV; p 0.007). Significant associations included lower percent intrathoracic stomach with regurgitation (p 0.04); higher percent intrathoracic stomach with early satiety (p 0.02), decreased meal size (p 0.007), and dyspnea (p < 0.001); and 50% to 74% intrathoracic stomach with anemia (p 0.001). With a median postoperative follow-up of 103 days, symptoms were subjectively better in patients with dyspnea (67%), early satiety (79%), regurgitation (92%), dysphagia (81%), chest pain (76%), and heartburn (93%). Conclusions. Paraesophageal hernia is associated with a greater diversity of symptomatic presentation than previously thought. Asymptomatic patients are rare, and size and configuration of the hernia are associated with specific symptoms. Patients with large PEHs should be assessed by an experienced surgeon for elective repair. (Ann Thorac Surg 2012;94:421 8) 2012 by The Society of Thoracic Surgeons There is currently no general consensus regarding the optimal management of giant (types II, III, and IV) paraesophageal hernias (PEHs) [1 7]. In part owing to the rarity of the problem, differing perceptions with respect to patient presentation, and misconceptions of the difference between PEH and simple hiatal hernia (type I), the optimal care of these patients remains controversial. In addition, PEH is most commonly seen in the elderly, who have often been aware of the presence of a hiatal hernia for many years. As a result, many have noted symptoms and changes in eating patterns over the course of years, which, because of their slow evolution, are relegated to advancing age rather than their evolving PEH. Recent literature, both case series and population data, depict Accepted for publication April 16, Presented at the Forty-eighth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28 Feb 1, Address correspondence to Dr Low, Section of General Thoracic Surgery, Virginia Mason Medical Center, 1100 Ninth Ave, C6-SUR, Seattle, WA 98111; gtsdel@vmmc.org. an increase in the reported incidence of PEH and in patients undergoing operative repair [8, 9]. According to one population study, emergent presentations associated with PEH occurred in 53%, although only 34% of those patients underwent surgery at the time of their emergent admission [8]. Overall surgical morbidity and mortality associated with PEH repair has been decreasing. Population studies from the United States and Finland have demonstrated that mortality is significantly elevated when operations are emergent, as well as among octogenarians [8 11]. There has also been the perception that a significant number of patients with PEH are asymptomatic. Previous reports have estimated the asymptomatic population involves up to 50% of all patients [7]. This has led others to suggest that a significant proportion of patients with an asymptomatic or minimally symptomatic PEH can be treated with watchful waiting [12]. Other recent case series have questioned the true size of the asymptomatic population, suggesting that the majority of patients who 2012 by The Society of Thoracic Surgeons /$36.00 Published by Elsevier Inc

2 GENERAL THORACIC 422 CARROTT ET AL Ann Thorac Surg PEH SYMPTOMS AND OUTCOMES 2012;94:421 8 are assessed by a surgeon will have symptoms affecting their daily quality of life [5, 13, 14]. We hypothesize that symptoms associated with large PEHs are more diverse than previously identified, and the truly asymptomatic patient is rare. Patients and Methods All patients presenting to the Thoracic Surgical Service at Virginia Mason Medical Center between 2000 and 2010 with giant PEH were entered into a prospective institutional review board approved database. Giant PEHs were defined as types II, III, or IV by the classic definition and involving at least 50% of the stomach. Presenting symptoms, anatomic characteristics, demographics, and subjective and objective outcomes were retrospectively reviewed. Seventeen presenting symptoms or signs and lifestyle modifications were assessed for incidence and improvement after surgery: heartburn, regurgitation, chest pain, cough, hoarseness, sore throat, head of bed elevation, avoiding evening meal, avoidance of specific foods, early satiety, decreased meal size, dyspnea, dysphagia, nausea or vomiting, water brash, gastrointestinal bleeding, and anemia. Presenting anatomy of PEH, both anatomic orientation (type II, III, or IV) and percentage intrathoracic stomach (%ITS), were recorded from the independent radiologist s estimation of upper gastrointestinal (UGI) series in 98% of patients and from endoscopic assessment in the remainder. Patients were typically assessed preoperatively with UGI and endoscopy. The endoscopic examination was often associated with placement of a guidewire to facilitate subsequent insertion of a high-resolution manometry catheter; ph-impedance or gastric emptying studies, or both, were obtained selectively. Surgery was performed in all cases, and patients in this series were most often treated with an open modified Hill repair, which involves anchoring of the gastroesophageal junction (GEJ) posteriorly and re-forming the flap valve apparatus. The hernia sac was dissected from the mediastinum and removed. In all cases the hiatus was closed primarily, and the Hill repair anchors the GEJ with five silk sutures, which prevents movement of the GEJ and obviates the need for esophageal lengthening procedures. Postoperative outcomes were assessed with UGI series, typically done 3 months after the operation. Patients subjective outcomes were assessed with respect to the presence or improvement of preoperative symptoms, as well as the presence or evolution of additional symptoms. Repeat endoscopy was performed in select patients, usually those with a history of Barrett esophagus or in patients with persistent or recurrent symptoms. Descriptive statistics were used to report continuous variables with range or standard deviation, and categorical variables were reported as frequencies with percentages. Between-group comparisons of categorical outcomes were performed using Fisher s exact test and Kruskal-Wallis test as appropriate to the distribution of the data with probability values denoting levels of statistical significance (p 0.05). Statistical analyses were performed using SPSS (version 18) software package (SPSS Inc, Chicago, IL). Results The study population included 270 consecutive patients undergoing operations between January 2000 and October Patients were predominantly female (63%), with a median age of 70 years (range, 39 to 94 years). Table 1 shows patient and presenting characteristics according to sex. Hernia size and type were similar, although female patients were significantly heavier and presented more often with regurgitation and anemia. Preoperative evaluations included UGI in 266 patients (98%), upper endoscopy in 266 patients (98%), esophageal manometry in 254 patients (94%), 24-hour ph-impedance study in 30 patients (11%), and gastric emptying study in 18 patients (7%). Upper endoscopy confirmed esophagitis in 76 patients (28%), with Savary-Miller grades I (n 25), II (n 9), III (n 10), IV (n 11), and V (n 21). Manometry showed abnormal peristalsis ( 80% of swallows) in 32 patients (13%) and low amplitude ( 30 mm Hg) in 16 patients (6%), and ph studies were abnormal in 13 patients (43%). Surgery was elective in 256 patients (95%) and urgent in 14 patients (5%). Previous antireflux operations or Barrett esophagus were present in 13 patients (5%) and 21 patients (8%), respectively. Surgical procedures included modified Hill repair by laparotomy in 257 patients, Nissen in 7 patients, Dor in 1 patient, Toupet in 1 patient, hiatal hernia repair with gastropexy alone in 2 patients, and gastrostomy alone in 2 patients. Laparoscopic surgery was used in 9 patients (3%). Hiatal hernia repair with or without gastropexy was performed in 268 patients (99%), and gastrostomy placement was done in Table 1. Comparison of Patients by Sex Variable Male Female Number of patients 99 (37%) 171 (63%) Average age SD Average BMI SD a Median %ITS (range) 75% (0 100) 75% (20 100) 100% ITS 40 (40%) 56 (33%) PEH type II 3 (3%) 7 (4%) PEH type III 76 (77%) 130 (76%) PEH type IV 20 (20%) 34 (20%) Heartburn 70% 62% Early satiety 42% 54% Chest pain 45% 50% Dyspnea 42% 51% Dysphagia 48% 47% Regurgitation a 37% 53% Anemia a 31% 47% Avoid foods 12% 15% a Significant differences were found in BMI, regurgitation, and anemia; p BMI body mass index; ITS intrathoracic stomach; PEH paraesophageal hernia; SD standard deviation.

3 Ann Thorac Surg CARROTT ET AL 2012;94:421 8 PEH SYMPTOMS AND OUTCOMES 38 patients (14%). There were no Collis procedures performed. One patient had crural reinforcement with Surgisis biologic mesh (Cook Medical, Bloomington, IN). Median operative time was 146 minutes (range, 72 to 431 minutes), and estimated blood loss was a median of 50 ml (range, 10 to 250 ml). Complications occurred in 104 patients (38%); there were no perioperative mortalities or recurrences requiring surgery. Length of stay was a median of 4 days (range, 2 to 13 days) for the entire population. Complications included arrhythmias in 13 patients, congestive heart failure requiring treatment in 3 patients, pneumonia in 6 patients, pneumothorax requiring drainage in 1 patient, pleural effusion requiring drainage in 2 patients, respiratory failure in 3 patients, acute renal insufficiency in 6 patients, urinary retention in 5 patients, urinary tract infection in 7 patients, wound infection in 7 patients, postoperative vomiting in 8 patients, prolonged nausea requiring treatment in 19 patients, ileus in 7 patients, deep venous thrombosis in 5 patients, pulmonary embolus in 1 patient, stroke in 2 patients, delirium in 15 patients, and epidural hematoma requiring surgery in 1 patient. In longer follow-up (median, 103 days), 44 patients (16%) had a symptomatic incisional hernia. Symptoms included heartburn in 175 patients (65%), early satiety in 136 patients (50%), chest pain in 131 patients (48%), dyspnea in 130 patients (48%), dysphagia in 129 patients (48%), regurgitation in 128 patients (47%), anemia in 112 patients (41%), decreased meal size in 50 patients (18%), cough in 39 patients (14%), avoidance of specific foods in 38 patients (14%), water brash in 34 patients (13%), head of bed elevation in 28 patients (10%), avoidance of evening meal in 28 patients (10%), nausea or vomiting in patients (10%), gastrointestinal bleeding in 24 patients (9%), persistent hoarseness in 4 patients (1%), and sore throat in 1 patient (0.4%). Two hundred sixty-nine patients (99.6%) had at least one symptom, with the median number of symptoms per patient being 4 (range, 0 to 10). Size and configuration of the PEH was assessed and related to presenting symptoms. Classification of PEH was II in 10 patients (4%), III in 206 patients (76%), and IV in 54 patients (20%), and %ITS was less than 50% in 33 patients (12%), 50% to 74% in 86 patients (32%), 75% to 99% in 55 patients (20%), and 100% in 96 patients (36%). Some symptoms were more commonly associated with certain types of PEH, including heartburn (type II/III, 69%; type IV, 46%; p 0.005) and dyspnea (type II/III, 44%; type IV, 65%; p 0.007). Other important associations are the relationships between symptoms and %ITS (Table 2). These included lower %ITS with regurgitation (p 0.04); higher %ITS with early satiety (p 0.02), decreased meal size (p 0.007), and dyspnea (p 0.001); and 50% to 74% ITS with anemia (57%; p 0.001). With a standardized symptomatic follow-up (median, 103 days for the series), symptoms were subjectively better in patients with dyspnea (67%), early satiety (79%), regurgitation (92%), dysphagia (81%), chest pain (76%), and heartburn (92%; Table 3). Follow-up was less than 30 days in 51 patients (19%). Follow-up UGI typically at 3 months follow-up was obtained in 170 patients (63%); 37 patients (22%) had reflux, of which 21 cases were spontaneous, 13 were induced, and 3 were unspecified. Recurrent hiatal hernia was seen in 25 patients (15%), 34 patients (20%) had the impression of delayed esophageal emptying, and 8 patients (5%) had esophageal dysmotility. Twenty-three of GENERAL THORACIC Table 2. Patient Demographics and Presenting Symptoms by Percent Intrathoracic Stomach a Variable 50% ITS 50% 74% ITS 75% 99% ITS 100% ITS p Value Number of patients Median age (y) 59 (42 90) 68 (39 89) 69 (45 89) 77 (41 94) Average BMI SD (kg/m 2 ) NS Median ASA 2 (2 3) 2 (2 4) 2 (1 3) 2 (2 4) Average ASA SD Median LOS (days) 4 (2 6) 4 (2 13) 4 (3 13) 5 (3 13) NS Complications 10 (30%) 34 (40%) 14 (25%) 46 (48%) Heartburn 76% 72% 62% 56% NS Regurgitation 54% 58% 42% 38% 0.04 Chest pain 48% 40% 60% 50% NS Early satiety 30% 44% 60% 57% Dysphagia 42% 50% 36% 54% NS Anemia 24% 57% 27% 42% Dyspnea 21% 37% 49% 67% Barrett esophagus 6 (18%) 5 (6%) 3 (5%) 7 (7%) NS Gastrostomy 3 (10%) 3 (3%) 3 (5%) 28 (29%) Postoperative arrhythmia 0 (0%) 2 (2%) 1 (2%) 10 (10%) a Symptom incidence was reported as percent affected for ease of interpretation. All other postoperative complications were assessed for differences, but no others were significant. ASA American Society of Anesthesiologists Classification; BMI body mass index; ITS intrathoracic stomach; LOS length of stay; NS not significant; SD standard deviation.

4 GENERAL THORACIC 424 CARROTT ET AL Ann Thorac Surg PEH SYMPTOMS AND OUTCOMES 2012;94:421 8 Table 3. Symptomatic Improvement After Repair a Symptom 25 hiatal hernias seen at barium swallow were described as small, or sliding (type 1). One of 2 patients with moderate hernias had a gastropexy only, without definitive closure of the hiatus. Postoperative esophagogastroduodenoscopy was performed in 44 patients (16%) with postoperative symptoms, 10 of whom (23%) had evidence of esophagitis and 15 (34%) had a recurrent type 1 hiatal hernia, ranging in size from 1 to 5 cm. Urgent cases accounted for 14 patients (5%) in our study population. These patients were somewhat older (mean age, 74.9 years; not significant) and had a fewer number of symptoms per patient (2.5 versus 4; p 0.002). Heartburn and early satiety were significantly less common in urgent cases, and chest pain was seen more often (48% versus 57%). Overall incidence of complications in the urgent group involved 5 patients (36%), which was not different from that of the elective population (n 99; 39%), although length of stay was significantly longer (mean, 6.8 days versus 4 days; p 0.034). Operative mortality was zero for the entire series. Comment Proportion Improved Postoperatively Heartburn 162/175 (93%) Regurgitation 118/128 (92%) Early satiety 108/136 (79%) Dysphagia 104/129 (81%) Chest pain 100/131 (76%) Dyspnea 87/130 (67%) Cough 24/39 (62%) a Common symptoms were assessed in standard follow-up at 3 to 4 months. Symptom improvement is reported only for those patients complaining of the symptom preoperatively. Previous reports highlight the controversies associated with patients presenting with PEH. The issues assessed include the utility and durability of the laparoscopic approach [13 16], how best to prevent recurrences [17], whether an antireflux procedure should be included as part of the procedure, the time course of the disease, and whether operative repair is justified in asymptomatic individuals [12], as well as assessing the significance of recurrence in a minimally symptomatic individual [16, 18]. This report of 270 consecutive patients with PEH undergoing surgical repair since 2000 provides some additional insight toward answering some of these questions while redefining the incidence of presenting symptoms in these patients. We have noted that when PEH patients are questioned closely regarding their eating habits, reflux, breathing, and health status, they will typically describe symptoms and other clinical issues that have evolved with time. In addition to typical symptoms associated with gastroesophageal reflux disease, additional symptoms and signs we have found to be specific to larger PEH include early satiety, dyspnea, and anemia. Symptom assessment in the literature, however, has concentrated on more typical gastroesophageal reflux disease related issues such as heartburn or dysphagia. The issues related to larger giant PEH, however namely early satiety or decreased meal size, dysphagia, dyspnea, and anemia were significantly associated with %ITS in our analysis, and are of a more insidious nature than pain, heartburn, or regurgitation, for example. Typically patients will note an evolving pattern of early satiety or dyspnea over the course of years. When we are reviewing symptoms with patients at an initial office visit, we will ask questions such as Compare the size of the meal you can eat currently to that of 5 or 10 years ago, or Do you feel breathless when you bend over to tie your shoes or pick something up off the floor? Frequently the patient or their spouse will acknowledge an evolving history of greatly diminishing meal size or sudden breathlessness associated with certain activities. Patients with urgent presentation also deserve comment. These patients had fewer presenting symptoms, and predicting patients who will present with incarceration is complex and inexact. Previous reports regarding PEH often focused on the emergent incarceration or strangulation. The most common unifying presenting symptom in these patients was chest pain, which is important in the urgent presentation of PEHs. Elective repair of patients with PEH is typically a more straightforward operation, associated with lower rates of morbidity and mortality. Standard symptoms of gastroesophageal reflux disease were noted in 65% of patients, in contrast to some previous reports that stated PEHs are rarely associated with reflux [19]. Type III hernia, in particular, with the GEJ often residing well above the hiatus will typically eliminate the natural flap valve mechanism, decreasing the threshold for heartburn and regurgitation [20]. Inour series, these patients were younger, had lower %ITS, lower incidence of anemia, and more often a type III hernia. In some patients, during the time course of their hernia (ie, as it progressed from 30%ITS to 100%ITS), they will describe a reduction in heartburn symptoms, with the evolution of other symptoms, eg, dyspnea, possibly marking the restoration of the flap valve apparatus as the stomach sits in a more normal configuration, albeit in an abnormal location. No previously published series has found the associations we have between symptoms and %ITS or anatomic presentation of PEH. Most case series will outline presenting symptoms and their improvement after repair, focusing on outcomes and durability of the repair. These patients are similar with regard to the American Society of Anesthesiologists Classification and body mass index, although differences are noted with regard to age and the occurrence of complications. A lower %ITS will have predominantly gastroesophageal reflux disease symptoms, while a higher %ITS is more likely to experience early satiety and dyspnea, and someone with half or two thirds of their stomach in an intrathoracic location is more likely to present with anemia. We found that 41% of patients presented with a history of iron-deficiency anemia and identified a significant association with an anatomic configuration, specifically when 50%

5 Ann Thorac Surg CARROTT ET AL 2012;94:421 8 PEH SYMPTOMS AND OUTCOMES to 67% of the stomach is herniated. This produces an hourglass shape, which was described by Windsor and Collis in 1967 [21]. Cameron and Higgins [22] reported on ulcerations seen with PEH at the diaphragmatic hiatus where the body of the stomach is pinched together and rides on itself, causing mucosal injury and both occult and overt bleeding. Although these ulcerations are not seen in every patient with anemia, the anemia typically resolves once the hernia is repaired. Symptomatically, the vast majority of patients are improved after repair, and this has been reported in numerous series for both laparoscopic and open repairs, both transthoracic and transabdominal [7]. We found significant short-term improvements in symptoms and presenting problems for the majority of patients (Table 3). A recurrent hernia was found in 25 of 170 postoperative UGI contrast studies, but was usually small. This is comparable to the largest laparoscopic series by Luketich and colleagues [17], at 15%. One patient had a symptomatic, large recurrent hernia, and was the only patient in whom a biologic buttress was used. Her symptoms are medically controlled, 10 years from her original surgery. Our population was elderly, with a mean age of 70 years, and therefore had the typical comorbidities and complications that would be expected in the older patient population [23]. Table 4 outlines differences across age groups, with increased length of stay and complications occurring in the older population, as well as significantly larger hernias in both %ITS and hernia type as patients increase in age. 425 Although complications were present at low levels across the board, only the occurrence of delirium correlated with age, which has been reported elsewhere [23]. The indication that these hernias will continue to increase in size with time supports the case for elective repair of even moderate sized hernias in younger patients with a lower likelihood of complications. Earlier repair will also result in less dilation of the hiatus and attenuation of the crura, which will translate into a more durable repair without the use of mesh reinforcement. Our series, although large for a single center, did not have a large number of urgent cases, only 5% of the total, with no deaths. This is a lower proportion than found in other series, in which the incidence was 16% to 18% [10, 17]. We did not have patients developing obstructive or ischemic symptoms before scheduled repair. Population data from New York showed that for the diagnosis of PEH, half of the hospital visits were emergent and a high proportion of these did not result in operation at the time of the index admission [8]. The emergent cases cost more, had a longer length of stay, and had a significantly higher mortality. Mortality for the entire population of emergent admissions was 2.7%, and it was 5.1% for those undergoing operation, which, although much lower than quoted in older series, is still higher than that for elective surgery (0% to 1.1%). A rise in operative intervention in this population was seen during the 5 years studied, accompanied with a reduction in emergent presentations. Elective repair of PEH in patients presenting with symp- GENERAL THORACIC Table 4. Patient Demographics and Presenting Symptoms by Age a Variable Age 60 years years years Age 80 years p Value Number of patients Average BMI SD (kg/m 2 ) Median ASA 2 (1 3) 2 (2 4) 2 (2 4) 2 (2 4) Average ASA SD Median LOS (days) 4 (2 10) 4 (2 13) 5 (3 13) 6 (3 13) Complications 18 (28%) 17 (24%) 39 (49%) 30 (54%) Median %ITS 50% (20 100) 75% (0 100) 75% (33 100) 100% (33 100) % ITS 12 (19%) 21 (30%) 34 (42%) 29 (53%) Heartburn 81% 66% 52% 62% Regurgitation 55% 49% 45% 40% NS Chest pain 53% 41% 46% 56% NS Early satiety 41% 55% 55% 49% NS Dysphagia 47% 39% 55% 49% NS Anemia 31% 42% 48% 44% NS Dyspnea 39% 49% 55% 47% NS PEH type II 5 (8%) 2 (3%) 2 (3%) 1 (2%) PEH type III 51 (80%) 57 (80%) 61 (76%) 37 (67%) PEH type IV 8 (12%) 12 (17%) 17 (21%) 17 (31%) Barrett esophagus 4 (6%) 11 (15%) 4 (5%) 2 (4%) Gastrostomy 3 (5%) 4 (6%) 17 (21%) 13 (24%) Postoperative delirium 0 (0%) 1 (1%) 8 (10%) 6 (11%) a Common preoperative symptoms are shown, although all were analyzed, and the remainder were found to be not significantly different. All other postoperative complications were assessed, but none were significant. ASA American Society of Anesthesiologists Classification; BMI body mass index; ITS intrathoracic stomach; LOS length of stay; NS not significant; PEH paraesophageal hernia; SD standard deviation.

6 GENERAL THORACIC 426 CARROTT ET AL Ann Thorac Surg PEH SYMPTOMS AND OUTCOMES 2012;94:421 8 toms can reliably produce good outcomes. Although the risks associated with emergent operations are not as high as previously perceived, elective repair is safer and associated with less hospital time and costs, in addition to providing the patient a resolution of symptoms. In this population in particular, the symptoms for larger hernias are central to eating and breathing; patients are typically not simply satisfied with their outcome, but identify significant improvement in their activities of daily living. We present our experience as a largely open operative series, whereas most experienced centers are moving to a principally laparoscopic approach. Our current practice has shifted to a selective laparoscopic approach for hernias that display good GEJ mobility on the UGI study, which will be easier to reduce and manipulate laparoscopically. We believe the Hill repair, as it is predicated on anchoring the GEJ posteriorly, gives an advantage in a low recurrence rate and is most appropriate for a difficult, longstanding hernia that may be associated with scarring and esophageal shortening from reflux esophagitis. Our reported rate of incisional hernia (16%) in this population may be in part attributable to a predisposition to the development of hernias [24]. This factor has also contributed to changing our practice for smaller hernias and those larger hernias with a mobile GEJ to use a laparoscopic approach. We would still recommend that larger, complex hernias be repaired by the anchored, open Hill procedure. Our practice is to recommend repair for physiologically appropriate patients. As demonstrated in this study, most patients will report four or more symptoms and are rarely asymptomatic. If a truly asymptomatic patient exists, he or she will unlikely present to a surgeon unless some issue prompts an investigation or endoscopy. On close questioning, lingering symptoms, such as early satiety or shortness of breath will become apparent. Therefore, surgically fit patients presenting with PEH should be provided the opportunity to discuss elective repair with an experienced surgeon to avoid future symptoms and improve quality of life. References 1. Awais O, Luketich JD. Management of giant paraesophageal hernia. Minerva Chir 2009;64: Davis SS Jr. Current controversies in paraesophageal hernia repair. Surg Clin North Am 2008;88:959 78, vi. 3. Draaisma WA, Gooszen HG, Tournoij E, Broeders IA. Controversies in paraesophageal hernia repair: a review of literature. Surg Endosc 2005;19: Ferri LE, Feldman LS, Stanbridge D, Mayrand S, Stein L, Fried GM. Should laparoscopic paraesophageal hernia repair be abandoned in favor of the open approach? Surg Endosc 2005;19: Maziak DE, Todd TR, Pearson FG. Massive hiatus hernia: evaluation and surgical management. J Thorac Cardiovasc Surg 1998;115: Oelschlager BK, Pellegrini CA. Paraesophageal hernias: open, laparoscopic, or thoracic repair? Chest Surg Clin N Am 2001;11: Schieman C, Grondin SC. Paraesophageal hernia: clinical presentation, evaluation, and management controversies. Thorac Surg Clin 2009;19: Polomsky M, Hu R, Sepesi B, et al. A population-based analysis of emergent vs. elective hospital admissions for an intrathoracic stomach. Surg Endosc 2010;24: Sihvo EI, Salo JA, Rasanen JV, Rantanen TK. Fatal complications of adult paraesophageal hernia: a population-based study. J Thorac Cardiovasc Surg 2009;137: Polomsky M, Jones CE, Sepesi B, et al. Should elective repair of intrathoracic stomach be encouraged? J Gastrointest Surg 2010;14: Poulose BK, Gosen C, Marks JM, et al. Inpatient mortality analysis of paraesophageal hernia repair in octogenarians. J Gastrointest Surg 2008;12: Stylopoulos N, Gazelle GS, Rattner DW. Paraesophageal hernias: operation or observation? Ann Surg 2002;236: Furnée EJ, Draaisma WA, Simmermacher RK, Stapper G, Broeders IA. Long-term symptomatic outcome and radiologic assessment of laparoscopic hiatal hernia repair. Am J Surg 2010;199: Nason KS, Luketich JD, Qureshi I, et al. Laparoscopic repair of giant paraesophageal hernia results in long-term patient satisfaction and a durable repair. J Gastrointest Surg 2008; 12: Dallemagne B, Kohnen L, Perretta S, Weerts J, Markiewicz S, Jehaes C. Laparoscopic repair of paraesophageal hernia: long-term follow-up reveals good clinical outcome despite high radiological recurrence rate. Ann Surg 2011;253: White BC, Jeansonne LO, Morgenthal CB, et al. do recurrences after paraesophageal hernia repair matter?: ten-year follow-up after laparoscopic repair. Surg Endosc 2008;22: Luketich JD, Nason KS, Christie NA, et al. Outcomes after a decade of laparoscopic giant paraesophageal hernia repair. J Thorac Cardiovasc Surg 2010;139: Andujar JJ, Papasavas PK, Birdas T, et al. Laparoscopic repair of large paraesophageal hernia is associated with a low incidence of recurrence and reoperation. Surg Endosc 2004;18: Ellis FH Jr, Crozier RE, Shea JA. Paraesophageal hiatus hernia. Arch Surg 1986;121: Collis JL. A review of surgical results in hiatus hernia. Thorax 1961;16: Windsor CW, Collis JL. Anaemia and hiatus hernia: experience in 450 patients. Thorax 1967;22: Cameron AJ, Higgins JA. Linear gastric erosion. A lesion associated with large diaphragmatic hernia and chronic blood loss anemia. Gastroenterology 1986;91: Rowell D, Nghiem HS, Jorm C, Jackson TJ. How different are complications that affect the older adult inpatient? Qual Saf Health Care 2010;19:e Landreneau RJ, Del Pino M, Santos R. Management of paraesophageal hernias. Surg Clin North Am 2005;85: DISCUSSION DR ROSS BREMNER (Phoenix, AZ): I think we have an epidemic of the intrathoracic stomach. I wondered if you can give a comment and on this. I have noticed that there are a number of patients who have had symptoms of reflux and regurgitation for decades who have had their symptoms controlled with antireflux medications, mostly PPIs (protonpump inhibitors), but they finally get referred to you when they are having these other symptoms of early satiety or chest pain and are then found to have an intrathoracic stomach and now they are in their mid-80s. I wondered whether you ve

7 Ann Thorac Surg CARROTT ET AL 2012;94:421 8 PEH SYMPTOMS AND OUTCOMES noticed a similar sort of trend. That s the first question. The second question is do you routinely recommend repair of some of these octogenarian patients with asymptomatic large intrathoracic stomachs? 427 older patients who are at an increased risk of aspiration. We have been religious on involving our speech pathologists in all of these patients prior to oral intake to prevent aspiration. I wonder if you could comment on that please. GENERAL THORACIC DR CARROTT: Yes, I believe that we do often see individuals who for 10 years or more, maybe 20 years, have known of hiatal hernia, that they have had evolving issues of early satiety, shortness of breath with certain activities and in certain positions, and even persistent issues with iron-deficiency anemia for that long. These hernias are often diagnosed on other investigations such as CAT (computed axial tomography) scan done for other reasons. We believe the symptoms associated with these hernias are very underappreciated, and we would recommend, as long as they are surgically fit patients, that the option of repair be reviewed with an experienced practitioner as most of these individuals are overwhelmingly satisfied following repair. DR AVRAHAM D. MERAV (Sleepy Hollow, NY): I have never forgotten the first case of a paraesophageal hernia that I saw as a surgical resident. The patient was admitted as an acute MI (myocardial infarction); what she had was a totally infarcted intrathoracic stomach. She required a total gastrectomy, and she didn t do too well. The most recent case I saw was only 2 weeks ago, a 94-year-old woman with her entire stomach up in the chest, admitted because of inability to eat or drink, losing weight, short[ness] of breath. There was a big debate whether to offer surgery at this point in her life, and she eventually declined surgery and went home after she got decompressed with an NG (endogastric) tube and so on. Now, clearly in the 40 years between these two cases, I have seen a lot of patients with a paraesophageal hernia and have come to recommend repair in suitable cases just upon the diagnosis, to prevent the terrible consequences of a gastric infarction. What we really are still lacking is convincing data that that surgery is the correct recommendation. This 94-year-old woman must have had her paraesophageal hernia for the last 30 years and here she is at 94 years of age and her stomach never infarcted. So what we really need is some indication, and it s not just those symptoms that you describe, as to who should be operated on and whom we should just follow, warning them that any symptoms that suggest torsion should be taken seriously and they should seek immediate help. I don t have an answer yet. DR CARROTT: Thank you for your comments. Historically, the concern for acute incarceration has been the major motivation for repair in selected patients. Acute symptoms can involve a variety of presentations. However, our current symptoms highlight how diverse the symptoms associated with paraesophageal hernias truly are. I think we would advocate in people who desire repair to proceed with it. However, older patients require a more careful physiologic assessment and a longer discussion as to what is appropriate in each individual case. DR DANIEL L. MILLER (Atlanta, GA): That was an excellent presentation. I would like to applaud you and your colleagues in Charlottesville for not increasing the health care expenditure by placing reinforcement mesh in these patients. I feel that a significant number of our general surgery colleagues use mesh reinforcement in a significant number of paraesophageal repairs. The cost of the biomaterials is more than the actual procedure itself. I know your follow-up is short. We will be interested in the long-term results. I have two questions. The first relates to the use of a speech pathology evaluation prior to starting a diet, especially in the DR CARROTT: That s true. When a normal eating pattern is restored, there is often a tendency to gain weight following repair. The mean age of our patient population was 70 years (range, 39 94). Although we do not typically get speech pathology involved, we agree that increased assessment may selectively be required in older patients. DR MILLER: I would recommend the evaluation in all of these patients. DR CARROTT: We did selectively use gastrostomy tubes in about 15% of patients. We agree with you that fixation is important, but the Hill procedure, which was used in 95% of cases, is based on firmly anchoring the paraesophageal attachments to the base of the crus and the median arcuate ligament. This provides very reliable fixation and is why the Hill operation is well suited for these particular hernias. DR RALPH AYE (Seattle, WA): The Virginia Mason group has previously studied the relationship between dyspnea and paraesophageal hernia repair. In this study 67% of the patients showed improvement in dyspnea. Can you tell us anything about preoperative factors that predict improvement for a given individual? How do we counsel the patient with a paraesophageal hernia whose primary symptom is dyspnea? DR CARROTT: I think most often we do see a great improvement in certain patients, and I think the larger the hernia, the more improvement there is in dyspnea. We have just presented our data on this issue at the Western Thoracic Surgical Association meeting. We reported that there was a mean improvement in FEV 1 (forced expiratory volume in 1 second) of 10%, and 67% of patients notice a subjective improvement in dyspnea, which matches the percentage reported in the current study. We think the impact of this side effect in particular is underappreciated. In general, however, the larger the hernia, the more patients will notice improvement. DR F. GRIFFITH PEARSON (Toronto, Ontario, Canada): I think it s important to read the past literature and I haven t heard it referred to. There is an article from the Mayo Clinic written by Mark Allen, and it follows 23 patients for a long period of time who were minimally symptomatic or thought they were asymptomatic and they decided not to operate. My recollection is that there were 2 or 3 of those patients at most who became symptomatic and had a repair, an elective repair, and in the remainder, as I recall, they had no single incidence of a lifethreatening or disastrous complication. Is Steve Cassivi still here? DR HENNING A. GAISSERT (Boston, MA): I think there was one death due to aspiration of barium in that group, if I recall correctly. DR PEARSON: Well, deaths can occur from aspiration of barium in older people with any disease. DR STEPHEN D. CASSIVI (Rochester, MN): Your memory is exact.

8 GENERAL THORACIC 428 CARROTT ET AL Ann Thorac Surg PEH SYMPTOMS AND OUTCOMES 2012;94:421 8 DR PEARSON: But you have to remember that information. That s clear information. And to suggest that you should operate on most of these patients even though they have mild symptoms I think is overtreatment and failure to read what other people have read. DR CARROTT: Thank you, Dr Pearson, for your comments. It is an honor to have you comment on our work. I think we do struggle with identifying those asymptomatic individuals because it is an unknown and, we believe, previously underappreciated percentage of patients presenting with paraesophageal hernias. Many of our patients had ascribed their symptoms to advancing age. When we assessed symptoms that are historically considered typical and atypical, pre[operatively] and postoperatively, only then did we appreciate the complete impact of these hernias in the majority of patients. In fact, we ultimately only had 1 patient we believed to be truly asymptomatic. These operations are no longer typically done transthoracically. Our mortality rate was zero in this series, and in spite of an older population, length of stay was a median of 4 days. We are not suggesting that all patients should undergo surgery. We are suggesting that physiologically fit patients should be more carefully assessed for symptoms, such as significant early satiety and dyspnea with basic activities, which we find can limit quality of life and significantly improve in the majority of patients following hernia repair. Southern Thoracic Surgical Association: Fifty-Ninth Annual Meeting Make plans now to attend the Fifty-Ninth Annual Meeting of the Southern Thoracic Surgical Association (STSA) on November 7 10, 2012, at the Naples Grande Beach Resort in Naples, FL. Please visit to make hotel reservations and to learn more about the schedule of events by The Society of Thoracic Surgeons Ann Thorac Surg 2012;94: /$36.00 Published by Elsevier Inc