Paraesophageal hiatal hernias (type II, III, IV) are. Effect of Paraesophageal Hernia Repair on Pulmonary Function

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1 Effect of Paraesophageal Hernia Repair on Pulmonary Function Donald E. Low, MD, and Eric J. Simchuk, MD Section of General Thoracic Surgery, Virginia Mason Medical Center, Seattle, Washington Background. Paraesophageal hernias classically present in elderly patients with symptoms of postprandial pain, bloating, dysphagia, and anemia. Most surgeons would advocate repairing paraesophageal hernias whenever they are encountered, however, significant levels of dyspnea or pulmonary dysfunction could previously have led to concerns regarding individual patient suitability for repair. We have noted that patients complaining of dyspnea prior to paraesophageal hernia repair often noted significant improvement following surgery. Methods. Between 1995 and 2001, 45 patients (mean age 71.5 years) presented with paraesophageal hernias. Patients had preoperative investigations including chest roentgenogram and barium swallow, 100%; upper endoscopy, 96%; manometry, 89%; and 24-hour ph studies, 27%. Operative repair was accomplished with an open Hill repair with intraoperative manometrics. All patients had assessment of pre- and postoperative spirometry, diffusion capacity, dyspnea index, and quality of life assessment. Results. Presenting symptoms included dyspnea, 84%; heartburn, 71%; dysphagia, 67%; regurgitation, 64%; and anemia, 47%. Type II hernias were found in 2 patients, type III in 33 patients, and type IV in 10 patients. Complications were minimal; mortality was zero. Mean length of stay was 4.7 days (range 3 to 9). Significant improvement in spirometry levels were noted in mean forced expiratory volume in 1 second (FEV 1 ) (preop, 1.87 liters; postop, 2.17 liters; percent improvement, 16%), p < ; mean forced vital capacity (FVC) (preop, 2.52 liters; postop, 2.89 liters; percent improvement, 14.7%), p < ; mean percent predicted FEV 1 (preop, 75.8%; postop, 88.6%), p < ; and mean percent predicted FVC (preop, 78.8%; postop, 91.5%), p < An improvement trend was noted in diffusing capacity, which did not reach statistical significance. The degree of improvement was seen to correlate with the size of the hernia. When hernias involved 100% of the stomach, percent improvement in FEV 1 of 19.6% and FVC of 19.7% were noted. Two patients who required home oxygen were able to discontinue therapy following surgery. Significant improvements in quality of life scores and dyspnea index were documented. Conclusions. Elderly patients with paraesophageal hernias are occasionally considered inappropriate candidates for surgical repair on the basis of coexistent medical problems including pulmonary dysfunction. Paraesophageal hernia repair is routinely associated with significant improvement in spirometry values, dyspnea index, and quality of life scores. (Ann Thorac Surg 2002;74:333 7) 2002 by The Society of Thoracic Surgeons Paraesophageal hiatal hernias (type II, III, IV) are much less common than the standard sliding hiatal hernia (type I) often associated with gastroesophageal reflux disease. These hernias classically present in the older patient population (age 60 to 90), and associated symptoms most commonly involve dysphagia, regurgitation, chest pain, and microcytic anemia. Paraesophageal hernias can reach massive proportions in certain patients producing profound attenuation of the esophageal hiatus and can volumetrically displace components in the inferior chest, mediastinum, and retrocardiac area. Patients with paraesophageal hernias are often considered to be poor operative risks due to advanced age and Presented at the Poster Session of the Thirty-eighth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28 30, Address reprint requests to Dr Low, Section of General Thoracic Surgery, Virginia Mason Medical Center, 1100 Ninth Ave, Seattle, WA 98101; donald.low@vmmc.org. impaired pulmonary function. We have noted that a significant component of patients will note increasing levels of dyspnea over the years prior to their presentation and that they will routinely report an improvement in breathing and exercise capacity following surgery. We hypothesize that the presence of paraesophageal hernias impairs respiratory function and that by restoring normal anatomy within the chest and the esophageal hiatus, respiratory parameters will improve. Material and Methods The study included patients presenting with type II, III, and IV paraesophageal hernias to Virginia Mason Medical Center between 1995 and All patients were reviewed to document preoperative symptoms. Preoperative studies included chest roentgenogram (100%), barium swallow (100%), endoscopy (96%), manometry (89%), and 24-hour ph study (27%). Basic spirometry studies and diffusion capacity mea by The Society of Thoracic Surgeons /02/$22.00 Published by Elsevier Science Inc PII S (02)

334 LOW AND SIMCHUK Ann Thorac Surg EFFECT OF PARAESOPHAGEAL HERNIA REPAIR 2002;74:333 7 Table 1. Presenting Factors in Patients With Paraesophageal Hernia Factors No.

surements were carried out 1 to 4 weeks preoperatively and repeated 1 to 6 months following surgery.

The procedure included reduction of the paraesophageal hernia, complete removal of the paraesophageal hernia sac, primary closure of the esophageal hiatus, and Hill repair.

2 334 LOW AND SIMCHUK Ann Thorac Surg EFFECT OF PARAESOPHAGEAL HERNIA REPAIR 2002;74:333 7 Table 1. Presenting Factors in Patients With Paraesophageal Hernia Factors No. of Patients (%) GERD 32 (71) Dysphagia 30 (67) Regurgitation 29 (64) Anemia 21 (47) Requiring preop transfusion 7 (16) Dyspnea 38 (84) Requiring home oxygen 2 (5) GERD gastroesophageal reflux disease. surements were carried out 1 to 4 weeks preoperatively and repeated 1 to 6 months following surgery. All patients underwent reconstruction of the gastroesophageal junction (Hill repair) done through an upper midline incision with an epidural catheter in place. The procedure included reduction of the paraesophageal hernia, complete removal of the paraesophageal hernia sac, primary closure of the esophageal hiatus, and Hill repair. Selected patients also underwent gastrostomy. Additional postoperative assessment involved documentation in changes in dyspnea index, quality of life parameters, and assessment of postoperative symptoms. Statistical analysis was carried out with Student s t test. Results Patients were studied between 1995 and These included 45 patients, 16 males and 29 females, mean age 71.5 years (range 46 to 91). Presenting symptoms are shown in Table 1. Over 50% of patients presented with symptoms of gastroesophageal reflux disease, dysphagia, Fig 2. Type III paraesophageal hernia combined sliding and paraesophageal hernia with intrathoracic air fluid level in stomach. and regurgitation. However, 84% complained of some degree of dyspnea preoperatively. Two patients (5%) were on home oxygen preoperatively. Three patients underwent urgent operations following hospitalization for what was thought to be transient incarceration of the paraesophageal hernias. Mean preoperative American Society of Anesthesiology score was The type of paraesophageal hernia was assessed preoperatively at the time of barium swallow. Type II hernias were found in 2 patients (Fig 1). Type III hernias were seen in 33 patients (Fig 2), and 10 patients presented with type IV paraesophageal hernia (Fig 3). Manometry Fig 1. Type II paraesophageal hernia esophagogastric junction (arrow) remains in normal subdiaphragmatic position. Fig 3. Type IV paraesophageal hernia combined hernia with other abdominal viscera within the hernia sac. This radiograph of the delayed portions of a barium swallow shows small bowel located alongside paraesophageal hernia.

3 Ann Thorac Surg LOW AND SIMCHUK 2002;74:333 7 EFFECT OF PARAESOPHAGEAL HERNIA REPAIR 335 Table 2. Postoperative Complications Complications No. of Patients Heartburn 0 Dysphagia ( 1 mo) 3 Requiring dilation 1 Esophagogastric junction ulcer 1 Mucus plugging requiring bronchoscopy 1 Atrial fibrillation 2 Mortality 0 Mean follow-up 19 months, range 2 mo 6 y. Table 3. Pre- and Postoperative Comparison of FEV 1, FVC, and Diffusion Capacity Variable Preop Postop % Improvement FEV 1 (liters) 1.87 ( ) FVC (liters) 2.52 ( ) DLCO (ml/mmhg/min) ( ) 2.17 ( ) 2.89 ( ) ( ) 16 p p p 0.2 DLCO diffusion capacity; FEV 1 forced expiratory volume in 1 second; FVC forced vital capacity. Table 4. Pre- and Postoperative Comparison of Percent Predicted FEV 1 and FVC Variable Preop Postop p Value FEV 1 (% predicted) 75.8 (31 117) 88.6 (50 126) p FVC (% predicted) 78.8 (40 120) 91.5 (64 122) p FEV 1 forced expiratory volume in 1 second; capacity. studies were carried out in 40 patients (89%). Peristalsis was found to be intact in 32 patients; 8 patients were found to have nonspecific motility disorders. Preoperative endoscopy demonstrated callous ulceration in 15 patients (33%). All patients underwent Hill procedure utilizing intraoperative manometrics. All patients were extubated immediately postoperatively, and postoperative pain was managed with patient-controlled epidural anesthesia. Other procedures performed at the same time included gastrostomy, 4; cholecystectomy, 3; resection of gut stromal tumor, 1; pelvic lymph dissection, 1; and coronary artery bypass grafts, 1. All 4 patients undergoing gastrostomy had very large type IV hernias. Mean length of stay was 4.7 days (range 3 to 9 days) and mean follow-up was 19 months (range 2 months to 6 years). Postoperative complications and symptoms are shown in Table 2. In-hospital and 30-day mortality was zero. Comparisons of pre- and postoperative forced expiratory volume in 1 second (FEV 1 ), FVC, percent predicted FEV 1 and FVC, and diffusion capacity is demonstrated in Tables 3 and 4. Significant improvements were documented with FEV 1, FVC, and percent predicted FEV 1 and FVC. There was a trend toward improvement with DLCO, although it did not reach statistical significance. A decrease in postoperative FEV 1 was noted in only 3 patients, whereas only 1 patient failed to show an increase in FVC. Table 5 examines the effect on pre- and postoperative spirometry values depending on the size of the paraesophageal hernia. Paraesophageal hernias that encompassed 75% to 100% of the stomach showed percent improvements ranging from 13.2% to 19.7% after paraesophageal hernia repair. Improvements in quality of life score and dyspnea index are shown in Table 6. The two patients who required home oxygen prior to surgery were able to discontinue this therapy following surgical repair. Comment FVC forced vital There is a significant body of literature suggesting a relationship between pulmonary symptoms and gastroesophageal reflux disease [1 3]. However, there is very little assessment of the potential ramifications of large hiatal hernias and pulmonary function. Sliding (type I) hiatal hernias can become very large, but do not often reach the proportions seen with paraesophageal hernias (type II, III, and IV). Patients who present with these hernias are typically elderly and often present with other complex medical problems. These patients usually demonstrate symptoms of postprandial pain and bloating, dysphagia, and anemia [4, 5]. It is clear, however, that a significant component will present with an evolving problem with dyspnea over the previous decade prior to their surgery. These symptoms are often ascribed to chronic obstructive pulmonary disease, heart problems, or simply the patient s advanced age. We have observed that the majority of patients will note an improvement in the level of dyspnea following paraesophageal hernia repair. Senyk and colleagues have previously reported changes in basic spirometry values [6] and ventilation studies [7] following repair of a variety of hiatal hernias. They have noted that the dimensions of the effect varied with the size of the hernia. We have documented a very similar relationship in patients with paraesophageal hernias demonstrating dramatic improvements in basic spirometry values in the range of 14% to 16% increases in FEV 1 and FVC. These improvements become more prominent as the size of the hiatal hernia increases. Objective findings are mirrored in improvements in dyspnea index and quality of life parameters. The explanation of these findings has previously been thought to be secondary to improvement in diaphragmatic function [8 10] or decreasing levels of atelectasis [11]. Considering the dimensions of the diaphragmatic defects encountered in many of these patients, the reestablishment of normal diaphragmatic contour and configuration is potentially a major factor. It may also be one of the most important reasons to provide an anatomic primary closure of the hiatus rather than using prosthetic material. Some of these hernias will contain not only the

4 336 LOW AND SIMCHUK Ann Thorac Surg EFFECT OF PARAESOPHAGEAL HERNIA REPAIR 2002;74:333 7 Table 5. Changes in Pulmonary Function Associated With Hernia Size Hernia Size (%) No. of Patients FEV 1 FVC Preop Postop % Change Preop Postop % Change p p p p p p FEV 1 forced expiratory volume in 1 second; FVC forced vital capacity. Table 6. Changes in Dyspnea Index and Quality of Life Scores Following Paraesophageal Hernia Repair Variable Preop (range) Postop (range) Mean dyspnea index a 2.12 (1 4) 1.35 (1 2) Mean quality of life score b 4.5 (2 9) 8.2 (6 10) a Dyspnea index: 1 no dyspnea; 2 dyspnea with exertion; 3 dyspnea with basic activities; 4 dyspnea at rest. b Quality of life score: worst 0; 10 best. entire stomach, but occasionally components of colon, omentum, and small bowel (type IV paraesophageal hernias). Previous reports in patients with hiatal hernias have documented ventilation abnormalities involving upper as well as lower pulmonary zones [7] supporting the hypothesis that dyspnea may be secondary to transient changes in ventilation and perfusion. It is also feasible that in this elderly population, acute distention may have a temporary impact on cardiac function contributing to symptoms of dyspnea and changes in exercise capability. Historical reports of open repairs have established the importance of hernia reduction, sac removal, secure closure of the esophageal hiatus, and anchoring the repair (usually in association with an antireflux procedure) in the abdominal cavity. There have been a large number of recent publications reporting the feasibility of laparoscopic paraesophageal hernia repair. Unfortunately, many of the basic tenets of the operation needed to be relearned during this process [12 14]. In addition, some recent publications have demonstrated the technical feasibility of paraesophageal hernia repair, but with the recognition that the approach is challenging and in some cases raising concerns regarding rates of recurrence and complications [4, 15 17]. There is also increasing recognition of the requirements for an esophageal lengthening procedure (Collis operation) in a proportion of these patients secondary to coexistent esophageal shortening [18, 19]. The current series reports the outcomes in patients having an open Hill repair in these technically challenging patients. This repair has the advantage of firmly anchoring the esophagogastric junction in the abdominal cavity. No patients required lengthening procedures and all patients had primary closure of the hiatus. Complications were minimal. No patients died. The mean length of hospital stay was 4.7 days and short-term follow-up demonstrated minimal problems with symptom recurrence and dramatic improvement in quality of life parameters. In conclusion, the presence of paraesophageal hernias can significantly impair respiratory function. Following surgical repair, improvement can be expected in spirometry values, subjective levels of dyspnea, and quality of life. As a result, significant respiratory embarrassment heretofore thought to be a relative contraindication for esophageal surgery may, in fact, be an indication for repair in patients with large paraesophageal hernias. References 1. Iverson LIG, May IA, Samson PC. Pulmonary complications in benign esophageal disease. Am J Surg 1973;126: Belsey R. The pulmonary complications of oesophageal disease. Br J Dis Chest 1960;54: Selmonosky CA, Blanc JS, Byrd R. Hiatal hernia and pulmonary function impairment: incidence or coincidence? South Med J 1980;73: Oddsdottir M. Paraesophageal hernia. Surg Clin North Am 2000;80: Wo JM, Branum GD, Hunter JG, et al. Clinic features of type III paraesophageal hernia. Am J Gastroenterol 1996;91: Senyk J, Arborelius M, Lilja B, et al. Respiratory function in esophageal hiatus hernia. I. Spirometry, gas distribution, and arterial blood gases. Respiration 1975;32: Senyk J, Arborelius M, Lilja B, et al. Respiratory function in esophageal hiatus hernia. II. Regional lung function. Respiration 1975;32: Marchand P. Hiatal hernia. Its varying modes of presentation and frequent early misdiagnosis. SAfr Med J 1965;39: Harrington SW. Various types of diaphragmatic hernia treated surgically. Report of 430 cases. Surg Gynecol Obstet 1948;86: Hill LD, Tobias JA. Paraesophageal hernia. Arch Surg 1968; 96: Malm A, Svanberg L. Synpunkter pa operationsindikationerna vid hiatusbrackk. Nord Med 1958;60: van der Peet DL, Klinkenberg-Knol EC, Poza AA, et al. Laparoscopic treatment of large paraesophageal hernias. Both excision of the sac and gastropexy are imperative for adequate surgical treatment. Surg Endosc 2000;14: Watson DI, Davies N, Devitt PG, et al. Importance of

5 Ann Thorac Surg LOW AND SIMCHUK 2002;74:333 7 EFFECT OF PARAESOPHAGEAL HERNIA REPAIR 337 dissection of the hernial sac in laparoscopic surgery for large hiatal hernias. Arch Surg 1999;134: Edye M, Salky B, Posner A, et al. Sac excision is essential to adequate laparoscopic repair of paraesophageal hernia. Surg Endosc 1998;12: Hashemi M, Peters JH, DeMeester TR, et al. Laparoscopic repair of large type III hiatal hernia: objective followup reveals high recurrence rate. J Am Coll Surg 2000;190: Dahlberg PS, Deschamps C, Miller DL, et al. Laparoscopic repair of large paraesophageal hiatal hernia. Ann Thorac Surg 2001;72: Trus TL, Bax T, Richardson WS, et al. Complications of laparoscopic paraesophageal hernia repair. J Gastrointest Surg 1997;1: Mittal SK, Awad ZT, Tasset M, et al. The preoperative predictability of the short esophagus in patients with stricture or paraesophageal hernia. Surg Endosc 2000;14: Urbach DR, Khajanchee YS, Glasgow RE, et al. Preoperative determinants of an esophageal lengthening procedure in laparoscopic antireflux surgery. Surg Endosc 2001;15: INVITED COMMENTARY These authors found preoperative dyspnea in 84% of their patients with paraesophageal hernia. This is higher than reported in most series and raises questions. Did these authors look more intensively for this symptom? Or, have previous studies not recognized dyspnea as a function of the hernia and gastroesophageal reflux but, rather, considered it a comorbidity related to primary pulmonary pathology? From a purely mechanical standpoint the concept of impaired respiratory function due to a paraesophageal hernia is logical. Returning herniated abdominal contents from the chest to the abdomen restores the total lung capacity to normal and would, therefore, be expected to improve respiratory function; the larger the volume of the intrathoracic hernia, the greater the expected improvement in function. This is confirmed by the work of these authors, but the mechanism of improvement doesn t seem so simple. Other potential mechanisms, such as returning the diaphragm to its normal contour and function, as suggested by these authors and others, are less intuitive but likely have merit. Senyk and associates. (references 6 and 7 in article by Low and Simchuk) long ago reported similar findings with all types of hiatal hernias. Senyk did not find an association with size of the thoracic hernia and spirometric or arterial oxygen findings. He did, however, find a correlation of lung volume and regional ventilation/perfusion abnormalities with the roentgenographic transverse diameter of the hernia. He suggested that herniated contents compressing lung parenchyma might cause regional ventilation/perfusion mismatch as a possible source of spirometric and arterial oxygen saturation abnormalities. All these proposed mechanisms, however, may be overlooking a potentially greater contributing factor; that is the well-established improvement in respiratory symptoms after surgical treatment of gastroesophageal reflux regardless of the type of hernia. Although this aspect of respiratory dysfunction is usually described as cough, asthma, pulmonary fibrosis or recurrent pneumonia and not distinctly dyspnea, this certainly may be a contributing factor as well. Regardless of the mechanism, these authors convincingly demonstrate overall respiratory improvement after surgical repair of paraesophageal hernias when accompanied by an anti-reflux procedure. They importantly point out that respiratory symptoms and findings of impaired respiratory function on diagnostic evaluations should not necessarily be contraindications to, and may even be indications for surgery in these patients. Geoffrey M. Stiles, MD Sharp Memorial Hospital San Diego, CA gstilesl@san.rr.com 2002 by The Society of Thoracic Surgeons /02/$22.00 Published by Elsevier Science Inc PII S (02)

Hiatal Hernias and Barrett s esophagus. Dr Sajida Ahad Mercy General Surgery

Hiatal Hernias and Barrett s esophagus Dr Sajida Ahad Mercy General Surgery Objectives Identify the use of different diagnostic modalities for hiatal hernias List the different types of hiatal hernias