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EXPERIENCES WITH 500 CASES OF HIATUS HERNIA
Original
Communications
EXPERIENCES W I T H 500 CASES OF HIATUS HERNIA A Statistical Survey Richard H. Sweet, M.D., Boston, Mass. (Presented
H
by Earle W. Wilkins,
Jr., M.D., Boston,
Mass.)
was to have been the subject of Dr. Richard H. Sweet's presi dential address today before this meeting of The American Association for Thoracic Surgery. It was long a subject of particular interest to the man whose career spanned the years of the modern development of thoracic surgery. It is my very distinct privilege, at the request of his widow and of the Council of this organization, to present the results of this study for him. It was my even greater privilege to have been his close associate during the last full 10 years of his practice. IATUS HERNIA
This series includes 500 patients with esophageal hiatus hernia seen in the private practice of one surgeon. Its breakdown is presented in Table I. Surgical repair was performed in 394 patients. In 78 patients the diagnosis of esophageal hiatus hernia was established conclusively but surgery was not advised. In 43 of these patients, symptoms were typical; of these, symptoms were not suffi ciently severe in 21, and were relieved by medical measures in 10. Twelve patients were physically unacceptable. In 35 patients, surgery was not advised because the symptoms were atypical, including those of coronary insufficiency, peptic ul cer, gastritis, anxiety neurosis, or esophagospasm. Asymptomatic hiatus hernias are sufficiently common that repair is never indicated in those whose complaints are most likely the result of other diseases. Twenty-eight patients, for a variety of personal reasons, did not accept the advice for surgical repair. TABLE
I.
500
P A T I E N T S SEEN
Operation not advised Operation advised Not carried out Completed Right thoracic Abdominal Abdominothoracic Left thoracic
78 422 28 394 3 16 17 358
Read a t the Forty-second Annual Meeting- of The American Association for Thoracic Surgery a t St. Louis, Mo., April 16-18, 1962. 145
146
SWEET
(PRESENTED
BY WILKINS)
J. Thoracic and Cardiovas. Surg.
The analysis of the 500 patients by sex and age is presented in Table I I . Women accounted for 68 per cent; a significant majority but perhaps less than anticipated. The greatest frequency was in the decade of 50 through 59 years of age, 31 per cent; followed by the decade 60 through 69, 27 per cent; and under 50, 21 per cent. I t is strikingly clear that esophageal hiatus hernias, although possibly congenital in many instances, become really symptomatic in the middle decades of life. TABLE I I . M A K E - U P OF SERIES
Sex Men Women
OPERATION NOT ADVISED
ADVISED NOT DONE
ADVISED AND COMPLETED
TOTAL
34 44
9 19
119 275
162 338 500
ge Under 49 50-59 60-69 70-79 80 and above Not stated
78 131 114 31 8 32
8 8 6 0 0 6
20 14 16 10 3 15
106 153 136 41 11 53 500
The sliding hernia was by far the dominant type (Table III.) I t repre sented 94 per cent of the total series of 500. This is the form once known as the "short esophagus," but, in this survey, patients with actual shortening, the group with peptic esophageal strictures, have not been included. The parahiatal or paraesophageal form occurred in only 3.5 per cent. An interesting 2.5 per cent presented a composite form, a combination of both sliding and parahiatal elements. TABLE I I I . OPERATION NOT ADVISED Sliding Parahiatal Composite Total known N o t known
T Y P E OF H E R N I A
ADVISED NOT DONE
ADVISED A N D COMPLETED
70 1 0
22 1 2
367 15 12
7
3
0
TOTAL 459 17 14 490 10
PER CENT 94.0 3.5 2.5 100.0
500
The size of the hernia is presented in Table IV. The usual variety, the small to medium hernia with less than one half the stomach involved, repre sented 65 per cent of the 500 cases. Truly large hernias were encountered in 33 per cent. The latter frequently presented obstructive symptoms; a few dem onstrated diminished pulmonary reserve as the result of interference with pul monary expansion. The very large hernia has been the single exception to the concept that only symptomatic hernias need be repaired. The concern for incarceration or volvulus and the possibility of pulmonary insufficiency ac companying the very large hernia are indications for its repair even when symp toms were absent.
Vol. 44, N o . 2 August, 1962
HIATUS HERNIA TABLE IV. OPERATION NOT ADVISED
Small to medium Large (one half of stomach) Very large (over half of stomach) Not stated
HERNIA
147
SIZE
ADVISED NOT DONE
ADVISED AND COMPLETED
TOTAL
64
18
244
326
4
6
82
92
3 7
4 0
68 0
75 7 "500
The principal indication for operation in 422 patients in whom surgery was advised is listed in Table V. Varieties of "dyspepsia" (pyrosis or heart burn, flatulence, eructations, distress) or pain accounted for operation in nearly two thirds of all patients. Some type of bleeding occurred in 19 per cent, which was either massive in approximately two thirds, or occult and insidious in one third. Extreme caution was exercised in this category to exclude, usually by roentgen examination, other common sources of gastrointestinal hemorrhage prior to surgical exploration. Obstruction occurred in 7 per cent, usually the result of incarceration or volvulus of the stomach within the hernia. When dysphagia accompanied hiatus hernia, other explanations were carefully ex cluded because of its infrequency as a presenting symptom. One source of dys phagia has been the mucosal fibrous ring at the exact junction of esophageal and gastric mucosa, in the presence of a small hernia, the so-called Schatzki ring. The exact etiology of this condition has not been explained but statistically seems related to the hernia. TABLE V.
PRINCIPAL INDICATION FOR OPERATION; 422
Pain, distress, pyrosis, etc. Pain and bleeding Bleeding alone Obstruction and bleeding Obstruction Slight dysphagia (+ " r i n g " ) Large size Dyspnea (large hernia) As a part of operation for achalasia leiomyoma epiphrenic diverticulum tumor of lung tumor of mediastinum
OPERATION NOT DONE
OPERATION COMPLETED
20 0 2 0 0
244 31 43 5 25
4 2 0
22 7 1
PATIENTS
PER C E N T
264
64.5
81 30
19.0 7.0
6 2 2 3 2
Local conditions found at operation appear in Table VI. The unusually low incidence of peptic esophagitis (3 per cent) is the result of (1) exclusion of patients with the truly " s h o r t " esophageal stricture, and (2) the method of diagnosis of esophagitis. It has been made only on the basis of gross physical changes encountered at the time of operation. Esophagoscopy with direct mucosal biopsy, the other reliable method of establishing its presence, has
148
SWEET
(PRESENTED BY WILKINS)
J. Thoracic and Cardiovas. Surg.
been considered unjustifiable as a routine measure. Symptomatic diagnosis, on the basis of regurgitation or heartburn, is completely unreliable. TABLE V I .
LOCAL CONDITIONS FOUND AT OPERATION
Esophagitis Gastritis Incarceration of stomach Necrosis of stomach (focal) Perforation of stomach Constricting omental band Other viscera in hernia sac Colon Duodenum
14 4 27 3 2 1 8 6 2
Incarceration of a portion or, occasionally, all of the stomach was the most common local abnormality (27 cases). Necrosis or local perforation of the stomach, a very serious complication, occurred in 5 patients and led to death in one. Operation, therefore, has been advised in patients with roentgenographically demonstrable incarceration, particularly in the hernias of large size. The hernia may be sufficiently large to accept colon, omentum, or duo denum, in addition to stomach. Total gastric herniation may be accompanied by a constricting band from the pyloric level to the underside of the margin of the hiatal opening. Failure to recognize and liberate such a band has been known to interfere with gastric emptying by local angulation. The majority of the hernias have, by personal preference, been repaired by the left thoracic approach (Table V I I ) . The primary consideration must always be the approach by which the well-trained surgeon can accomplish his most satisfactory repair. Exposure of other specific organs in either thorax or abdomen is a secondary consideration in selection of the route of approach. TABLE V I I .
DETAILS OP EEPAIB—THORACIC APPROACH*
Plication of hernia sac Excision of hernia sac (mediastinal) Excision of hernia sac (abdominal) No plication or excision of sac Counterincision of diaphragm Insertion of fascia lata •Left side = 358 ; right side = 3.
299 31 30 1 85 4
When accomplished through the left hemithorax, the repair has followed two principles: (1) the obliteration of the peritoneal sac with reduction of the herniated stomach, and (2) the narrowing of the hiatus by placement of sutures in the muscular margins of the hiatal aperture behind, and occasionally in front of, the esophagus. The ablation of the sac has been effected by plication and inversion, or by excision, from either the mediastinal aspect or through a counterincision in the diaphragm from the abdominal side. When tissue inadequacy has demanded it, fascia lata has been employed to strengthen the closure of the widened hiatus, particularly in the recurrent hernia. Late in the series, effective ablation of the sac was effected by horizontal mattress sutures running from the esophageal musculature at the point of attachment of the
Vol. 44, No. 2
HIATUS HERNIA
August, 1962
149
sac to the margin of the hiatus through only that portion of the circumference where the sac normally lies. Associated lesions were present in 25 per cent or 126 patients (Table V I I I ) . Respiratory lesions were largely incidental and unrelated to the hernia. They included bronchiectasis in 6; bronchopulmonary suppuration, emphysematous bleb, granuloma, hamartoma, and carcinoma in one each. The mediastinal lesions were a lipoma in the cardiophrenic angle and a chylous cyst of the thoracic duet. The associated esophageal lesions were closely related to the hernia in most cases, including esophagitis (18 cases), esophageal web (12), various diverticula (12), achalasia (7), and leiomyoma, neuroflbroma, and scleroderma (1 each). The commonly associated gastroduodenal lesion was gastritis or peptic ulceration in 28 patients, presumably a statistical coincidence because of the frequency of each entity. Others included diverticulum (4) and pyloric stenosis (1). The com mon lesion of the biliary tract was cholelithiasis, known in only 9 instances; the remaining lesion was hepatic cirrhosis. The 18 miscellaneous lesions included all possible unrelated abdominal conditions. TABLE V I I I .
SUMMARY OF ASSOCIATED L E S I O N S
OPERATION NOT ADVISED
Respiratory tract Mediastinum Esophagus Stomach and duodenum Biliary tract Miscellaneous
4 0 8 16 1 6
ADVISED NOT DONE 2 0 4 1 1 2
ADVISED AND COMPLETED 5 2 40 16 8 10
11 2 52 33 10 18 126
Other surgical procedures carried out in conjunction with the hernia re pair appear in Table IX. Of the 92, 27 were associated with the esophagus, the one organ that can be exposed properly only by the thoracic approach. TABLE I X .
SUMMARY OF OPERATIONS COMBINED W I T H REPAIR
Esophagus Stomach and duodenum Biliary tract Lung Mediastinum Miscellaneous
27 43 13 3 2 4 92
They included excision of a web (9), esophagomyotomy (7), esophagoplasty (4), excision of an epiphrenic diverticulum (5), and removal of a leiomyoma or neuroflbroma (2). The 43 procedures on the stomach and duodenum could equally well have been approached by thoracic or abdominal routes. They in volved either interior gastric exploration (21), or procedures for the manage ment of gastritis or ulcer (22), including distal resection, pyloroplasty, gastroenterostomy, vagotomy, or any combination thereof. The thirteen biliary tract procedures were cholecystectomy or related operations, all by the abdominal or
150
SWEET ( P R E S E N T E D BY W I L K I N S )
J. Thoracic and Cardiovas. Surg.
abdominothoracic route. This is the greatest single application of the abdomi nal approach. Lesions of the lower lung or mediastinum may be handled simultaneously only through the thoracic route. There was one lobectomy for carcinoma and excision of a granuloma, hamartoma, mediastinal lipoma, and a chylous cyst (1 each). 6 men Indication gallbladder suspect cholelithiasis (proved) gastric diverticulum duodenal ulcer scoliosis (extreme) Type of incision subcostal transverse inverted T paramedian
KH )^t )^( Y*\~(
lOwomen
0 3 1 2 0
16 Total
2 5
2 8 1 3 2
0 I 2
1 2 I
0
1 6 2 7
4 I 2
Fig. 1.—Esophageal hiatus hernia.
5
Use of abdominal approach.
The abdominal approach was employed in a small group in this series but its application is worthy of inspection (Fig. 1). Ten abdominal approaches were used because of known or suspected gall bladder disease; four for peptic ulcer or gastric diverticulum. Two were occasioned by anatomic considerations (extreme scoliosis). The type of incision varied. The paramedian or inverted T (usually a conversion of an initial transverse) incision offered the better ex posure. The abdominothoracic approach (Table X) was utilized primarily for simultaneous gastric resection for gastric lesions or duodenal ulcer, once for a tumor of the body of the pancreas. The relative inaccessibility of the duodenum by the strictly thoracic approach necessitated this modification when gastrectomy seemed indicated preoperatively. This extensive incision was well tol erated by patients. TABLE X.
1 Indication Lesion of (actual Lesion of Duodenal
stomach or suspected) pancreas ulcer
Hernia size Small to medium Large Very large Hernia type Sliding Parahiatal Composite
10
ABDOMINOTHORACIC APPROACH MEN
1
7 WOMEN
1
17 TOTAL
4 0 6
4 1 2
8 1 8
8 2 0
7 0 0
15 2 0
10 0 0
7 0 0
17 0 0
Vol. 44, No. 2 August, 1962
HIATUS HERNIA
151
Postsurgical complications are listed in Table XI. There is no significant difference in rates of incidence among the routes of operation employed. The over-all complication rate was 16 per cent, 63 of the 394 patients subjected to operation. The incidence of wound infection was low; 3 cases, or under 1 per cent. Eespiratory complications occurred 16 times: atelectasis (7), unusual degrees of pleural effusion (3), sublethal pulmonary emboli (2), asthmatic episodes (2), and laryngeal edema and vocal cord paralysis (1 each). Vascular complications numbered ten, largely thrombophlebitis of the leg veins (6), but included also acute myocardial infarction (2), and auricular fibrillation and cerebrovascular hemorrhage (1 each). Gastrointestinal complications num bered fifteen: transient dysphagia (6), unusual ileus (3), gastric dilatation (2), and esophagitis, hemorrhage, gastric rupture, and jejunal perforation (1 each). Miscellaneous complications numbered 22, all unrelated to the specific operation except for the three instances of wound infection. TABLE X I .
S U M M A R Y OP ALL CASES
Respiratory tract Heart and blood vessels Esophagus, stomach, etc. Miscellaneous
POSTOPERATIVE COMPLICATIONS*
THORACIC
ABDOMINOTHORACIC
ABDOMINAL
TOTAL
361
17
16
394
15 9 14 19
1 0 1 0
0 1 0 3
16 10 15 22 63
•Sixteen per cent of 394.
There were four deaths in the 394 operations, an incidence of just 1 per cent (Table X I I ) . The causes included a massive coronary occlusion, a major pulmonary embolus, sepsis resulting from a preoperative gastric perforation with mediastinitis, and an unexplained postoperative jejunal perforation. The latter patient died from bile peritonitis, despite prompt recognition of the com plication and surgical re-exploration. TABLE X I I . |
Coronary thrombosis Pulmonary embolism Sepsis Gastric perforation Jejunal perforation ♦One per cent of 394.
POSTOPERATIVE D E A T H S *
THORACIC
j ABDOMINOTHORACIC
f
ABDOMINAL
1 1
0 0
0 0
1 1
0 0
0 0
There are few good follow-up reports of the incidence of recurrence fol lowing the surgical repair of hiatus hernia. These patients were followed a minimum of one year, the longest period was 19 years. The large majority were very grateful for their operation; many were among the most grateful of all surgical patients. Follow-up studies included detailed questionnaires to the patients and letters of inquiry to the referring physician. Symptomatic pa tients were subjected to follow-up barium studies of the upper gastrointestinal
J. Thoracic and Cardiovas. Surg.
SWEET (PRESENTED BY WILKINS)
152
tract. Table X I I I shows that recurrences totaled thirty-one in 394 operations, an incidence of approximately 8 per cent. There have been no recurrences in the parahiatal group. There is no significant difference in the recurrence rate between the sexes. The number of abdominal repairs is too few to permit sta tistical comparison. In addition to the proved recurrences, 3 patients have symptoms of regurgitation but have no demonstrable recurrence by repeated, careful roentgenographic study. TABLE X I I I . |
Male Thoracie Abdominal Female Thoracie Abdominal
H I A T U S H E R N I A RECURRENCES
RECURRENCES
I
TOTAL NO.
6 1
113 6
24 0 ~31
265 10 394"
I
PER CENT
5 16 9 0 TI
Of the recurrences, three were detected in patients without symptoms who had routine upper gastrointestinal examinations. In 21, symptoms recurred in less than 2 years; in 7, the recurrence was demonstrated between 2 and 9 years with the exact date of onset of symptoms unknown. It is clear that the majority of recurrences appear early, a fact which lends a greater measure of accuracy to the 8 per cent recurrence figure. CONCLUSION
This series demonstrates the minimal risk attending the surgical repair of hiatus hernia and the significant possibility of recurrence (7.8 per cent). I t is the task of the thoracic and gastrointestinal surgeon to explore methods of reducing this figure.
Communications
EXPERIENCES W I T H 500 CASES OF HIATUS HERNIA A Statistical Survey Richard H. Sweet, M.D., Boston, Mass. (Presented
H
by Earle W. Wilkins,
Jr., M.D., Boston,
Mass.)
was to have been the subject of Dr. Richard H. Sweet's presi dential address today before this meeting of The American Association for Thoracic Surgery. It was long a subject of particular interest to the man whose career spanned the years of the modern development of thoracic surgery. It is my very distinct privilege, at the request of his widow and of the Council of this organization, to present the results of this study for him. It was my even greater privilege to have been his close associate during the last full 10 years of his practice. IATUS HERNIA
This series includes 500 patients with esophageal hiatus hernia seen in the private practice of one surgeon. Its breakdown is presented in Table I. Surgical repair was performed in 394 patients. In 78 patients the diagnosis of esophageal hiatus hernia was established conclusively but surgery was not advised. In 43 of these patients, symptoms were typical; of these, symptoms were not suffi ciently severe in 21, and were relieved by medical measures in 10. Twelve patients were physically unacceptable. In 35 patients, surgery was not advised because the symptoms were atypical, including those of coronary insufficiency, peptic ul cer, gastritis, anxiety neurosis, or esophagospasm. Asymptomatic hiatus hernias are sufficiently common that repair is never indicated in those whose complaints are most likely the result of other diseases. Twenty-eight patients, for a variety of personal reasons, did not accept the advice for surgical repair. TABLE
I.
500
P A T I E N T S SEEN
Operation not advised Operation advised Not carried out Completed Right thoracic Abdominal Abdominothoracic Left thoracic
78 422 28 394 3 16 17 358
Read a t the Forty-second Annual Meeting- of The American Association for Thoracic Surgery a t St. Louis, Mo., April 16-18, 1962. 145
146
SWEET
(PRESENTED
BY WILKINS)
J. Thoracic and Cardiovas. Surg.
The analysis of the 500 patients by sex and age is presented in Table I I . Women accounted for 68 per cent; a significant majority but perhaps less than anticipated. The greatest frequency was in the decade of 50 through 59 years of age, 31 per cent; followed by the decade 60 through 69, 27 per cent; and under 50, 21 per cent. I t is strikingly clear that esophageal hiatus hernias, although possibly congenital in many instances, become really symptomatic in the middle decades of life. TABLE I I . M A K E - U P OF SERIES
Sex Men Women
OPERATION NOT ADVISED
ADVISED NOT DONE
ADVISED AND COMPLETED
TOTAL
34 44
9 19
119 275
162 338 500
ge Under 49 50-59 60-69 70-79 80 and above Not stated
78 131 114 31 8 32
8 8 6 0 0 6
20 14 16 10 3 15
106 153 136 41 11 53 500
The sliding hernia was by far the dominant type (Table III.) I t repre sented 94 per cent of the total series of 500. This is the form once known as the "short esophagus," but, in this survey, patients with actual shortening, the group with peptic esophageal strictures, have not been included. The parahiatal or paraesophageal form occurred in only 3.5 per cent. An interesting 2.5 per cent presented a composite form, a combination of both sliding and parahiatal elements. TABLE I I I . OPERATION NOT ADVISED Sliding Parahiatal Composite Total known N o t known
T Y P E OF H E R N I A
ADVISED NOT DONE
ADVISED A N D COMPLETED
70 1 0
22 1 2
367 15 12
7
3
0
TOTAL 459 17 14 490 10
PER CENT 94.0 3.5 2.5 100.0
500
The size of the hernia is presented in Table IV. The usual variety, the small to medium hernia with less than one half the stomach involved, repre sented 65 per cent of the 500 cases. Truly large hernias were encountered in 33 per cent. The latter frequently presented obstructive symptoms; a few dem onstrated diminished pulmonary reserve as the result of interference with pul monary expansion. The very large hernia has been the single exception to the concept that only symptomatic hernias need be repaired. The concern for incarceration or volvulus and the possibility of pulmonary insufficiency ac companying the very large hernia are indications for its repair even when symp toms were absent.
Vol. 44, N o . 2 August, 1962
HIATUS HERNIA TABLE IV. OPERATION NOT ADVISED
Small to medium Large (one half of stomach) Very large (over half of stomach) Not stated
HERNIA
147
SIZE
ADVISED NOT DONE
ADVISED AND COMPLETED
TOTAL
64
18
244
326
4
6
82
92
3 7
4 0
68 0
75 7 "500
The principal indication for operation in 422 patients in whom surgery was advised is listed in Table V. Varieties of "dyspepsia" (pyrosis or heart burn, flatulence, eructations, distress) or pain accounted for operation in nearly two thirds of all patients. Some type of bleeding occurred in 19 per cent, which was either massive in approximately two thirds, or occult and insidious in one third. Extreme caution was exercised in this category to exclude, usually by roentgen examination, other common sources of gastrointestinal hemorrhage prior to surgical exploration. Obstruction occurred in 7 per cent, usually the result of incarceration or volvulus of the stomach within the hernia. When dysphagia accompanied hiatus hernia, other explanations were carefully ex cluded because of its infrequency as a presenting symptom. One source of dys phagia has been the mucosal fibrous ring at the exact junction of esophageal and gastric mucosa, in the presence of a small hernia, the so-called Schatzki ring. The exact etiology of this condition has not been explained but statistically seems related to the hernia. TABLE V.
PRINCIPAL INDICATION FOR OPERATION; 422
Pain, distress, pyrosis, etc. Pain and bleeding Bleeding alone Obstruction and bleeding Obstruction Slight dysphagia (+ " r i n g " ) Large size Dyspnea (large hernia) As a part of operation for achalasia leiomyoma epiphrenic diverticulum tumor of lung tumor of mediastinum
OPERATION NOT DONE
OPERATION COMPLETED
20 0 2 0 0
244 31 43 5 25
4 2 0
22 7 1
PATIENTS
PER C E N T
264
64.5
81 30
19.0 7.0
6 2 2 3 2
Local conditions found at operation appear in Table VI. The unusually low incidence of peptic esophagitis (3 per cent) is the result of (1) exclusion of patients with the truly " s h o r t " esophageal stricture, and (2) the method of diagnosis of esophagitis. It has been made only on the basis of gross physical changes encountered at the time of operation. Esophagoscopy with direct mucosal biopsy, the other reliable method of establishing its presence, has
148
SWEET
(PRESENTED BY WILKINS)
J. Thoracic and Cardiovas. Surg.
been considered unjustifiable as a routine measure. Symptomatic diagnosis, on the basis of regurgitation or heartburn, is completely unreliable. TABLE V I .
LOCAL CONDITIONS FOUND AT OPERATION
Esophagitis Gastritis Incarceration of stomach Necrosis of stomach (focal) Perforation of stomach Constricting omental band Other viscera in hernia sac Colon Duodenum
14 4 27 3 2 1 8 6 2
Incarceration of a portion or, occasionally, all of the stomach was the most common local abnormality (27 cases). Necrosis or local perforation of the stomach, a very serious complication, occurred in 5 patients and led to death in one. Operation, therefore, has been advised in patients with roentgenographically demonstrable incarceration, particularly in the hernias of large size. The hernia may be sufficiently large to accept colon, omentum, or duo denum, in addition to stomach. Total gastric herniation may be accompanied by a constricting band from the pyloric level to the underside of the margin of the hiatal opening. Failure to recognize and liberate such a band has been known to interfere with gastric emptying by local angulation. The majority of the hernias have, by personal preference, been repaired by the left thoracic approach (Table V I I ) . The primary consideration must always be the approach by which the well-trained surgeon can accomplish his most satisfactory repair. Exposure of other specific organs in either thorax or abdomen is a secondary consideration in selection of the route of approach. TABLE V I I .
DETAILS OP EEPAIB—THORACIC APPROACH*
Plication of hernia sac Excision of hernia sac (mediastinal) Excision of hernia sac (abdominal) No plication or excision of sac Counterincision of diaphragm Insertion of fascia lata •Left side = 358 ; right side = 3.
299 31 30 1 85 4
When accomplished through the left hemithorax, the repair has followed two principles: (1) the obliteration of the peritoneal sac with reduction of the herniated stomach, and (2) the narrowing of the hiatus by placement of sutures in the muscular margins of the hiatal aperture behind, and occasionally in front of, the esophagus. The ablation of the sac has been effected by plication and inversion, or by excision, from either the mediastinal aspect or through a counterincision in the diaphragm from the abdominal side. When tissue inadequacy has demanded it, fascia lata has been employed to strengthen the closure of the widened hiatus, particularly in the recurrent hernia. Late in the series, effective ablation of the sac was effected by horizontal mattress sutures running from the esophageal musculature at the point of attachment of the
Vol. 44, No. 2
HIATUS HERNIA
August, 1962
149
sac to the margin of the hiatus through only that portion of the circumference where the sac normally lies. Associated lesions were present in 25 per cent or 126 patients (Table V I I I ) . Respiratory lesions were largely incidental and unrelated to the hernia. They included bronchiectasis in 6; bronchopulmonary suppuration, emphysematous bleb, granuloma, hamartoma, and carcinoma in one each. The mediastinal lesions were a lipoma in the cardiophrenic angle and a chylous cyst of the thoracic duet. The associated esophageal lesions were closely related to the hernia in most cases, including esophagitis (18 cases), esophageal web (12), various diverticula (12), achalasia (7), and leiomyoma, neuroflbroma, and scleroderma (1 each). The commonly associated gastroduodenal lesion was gastritis or peptic ulceration in 28 patients, presumably a statistical coincidence because of the frequency of each entity. Others included diverticulum (4) and pyloric stenosis (1). The com mon lesion of the biliary tract was cholelithiasis, known in only 9 instances; the remaining lesion was hepatic cirrhosis. The 18 miscellaneous lesions included all possible unrelated abdominal conditions. TABLE V I I I .
SUMMARY OF ASSOCIATED L E S I O N S
OPERATION NOT ADVISED
Respiratory tract Mediastinum Esophagus Stomach and duodenum Biliary tract Miscellaneous
4 0 8 16 1 6
ADVISED NOT DONE 2 0 4 1 1 2
ADVISED AND COMPLETED 5 2 40 16 8 10
11 2 52 33 10 18 126
Other surgical procedures carried out in conjunction with the hernia re pair appear in Table IX. Of the 92, 27 were associated with the esophagus, the one organ that can be exposed properly only by the thoracic approach. TABLE I X .
SUMMARY OF OPERATIONS COMBINED W I T H REPAIR
Esophagus Stomach and duodenum Biliary tract Lung Mediastinum Miscellaneous
27 43 13 3 2 4 92
They included excision of a web (9), esophagomyotomy (7), esophagoplasty (4), excision of an epiphrenic diverticulum (5), and removal of a leiomyoma or neuroflbroma (2). The 43 procedures on the stomach and duodenum could equally well have been approached by thoracic or abdominal routes. They in volved either interior gastric exploration (21), or procedures for the manage ment of gastritis or ulcer (22), including distal resection, pyloroplasty, gastroenterostomy, vagotomy, or any combination thereof. The thirteen biliary tract procedures were cholecystectomy or related operations, all by the abdominal or
150
SWEET ( P R E S E N T E D BY W I L K I N S )
J. Thoracic and Cardiovas. Surg.
abdominothoracic route. This is the greatest single application of the abdomi nal approach. Lesions of the lower lung or mediastinum may be handled simultaneously only through the thoracic route. There was one lobectomy for carcinoma and excision of a granuloma, hamartoma, mediastinal lipoma, and a chylous cyst (1 each). 6 men Indication gallbladder suspect cholelithiasis (proved) gastric diverticulum duodenal ulcer scoliosis (extreme) Type of incision subcostal transverse inverted T paramedian
KH )^t )^( Y*\~(
lOwomen
0 3 1 2 0
16 Total
2 5
2 8 1 3 2
0 I 2
1 2 I
0
1 6 2 7
4 I 2
Fig. 1.—Esophageal hiatus hernia.
5
Use of abdominal approach.
The abdominal approach was employed in a small group in this series but its application is worthy of inspection (Fig. 1). Ten abdominal approaches were used because of known or suspected gall bladder disease; four for peptic ulcer or gastric diverticulum. Two were occasioned by anatomic considerations (extreme scoliosis). The type of incision varied. The paramedian or inverted T (usually a conversion of an initial transverse) incision offered the better ex posure. The abdominothoracic approach (Table X) was utilized primarily for simultaneous gastric resection for gastric lesions or duodenal ulcer, once for a tumor of the body of the pancreas. The relative inaccessibility of the duodenum by the strictly thoracic approach necessitated this modification when gastrectomy seemed indicated preoperatively. This extensive incision was well tol erated by patients. TABLE X.
1 Indication Lesion of (actual Lesion of Duodenal
stomach or suspected) pancreas ulcer
Hernia size Small to medium Large Very large Hernia type Sliding Parahiatal Composite
10
ABDOMINOTHORACIC APPROACH MEN
1
7 WOMEN
1
17 TOTAL
4 0 6
4 1 2
8 1 8
8 2 0
7 0 0
15 2 0
10 0 0
7 0 0
17 0 0
Vol. 44, No. 2 August, 1962
HIATUS HERNIA
151
Postsurgical complications are listed in Table XI. There is no significant difference in rates of incidence among the routes of operation employed. The over-all complication rate was 16 per cent, 63 of the 394 patients subjected to operation. The incidence of wound infection was low; 3 cases, or under 1 per cent. Eespiratory complications occurred 16 times: atelectasis (7), unusual degrees of pleural effusion (3), sublethal pulmonary emboli (2), asthmatic episodes (2), and laryngeal edema and vocal cord paralysis (1 each). Vascular complications numbered ten, largely thrombophlebitis of the leg veins (6), but included also acute myocardial infarction (2), and auricular fibrillation and cerebrovascular hemorrhage (1 each). Gastrointestinal complications num bered fifteen: transient dysphagia (6), unusual ileus (3), gastric dilatation (2), and esophagitis, hemorrhage, gastric rupture, and jejunal perforation (1 each). Miscellaneous complications numbered 22, all unrelated to the specific operation except for the three instances of wound infection. TABLE X I .
S U M M A R Y OP ALL CASES
Respiratory tract Heart and blood vessels Esophagus, stomach, etc. Miscellaneous
POSTOPERATIVE COMPLICATIONS*
THORACIC
ABDOMINOTHORACIC
ABDOMINAL
TOTAL
361
17
16
394
15 9 14 19
1 0 1 0
0 1 0 3
16 10 15 22 63
•Sixteen per cent of 394.
There were four deaths in the 394 operations, an incidence of just 1 per cent (Table X I I ) . The causes included a massive coronary occlusion, a major pulmonary embolus, sepsis resulting from a preoperative gastric perforation with mediastinitis, and an unexplained postoperative jejunal perforation. The latter patient died from bile peritonitis, despite prompt recognition of the com plication and surgical re-exploration. TABLE X I I . |
Coronary thrombosis Pulmonary embolism Sepsis Gastric perforation Jejunal perforation ♦One per cent of 394.
POSTOPERATIVE D E A T H S *
THORACIC
j ABDOMINOTHORACIC
f
ABDOMINAL
1 1
0 0
0 0
1 1
0 0
0 0
There are few good follow-up reports of the incidence of recurrence fol lowing the surgical repair of hiatus hernia. These patients were followed a minimum of one year, the longest period was 19 years. The large majority were very grateful for their operation; many were among the most grateful of all surgical patients. Follow-up studies included detailed questionnaires to the patients and letters of inquiry to the referring physician. Symptomatic pa tients were subjected to follow-up barium studies of the upper gastrointestinal
J. Thoracic and Cardiovas. Surg.
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tract. Table X I I I shows that recurrences totaled thirty-one in 394 operations, an incidence of approximately 8 per cent. There have been no recurrences in the parahiatal group. There is no significant difference in the recurrence rate between the sexes. The number of abdominal repairs is too few to permit sta tistical comparison. In addition to the proved recurrences, 3 patients have symptoms of regurgitation but have no demonstrable recurrence by repeated, careful roentgenographic study. TABLE X I I I . |
Male Thoracie Abdominal Female Thoracie Abdominal
H I A T U S H E R N I A RECURRENCES
RECURRENCES
I
TOTAL NO.
6 1
113 6
24 0 ~31
265 10 394"
I
PER CENT
5 16 9 0 TI
Of the recurrences, three were detected in patients without symptoms who had routine upper gastrointestinal examinations. In 21, symptoms recurred in less than 2 years; in 7, the recurrence was demonstrated between 2 and 9 years with the exact date of onset of symptoms unknown. It is clear that the majority of recurrences appear early, a fact which lends a greater measure of accuracy to the 8 per cent recurrence figure. CONCLUSION
This series demonstrates the minimal risk attending the surgical repair of hiatus hernia and the significant possibility of recurrence (7.8 per cent). I t is the task of the thoracic and gastrointestinal surgeon to explore methods of reducing this figure.