Objective Evaluation of Results of Hiatal Hernia Repair

Objective Evaluation of Results of Hiatal Hernia Repair

THE Journal of The Society of Thoracic Surgeons ANNALS and the OF THORACIC Southern Thoracic Surgical Association VOLUME 2 NUMBER 2 MARCH 1966 SURGERY...

1MB Sizes 0 Downloads 71 Views

THE Journal of The Society of Thoracic Surgeons ANNALS and the OF THORACIC Southern Thoracic Surgical Association VOLUME 2 NUMBER 2 MARCH 1966 SURGERY

Objective Evaluation of Results of Hiatal Hernia Repair Paul C. Adkins, M.D., Joginder Bhayana, M.D., and Brian Blades, M.D.

I

n general, results of surgical repair of a sliding hiatal hernia are satisfactory. Various postoperative studies, including our own, report good results in 80% to 90% of the patients, with recurrence rates varying from 1% to 40% [l, 2,4,7,9,13]. Most of the reports concerning results of this operation have been based upon either the incidence of recurrence as demonstrated by standard roentgenographic studies of the upper gastrointestinal tract or based upon relief of symptoms. As pointed out by Raphael and associates from the Mayo Clinic [13], the correlation between the objective and symptomatic results was not good. In our opinion neither symptomatic relief nor routine roentgenograms are a totally satisfactory method for realistic appraisal of the efficacy of the operative procedure. Although it is apparent that relief of symptoms is the surgeon’s ultimate goal, in some instances following hiatal hernia repair this achievement may not be clear-cut. A sliding hiatal hernia is an exFrom The Department of Surgery, George Washington University School of Medicine, Washington, D.C. Presented at the Twelfth Annual Meeting of the Southern Thoracic Surgical Association, Freeport, Grand Bahama Island, Nov. 11-13, 1965.

VOL. 2, NO. 2, MAR.,

1966

139

ADKINS, BHAYANA, AND BLADES

tremely common finding on routine x-ray studies. Many of these patients may be asymptomatic and are not candidates for operation. Others may have associated gastrointestinal pathology such as peptic ulcer, gallbladder disease, diverticulitis, or a host of vague complaints generally termed “indigestion.” T h e presence of any of these factors may distort the accuracy of results of hiatal hernia repair when one is evaluating on the basis of relief of symptomatology. Routine upper gastrointestinal barium studies have also been somewhat unsatisfactory in postoperative evaluation following surgical repair of a hiatal hernia. Detection of gastric reflux into the lower esophagus with this method is difficult and often equivocal. In addition, detection of a small recurrence of the hiatal hernia may be difficult if not impossible, since the esophageal hiatus cannot be definitely localized by the radiologist with standard techniques, and knowledge of the relative position of the hiatus and the gastroesophageal junction is essential in assessing the postoperative result. Routine esophagoscopy following operation has also rarely been helpful in evaluating the adequacy of repair. Consequently, in the occasional patient with mild persistent symptoms following hiatal hernia repair it has been frustrating to be unable to detect any abnormality by these gross methods. METHODS

In an attempt to solve this problem, we sought other more sensitive and objective methods of evaluating the success of the operative procedure. Two modalities were added to the program in order to more carefully detect failure of operation, the first being in order to analyze better the anatomical result of repair, and the second, to measure the functional aspect of the esophagogastric mechanism. Since it is nearly impossible for the radiologist to accurately identify the position of the esophageal hiatus, Pecora [ll], Botha [3], and others have suggested using radiopaque markers to identify the hiatus. In addition, Palmer [lo] has advocated the use of similar markers to identify the esophagogastric mucosal junction. Although we were unaware of these suggestions at the time, it occurred to us that using markers to identify the hiatus and the esophagogastric junction would be valuable in postoperative follow-ups. Consequently in the past sixteen months this method has been used on all patients who presented for repair of a sliding esophageal hiatus hernia. Preoperative work-up includes standard gastrointestinal roentgenograms, cinefluoroscopy, esophagoscopy, pH studies of the esophagus and stomach, and in some instances, esophageal motility studies. Operations are carried out by the transthoracic route in all cases. After opening the sac and defining the phrenoesophageal ligament, a single metal clip is 140

THE ANNALS OF THORACIC SURGERY

Results of Hiatal Hernia Repair

firmly placed at the point of demarcation between the esophagus and the stomach. I n most instances repair of the hernia is carried out by the technique described by Effler [5]. A counter incision in the diaphragm is employed when an extremely large hernia is present and reduction somewhat difficult. A series of mattress sutures (usually four or five) are placed in the phrenoesophageal ligament and brought down through the hiatus and back up through the diaphragm at a point approximately 1.5 to 2 cm. anterior and lateral to the hiatus. T h e hernia is then reduced and the mattress sutures are then pulled up and tied. Following this the hiatus is approximated snugly around the esophagus using No. 1 silk sutures. At the time of approximation of the crural fibers, a pair of similar metal clips are placed side by side in the hiatus for future identification. T h e chest is then closed in a routine fashion. In the postoperative period identification of the relationship between the esophagogastric junction and the esophageal hiatus is made

A

B A

C

D

FIG. 1. ( A ) Diagramatic relationships of the normal esophagogastric junction

and esophageal hiatus. Dark area represents the esophageal pH in the 6-7 cm. range. (B) Sliding hiatal hernia, showing change in anatomical relationship and loss of abrupt pH transition. (C) Position of metal clips marking esophagogastric junction and esophageal hiatus. ( D ) Projected change in relationship of clips if hernia T ~ C U T S . VOL. 2, NO. 2, MAR., 1966

141

ADKINS, BHAYANA, .4ND BLADES

FIG. 2. Roentgenogram following surgical repair of sliding hiatal hernia. Note the relationship of the single clip (esophagogastric junction) to the paired clips (esophageal hiatus). The p H electrode is in the stomach.

apparent by means of these clips. The single clip at the esophagogastric junction should lie below the level of the double clips at the esophageal hiatus (Fig. 1). This relationship may be readily appreciated by fluoroscopy or by Bucky film of the chest (Fig. 2). This has proved to be simple and valuable in subsequent follow-up studies since barium ingestion is then unnecessary to confirm the soundness of the repair from an anatomical standpoint. In at least one instance it also has been helpful from a diagnostic standpoint-a patient developed an intestinal obstruction approximately eight months following hiatal hernia repair. Routine abdominal films readily visualized the clips and confirmed the intactness of the hiatal hernia repair (Fig. 3). Barium studies with cinefluoroscopy in the postoperative period have been of considerable interest when performed on patients with these identifying clips. Knowledge of the anatomical level of the esophageal hiatus in relation to the esophagogastric junction and the stomach eliminates any doubt regarding the presence or absence of recurrence of the hernia or the demonstrable degree of reflux of barium into the lower esophagus. This affords the radiologist a previously unavailable opportunity to study the relationship between the esophageal hiatus and the so-called esophageal vestibular complex [ 151. Although anatomical reduction of the hernia may be confirmed by visualization of the clips, this does not necessarily verify the competency of the esophagogastric mechanism. For a number of years it has been 142

THE ANNALS OF THORACIC SURGERY

Results of Hiatal Hernia Repair

FIG. 3 . Abdominal film in a patient with intestinal obstruction eight months

after hiatal hernia repair. Position of clips confirms intactness of repair.

appreciated that reflux esophagitis may occur in the absence of a demonstrable hiatal hernia. In recent years, a number of sensitive physiological studies have been proposed to measure the function of the esophagus and the esophagogastric junction. Esophageal motility studies and pH determinations of the stomach and esophagus as advocated by Hill et al. [8], by Ellis et al. [6], and others [12, 141 have been of great value in diagnosis of esophagogastric disorders. I n our hands, pH studies of the esophagogastric region have been the most sensitive method of detecting the presence or absence of reflux of gastric contents. These yield much more accurate information than esophagoscopy, radiographic studies, or esophageal motility studies. Utilization of pH studies have been of value not only in the diagnosis of reflux preoperatively but also in the postoperative period as far as objective assessment of the results of operation. In the past eleven months, studies have been carried out on approximately fifty patients with an esophageal hiatus hernia or symptoms of reflux esophagitis. A Beckman Expandomatic pH Meter with a standard gastroesophageal electrode is used. T h e electrode is passed into the stomach and then withdrawn gradually. T h e pH is read at 1 cm. intervals as the electrode is withdrawn. In the individual with a competent esophagogastric mechanism, the pH will rise abruptly as the electrode is withdrawn from the stomach across the esophagogastric junction into the esophagus (Fig. 4). VOL. 2 , NO. 2, MAR.,

1966

143

ADKINS, BHAYANA, AND BLADES

This is true in both erect and supine positions. On the other hand, the individual with reflux esophagitis shows a much more gradual change in the pH as the electrode is withdrawn. This is particularly true in the supine position or with a Valsalva maneuver (Fig. 5). In the postoperative patient it has been invariably found that the pH change as monitored by fluoroscopy occurs as the electrode passes the point of the single -

7 0

6 5 .

.

60

5 5 .

5 0 . 4 5 . I

n

4 0 .

35.

30. 2 5 . 2 0 . 1 5 ' 10. I

Ditlanu fmn 55 Nostril

50

45

40

35

30

F I G . 4. Changes in pH as electrode is withdrawn from stomach to esophagus in a normal patient and a patient with gastric reflux. 70

-

6 5

-

6 0 .

5 5 5 0 .

45

-

4 0 . P I

35-

30

-

25

-

2 0 .

1510.

Dl*laK* fmm NWrIl

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

55

50

45

40

35

30

CM

FZG. 5. Changes in pH in same patient with gastric reflux as in Fig. 4 , erect and supine.

144

THE ANNALS OF THORACIC SURGERY

Results of Hiatal Hernia Repair 70

I

6 5

-

6 0 .

5 5 50 4 5

I

-

POSTOP

-

40

-

35

-

30

-

2 5 -

FZG. 7.

20

-

1.5

.

1.0

-

Electrode at point of abrupt p H change. Note relationship to single clip.

clip, i.e., at the esophagogastric junction, rather than at the level of the hiatus (Figs. 6, 7). RESULTS

At the present time 50 patients with hiatal hernia or symptoms of peptic esophagitis have had preoperative pH studies of the esophagogasVOL. 2, NO. 2, MAR., 1966

145

ADKINS, BHAYANA, AND BLADES TABLE 1. SEVERITY OF REFLUX ACCORDING T O pH CHANGES IN 50 PATIENTS EXAMINED

Reflux

No. Pts.

M i l d 4 2 4 cm.) Moderate-(5-7 cm.) Severe48 cm. & over) Total

7

16

10 33

tric region (Table 1). Thirty-three of these patients showed definite evidence of gastric reflux. T h e severity of the reflux was quantitated on the basis of level of pH change above the esophagogastric junction as estimated by fluoroscopy. Mild changes were defined as those which occurred in the distal 2 to 4 cm. of the esophagus, where the p H remained at a gastric level. Moderate reflux was defined as those cases in which p H changes extended over 5 to 7 cm. of the distal esophagus, and severe reflux was cases in which pH changes were over an 8 cm. or greater distance. Five patients were found to have demonstrable reflux in the absence of a radiologically apparent hiatal hernia (Table 2). After careTABLE 2. PATIENTS SHOWING REFLUX WITH NO DEMONSTRABLE HERNIA

Reflux

No. Pts.

Mild (2-4 an.) Moderate (5-7 cm.) Severe (8 cm. & over) Total

ful evaluation of the symptomatology and objective findings, surgical repair of the hiatal hernia was recommended in 15 patients. One of these had mild reflux, while 6 had moderate and 8 severe reflux (Table 3). TABLE 3. INFLUENCE OF SEVERITY OF REFLUX ON POSTOPERATIVE RESULTS

Postop. Result Reflux

No. Pts.

Mild Moderate Severe

1 6

Good

8

Fair

Poor

1

5 7

1

1

Fifteen patients have now had postoperative studies, including identification of the clips and pH studies performed one to three months postoperatively. Although this is a brief follow-up, the longest period of follow-up being sixteen months, we believe it is a far more accurate 146

THE ANNALS OF THORACIC SURGERY

Results of Hiatal Hernia Repair

method of appraisal of operative results than that used previously. Objectively there has been no evidence of anatomical recurrence of the hernia based upon the position of the clips. Fourteen patients demonstrated no reflux by pH study, and 1 patient had mild reflux (Table 4). TABLE 4. COMPARISON OF PREOPERATIVE AND POSTOPERATIVE pH STUDY

Severity of Reflux

Preop.

Postop.

Postop. Clinical Results

Mild Moderate Severe

1 6 8

0 0

1 poor; 5 good

Good

1 mild reflux

7 good; 1 fair

This patient had been classified as having severe reflux preoperatively, but has had moderate relief of symptoms following hernia repair with some mild residual substernal discomfort. In addition, one patient who had no evidence of gastric reflux by pH study postoperatively continued to complain of substernal fullness and burning. Cinefluoroscopy studies demonstrated no gross abnormality of the esophagus or esophagogastric mechanism. This patient also had multiple other complaints and probably represents poor patient selection in advising operation. None of the operated patients had moderate or severe reflux postoperatively. DISCUSSION

In a series of 295 hiatal hernia repairs carried out by the transthoracic route, it has been our experience that symptomatic relief was achieved in approximately 85% of the patients [l, 21. On the other hand, persistence of some symptoms occurred in patients which could not be ascribed to gross recurrence of the hernia by standard methods of evaluation. In many instances esophagoscopy and routine gastrointestinal x-rays were equivocal, and the presence or absence of continued reflux or small recurrence of the hernia was in question. Utilizing the technique of marking the esophagogastric junction and hiatus with metal clips has been a great help to the radiologist and ourselves in identifying these anatomical structures in follow-up studies. In addition, we have found that pH determinations of the esophagus and stomach have been the most sensitive means of detecting reflux. T h e objective of hiatal hernia repair is anatomical correction of the hernia with placement of the esophagogastric junction beneath the diaphragm and restoration of the normal mechanism to prevent gastric reflux into the esophagus. T h e achievement of these two goals can be accurately measured by the techniques which we have described. Evaluation of symptomatic results is not necessarily an adequate assessment of the technique of hiatal hernia VOL. 2, NO. 2, MAR.,

1966

147

ADKINS, BHAYANA, AND BLADES

repair. It is perhaps a better measure of adequate patient selection. On the basis of these studies, although the follow-up period is brief, we see no reason for believing more radical procedures such as hemigastrectomy, vagotomy, and drainage procedures are necessary in the treatment of the uncomplicated sliding hiatal hernia. Utilization of pH studies and radiopaque clip markers in evaluating patients in the postoperative period following other methods of correction of the hernia may give a far more objective and realistic answer regarding the efficacy of the various procedures. SUMMARY

A method for accurately assessing the anatomical and functional result after surgical repair of a sliding hiatal hernia is presented. This consists of marking the esophageal hiatus and the esophagogastric junction with radiopaque metal clips and performing pH studies of the stomach and esophagus prior to and following operation. In addition to other routine studies, we believe that these are more sensitive methods for detecting recurrence of the hernia or postoperative gastroesophageal reflux. A short follow-up study on a small series of patients with these tests is presented. REFERENCES 1. Adkins, P. C., and Blades, B. Surgical treatment of hiatal hernia. Postgrad. Med. 36:129, 1964. 2. Adkins, P. C., Hughes, R. K., and Blades, B. Peptic esophagitis and hiatal hernia: Follow-up study. Amer. Surg. 27:733, 1961. 3. Botha, G. S. Radiological localization of diaphragmatic hiatus. Lancet 1:662, 1957. 4. Brintall, E. S., Blome, R. A., and Tisrick, R. T. Late results of hiatus hernia repair. Amer. J. Surg. 101:159, 1961. 5. Effler, D. B. Allison’s repair of hiatal hernia: Late complications of diaphragmatic counter incision and technique to avoid it. J . Thorac. Cardiov. Surg. 49:669, 1964. 6. Ellis, F. H., Jr., and Payne, W. S. Motility Disturbances of the Esophagus and Its Inferior Sphincter: Recent Surgical Advances. I n Welch, C. D. (Ed.), Advances in Surgery. Chicago: Year Book, 1965. P. 179. 7. Groves, L. K., Martinez, M. V., and Effler, D. B. Transthoracic repair of esophageal hiatus hernia: Evaluation of 200 consecutive cases. J. Thorac. Cardiov. Surg. 38:537, 1959. 8. Hill, L. D., Chapman, K. W., and Morgan, E. H. Objective evaluation of surgery for hiatus hernia and esophagitis. J. Thorac. Cardiov. Surg. 41:60, 1961. 9. Humphreys, G. H., Ferrer, J. M., and Wiedel, P. D. Esophageal hiatus hernia of the diaphragm: Analysis of surgical results. J. Thorac. Surg. 34:749, 1957. 10. Palmer, E. D. Attempt to localize normal esophago-gastric junction. Radiology 60:825, 1953. 11. Pecora, D. V. The balloon tube as an aid in roentgenologic examination of the esophago-gastricregion. Amer. J. Roentgen. 79:768, 1958.

148

THE ANNALS OF THORACIC SURGERY

Results of Hiatal Hernia Repair

12. Piccone, V. A., Gutelius, J. R., and McCarriston, J. R. A multiphased esophageal p H test for gastroesophageal reflux. Surgey, 57: 638, 1965. 13. Raphael, H. A., Ellis, F. H., Jr., Carlson, H. C., and Anderson, H. A. Surgical repair of sliding esophageal hiatal hernia. Arch. Surg. (Chicago) 91:228, 1965. 14. Tuttle, S. G., and Grossman, M. I. Detection of gastroesophageal reflux by simultaneous measurement of intraluminal pressure and pH. Proc. SOC. Exper. Biol. Med. 98~225,1958. 15. Zaino, C., Poppel, M. H., Jacobson, H. G., Lepow, H., and Osturk, C. H. The lower esophageal vestibular complex. Amer. J . Roentgen. 84:1045, 1960.

VOI.. 2, NO. 2, MAR.,

1966

149