- Email: [email protected]
Surgical Therapy for Esophageal Disease: Lessons From a Master
Surgical Therapy for Esophageal Disease: Lessons From a Master F. Griffith Pearson, MD, FRCS (CAN) Department of Surgery, Toronto General Hospital, Mansfield, Ontario, Canada
Preamble
I
was assigned this topic as concluding commentary for a “session” on the surgical management of esophageal disease. I was uncertain how to deal with this topic until recalling, vividly, my personal “Lessons from a Master.” These lessons remain clearly with me to this day. Fifty years have elapsed since I had the good fortune to spend seven months as “Senior House Officer” on the service of Ronald Belsey in the West of England. During his long, active, and colorful career, Belsey profoundly influenced generations of thoracic “trainees,” who came to his Thoracic Surgical Service from all parts of the globe. Prominent among his contributions were original observations on the etiology, diagnosis, and surgical management of esophageal disease. When I trained with Belsey in 1959 to 1960, esophageal surgery was a “no man’s land,” practiced by general surgeons, thoracic surgeons, and otolaryngologists. In those days, relatively few surgeons reported extensive experience in this field. The “occasional operator” was often discouraged by the unforgiving nature of the postoperative complications. In Belsey’s words, the occasional operator “took it up, mucked it up, then gave it up!” Fifty years later, the surgical management of benign esophageal disease remains challenging, demanding, and a relative “no man’s land.” Belsey’s contributions to the surgery of esophageal disease are presented as a summary of his talents in the operating room and his innovation and attention to critical features of perioperative care. His enduring effectiveness as a teacher was a product of the clarity and critical quality of observation, exceptional surgical skills, and a compelling, colorful command of English expression.
Preoperative Evaluation History
SUPPLEMENT
The critical importance of a thorough and careful history was a fundamental first step. In Belsey’s words, “listen to the patient–the customer is always right.” Examples: An adequate history can clearly distinguish between regurgitation from the obstructed esophagus and gastroesophageal reflux, or vomiting from the stomach. Patients frequently label all three conditions as “vomiting.” Presented at the 2nd International Bi-Annual Minimally Invasive Thoracic Surgery Summit, Boston, MA, October 9 –10, 2009. Address correspondence to Dr Pearson, Department of Surgery, Toronto General Hospital, 796535 3rd line East, RR1, Mansfield, ON, Canada L0N 1M0; e-mail: [email protected]
© 2010 by The Society of Thoracic Surgeons Published by Elsevier Inc
Patients identify pain of lower esophageal origin as midline in location, precisely localized, and defined by the finger tip, whereas gastric pain is more broadly perceived and may be illustrated with the palm of the hand.
Radiology Contrast radiography affords information on the caliber of the lumen, presence and level of obstruction, reflux, peristaltic activity, contractile abnormalities, emptying time, wall thickness, and mucosal abnormalities. When the precise diagnosis is uncertain, as frequently occurs in the evaluation of the less common primary motor disorders, the surgeon may better arrive at diagnosis by attending the contrast radiography examination along with the radiologist.
Endoscopy Belsey was an experienced and skilled endoscopist before the advent of flexible endoscopy. Until the early 1970s, bronchoscopy and esophagoscopy were performed with rigid metal scopes, often using only intravenous sedation and topical anesthesia (Fig 1). Furthermore, in those days most rigid endoscopy was performed by otolaryngologists. Belsey recognized the critical role of endoscopy in the preoperative evaluation and postoperative follow-up of esophageal disorders amenable to surgical management. He correctly concluded, I believe, that the operating surgeon is best qualified to carry out such endoscopic assessment. He or she learns “the hard way,” at the time of surgery, if endoscopic interpretation has been incorrect and misleading.
Esophageal Function Tests Esophageal function tests such as manometry and pH studies were embryonic or unknown during those early years. To understand the pathophysiology of the various benign disorders, Belsey depended upon observations from the history, radiology, rigid endoscopy, operative findings, and critical postoperative follow-up.
The Operating Room In the operating room, Belsey was consistently gentle and unhurried but lost no time due to wasted moves. He practiced precision and repetition for any successful “surgical recipes” such as the Belsey Mark 1V repair for hiatus hernia (earlier
Dr Pearson has no conflicts of interest to disclose.
Ann Thorac Surg 2010;89:S2180 –2 • 0003-4975/$36.00 doi:10.1016/j.athoracsur.2010.03.076
MINIMALLY INVASIVE THORACIC SURGERY SUMMIT 2009 PEARSON SURGICAL THERAPY FOR ESOPHAGEAL DISEASE
Fig 1. Ronald Belsey doing a rigid esophagoscopy in 1959. The patient is in a dental chair, and “protected” from the pressure and discomfort of the rigid 60-cm scope by Demerol (Abbott Laboratories, Abbott Park, IL) sedation and topical Xylocaine (Astra-Zeneca Pharmaceuticals, Wilmington, DE). Note the towel covering the eyes; the patient never saw the large metal scope to be passed through the full length of the esophagus and into the proximal stomach. A series of these esophagoscopies was done in the outpatient endoscopy suite each week.
Marks 1, 11, and 111 repairs were found wanting through follow-up evaluation). Such disciplined action requires focus and practice to achieve. He remained calm and controlled in the face of “hair raising” emergencies, and decried the hazards of “haste” in response to surgical misadventure. He stressed the importance of objective observation of the anatomy and pathology encountered: esophageal wall thickening, esophagitis; muscular wall hypertrophy; esophageal shortening in advanced mural esophagitis; a dilated hiatus and thinning of muscular margins in large hiatus hernias; any one of these observed findings may prompt modification of the surgical procedure. Only recently I was given a paper by Ronald Belsey entitled “On the Teaching of Operative Surgery,” published in the West of England Medical Journal in December of 1990 [1]. Belsey was 80 years of age in that year, and had presented the paper at a surgical meeting in Palermo, Italy. This paper is wonderful reading and illustrates, in Belsey’s inimitable English, his principles for teaching in the operating “theatre.” I quote two excerpts verbatim, hoping to whet your appetite, that you may read the entire publication.
S2181
(1) “. . . important is the attitude of the instructor to his assistants. Unnecessary comments on clumsiness, flashes of irritation and bad temper, offensive comments to the scrub nurse, are the antithesis of equanimity. Such behaviour in the operating room may appeal to the “prima donna” ethos of some surgeons, but will certainly inhibit the assistant trying to be helpful and to learn. At this stage of his training the student must be taught how to watch an operation profitably. It is a basic principle that nobody can absorb the subtleties of any procedure till he has attempted it personally. A principle I have always adopted is to allow an assistant quite early on in his training to start an operation without my presence in the room, but on the end of a telephone in the hospital. He spends twenty minutes toweling up the patient dismayed by the sudden realization that although he has assisted on many occasions he has seen nothing. He is rescued from his dilemma before he can commit any irrevocable havoc but from that moment he has learned the most important lesson of his career: how to watch and assimilate.” (2) “Surgical technique does not end with insertion of the final stitch of the wound closure. Every surgical operation is an experiment in pathology and accurately and promptly recorded details of the procedures, and the outcome, are the surgical history of tomorrow. Any report delayed for 24 hours, or longer, or dictated by other than the operating surgeon, is useless.” Belsey developed some of his own techniques for sharp dissection in the depths of an open thorax. He held the long heavy Allison scissors or clamps in an “upside down” position, and manipulated these instruments with the thumb and index or middle finger through the loops (see Fig 2). The ulnar side of the hands rest comfortably alongside the margins of the incision, and there is no need to awkwardly elevate the forearms or elbows. Generations of trainees continue to favor this grip, which is often considered “odd” until the newcomer tries it.
Postoperative Care Belsey had a well-organized mind, and created a general thoracic unit in which he was undoubtedly in control of the operating room team, nurses, radiologists, physiotherapists, and most importantly, the patients. He frequently voiced concern that he lacked control of anesthestists; “I look forward to the day when we have electrical anaesthesia.” Intensive care was in its infancy, and Belsey was loathe to assign his patients to a small intensive care unit (ICU) available in those early decades. To quote his perspective “. . . it is the surgeon who should review the immediate post operative chest x-ray, the fluid balance of the patient, and decide whether the patient should be inflicted with the chaos of the ICU or transferred back to the relative calm of his own ward and the nursing staff with whom he is already acquainted.” There remain real benefits from this consid-
SUPPLEMENT
Ann Thorac Surg 2010;89:S2180 –2
S2182
MINIMALLY INVASIVE THORACIC SURGERY SUMMIT 2009 SURGICAL THERAPY FOR ESOPHAGEAL DISEASE
PEARSON
Ann Thorac Surg 2010;89:S2180 –2
cation of his extensive experience reported in a national or international journal. He cited Allison as a “shining example of intellectual honesty and courage of which every surgeon should take note.” In 1951, Allison reported early results in 553 patients managed by his own technique of repair. Reflux control was achieved in 90.4% of patients [3]. In 1973, he published a review of 421 patients followed-up from 3 to 20 years. The recurrence rate in type 1 hernias was 49% and in the type 11 hernias 33% [4].
A Few More “Belseyisms”
Fig 2. Belsey’ s method of holding the long “Allison” scissors and clamps for dissection in the depths of the thorax through an open thoracotomy. The ulnar side of the hands “rest” alongside the margins of the incision. The elbows are not held laterally and unsupported. Control in the depths of the incision is comfortable and precise, no tremor! Generations of trainees have been introduced to this “atypical” technique. With few exceptions, most of us retained it permanently thereafter and passed it on to our students.
Re the unduly talkative student: “doctor, remember the fish; so long as it keeps its mouth shut it stays out of trouble.” Re haste: “we don’t need a speedy surgeon, we need a speedy diagnosis” or “remember, diagnosis precedes treatment.” When reoperating for a failed procedure: “we are faced with the muddy footprints of the sportsman who was here before us.” “don’t wait and see, look and see!”
Concluding Comments eration. After returning from England in 1960 to the Toronto General Hospital, I established “postoperative step down beds” on our Thoracic Surgical nursing unit. These were monitored acute care beds, with the necessary increase in nursing complement, and provided the immediate postoperative care for a majority of the thoracic surgical patients. Beds in a central, multiservice ICU were reserved for those with critical multiple organ failure, or patients requiring mechanical ventilation). Our thoracic floor nurses all rotated through this acute care facility, became more expert and knowledgeable in acute care management, and a majority of patients were never subjected to the unknowns and “chaos of the ICU.” This remains our organization of choice to the present day.
Patient Follow-Up
SUPPLEMENT
It is my opinion that one of Belsey’s most important contributions was his emphasis and organization of patient follow-up. Quote: “. . . follow-up philosophy assumes that every surgical operation lasts for the duration of the patient’s, and the surgeon’s life.” Follow-up was preferably lifelong, pertinent data were prospectively recorded, and all staff attended the clinics. He decried the practice of early publication or “rushing into print.” Quote: “The battlefields of surgery are littered with the remains of new operations, which foundered and perished in the follow-up clinic.” He practiced what he preached. In 1965, at the annual meeting of the American Association for Thoracic Surgery, Belsey and his pupil David Skinner presented experience with 1,030 patients undergoing Belsey “Mark 1V” repairs for hiatus hernia and reflux. Many cases had been followed beyond 10 years and none less than one [2]. This paper was Belsey’s first publi-
Belsey’s greatest impact on the surgery of esophageal disease is evident in the competence of a legion of trainees from all parts of the globe. There have been some 45 foreign students from all corners of the world, many of whom went on to develop strong academic programs in esophageal surgery: Clement Hiebert, David Skinner, Arthur Baue, Mark Orringer, Joel Cooper, and Tony Lerut. After retirement from the National Health Service in Great Britain in 1976, Belsey continued to work for two decades (6 months each year) as an invaluable resource on the service of David Skinner in Chicago and in New York, thus continuing to teach and to influence yet another generation of American trainees. During these same years he continued consulting, operating, and teaching in Egypt and the Netherlands. He was a man of broad and diverse interests. He was a gifted practitioner of fly fishing, upland game hunting, and the fine arts. He was never idle or bored in retirement. He advised his students that it was important to “begin planning your retirement from the day you begin practice!” His retirement from the National Health Service was obligatory for all physician Consultants in the National Health Service. He was 97 years of age at the time of his death in 2007. He filled his own “prescription” for retirement extremely well.
References 1. Belsey R. On the teaching of operative surgery (Address to the Faculty of Medicine at the University of Palermo on the occasion of receiving an honorary degree.). West Engl Med J 1990;105: 102,122 2. Skinner DB, Belsey RH. Surgical management of hiatus hernia and reflux: long-term results with 1,030 patients. J Thorac Cardiovasc Surg 1967;53:33–54. 3. Allison PR. Reflux esophagitis, sliding hiatal hernia, and the anatomy of repair. Surg Gynecol Obstet 1951;92:419 –31. 4. Hiatus hernia: (a 20 year retrospective survey). Ann Surg 1973; 178:273– 6.
Preamble
I
was assigned this topic as concluding commentary for a “session” on the surgical management of esophageal disease. I was uncertain how to deal with this topic until recalling, vividly, my personal “Lessons from a Master.” These lessons remain clearly with me to this day. Fifty years have elapsed since I had the good fortune to spend seven months as “Senior House Officer” on the service of Ronald Belsey in the West of England. During his long, active, and colorful career, Belsey profoundly influenced generations of thoracic “trainees,” who came to his Thoracic Surgical Service from all parts of the globe. Prominent among his contributions were original observations on the etiology, diagnosis, and surgical management of esophageal disease. When I trained with Belsey in 1959 to 1960, esophageal surgery was a “no man’s land,” practiced by general surgeons, thoracic surgeons, and otolaryngologists. In those days, relatively few surgeons reported extensive experience in this field. The “occasional operator” was often discouraged by the unforgiving nature of the postoperative complications. In Belsey’s words, the occasional operator “took it up, mucked it up, then gave it up!” Fifty years later, the surgical management of benign esophageal disease remains challenging, demanding, and a relative “no man’s land.” Belsey’s contributions to the surgery of esophageal disease are presented as a summary of his talents in the operating room and his innovation and attention to critical features of perioperative care. His enduring effectiveness as a teacher was a product of the clarity and critical quality of observation, exceptional surgical skills, and a compelling, colorful command of English expression.
Preoperative Evaluation History
SUPPLEMENT
The critical importance of a thorough and careful history was a fundamental first step. In Belsey’s words, “listen to the patient–the customer is always right.” Examples: An adequate history can clearly distinguish between regurgitation from the obstructed esophagus and gastroesophageal reflux, or vomiting from the stomach. Patients frequently label all three conditions as “vomiting.” Presented at the 2nd International Bi-Annual Minimally Invasive Thoracic Surgery Summit, Boston, MA, October 9 –10, 2009. Address correspondence to Dr Pearson, Department of Surgery, Toronto General Hospital, 796535 3rd line East, RR1, Mansfield, ON, Canada L0N 1M0; e-mail: [email protected]
© 2010 by The Society of Thoracic Surgeons Published by Elsevier Inc
Patients identify pain of lower esophageal origin as midline in location, precisely localized, and defined by the finger tip, whereas gastric pain is more broadly perceived and may be illustrated with the palm of the hand.
Radiology Contrast radiography affords information on the caliber of the lumen, presence and level of obstruction, reflux, peristaltic activity, contractile abnormalities, emptying time, wall thickness, and mucosal abnormalities. When the precise diagnosis is uncertain, as frequently occurs in the evaluation of the less common primary motor disorders, the surgeon may better arrive at diagnosis by attending the contrast radiography examination along with the radiologist.
Endoscopy Belsey was an experienced and skilled endoscopist before the advent of flexible endoscopy. Until the early 1970s, bronchoscopy and esophagoscopy were performed with rigid metal scopes, often using only intravenous sedation and topical anesthesia (Fig 1). Furthermore, in those days most rigid endoscopy was performed by otolaryngologists. Belsey recognized the critical role of endoscopy in the preoperative evaluation and postoperative follow-up of esophageal disorders amenable to surgical management. He correctly concluded, I believe, that the operating surgeon is best qualified to carry out such endoscopic assessment. He or she learns “the hard way,” at the time of surgery, if endoscopic interpretation has been incorrect and misleading.
Esophageal Function Tests Esophageal function tests such as manometry and pH studies were embryonic or unknown during those early years. To understand the pathophysiology of the various benign disorders, Belsey depended upon observations from the history, radiology, rigid endoscopy, operative findings, and critical postoperative follow-up.
The Operating Room In the operating room, Belsey was consistently gentle and unhurried but lost no time due to wasted moves. He practiced precision and repetition for any successful “surgical recipes” such as the Belsey Mark 1V repair for hiatus hernia (earlier
Dr Pearson has no conflicts of interest to disclose.
Ann Thorac Surg 2010;89:S2180 –2 • 0003-4975/$36.00 doi:10.1016/j.athoracsur.2010.03.076
MINIMALLY INVASIVE THORACIC SURGERY SUMMIT 2009 PEARSON SURGICAL THERAPY FOR ESOPHAGEAL DISEASE
Fig 1. Ronald Belsey doing a rigid esophagoscopy in 1959. The patient is in a dental chair, and “protected” from the pressure and discomfort of the rigid 60-cm scope by Demerol (Abbott Laboratories, Abbott Park, IL) sedation and topical Xylocaine (Astra-Zeneca Pharmaceuticals, Wilmington, DE). Note the towel covering the eyes; the patient never saw the large metal scope to be passed through the full length of the esophagus and into the proximal stomach. A series of these esophagoscopies was done in the outpatient endoscopy suite each week.
Marks 1, 11, and 111 repairs were found wanting through follow-up evaluation). Such disciplined action requires focus and practice to achieve. He remained calm and controlled in the face of “hair raising” emergencies, and decried the hazards of “haste” in response to surgical misadventure. He stressed the importance of objective observation of the anatomy and pathology encountered: esophageal wall thickening, esophagitis; muscular wall hypertrophy; esophageal shortening in advanced mural esophagitis; a dilated hiatus and thinning of muscular margins in large hiatus hernias; any one of these observed findings may prompt modification of the surgical procedure. Only recently I was given a paper by Ronald Belsey entitled “On the Teaching of Operative Surgery,” published in the West of England Medical Journal in December of 1990 [1]. Belsey was 80 years of age in that year, and had presented the paper at a surgical meeting in Palermo, Italy. This paper is wonderful reading and illustrates, in Belsey’s inimitable English, his principles for teaching in the operating “theatre.” I quote two excerpts verbatim, hoping to whet your appetite, that you may read the entire publication.
S2181
(1) “. . . important is the attitude of the instructor to his assistants. Unnecessary comments on clumsiness, flashes of irritation and bad temper, offensive comments to the scrub nurse, are the antithesis of equanimity. Such behaviour in the operating room may appeal to the “prima donna” ethos of some surgeons, but will certainly inhibit the assistant trying to be helpful and to learn. At this stage of his training the student must be taught how to watch an operation profitably. It is a basic principle that nobody can absorb the subtleties of any procedure till he has attempted it personally. A principle I have always adopted is to allow an assistant quite early on in his training to start an operation without my presence in the room, but on the end of a telephone in the hospital. He spends twenty minutes toweling up the patient dismayed by the sudden realization that although he has assisted on many occasions he has seen nothing. He is rescued from his dilemma before he can commit any irrevocable havoc but from that moment he has learned the most important lesson of his career: how to watch and assimilate.” (2) “Surgical technique does not end with insertion of the final stitch of the wound closure. Every surgical operation is an experiment in pathology and accurately and promptly recorded details of the procedures, and the outcome, are the surgical history of tomorrow. Any report delayed for 24 hours, or longer, or dictated by other than the operating surgeon, is useless.” Belsey developed some of his own techniques for sharp dissection in the depths of an open thorax. He held the long heavy Allison scissors or clamps in an “upside down” position, and manipulated these instruments with the thumb and index or middle finger through the loops (see Fig 2). The ulnar side of the hands rest comfortably alongside the margins of the incision, and there is no need to awkwardly elevate the forearms or elbows. Generations of trainees continue to favor this grip, which is often considered “odd” until the newcomer tries it.
Postoperative Care Belsey had a well-organized mind, and created a general thoracic unit in which he was undoubtedly in control of the operating room team, nurses, radiologists, physiotherapists, and most importantly, the patients. He frequently voiced concern that he lacked control of anesthestists; “I look forward to the day when we have electrical anaesthesia.” Intensive care was in its infancy, and Belsey was loathe to assign his patients to a small intensive care unit (ICU) available in those early decades. To quote his perspective “. . . it is the surgeon who should review the immediate post operative chest x-ray, the fluid balance of the patient, and decide whether the patient should be inflicted with the chaos of the ICU or transferred back to the relative calm of his own ward and the nursing staff with whom he is already acquainted.” There remain real benefits from this consid-
SUPPLEMENT
Ann Thorac Surg 2010;89:S2180 –2
S2182
MINIMALLY INVASIVE THORACIC SURGERY SUMMIT 2009 SURGICAL THERAPY FOR ESOPHAGEAL DISEASE
PEARSON
Ann Thorac Surg 2010;89:S2180 –2
cation of his extensive experience reported in a national or international journal. He cited Allison as a “shining example of intellectual honesty and courage of which every surgeon should take note.” In 1951, Allison reported early results in 553 patients managed by his own technique of repair. Reflux control was achieved in 90.4% of patients [3]. In 1973, he published a review of 421 patients followed-up from 3 to 20 years. The recurrence rate in type 1 hernias was 49% and in the type 11 hernias 33% [4].
A Few More “Belseyisms”
Fig 2. Belsey’ s method of holding the long “Allison” scissors and clamps for dissection in the depths of the thorax through an open thoracotomy. The ulnar side of the hands “rest” alongside the margins of the incision. The elbows are not held laterally and unsupported. Control in the depths of the incision is comfortable and precise, no tremor! Generations of trainees have been introduced to this “atypical” technique. With few exceptions, most of us retained it permanently thereafter and passed it on to our students.
Re the unduly talkative student: “doctor, remember the fish; so long as it keeps its mouth shut it stays out of trouble.” Re haste: “we don’t need a speedy surgeon, we need a speedy diagnosis” or “remember, diagnosis precedes treatment.” When reoperating for a failed procedure: “we are faced with the muddy footprints of the sportsman who was here before us.” “don’t wait and see, look and see!”
Concluding Comments eration. After returning from England in 1960 to the Toronto General Hospital, I established “postoperative step down beds” on our Thoracic Surgical nursing unit. These were monitored acute care beds, with the necessary increase in nursing complement, and provided the immediate postoperative care for a majority of the thoracic surgical patients. Beds in a central, multiservice ICU were reserved for those with critical multiple organ failure, or patients requiring mechanical ventilation). Our thoracic floor nurses all rotated through this acute care facility, became more expert and knowledgeable in acute care management, and a majority of patients were never subjected to the unknowns and “chaos of the ICU.” This remains our organization of choice to the present day.
Patient Follow-Up
SUPPLEMENT
It is my opinion that one of Belsey’s most important contributions was his emphasis and organization of patient follow-up. Quote: “. . . follow-up philosophy assumes that every surgical operation lasts for the duration of the patient’s, and the surgeon’s life.” Follow-up was preferably lifelong, pertinent data were prospectively recorded, and all staff attended the clinics. He decried the practice of early publication or “rushing into print.” Quote: “The battlefields of surgery are littered with the remains of new operations, which foundered and perished in the follow-up clinic.” He practiced what he preached. In 1965, at the annual meeting of the American Association for Thoracic Surgery, Belsey and his pupil David Skinner presented experience with 1,030 patients undergoing Belsey “Mark 1V” repairs for hiatus hernia and reflux. Many cases had been followed beyond 10 years and none less than one [2]. This paper was Belsey’s first publi-
Belsey’s greatest impact on the surgery of esophageal disease is evident in the competence of a legion of trainees from all parts of the globe. There have been some 45 foreign students from all corners of the world, many of whom went on to develop strong academic programs in esophageal surgery: Clement Hiebert, David Skinner, Arthur Baue, Mark Orringer, Joel Cooper, and Tony Lerut. After retirement from the National Health Service in Great Britain in 1976, Belsey continued to work for two decades (6 months each year) as an invaluable resource on the service of David Skinner in Chicago and in New York, thus continuing to teach and to influence yet another generation of American trainees. During these same years he continued consulting, operating, and teaching in Egypt and the Netherlands. He was a man of broad and diverse interests. He was a gifted practitioner of fly fishing, upland game hunting, and the fine arts. He was never idle or bored in retirement. He advised his students that it was important to “begin planning your retirement from the day you begin practice!” His retirement from the National Health Service was obligatory for all physician Consultants in the National Health Service. He was 97 years of age at the time of his death in 2007. He filled his own “prescription” for retirement extremely well.
References 1. Belsey R. On the teaching of operative surgery (Address to the Faculty of Medicine at the University of Palermo on the occasion of receiving an honorary degree.). West Engl Med J 1990;105: 102,122 2. Skinner DB, Belsey RH. Surgical management of hiatus hernia and reflux: long-term results with 1,030 patients. J Thorac Cardiovasc Surg 1967;53:33–54. 3. Allison PR. Reflux esophagitis, sliding hiatal hernia, and the anatomy of repair. Surg Gynecol Obstet 1951;92:419 –31. 4. Hiatus hernia: (a 20 year retrospective survey). Ann Surg 1973; 178:273– 6.