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The surgical treatment of esophageal hiatus hernia
The Surgical Treatment
of Esophageal Hiatus Hernia ROBERT A. MUSTARD,
This is a review of my personal experience with the surgical treatment of esophageal hiatus hernia in private patients. Residents’ cases have not been included since their records are not so readily available, the patients are more difficult to trace, and operative technics were less consistent. This study utilizes only patients with symptomatic hiatus hernia; it excludes those in whom a symptomless hiatus hernia was repaired in the course of an operation primarily planned to deal with some other intra-abdominal lesion. Clinical Material
The series consists of ninety-eight patients, of whom ninety-two had a “sliding” or axial-type hiatus hernia, four had a paraesophageal or “rolling” type hiatus hernia, one had a “combined” type hernia, and one had symptomatic esophageal reflux without radiologically demonstrable herniation. In these ninety-eight patients 101 hiatal hernia repairs were performed; three patients required a second operation when the first was followed by recurrent hemiation. Three others were referred with recurrent hernia; eight had radiologic and/or esophagoscopic evidence of early stricture of the esophagus; four had a lower esophageal ring. The incidence by age was as follows: from ten to nineteen years, one patient; twenty to twenty-nine years, two; thirty to thirty-nine ye;lrs, ten: forty to forty-nine years, twenty-three; fifty to fifty-nine years, twenty-nine; sixty to sixty-nine years, twenty-two; over seventy years, seven. Age was not stated in four patients. Of the ninety-eight patients, forty-four were male and fifty-four were female. From 1952 through 1959 twenty-one operations were performed; and from 1960 through 1967 eighty operations were performed. The distribution of operations by year is as follows: 1960, nine; 1961, thirteen; 1962, nine; 1963, thirteen; 1964, eleven; 1965, ten; 1966, eleven; 1967, four. Half of the group had associated conditions (Table I), most causing separate symptoms. All patients in this series had a variety of the complaints usually attributed to esophageal hiatus hernia and/or reflux esophagitis, namely, heartburn, epigastric or chest pain, flatulence and belching, acid eructation, food intolerances, and “sticking” on swallowing. Characteristically the heartburn was exacerbated by recumFrom the Department of sion of General Surgery,
674
Surgery, Toronto
University General
of Toronto, and Hospital, Toronto,
the DiviCanada.
MD, FRCS(C),
FACS, Toronto, Canada
bency or by stooping over and relieved by standing up, by drinking milk or water, or by antacids. Indications for Operation
In eighty-two cases the indication for operation was symptoms related to the hiatus hernia, considered “intractable” in fifty-six cases and associated with recurrent herniation in six others. Episodic chest or epigastric pain suggesting heart disease was a prominent feature in eight cases, and true dysphagia in thirteen, of whom six had a demonstrable stricture. Massive bleeding had occurred in six cases (in addition to those with hemorrhage from an associated duodenal or gastric ulcer), whereas anemia due to chronic blood loss was present in three cases. Gross esophagitis was observed on direct examination in eighteen patients, and was judged severe in twelve. In five other cases esophagoscopic examination failed to show inflammatory changes. In the remaining nineteen patients with symptomatic hiatus hernia the indication for operation was an associated lesion requiring surgical treatment: duodenal ulcer in twelve cases, gallstones in five, pharyngeal diverticulum in one, and polyp3 of the colon in one. Operative Technics
Of 101 hiatus hernia repairs forty-one were performed via left thoracotomy, using the Allison technic [I] in two cases and the Belsey “Mark IV” technic in thirty-nine others. Transabdominal repair was carried out in fifty-eight cases, and combined thoracoabdominal approach was utilized in two cases. As shown in Table II associated operative procedures were carried out in fifty-eight cases. The Belsey Mark IV procedure has been described by Skinner and Belsey [2] and by Baue and Belsey [3]. Our abdominal repairs utilized a method by which we tried to achieve objectives similar to those of the Belsey procedure; this technic, which will be subsequently referred to as “standard abdominal repair,” is carried out as follows: Through an upper abdominal incision, the left lobe of liver is separated from the diaphragm and retracted to the right. The spleen is protected by a large pack. The stomach is pulled down and the cardia mobilized by dividing transversely the phrenoesophageal ligament. A finger and then a soft rubber drain is passed around the esophagus, making sure to include both vagi. The upper one to two inches of lesser omentum is divided and the esophagus dis-
The
American
Journal of Surgery
Esophageal
placed forward and to the left. The margins of the hiatus are then approximated from behind forwards with three to five sutures of Number 1 silk. Interrupted stitches of Number 2-O silk are now used to fasten the muscular wall of the esophagus to the margins of the newly created hiatus with about two inches of esophagus held down in the peritoneal cavity. The fundus of the stomach is now brought forward and to the right over the abdominal esophagus and tacked with silk stitches to its right margin. Finally a tube gastrostomy is instituted for postoperative decompression; it can also be used for feeding in those patients who have temporary dysphagia. Mortality
and Complications
The mortality in these 101 operations was nil. Major complications in the postoperative period were seen in eight patients and were, respectively, as follows: acute gastric dilatation requiring reoperation; pulmonary emboli and wound infection; “serum sickness;” pyloric obstruction requiring reoperation; laryngeal edema requiring tracheostomy; left pleural effusion; temporary esophageal fistula requiring jejunostomy; chronic subphrenic abscess requiring removal of silk sutures. Follow-Up
Studies
In eighty-eight patients follow-up data have been obtained to date of survey (July 1968), forty-two by personal interview and forty-six by questionnaire. In three other patients incomplete follow-up data have been considered adequate for evaluation of results: One of these patients was followed up to seven years and six months after operation, at which time the result was reported as “excellent.” Another patient was untraced after three years, at which time recurrence of hiatus hernia was treated elsewhere. The third patient was untraced after eight months and was considered at that time to have a “poor” result. The remaining seven cases are considered lost to follow-up study: Five were untraced since a few months after operation, and two were known to have died of coronary occlusion (eight months and thirteen months, respectively, after operation). The duration of follow-up in the ninety-one cases is as follows: Fifteen patients have been followed up from ten to fourteen years; forty-one patients have been followed up from five to nine years; and thirty-five patients have been followed up from one to four years (nine patients for four years, ten for three years, eleven for two years, and five for one year). Clinical
Evaluation
of Results
In the clinical evaluation of the results of these operations we have attempted to balance the relief of preoperative symptoms against the imposition of new
Vol.
119,
June
1970
TABLE
I
Associated Conditions Eight Patients
in Forty-Eight
with Hiatus
Condition
Hiatus
Hernia
of Ninety-
Hernia Number of Patients
Duodenal
ulcer Duodenal ulcer and cholelithiasis Cholelithiasis Gastric ulcer Leiomyoma of stomach Pharyngeal diverticulum Polyps of colon Scleroderma Steroid therapy Adrenalectomy (Cushing’s) Arthritis Hypopituitarism Total
19 15 3
48
symptoms due to surgical treatment. For example, if preoperative heartburn has been replaced by postoperative dysphagia or diarrhea, the procedure cannot be considered an unqualified success. We have used the following categories for evaluation : “Excellent” results indicate that the patient is asymptomatic; “good” that he is greatly improved, with occasional mild symptoms; “fair” that he is partially improved, with some recurrence of preoperative symptoms or other troublesome digestive tract disturbance; and “poor” that he is unimproved. It should be noted that in almost all cases the clinical assessment was made before the results of radiologic follow-up study were known. The distribution of the results on the basis of clinical
TABLE
II
Associated
Operative
Procedures
Associated Procedures With 41 Transthoracic Repairs Dilation of stricture of esophagus (plus vagotomy and pyloroplasty in one) Vagotdmy Vagotomy and pyloroplasty plus cholecystectomy Myotomy Excision of leiomyoma of stomach With 58 Transabdominal Repairs Vagotomy and pyloroplasty (plus cholecystectomy in four, and dilation of stricture of esophagus in one) Vagotomy and partial gastrectomy Cholecystectomy Partial gastrectomy Excision of pharyngeal diverticulum (plus vagotomy and pyloroplasty in one) Excision of polyps in colon With 2 Thoracoabdominal Repairs Dilation of stricture of esophagus Vagotomy and gastrojejunostomy Total
Number of Patients
2 1 1 2 1 26
4 15 1 2 1 1 1 58
675
Mustard
TABLE III
Results of 101 Operations for Repair of Hiatus Hernia Results Operation
Transthoracic repair Transabdominal repair Abdominothoracic repair Total
Excellent
Good
Fair
Poor
Total Traced
Untraced
19 (49%) 20 (39%)
10 (29%) 21(39%)
2 (5%) 9 (16%)
g (20%) 4 (7%)
2 5
4: (44%)
31(32%)
10 (11%)
12 (13%)
39 53 2 94
evaluation is shown in Table III. It is seen that 76 per cent of traced cases have had a satisfactory clinical result (44 per cent “excellent”; 32 per cent “good”), whereas 24 per cent have had an unsatisfactory clinical result (11 per cent “fair”; 13 per cent “poor”). It is noted that the clinical results of transthoracic and abdominal repairs have been satisfactory in about equal rates, 75 and 77 per cent, respectively. It is interesting to examine the reasons for the unsatisfactory results in twenty-two cases. (Table IV.) Recurrent hiatus herniation was demonstrated in only ten patients, but was considered probable in two others on the basis of symptomatic evaluation. In two other patients preoperative symptoms returned despite “negative” radiologic studies. A poor result was caused in one patient by too-tight closure of the hiatus and reoperation was required. In another patient technical failure was the result of chronic postoperative infection, necessitating reoperation to remove the silk sutures utilized in the repair. In two patients with concomitant vagotomy and pyloroplasty there has been such severe and persistent diarrhea that they must be classified as having “unsatisfactory” results. Finally, in four patients the unsatisfactory result must be attributed to poor selection: two patients whose continuing multiple complaints are now considered psychosomatic in origin, one other with persisting symptoms now recognized as those of “irritable colon” syndrome, and one with advanced scleroderma which is probably responsible for the continuing dysphagia. In none of these last six patients has there been radiologic evidence of recurrent hernia or reflux. Eight patients volunteered the information that after operation they were unable to vomit. In six patients this TABLE IV
Clinically Unsatisfactory Results Result
Recurrent hiatus hernia Symptomatic recurrence Without radiologic recurrence No radiologic follow-up Technical failure Too-tight repair Chronic postoperative infection Postvagotomy diarrhea Poor selection Total
676
Number of Cases 10 4 2 2 2 1 1 2 4 22
7
persisted for over two years up to a maximum in one patient of seven years. This has not been registered as a complaint but it does seem significant as an indication of the effectiveness of these operations in restoring a competent gastroesophageal valve mechanism. After hiatus hernia repair almost all patients complain of temporary dysphagia which usually clears up spontaneously within a few weeks. We have found, however, by direct questioning that twenty-eight patients (30 per cent of traced cases) noted persisting dysphagia, lasting more than one year in twenty-two cases up to a maximum of fourteen years. In most cases this symptom was described as “mild and intermittent,” but in four patient it was “severe,” three requiring treatment by bougienage. Since operations for repair of hiatus hernia are designed to constrict and immobilize the lower esophagus, it is not surprising that they interfere to some extent with normal esophageal function. Radiologic Follow-Up Study
After 101 operations for repair of esophageal hiatus hernia the results have been traced in ninety-four patients, with radiologic follow-up study in eighty-three. In sixty-two patients recent tine studies have been carried out by Dr Robert Parrish of the Department of Radiology, Toronto General Hospital, utilizing a uniform technic and reporting his findings without knowledge of the clinical evaluation. In every case an effort was made to demonstrate recurrent herniation. The degree of spontaneous reflux was noted, and the water siphon test [4] was carried out. Reflux was classified “slight,” “moderate,” or “marked” according to its volume and height; only the latter two categories were considered “significant.” Finally each patient swallowed a barium-filled capsule 1.0 cm in diameter to detect narrowing of the esophagus or a tight hiatal repair. In twenty-one other patients standard upper gastrointestinal radiologic studies were carried out from fifteen months to twelve years after operation. Anatomic recurrences are expressed as a percentage of those subjected to radiologic follow-up examination. Patients known to have recurrence and who were reoperated on elsewhere are included. The results of these studies in relation to recurrence of hiatus herniation are shown in Table V. The over-all
The American Journal of Surgery
Esophageal
TABLE
V
Results
of Radiologic
Follow-Up
Operation Thoracic repair Abdominal repair Thoracoabdominal Total
repair
* Over-all recurrence rates cases, 17/83 (20 per cent).
from
119.June 1970
1960-1967
-
Rechecked
Recurrent Hiatus Hernia
Recurrent Reflux Only
Total Rechecked
Recurrent Hiatus Hernia
Recurrent Reflux Only
12 2 2 16
7 (58%) 2 1 10 (63%)
...
21
...
4 (20%) 3 (7%)
4 14
...
46 ...
...
67
1952 to 1967.
Thoracic
repair,
recurrence rate of 20 per cent is disappointingly high, but it should be noted that the Irate was only 10 per cent during the last eight years of the survey in which 80 per cent of the operations were performed. It seems likely that this recent improvement is partly accounted for by the development of increased skill and the use of improved technics in the operative procedure. However, the possibility cannot be excluded that the poor results in the earlier group may indicate merely that the recurrence rate increases with duration of the followup period. In this regard five of the seventeen recurrences in the present series are known to have occurred in less than two years from the date of operation, and another five in less than five years. Judging by the date of onset of recurrent symptoms two appear to have developed at about six years after operation and one at seven years postoperatively. In two patients operated on eleven years ago, and in two others operated on ten years ago, recurrent herniation has recently been demonstrated on radiologic follow-up study, but since symptoms have not reappeared, the time of recurrence cannot be established. Although there is as yet little precise information on this point, it seems reasonable to suppose that the number of recurrences would increase with the passage of time and aging of the patient. However, both Skinner and Belsey [2] and Urschel and Paulson [S] claim that the majority of the recurrences in their patients occurred in the first two years after operation. As expected, recurrence was more common in patients with advanced pathologic changes caused by reflux esophagitis. Of the seventeen patients with recurrence in this series four had a stricture before operation, four had gross esophagitis demonstrated by direct examination, and one already had recurrence after a previous operation elsewhere. In two other patients with recurrence, an esophagocardiomyotomy at the time of hiatus hernia repair was carried out because the patient’s prime complaint had been spasmodic painful dysphagia; it is now believed that myotomy is not indicated in such cases, and that, if performed, it prejudices the security of the hernia repair. It is also seen from Table V that in my experience
Vol.
Hernia
Study*
1952-1959 Total
Hiatus
11/33
(33 per cent);
Abdominal
...
...
7 (10%) repair,
18
5/‘48 (10 per cent);
total
of all
the recent recurrence rate ( 1960-67 ) after transthoracic repair (20 per cent) has been higher than that after abdominal repair (7 per cent). This should not be taken to indicate a clear superiority of the abdominal type repair since the figures are really too small to be significant. Actually all four recurrences after transthoracic repair are readily accounted for by special circumstances: two patients had myotomy performed (vide supra), one patient had recurrent hernia with a short esophagus, and one patient with a large paraesophageal hernia was found to have a tumor in the fundus of the stomach which required resection. Attention must be called to the fact that not all patients with recurrent hemiation have unsatisfactory results on clinical evaluation. Of the seventeen patients with demonstrated recurrences two were found to have “excellent” and four “good” results on clinical evaluation. Results in four others were rated “fair” and in seven “poor” (of these latter patients, five were reoperated on, three by the author and two elsewhere). It would appear that in certain patients even though recurrent herniation develops, there may be some quantitative alteration in gastroesophageal function which allows them to remain free of recurrent symptoms. The presence or absence of recurrent reflux was reported in seventy of eighty-three patients undergoing radiologic follow-up examinations. (Tables VI and VII). Eleven showed a significant degree of spontaneous reflux; all but one of these was associated with recurrent herniation. Nine of eleven had also some degree of symptomatic recurrence (that is, return of the symptoms of reflux esophagitis). Thus, there was a close correlation between recurrent spontaneous reflux, recurrent hernia, and symptomatic recurrence. TABLE VI
Relation of Recurrent Hiatus Hernia
No significant reflux Spontaneous reflux Reflux on water siphon test only
Reflux
to
Recurrent
Recurrent Hiatus Hernia
No Recurrence Hernia
2 10
39 1
2
17
677
Mustard
TABLE VII
Relation of Recurrent Reflux to Symptomatic Recurrence No Symptoms
No significant Spontaneous
reflux reflux
Reflux on water siphon test only
Slight Symptoms
Moderate to Severe Symptoms
31 2
9 3
1 6
16
3
0
Our observations, however, throw doubt on the significance of the water siphon test. Of nineteen patients with recurrent reflux demonstrated only by the water siphon test, only two had a recurrent hernia, three had slight symptomatic recurrence, and sixteen were symp tom-free. The Role of Vagotomy in the Treatment of Hiatus Hernia
Vagotomy with a drainage procedure has been recommended as an adjunct to the repair of hiatus hernia in patients with associated duodenal ulcer, peptic esophagitis or stricture, or gastric hyperacidity [6-8]. Some have gone so far as to advocate routine vagotomy and pyloroplasty with each hiatus hernia repair [9]. The rationale is that, by reducing acid secretion, vagotomy and pyloroplasty may protect against the ill effects of any reflux which may persist or recur after hiatus hernia repair. It would be difficult, indeed, to prove this thesis, and no published evidence to this effect has yet been discovered. In this series of 101 operations for repair of symp tomatic hiatus hernia, an acid-reducing procedure was carried out in thirty-three patients, of whom twenty-one had a duodenal ulcer. In five other patients the indication for vagotomy was recurrent hiatus hernia, and in one the indication was esophageal stricture. In six patients there was no clear cut indication for vagotomy. The adjunctive procedures consisted of vagotomy and pyloroplasty in twenty-nine cases, vagotomy and distal gastrectomy in three, and vagotomy and gastrojejunostomy in one case. Two of the group were lost to follow-up study soon after operation. Of the remaining thirty-one, recent radiologic follow-up study has been carried out in twenty-nine, disclosing only one recurrent hernia. One other patient showed a moderate degree of spontaneous reflux but remained symptom-free. In. an additional twelve moderate to marked reflux was demonstrated on the water siphon test, but none suffered recurrent symptoms from this cause. At first sight this would suggest that vagotomy and pyloroplasty had given protection against the ill effects of recurrent reflux. However, this conclusion is not justified since ten other patients with recurrent reflux shown only on the water
678
siphon test (including six with recurrent hiatus hernia) also remain clinically satisfactory although none of them had vagotomy. On the other hand it must be noted that among the thirty-three patients who had concomitant vagotomy and drainage, eight (24 per cent) had troublesome postvagotomy symptoms: diarrhea in seven and diarrhea plus “dumping” in one. Others have also noted the high incidence of such complications [10,11], From all this evidence it is concluded that vagotomy and pyloroplasty should not be a routine accompaniment of hiatus hernia repair except when there is coexisting duodenal ulcer disease. Comments
Although this survey has revealed major shortcomings in our surgical treatment of esophageal hiatus hernia, it must be emphasized that, in going over the material case by case, one is struck by the great preponderance of patients who are grateful for relief of symptoms and for restored ability to enjoy a full normal diet. Unsatisfactory results in those patients treated during the early years of this survey were undoubtedly due mainly to lack of experience and to imperfectly developed operative technics. We have, however, evidence which suggests that the number of recurrences may increase progressively with the length of the postoperative follow-up period. Further information is needed on this point. Poor selection of patients for operative treatment (such as those with symptoms not due to hiatus hernia), unjustified addition of concomitant vagotomy and “drainage,” and a tendency to unnecessarily tight closure of the hiatus have been other factors responsible for some of the imperfect results. The findings in this series do not give any clear evidence as to which is the best method of hiatus hernia repair. This question is discussed at length by me in a recent paper [12] in which emphasis is laid on the fundamental importance of re-establishing and maintaining an intra-abdominal segment of esophagus. Also discussed in that paper are the indications for the transthoracic versus the transabdominal repair. The transthoracic route is mandatory when there is evidence of severe esophagitis, short esophagus, or stricture formation. This approach is also advocated in obese patients or in those with deep or long chests. There can be little doubt at the present time that the Belsey Mark IV procedure is the best method for those whose hiatus hernia is to be repaired through the chest. Skinner and Belsey [2] have reported 610 patients treated this way with known recurrences in 8 per cent and excellent or good results on clinical evaluation in 88 per cent. Urschel and Paulson [5] have
The Amerkan
Journal
of Surgery
Esophageal
Hiatus
Hernia
reported 21 1 operations of this type with only 2 per cent recurrent herniation. Their follow-up period is somewhat shorter and they admit “symptomatic recurrent reflux” in fourteen other cases. The abdominal approach may be selected when there is no compelling reason for thoracotomy and is the preferred method in patients with associated intraabdominal conditions such as peptic ulcer or cholelithiasis. My technic of “standard abdominal repair” has proved quite satisfactory. In forty-six patients treated this way during the period from 1960 through 1967 there have been so far only three recurrences (7 per cent ) . Hill [ZO] has described a new method of anchoring the esophagus below the diaphragm by suturing the cardia to the preaortic fascia. He has reported 149 cases treated this way with “no demonstrable anatomic recurrence,” and “good to excellent [clinical results] in all but five cases.” If others can duplicate these results a real advance will have been made in the surgical treatment of this condition.
is firmly tethered below the diaphragm and that the acute esophagogastric angle is reconstituted. The standard abdominal repair may in some cases be reinforced by combining it with Eundoplication or gastropexy. Collis and Hill have each had excellent results with their own technics; after further trial these methods may be widely adopted.
Another possible method of improving the results of transabdominal repair might be by more frequent use of Nissen’s “fundoplication” [13]. This technic has been endorsed by Krupp and Rossetti [24], who reported 109 cases with only four recurrences, and by Casten who records its use in eighty-eight patients with eight recurrences [6]. It is also possible that the Nissen-Boerema “gastropexy” [15] (in which the esophagus is held down by suturing the stomach to the anterior abdominal wall) may have a place either as an adjunct to other methods of abdominal repair or as the sole procedure in poorrisk patients. Finally reference should be made to the Collis procedure [16] in which the hiatus is closed above and in front of the esophagus in order to force the esophagogsstric junction downwards and so accentuate the acute angle of implantation. In 200 patients treated this way and checked by radiologic examination at the end of four years Collis found only 2.5 per cent with recurrent herniation. This method deserves further trial. It seems clear that the surgical repair of esophageal hiatus hernia should not be lightly undertaken. Cases should be carefully selected on the basis of intractable symptoms, demonstrated pathologic complications, or associated conditions, such as peptic ulcer or cholelithiasis, requiring operation. The Belsey Mark IV technic is at present probably the most effective method and should be used in all suitable cases. Good results necessitate skill, experience, and close attention to precise details of technic. When the abdominal approach is selected, the surgeon must ensure that a generous length of esophagus
On clinical evaluation 76 per cent of the patients were rated as having “excellent” or “good” results. About half of the clinically unsatisfactory results were associated with recurrence of the hernia. Radiologic follow-up study was achieved in eightythree of the ninety-one traced cases. In this group there was an over-all anatomic recurrence rate of 20 per cent, but this was reduced to 10 per cent during the last eight years of the survey in which four-fifths of the operations were performed. It is beli.:ved that the apparent superiority of the standard ab!!ominal repair over the Belsey Mark IV transthoracic repair in this series is not significant because of the small number of patients involved and because more difficult cases were selected for the latter procedure. A very good correlation was demonstrated between the recurrence of spontaneous reflux and anatomic and symptomatic recurrence. On the other hand the significance of reflux provoked by the water siphon test is questioned since the majority of patients with this finding were free of recurrent symptoms. In thirty-three patients (twenty-one with associated duodenal ulcer) a concomitant acid-reducing procedure was carried out at the time of hiatus hernia repair. From the observed results no evidence could be adduced that this procedure gave protection against the ill effects of recurrent reflux. It was, however, noted that eight of the thirty-three patients (24 per cent) had troublesome postvagotomy symptoms. It is now believed that vagotomy should not be added to hiatus hernia repair unless it is indicated for the treatment of duodenal ulcer.
Vol.119,June1970
Summary The author’s personal experience with 101 operations for repair of esophageal hiatus hernia in ninety-eight private patients is reviewed. Forty-one operations were performed by the transthoracic route using the Belsey Mark IV technic in all but two instances. Standard abdominal repair was utilized in fifty-eight cases. In two cases an abdominothoracic approach was utilized. Complete follow-up study has been achieved in ninety-one cases, ten to fourteen years since operation in fifteen cases, five to nine years since operation in forty-one cases, and one to four years after operation in thirty-five cases.
679
Mustard
On the basis of this survey plus a review of the literature it is concluded that the Belsey Mark IV transthoracic repair is probably the most reliable method at present and should be used in all suitable cases. When it is necessary to repair an hiatus hernia through the abdomen, great care should be taken to fasten the esophagus down so as to maintain a generous length below the diaphragm. This can be accomplished by suturing the esophagus to the margins of the newly created hiatus (standard abdominal repair), or by fastening the cardia to the preaortic fascia (Hill technic), or by anchoring the lesser curvature of the stomach to the anterior abdominal wall (gastropexy), In some cases it may be advisable to combine these methods.
the
PR: Refiux esophagitis, sliding hiatal hernia and anatomy of repair. Sorg Gynec Obstet 92: 419,
1951.
2. Skinner
DB, Belsey RHR: Surgical management of esophageal reflux and hiatus hernia. J Thorac Cardiovasc Surg 53: 33, 1967. 3. Baue AE, Belsey RHR: The treatment of sliding hiatus hernia and reflux esophagitis by the Mark IV technique. Surgery 62: 396, 1967. 4. Linsman JF: Gastroesophageal reflux elicited while drinking water (water siphonage test): its clinical correlation with pyrosis. Amer J Roentgen 94: 325, 1965. 5. Urschel HC Jr, Paulson DL: Gastroesophageal reflux
680
1967. 7. Clarke JS, Gordon HE, Winner
8.
9.
10.
RB: Treatment of hiatus hernia by hiatus herniorrhaphy, vagotomy and drainage procedure. Amer J Surg 107: 253, 1964. Herrington JL Jr: Treatment of esophageal hiatal hernia. Arch Surg 84: 379, 1962. Berman JK, Berman EJ, Lalonde AH: Management of esophageal hiatus hernia syndrome and associated abnormalities with balanced operations. Dis Chest 39: 1, 1961. Hill LD: An’ effective operation for hiatal hernia. Ann
Surg 166: 681, 1967. 11. Pearson FG, Stone RM, Parrish
RM, Falk RE, Drucker WR: Role of vagotomy and pyloroplasty in the therapy of symptomatic hiatus hernia. Amer J Surg 117:
130,1969. 12. Mustard RA: A survey
References 1. Allison
and hiatal hernia. J Thorac Cardiovasc Surg 53: 21, 1967. 6. Casten DF: Peptic esophagitis, hiatal hernia and duodenal ulcer: a unified concept. Arner J Surg 113: 638,
hiatus
hernia
repair.
of techniques and results of Surg Gynec Obstet 130: 131,
1970. 13. Nissen R: Gastropexy
14.
15.
16.
and “fundoplication” in surgical treatment of hiatal hernia. Amer J Dig Dis 6: 954, 1961. Krupp S, Rossetti M: Surgical treatment of hiatal hernias by fundoplication and gastropexy (Nissen repair) Ann Surg 164: 927, 1966. Boerema I: Gastropexia anterior geniculata for sliding hiatus hernia and for cardiospasm. J lnternat Coil Sorg 29: 533, 1958. Collis LJ: Surgical control of reflux in hiatus hernia. Amer J Surg 115: 465, 1968.
The American Journal
of Surgery
of Esophageal Hiatus Hernia ROBERT A. MUSTARD,
This is a review of my personal experience with the surgical treatment of esophageal hiatus hernia in private patients. Residents’ cases have not been included since their records are not so readily available, the patients are more difficult to trace, and operative technics were less consistent. This study utilizes only patients with symptomatic hiatus hernia; it excludes those in whom a symptomless hiatus hernia was repaired in the course of an operation primarily planned to deal with some other intra-abdominal lesion. Clinical Material
The series consists of ninety-eight patients, of whom ninety-two had a “sliding” or axial-type hiatus hernia, four had a paraesophageal or “rolling” type hiatus hernia, one had a “combined” type hernia, and one had symptomatic esophageal reflux without radiologically demonstrable herniation. In these ninety-eight patients 101 hiatal hernia repairs were performed; three patients required a second operation when the first was followed by recurrent hemiation. Three others were referred with recurrent hernia; eight had radiologic and/or esophagoscopic evidence of early stricture of the esophagus; four had a lower esophageal ring. The incidence by age was as follows: from ten to nineteen years, one patient; twenty to twenty-nine years, two; thirty to thirty-nine ye;lrs, ten: forty to forty-nine years, twenty-three; fifty to fifty-nine years, twenty-nine; sixty to sixty-nine years, twenty-two; over seventy years, seven. Age was not stated in four patients. Of the ninety-eight patients, forty-four were male and fifty-four were female. From 1952 through 1959 twenty-one operations were performed; and from 1960 through 1967 eighty operations were performed. The distribution of operations by year is as follows: 1960, nine; 1961, thirteen; 1962, nine; 1963, thirteen; 1964, eleven; 1965, ten; 1966, eleven; 1967, four. Half of the group had associated conditions (Table I), most causing separate symptoms. All patients in this series had a variety of the complaints usually attributed to esophageal hiatus hernia and/or reflux esophagitis, namely, heartburn, epigastric or chest pain, flatulence and belching, acid eructation, food intolerances, and “sticking” on swallowing. Characteristically the heartburn was exacerbated by recumFrom the Department of sion of General Surgery,
674
Surgery, Toronto
University General
of Toronto, and Hospital, Toronto,
the DiviCanada.
MD, FRCS(C),
FACS, Toronto, Canada
bency or by stooping over and relieved by standing up, by drinking milk or water, or by antacids. Indications for Operation
In eighty-two cases the indication for operation was symptoms related to the hiatus hernia, considered “intractable” in fifty-six cases and associated with recurrent herniation in six others. Episodic chest or epigastric pain suggesting heart disease was a prominent feature in eight cases, and true dysphagia in thirteen, of whom six had a demonstrable stricture. Massive bleeding had occurred in six cases (in addition to those with hemorrhage from an associated duodenal or gastric ulcer), whereas anemia due to chronic blood loss was present in three cases. Gross esophagitis was observed on direct examination in eighteen patients, and was judged severe in twelve. In five other cases esophagoscopic examination failed to show inflammatory changes. In the remaining nineteen patients with symptomatic hiatus hernia the indication for operation was an associated lesion requiring surgical treatment: duodenal ulcer in twelve cases, gallstones in five, pharyngeal diverticulum in one, and polyp3 of the colon in one. Operative Technics
Of 101 hiatus hernia repairs forty-one were performed via left thoracotomy, using the Allison technic [I] in two cases and the Belsey “Mark IV” technic in thirty-nine others. Transabdominal repair was carried out in fifty-eight cases, and combined thoracoabdominal approach was utilized in two cases. As shown in Table II associated operative procedures were carried out in fifty-eight cases. The Belsey Mark IV procedure has been described by Skinner and Belsey [2] and by Baue and Belsey [3]. Our abdominal repairs utilized a method by which we tried to achieve objectives similar to those of the Belsey procedure; this technic, which will be subsequently referred to as “standard abdominal repair,” is carried out as follows: Through an upper abdominal incision, the left lobe of liver is separated from the diaphragm and retracted to the right. The spleen is protected by a large pack. The stomach is pulled down and the cardia mobilized by dividing transversely the phrenoesophageal ligament. A finger and then a soft rubber drain is passed around the esophagus, making sure to include both vagi. The upper one to two inches of lesser omentum is divided and the esophagus dis-
The
American
Journal of Surgery
Esophageal
placed forward and to the left. The margins of the hiatus are then approximated from behind forwards with three to five sutures of Number 1 silk. Interrupted stitches of Number 2-O silk are now used to fasten the muscular wall of the esophagus to the margins of the newly created hiatus with about two inches of esophagus held down in the peritoneal cavity. The fundus of the stomach is now brought forward and to the right over the abdominal esophagus and tacked with silk stitches to its right margin. Finally a tube gastrostomy is instituted for postoperative decompression; it can also be used for feeding in those patients who have temporary dysphagia. Mortality
and Complications
The mortality in these 101 operations was nil. Major complications in the postoperative period were seen in eight patients and were, respectively, as follows: acute gastric dilatation requiring reoperation; pulmonary emboli and wound infection; “serum sickness;” pyloric obstruction requiring reoperation; laryngeal edema requiring tracheostomy; left pleural effusion; temporary esophageal fistula requiring jejunostomy; chronic subphrenic abscess requiring removal of silk sutures. Follow-Up
Studies
In eighty-eight patients follow-up data have been obtained to date of survey (July 1968), forty-two by personal interview and forty-six by questionnaire. In three other patients incomplete follow-up data have been considered adequate for evaluation of results: One of these patients was followed up to seven years and six months after operation, at which time the result was reported as “excellent.” Another patient was untraced after three years, at which time recurrence of hiatus hernia was treated elsewhere. The third patient was untraced after eight months and was considered at that time to have a “poor” result. The remaining seven cases are considered lost to follow-up study: Five were untraced since a few months after operation, and two were known to have died of coronary occlusion (eight months and thirteen months, respectively, after operation). The duration of follow-up in the ninety-one cases is as follows: Fifteen patients have been followed up from ten to fourteen years; forty-one patients have been followed up from five to nine years; and thirty-five patients have been followed up from one to four years (nine patients for four years, ten for three years, eleven for two years, and five for one year). Clinical
Evaluation
of Results
In the clinical evaluation of the results of these operations we have attempted to balance the relief of preoperative symptoms against the imposition of new
Vol.
119,
June
1970
TABLE
I
Associated Conditions Eight Patients
in Forty-Eight
with Hiatus
Condition
Hiatus
Hernia
of Ninety-
Hernia Number of Patients
Duodenal
ulcer Duodenal ulcer and cholelithiasis Cholelithiasis Gastric ulcer Leiomyoma of stomach Pharyngeal diverticulum Polyps of colon Scleroderma Steroid therapy Adrenalectomy (Cushing’s) Arthritis Hypopituitarism Total
19 15 3
48
symptoms due to surgical treatment. For example, if preoperative heartburn has been replaced by postoperative dysphagia or diarrhea, the procedure cannot be considered an unqualified success. We have used the following categories for evaluation : “Excellent” results indicate that the patient is asymptomatic; “good” that he is greatly improved, with occasional mild symptoms; “fair” that he is partially improved, with some recurrence of preoperative symptoms or other troublesome digestive tract disturbance; and “poor” that he is unimproved. It should be noted that in almost all cases the clinical assessment was made before the results of radiologic follow-up study were known. The distribution of the results on the basis of clinical
TABLE
II
Associated
Operative
Procedures
Associated Procedures With 41 Transthoracic Repairs Dilation of stricture of esophagus (plus vagotomy and pyloroplasty in one) Vagotdmy Vagotomy and pyloroplasty plus cholecystectomy Myotomy Excision of leiomyoma of stomach With 58 Transabdominal Repairs Vagotomy and pyloroplasty (plus cholecystectomy in four, and dilation of stricture of esophagus in one) Vagotomy and partial gastrectomy Cholecystectomy Partial gastrectomy Excision of pharyngeal diverticulum (plus vagotomy and pyloroplasty in one) Excision of polyps in colon With 2 Thoracoabdominal Repairs Dilation of stricture of esophagus Vagotomy and gastrojejunostomy Total
Number of Patients
2 1 1 2 1 26
4 15 1 2 1 1 1 58
675
Mustard
TABLE III
Results of 101 Operations for Repair of Hiatus Hernia Results Operation
Transthoracic repair Transabdominal repair Abdominothoracic repair Total
Excellent
Good
Fair
Poor
Total Traced
Untraced
19 (49%) 20 (39%)
10 (29%) 21(39%)
2 (5%) 9 (16%)
g (20%) 4 (7%)
2 5
4: (44%)
31(32%)
10 (11%)
12 (13%)
39 53 2 94
evaluation is shown in Table III. It is seen that 76 per cent of traced cases have had a satisfactory clinical result (44 per cent “excellent”; 32 per cent “good”), whereas 24 per cent have had an unsatisfactory clinical result (11 per cent “fair”; 13 per cent “poor”). It is noted that the clinical results of transthoracic and abdominal repairs have been satisfactory in about equal rates, 75 and 77 per cent, respectively. It is interesting to examine the reasons for the unsatisfactory results in twenty-two cases. (Table IV.) Recurrent hiatus herniation was demonstrated in only ten patients, but was considered probable in two others on the basis of symptomatic evaluation. In two other patients preoperative symptoms returned despite “negative” radiologic studies. A poor result was caused in one patient by too-tight closure of the hiatus and reoperation was required. In another patient technical failure was the result of chronic postoperative infection, necessitating reoperation to remove the silk sutures utilized in the repair. In two patients with concomitant vagotomy and pyloroplasty there has been such severe and persistent diarrhea that they must be classified as having “unsatisfactory” results. Finally, in four patients the unsatisfactory result must be attributed to poor selection: two patients whose continuing multiple complaints are now considered psychosomatic in origin, one other with persisting symptoms now recognized as those of “irritable colon” syndrome, and one with advanced scleroderma which is probably responsible for the continuing dysphagia. In none of these last six patients has there been radiologic evidence of recurrent hernia or reflux. Eight patients volunteered the information that after operation they were unable to vomit. In six patients this TABLE IV
Clinically Unsatisfactory Results Result
Recurrent hiatus hernia Symptomatic recurrence Without radiologic recurrence No radiologic follow-up Technical failure Too-tight repair Chronic postoperative infection Postvagotomy diarrhea Poor selection Total
676
Number of Cases 10 4 2 2 2 1 1 2 4 22
7
persisted for over two years up to a maximum in one patient of seven years. This has not been registered as a complaint but it does seem significant as an indication of the effectiveness of these operations in restoring a competent gastroesophageal valve mechanism. After hiatus hernia repair almost all patients complain of temporary dysphagia which usually clears up spontaneously within a few weeks. We have found, however, by direct questioning that twenty-eight patients (30 per cent of traced cases) noted persisting dysphagia, lasting more than one year in twenty-two cases up to a maximum of fourteen years. In most cases this symptom was described as “mild and intermittent,” but in four patient it was “severe,” three requiring treatment by bougienage. Since operations for repair of hiatus hernia are designed to constrict and immobilize the lower esophagus, it is not surprising that they interfere to some extent with normal esophageal function. Radiologic Follow-Up Study
After 101 operations for repair of esophageal hiatus hernia the results have been traced in ninety-four patients, with radiologic follow-up study in eighty-three. In sixty-two patients recent tine studies have been carried out by Dr Robert Parrish of the Department of Radiology, Toronto General Hospital, utilizing a uniform technic and reporting his findings without knowledge of the clinical evaluation. In every case an effort was made to demonstrate recurrent herniation. The degree of spontaneous reflux was noted, and the water siphon test [4] was carried out. Reflux was classified “slight,” “moderate,” or “marked” according to its volume and height; only the latter two categories were considered “significant.” Finally each patient swallowed a barium-filled capsule 1.0 cm in diameter to detect narrowing of the esophagus or a tight hiatal repair. In twenty-one other patients standard upper gastrointestinal radiologic studies were carried out from fifteen months to twelve years after operation. Anatomic recurrences are expressed as a percentage of those subjected to radiologic follow-up examination. Patients known to have recurrence and who were reoperated on elsewhere are included. The results of these studies in relation to recurrence of hiatus herniation are shown in Table V. The over-all
The American Journal of Surgery
Esophageal
TABLE
V
Results
of Radiologic
Follow-Up
Operation Thoracic repair Abdominal repair Thoracoabdominal Total
repair
* Over-all recurrence rates cases, 17/83 (20 per cent).
from
119.June 1970
1960-1967
-
Rechecked
Recurrent Hiatus Hernia
Recurrent Reflux Only
Total Rechecked
Recurrent Hiatus Hernia
Recurrent Reflux Only
12 2 2 16
7 (58%) 2 1 10 (63%)
...
21
...
4 (20%) 3 (7%)
4 14
...
46 ...
...
67
1952 to 1967.
Thoracic
repair,
recurrence rate of 20 per cent is disappointingly high, but it should be noted that the Irate was only 10 per cent during the last eight years of the survey in which 80 per cent of the operations were performed. It seems likely that this recent improvement is partly accounted for by the development of increased skill and the use of improved technics in the operative procedure. However, the possibility cannot be excluded that the poor results in the earlier group may indicate merely that the recurrence rate increases with duration of the followup period. In this regard five of the seventeen recurrences in the present series are known to have occurred in less than two years from the date of operation, and another five in less than five years. Judging by the date of onset of recurrent symptoms two appear to have developed at about six years after operation and one at seven years postoperatively. In two patients operated on eleven years ago, and in two others operated on ten years ago, recurrent herniation has recently been demonstrated on radiologic follow-up study, but since symptoms have not reappeared, the time of recurrence cannot be established. Although there is as yet little precise information on this point, it seems reasonable to suppose that the number of recurrences would increase with the passage of time and aging of the patient. However, both Skinner and Belsey [2] and Urschel and Paulson [S] claim that the majority of the recurrences in their patients occurred in the first two years after operation. As expected, recurrence was more common in patients with advanced pathologic changes caused by reflux esophagitis. Of the seventeen patients with recurrence in this series four had a stricture before operation, four had gross esophagitis demonstrated by direct examination, and one already had recurrence after a previous operation elsewhere. In two other patients with recurrence, an esophagocardiomyotomy at the time of hiatus hernia repair was carried out because the patient’s prime complaint had been spasmodic painful dysphagia; it is now believed that myotomy is not indicated in such cases, and that, if performed, it prejudices the security of the hernia repair. It is also seen from Table V that in my experience
Vol.
Hernia
Study*
1952-1959 Total
Hiatus
11/33
(33 per cent);
Abdominal
...
...
7 (10%) repair,
18
5/‘48 (10 per cent);
total
of all
the recent recurrence rate ( 1960-67 ) after transthoracic repair (20 per cent) has been higher than that after abdominal repair (7 per cent). This should not be taken to indicate a clear superiority of the abdominal type repair since the figures are really too small to be significant. Actually all four recurrences after transthoracic repair are readily accounted for by special circumstances: two patients had myotomy performed (vide supra), one patient had recurrent hernia with a short esophagus, and one patient with a large paraesophageal hernia was found to have a tumor in the fundus of the stomach which required resection. Attention must be called to the fact that not all patients with recurrent hemiation have unsatisfactory results on clinical evaluation. Of the seventeen patients with demonstrated recurrences two were found to have “excellent” and four “good” results on clinical evaluation. Results in four others were rated “fair” and in seven “poor” (of these latter patients, five were reoperated on, three by the author and two elsewhere). It would appear that in certain patients even though recurrent herniation develops, there may be some quantitative alteration in gastroesophageal function which allows them to remain free of recurrent symptoms. The presence or absence of recurrent reflux was reported in seventy of eighty-three patients undergoing radiologic follow-up examinations. (Tables VI and VII). Eleven showed a significant degree of spontaneous reflux; all but one of these was associated with recurrent herniation. Nine of eleven had also some degree of symptomatic recurrence (that is, return of the symptoms of reflux esophagitis). Thus, there was a close correlation between recurrent spontaneous reflux, recurrent hernia, and symptomatic recurrence. TABLE VI
Relation of Recurrent Hiatus Hernia
No significant reflux Spontaneous reflux Reflux on water siphon test only
Reflux
to
Recurrent
Recurrent Hiatus Hernia
No Recurrence Hernia
2 10
39 1
2
17
677
Mustard
TABLE VII
Relation of Recurrent Reflux to Symptomatic Recurrence No Symptoms
No significant Spontaneous
reflux reflux
Reflux on water siphon test only
Slight Symptoms
Moderate to Severe Symptoms
31 2
9 3
1 6
16
3
0
Our observations, however, throw doubt on the significance of the water siphon test. Of nineteen patients with recurrent reflux demonstrated only by the water siphon test, only two had a recurrent hernia, three had slight symptomatic recurrence, and sixteen were symp tom-free. The Role of Vagotomy in the Treatment of Hiatus Hernia
Vagotomy with a drainage procedure has been recommended as an adjunct to the repair of hiatus hernia in patients with associated duodenal ulcer, peptic esophagitis or stricture, or gastric hyperacidity [6-8]. Some have gone so far as to advocate routine vagotomy and pyloroplasty with each hiatus hernia repair [9]. The rationale is that, by reducing acid secretion, vagotomy and pyloroplasty may protect against the ill effects of any reflux which may persist or recur after hiatus hernia repair. It would be difficult, indeed, to prove this thesis, and no published evidence to this effect has yet been discovered. In this series of 101 operations for repair of symp tomatic hiatus hernia, an acid-reducing procedure was carried out in thirty-three patients, of whom twenty-one had a duodenal ulcer. In five other patients the indication for vagotomy was recurrent hiatus hernia, and in one the indication was esophageal stricture. In six patients there was no clear cut indication for vagotomy. The adjunctive procedures consisted of vagotomy and pyloroplasty in twenty-nine cases, vagotomy and distal gastrectomy in three, and vagotomy and gastrojejunostomy in one case. Two of the group were lost to follow-up study soon after operation. Of the remaining thirty-one, recent radiologic follow-up study has been carried out in twenty-nine, disclosing only one recurrent hernia. One other patient showed a moderate degree of spontaneous reflux but remained symptom-free. In. an additional twelve moderate to marked reflux was demonstrated on the water siphon test, but none suffered recurrent symptoms from this cause. At first sight this would suggest that vagotomy and pyloroplasty had given protection against the ill effects of recurrent reflux. However, this conclusion is not justified since ten other patients with recurrent reflux shown only on the water
678
siphon test (including six with recurrent hiatus hernia) also remain clinically satisfactory although none of them had vagotomy. On the other hand it must be noted that among the thirty-three patients who had concomitant vagotomy and drainage, eight (24 per cent) had troublesome postvagotomy symptoms: diarrhea in seven and diarrhea plus “dumping” in one. Others have also noted the high incidence of such complications [10,11], From all this evidence it is concluded that vagotomy and pyloroplasty should not be a routine accompaniment of hiatus hernia repair except when there is coexisting duodenal ulcer disease. Comments
Although this survey has revealed major shortcomings in our surgical treatment of esophageal hiatus hernia, it must be emphasized that, in going over the material case by case, one is struck by the great preponderance of patients who are grateful for relief of symptoms and for restored ability to enjoy a full normal diet. Unsatisfactory results in those patients treated during the early years of this survey were undoubtedly due mainly to lack of experience and to imperfectly developed operative technics. We have, however, evidence which suggests that the number of recurrences may increase progressively with the length of the postoperative follow-up period. Further information is needed on this point. Poor selection of patients for operative treatment (such as those with symptoms not due to hiatus hernia), unjustified addition of concomitant vagotomy and “drainage,” and a tendency to unnecessarily tight closure of the hiatus have been other factors responsible for some of the imperfect results. The findings in this series do not give any clear evidence as to which is the best method of hiatus hernia repair. This question is discussed at length by me in a recent paper [12] in which emphasis is laid on the fundamental importance of re-establishing and maintaining an intra-abdominal segment of esophagus. Also discussed in that paper are the indications for the transthoracic versus the transabdominal repair. The transthoracic route is mandatory when there is evidence of severe esophagitis, short esophagus, or stricture formation. This approach is also advocated in obese patients or in those with deep or long chests. There can be little doubt at the present time that the Belsey Mark IV procedure is the best method for those whose hiatus hernia is to be repaired through the chest. Skinner and Belsey [2] have reported 610 patients treated this way with known recurrences in 8 per cent and excellent or good results on clinical evaluation in 88 per cent. Urschel and Paulson [5] have
The Amerkan
Journal
of Surgery
Esophageal
Hiatus
Hernia
reported 21 1 operations of this type with only 2 per cent recurrent herniation. Their follow-up period is somewhat shorter and they admit “symptomatic recurrent reflux” in fourteen other cases. The abdominal approach may be selected when there is no compelling reason for thoracotomy and is the preferred method in patients with associated intraabdominal conditions such as peptic ulcer or cholelithiasis. My technic of “standard abdominal repair” has proved quite satisfactory. In forty-six patients treated this way during the period from 1960 through 1967 there have been so far only three recurrences (7 per cent ) . Hill [ZO] has described a new method of anchoring the esophagus below the diaphragm by suturing the cardia to the preaortic fascia. He has reported 149 cases treated this way with “no demonstrable anatomic recurrence,” and “good to excellent [clinical results] in all but five cases.” If others can duplicate these results a real advance will have been made in the surgical treatment of this condition.
is firmly tethered below the diaphragm and that the acute esophagogastric angle is reconstituted. The standard abdominal repair may in some cases be reinforced by combining it with Eundoplication or gastropexy. Collis and Hill have each had excellent results with their own technics; after further trial these methods may be widely adopted.
Another possible method of improving the results of transabdominal repair might be by more frequent use of Nissen’s “fundoplication” [13]. This technic has been endorsed by Krupp and Rossetti [24], who reported 109 cases with only four recurrences, and by Casten who records its use in eighty-eight patients with eight recurrences [6]. It is also possible that the Nissen-Boerema “gastropexy” [15] (in which the esophagus is held down by suturing the stomach to the anterior abdominal wall) may have a place either as an adjunct to other methods of abdominal repair or as the sole procedure in poorrisk patients. Finally reference should be made to the Collis procedure [16] in which the hiatus is closed above and in front of the esophagus in order to force the esophagogsstric junction downwards and so accentuate the acute angle of implantation. In 200 patients treated this way and checked by radiologic examination at the end of four years Collis found only 2.5 per cent with recurrent herniation. This method deserves further trial. It seems clear that the surgical repair of esophageal hiatus hernia should not be lightly undertaken. Cases should be carefully selected on the basis of intractable symptoms, demonstrated pathologic complications, or associated conditions, such as peptic ulcer or cholelithiasis, requiring operation. The Belsey Mark IV technic is at present probably the most effective method and should be used in all suitable cases. Good results necessitate skill, experience, and close attention to precise details of technic. When the abdominal approach is selected, the surgeon must ensure that a generous length of esophagus
On clinical evaluation 76 per cent of the patients were rated as having “excellent” or “good” results. About half of the clinically unsatisfactory results were associated with recurrence of the hernia. Radiologic follow-up study was achieved in eightythree of the ninety-one traced cases. In this group there was an over-all anatomic recurrence rate of 20 per cent, but this was reduced to 10 per cent during the last eight years of the survey in which four-fifths of the operations were performed. It is beli.:ved that the apparent superiority of the standard ab!!ominal repair over the Belsey Mark IV transthoracic repair in this series is not significant because of the small number of patients involved and because more difficult cases were selected for the latter procedure. A very good correlation was demonstrated between the recurrence of spontaneous reflux and anatomic and symptomatic recurrence. On the other hand the significance of reflux provoked by the water siphon test is questioned since the majority of patients with this finding were free of recurrent symptoms. In thirty-three patients (twenty-one with associated duodenal ulcer) a concomitant acid-reducing procedure was carried out at the time of hiatus hernia repair. From the observed results no evidence could be adduced that this procedure gave protection against the ill effects of recurrent reflux. It was, however, noted that eight of the thirty-three patients (24 per cent) had troublesome postvagotomy symptoms. It is now believed that vagotomy should not be added to hiatus hernia repair unless it is indicated for the treatment of duodenal ulcer.
Vol.119,June1970
Summary The author’s personal experience with 101 operations for repair of esophageal hiatus hernia in ninety-eight private patients is reviewed. Forty-one operations were performed by the transthoracic route using the Belsey Mark IV technic in all but two instances. Standard abdominal repair was utilized in fifty-eight cases. In two cases an abdominothoracic approach was utilized. Complete follow-up study has been achieved in ninety-one cases, ten to fourteen years since operation in fifteen cases, five to nine years since operation in forty-one cases, and one to four years after operation in thirty-five cases.
679
Mustard
On the basis of this survey plus a review of the literature it is concluded that the Belsey Mark IV transthoracic repair is probably the most reliable method at present and should be used in all suitable cases. When it is necessary to repair an hiatus hernia through the abdomen, great care should be taken to fasten the esophagus down so as to maintain a generous length below the diaphragm. This can be accomplished by suturing the esophagus to the margins of the newly created hiatus (standard abdominal repair), or by fastening the cardia to the preaortic fascia (Hill technic), or by anchoring the lesser curvature of the stomach to the anterior abdominal wall (gastropexy), In some cases it may be advisable to combine these methods.
the
PR: Refiux esophagitis, sliding hiatal hernia and anatomy of repair. Sorg Gynec Obstet 92: 419,
1951.
2. Skinner
DB, Belsey RHR: Surgical management of esophageal reflux and hiatus hernia. J Thorac Cardiovasc Surg 53: 33, 1967. 3. Baue AE, Belsey RHR: The treatment of sliding hiatus hernia and reflux esophagitis by the Mark IV technique. Surgery 62: 396, 1967. 4. Linsman JF: Gastroesophageal reflux elicited while drinking water (water siphonage test): its clinical correlation with pyrosis. Amer J Roentgen 94: 325, 1965. 5. Urschel HC Jr, Paulson DL: Gastroesophageal reflux
680
1967. 7. Clarke JS, Gordon HE, Winner
8.
9.
10.
RB: Treatment of hiatus hernia by hiatus herniorrhaphy, vagotomy and drainage procedure. Amer J Surg 107: 253, 1964. Herrington JL Jr: Treatment of esophageal hiatal hernia. Arch Surg 84: 379, 1962. Berman JK, Berman EJ, Lalonde AH: Management of esophageal hiatus hernia syndrome and associated abnormalities with balanced operations. Dis Chest 39: 1, 1961. Hill LD: An’ effective operation for hiatal hernia. Ann
Surg 166: 681, 1967. 11. Pearson FG, Stone RM, Parrish
RM, Falk RE, Drucker WR: Role of vagotomy and pyloroplasty in the therapy of symptomatic hiatus hernia. Amer J Surg 117:
130,1969. 12. Mustard RA: A survey
References 1. Allison
and hiatal hernia. J Thorac Cardiovasc Surg 53: 21, 1967. 6. Casten DF: Peptic esophagitis, hiatal hernia and duodenal ulcer: a unified concept. Arner J Surg 113: 638,
hiatus
hernia
repair.
of techniques and results of Surg Gynec Obstet 130: 131,
1970. 13. Nissen R: Gastropexy
14.
15.
16.
and “fundoplication” in surgical treatment of hiatal hernia. Amer J Dig Dis 6: 954, 1961. Krupp S, Rossetti M: Surgical treatment of hiatal hernias by fundoplication and gastropexy (Nissen repair) Ann Surg 164: 927, 1966. Boerema I: Gastropexia anterior geniculata for sliding hiatus hernia and for cardiospasm. J lnternat Coil Sorg 29: 533, 1958. Collis LJ: Surgical control of reflux in hiatus hernia. Amer J Surg 115: 465, 1968.
The American Journal
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