Ann Thorac Surg 2001;71:1080-1087
© 2001 The Society of Thoracic Surgeons
Original article: general thoracic
Laparoscopic management of giant paraesophageal herniation
Robert J. Wiechmann, MDa,
Mark K. Ferguson, MDc,
Keith S. Naunheim, MDb,
Paul McKeseya,
Steven J. Hazelrigg, MDd,
Tibetha S. Santucci, RNa,
Robin S. Macherey, RNa,
Rodney J. Landreneau, MDa
a Allegheny General Hospital Campus, Allegheny University of the Health Sciences, Pittsburgh, Pennsylvania, USA
b St. Louis University Medical Center, St. Louis, Missouri, USA
c University of Chicago Medical Center, Chicago, Illinois, USA
d Southern Illinois University, Springfield, Illinois, USA
Address reprint requests to Dr Landreneau, Division of Cardiothoracic Surgery, Allegheny General Hospital, 490 East North Ave, Pittsburgh, PA 15212
e-mail: rlandren{at}aherf.edu
Presented at the Thirty-fourth Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Jan 26–28, 1998.
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Abstract
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Background. Many surgeons have found laparoscopic fundoplication effective management of medically recalcitrant gastroesophageal reflux disease (GERD) associated with sliding type I hiatal hernias. The anatomic distortion and technical difficulty inherent with repair has limited the use of laparoscopy for repair of "giant" paraesophageal hernias (gPH).
Methods. Since July 1993, we have accomplished laparoscopic repair of paraesophageal hiatal hernias in 54 of 60 (90%) patients. Five patients had classic type II hernias with total intrathoracic stomachs, and 53 patients had large sliding/paraesophageal type III herniation. Two patients had true parahiatal hernias. None had gastric incarceration. Median age was 53 years and 28 of 60 (47%) were women. Chest pain and dysphagia were primary complaints from 39 of 60 (65%). Heartburn with or without regurgitation was present in 52 of 60 (85%). Preoperative manometry and prolonged pH testing were obtained on 43 of 60 (72%) and 44 of 60 (73%) patients, respectively. Principles of repair included reduction of the hernia, excision of the sac, crural approximation, and fundoplication over a 54F bougie (Nissen, 41; Dor, 1; Toupet, 18) to "pexy" the stomach within the abdomen and to control postoperative reflux.
Results. Mean operative time was 202 ± 81 minutes. Conversion to "open" repair was required in 6 patients (iatrogenic esophageal injury in 2 patients and difficult hernia sac dissection in 4 patients). One postoperative mortality occurred as a result of sepsis and multiorgan failure after an intraoperative esophageal perforation. Follow-up barium swallow performed in 44 of 60 patients demonstrated recurrent hiatal hernias in 3 patients. Preoperative symptoms have been relieved in all but 3 patients. Reoperation for recurrent paraesophageal herniation has been required in these latter 3 patients.
Conclusions. Although technically challenging, laparoscopic repair of paraesophageal hiatal hernias is a viable alternative to "open" surgical approaches. Control of the herniation and the patient’s symptoms are equivalent and hospitalization and return to full activity are shorter.
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Introduction
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Paraesophageal herniation is an uncommon disorder of the gastroesophageal hiatus characterized by the potential for life-threatening complications resulting from mechanical obstruction and vascular compromise of the stomach [1–7]. This scenario of paraesophageal hernias contrasts with the more common sliding esophageal hiatal hernia, which is principally defined by its frequent association with symptomatic gastroesophageal reflux [8].
The sliding esophageal hiatal hernia is anatomically characterized by a laxity in the phrenoesophageal ligament, which usually anchors the gastroesophageal junction to its normal intraabdominal location and maintains the relationship of the distal esophagus to the gastric cardia and fundus [9, 10]. A variable cephalad migration of the gastroesophageal junction through the hiatus into the posterior mediastinum is characteristic (Fig 1).
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Fig 1. Anatomic characteristics of the "sliding" hiatus hernia. The phreno-esophageal ligament is attenuated, resulting in cephalic migration of the gastroesophageal junction into the chest. This is commonly associated with functional disturbance in the integrity of the lower esophageal sphincter and pathologic gastroesophageal reflux. (Reprinted with permission from Nyhus LM, Baker RJ, Fisher JE, eds. Mastery of Surgery. Boston: Little, Brown and Co., Inc, 1996.)
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In distinction, primary paraesophageal (type II) hiatal hernias are associated with preservation of the normal posterior phrenoesophageal ligamentous anchorage of the gastroesophageal junction within the abdomen. These true hernias are defined by a large peritoneal lined opening in the esophageal hiatus anterior to a normally positioned gastroesophageal junction (Fig 2).
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Fig 2. Anatomic characteristics of a primary paraesophageal hiatal hernia demonstrating preservation of the posterior phreno-esophageal ligament attachments and a true peritoneal lined herniation of the gastric fundus through an anterior expansion of the esophageal hiatal opening. (Reprinted with permission from Nyhus LM, Baker RJ, Fisher JE, eds. Mastery of Surgery. Boston: Little, Brown and Co., Inc, 1996.)
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The combination of sliding and paraesophageal hernia components (type III hiatal hernia) is also commonly encountered. Patients with this combined hernia process will often have symptoms related to pathologic gastroesophageal reflux and to mechanical obstruction of the stomach within the paraesophageal component of the hernia (Fig 3). Occasionally, colon and omentum may be drawn up into the thoracic hernia sac by the organo-axial rotation of the stomach. This creates complex symptoms of upper and lower gastrointestinal (GI) obstruction and a confusing contrast radiograph of the upper GI tract (Fig 4).
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Fig 3. Contrast radiograph demonstrating classic giant paraesophageal hernia with organo-axial rotation of the stomach.
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Fig 4. (A) Large paraesophageal hernia with stomach and omentum migrating into the intrathoracic hernia sac. (Reprinted with permission from Nyhus LM, Baker RJ, Fisher JE, eds. Mastery of Surgery. Boston: Little, Brown and Co., Inc, 1996.) (B) Contrast radiograph demonstrating herniation of stomach and transverse colon within the paraesophageal hernia sac (type IV hiatal hernia).
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Controversy remains regarding the frequency, pathophysiology, and treatment of giant paraesophageal hiatal hernias [2, 5, 7, 11–13]. The incidence of true (type II) paraesophageal hiatal hernias versus type III combined sliding paraesophageal hiatal hernias remains in question [14]. Considerable debate exists regarding the surgical treatment of paraesophageal hiatal hernias. The approaches to paraesophageal hiatal hernia, including transthoracic and transabdominal, each have their advocates. The necessity for a standard esophageal fundoplication procedure associated with the paraesophageal hiatal hernia repair is also controversial. And, finally, the need for a Collis gastroplasty associated with repair of paraesophageal hiatal hernias for esophageal shortening is in debate [13–16].
Large series have been published demonstrating the safety, efficacy, and median-term results of a laparoscopic repair of sliding hiatal hernias for the treatment of gastroesophageal reflux disease [17, 18]. The laparoscopic treatment of paraesophageal hernias have been slow to develop because of the complex dissection of the hernia sac and the repair of the paraesophageal hiatal hernia. We are presenting our series of 60 patients who have undergone attempted laparoscopic repair of paraesophageal hiatal hernias.
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Material and methods
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Between July 1993 and December 1997, we attempted 60 laparoscopic repairs of giant paraesophageal hiatal hernias at four institutions. Thirty-two men and 28 women ranged in age from 25 years to 80 years, with a mean age of 56.7 (± 15.7) years. Our patients were followed for 1 to 54 months, for a mean follow-up of 19.3 (± 14.5) months and a median follow-up 12.9 months. Preoperative contrast roentgenographic studies of the esophageal and gastric anatomy were routinely employed. Esophagogastric obstruction was documented by preoperative barium esophagram in 8 patients (Fig 5). We are presenting these 60 patients who underwent laparoscopic repair of paraesophageal hiatal hernias in an effort to demonstrate the efficacy, safety, and short-term success. Two of the 60 patients had true parahiatal hernias with nearly total herniation of the stomach through a defect in the hiatus separated from the esophageal hiatus by a segment of diaphragm.
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Fig 5. Barium radiograph demonstrating prolapse of the previously intrathoracic gastric fundus back into the abdomen resulting in gastric volvulus and closed loop obstruction of the fundus and antrum of the stomach. (Reprinted with permission from Nyhus LM, Baker RJ, Fisher JE, eds. Mastery of Surgery. Boston: Little, Brown and Co., Inc, 1996.)
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Clinical features
Chest pain and dysphagia occurred in 39 of 60 (60%) patients with giant paraesophageal hiatal hernias. The pain was typically postprandial and was characterized as chest (substernal) pain, epigastric pain, and occasionally pain radiating to the left side, back, or shoulders. The pain was frequently associated with nausea and vomiting. Heartburn occurred in 52 of 60 (87%) patients and dysphagia and regurgitation occurred 43 of 60 (72%) patients. Preoperative barium studies identified 7 patients with features consistent with classic type II hernias (ie, total intrathoracic stomachs without a sliding hernia component). Two of these patients were found to actually have the rare entity of a true parahiatal hernia. Fifty-three patients had large mixed sliding/paraesophageal type III herniation with near total displacement of the stomach within the thoracic hernia sac and associated organoaxial rotation.
Preoperative manometry and prolonged esophageal pH testing was performed in 44 of 60 (73%) patients, revealing mean peristalsis of 77.5 ± 40.6 mm Hg, mean lower esophageal sphincter (LES) of 15.5 ± 8.2, and mean percent of time during 24 hours with a pH less than 4 of 13.7% ± 10.9%. It is not infrequent that pH or manometry catheters cannot be adequately positioned secondary to the inability to position the catheter in a patient with a paraesophageal hiatal hernia. These studies demonstrated abnormal acid exposure to the esophagus in 40 of the 44 patients tested. Disordered esophageal motility characterized by frequent tertiary contractions and marginal peristaltic amplitude of contraction in the esophageal body (< 30 mm Hg) was noted in 18 patients, which led us to use partial rather than circumferential fundoplication procedures as part of the repair.
Preoperative endoscopic evaluation of the esophagus, stomach, and duodenum was routinely performed by the operating surgeon after the induction of general anesthesia. Care was taken to aspirate all air from the stomach upon completion of this endoscopic examination to avoid potential trochar injury to a distended stomach.
Surgical features
Familiarity with the technical nuances of endosurgical instrumentation and the general conduct of laparoscopic surgical approaches are vital prerequisites before attempting laparoscopic repair of paraesophageal hernias. Likewise, the surgeon should be experienced with the "open surgical" approaches to repair of paraesophageal hernias, as the technical standards of "open surgical" management must be maintained to avoid suboptimal results. The surgeon must also be prepared to convert to an open surgical approach when the operative conditions preclude a safe or effective surgical repair of the paraesophageal hernia.
Laparoscopic techniques can be readily applied in the management of paraesophageal herniation. The trochar access utilized to conduct the laparoscopic intervention is illustrated in Figure 6. Five sites of trochar access are routinely employed. These same trochar sites are also utilized by us for the laparoscopic approach to fundoplication in the management of pathologic gastroesophageal disease.
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Fig 6. Approximate location of abdominal trochar access sites used by our group for laparoscopic antireflux surgery. (Reprinted with permission from Landreneau RJ, Keenan RJ, Ferson PF. Gastroesophageal reflux disease. In: Cameron JL, ed. Current Surgical Therapy, 5th ed. St. Louis: Mosby Year Book, 1995:29.)
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After abdominal insufflation is achieved, the initial trochar access used for the laparoscopic camera unit is established. We choose a left paramedian location 3 to 5 cm above the umbilicus for this access because this gives the greatest direct visibility of the esophageal hiatal anatomy.
The second 11-mm trochar access achieved is in the right upper quadrant 3 cm below the costal margin. It is best to keep this trochar access site in a far lateral position to prevent crowding of subsequent instrumentation. This right upper quadrant site is primarily utilized to introduce an expandable retracting instrument beneath the left lobe of the liver to expose the esophageal hiatus. The hiatal exposure is facilitated by leaving the triangular ligamentous attachments of the liver intact. A third 11-mm trochar access site is established in the left upper quadrant for the "right-handed" endoscopic instrument access used to accomplish the hiatal dissection. A fourth 11-mm trochar access is placed approximately 4 to 5 cm below the first left upper quadrant site. This site is primarily used for retraction of the gastric fundus during the hiatal dissection. A final trochar access (5 mm) is achieved in the midline subxiphoid position to introduce the "left-handed" endoscopic dissecting instrumentation.
Dissection about the esophageal hiatus is completed with division of the posterior phrenoesophageal ligamentous attachments along the entire circumference of the distal esophagus and the lesser curvature of the stomach. Care is taken to identify and preserve the posterior vagus nerve. The diaphragmatic crura are identified, reapproximated behind the esophagus with interrupted 0 nonabsorbable sutures over a 54-bougie dilator. The short gastric vessels are divided using the Harmonic scalpel (Ultracision, Inc, Smithfield, RI) from the mid body of the stomach to the diaphragmatic hiatus. The fundoplication procedure chosen is dictated by determination of the severity of the reflux process and the integrity of the esophageal peristaltic pump, as determined by preoperative esophageal barium studies and standard esophageal manometric testing of esophageal body function.
With normal esophageal peristalsis, we perform the standard three-stitch 360° Nissen wrap over a 54-bougie dilator. When the adequacy of esophageal peristalsis is in question, we rely upon a partial fundoplication to avoid the potential postoperative dysphagia that may result after total fundoplication.
Follow-up
All 60 patients were followed in the early postoperative period (within 30 days), at 6 months postoperatively, and annually with questioning and examination. Symptomatic evaluation was performed using a visual analogue scale. Patients were asked to grade their lifestyle and sense of well-being and their symptoms of heartburn, regurgitation, dysphagia and chest pain, gas bloat, and diarrhea on a scale of 1 to 10. These symptoms at 1 month, 6 months, and annually were compared with the preoperative symptoms. A hiatal hernia symptom score similar to the system described by Jamieson and Duranceau was also used to characterize the patients’ symptom before and after repair of their paraesophageal hernias [19]. The frequency of symptoms is added to the duration of symptoms and the sum is multiplied by the severity of symptoms. A minimum score of 0 and a maximum score of 32 is available and the percent change was calculated (Table 1). Symptom classification includes mild (1 to 7), moderate (8 to 15), marked (16 to 23), and severe (24 to 32).
One institution obtained barium esophagrams on all patients on the first postoperative day. Follow-up contrast radiographic studies of the stomach and esophagus were performed in 44 of 60 (73%), and follow-up manometry and prolonged pH testing were performed in 17 of 60 (28%) patients.
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Results
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Sixty patients underwent attempted laparoscopic repair of a paraesophageal hiatal hernia. There was one mortality from complications associated with an iatrogenic esophageal perforation. The perforation was identified and immediately repaired, although the patient subsequently required esophageal resection and died of complications of sepsis.
Conversion to open repair was required in 6 patients (10%). Iatrogenic esophageal perforation resulted in two conversions to an open procedure (one of these perforations is described in the above paragraph), and difficulty in dissecting out the hernia sac resulted in 4 patients requiring an open procedure.
The mean operative time for all 60 patients was 202 (± 81) minutes, although the operative time for our last 10 patients was 151 (± 25) minutes. Forty-one patients underwent a Nissen esophageal fundoplication, while 18 patients had a partial Toupet fundoplication and 1 patient had a Dor procedure.
Follow-up examinations and questionnaires were performed on all 60 patients. All but 3 patients experienced symptomatic relief. Analysis of the change in symptoms from pre-op to 1 year post-op were expressed in mean increase or decrease. Heartburn had a mean decrease of 8.3 ± 1.8 (p < 0.0001), regurgitation had a mean decrease of 7.5 ± 3.5 (p < 0.0001), and symptom score had a mean decrease of 19.1 ± 8.7 (p < 0.0001). Patients described significant improvement in their lifestyle, with a mean increase of 1.3 ± 1.8 (p < 0.0001), and their overall sense of well-being, with a mean increase of 2.7 ± 2.2 (p < 0.001) (Table 2).
At one institution, routine barium esophageal studies were performed on the first postoperative day (37 patients). This early radiographic evaluation revealed one recurrent hernia in 37 patients. This patient underwent immediate repair of his recurrent paraesophageal hernia with subsequent good symptomatic and function results.
At 6 months, 44 of 60 patients had a barium esophagram evaluation performed. Of these 44 studies, 3 patients suffered recurrent herniation and all 3 patients described recurrent symptoms. These 3 patients required repair of their recurrent paraesophageal herniation.
Follow-up manometry and prolonged pH testing were performed in 17 of 60 patients (28%). The postoperative evaluation demonstrated a significant increase in the lower esophageal sphincter pressure compared with the same patients who had undergone preoperative manometry, and a significant decrease in the percentage of time the esophageal pH was less than 5 compared with the patients who had undergone preoperative prolonged pH testing.
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Comment
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In 1904, Borchardt described the triad of findings in patients with gastric volvulus due to organoaxial rotation of the stomach within the paraesophageal hiatal hernia sac [20]. These symptoms included chest pain, retching without the ability to vomit, and the inability to pass a nasogastric tube beyond the intrathoracic stomach. Since Borchardt’s accurate description, we have learned that elective repair of these complex paraesophageal hiatal hernias should be performed in all but the most unfit patients. Treacy and Jamieson demonstrated that a policy of observation was unsuccessful in nearly 50% of patients [1]. Skinner’s series also demonstrated that elective observation resulted in death in 27% of patients with paraesophageal hiatal hernias [8]. We propose elective repair of all paraesophageal hiatal hernias, regardless of symptoms, to avoid the life-threatening complications of gastric strangulation, obstructive, perforation, bleeding, and respiratory complications [7].
While this aggressive approach to paraesophageal hiatal hernias is generally agreed upon, several aspects of the surgical management of paraesophageal hiatal hernias are controversial. The need to perform an antireflux procedure in all patients who undergo repair of a paraesophageal hiatal hernia is a major topic of disagreement [5, 9, 11–13]. We routinely performed an antireflux procedure in all patients. The majority of our patients (88%) demonstrated combined sliding and paraesophageal components, and a similarly high percentage of our patients (85%) suffered preoperative symptoms of heartburn and regurgitation. It can certainly be argued that patients with a sliding component to their hernia and symptomatic reflux should be managed with an antireflux procedure. An exception should be considered in the very elderly, debilitated, or seriously ill patient in whom a gastropexy or gastrostomy may be sufficient and a more efficient way to "pexy" the stomach [2, 6, 7, 20].
Considerable debate also exists regarding the approach to the repair of paraesophageal hiatal hernias [2, 5, 12]. Many surgeons feel the extent of esophagitis and esophageal shortening can not be adequately assessed until the esophagus is mobilized. A transthoracic approach allows the surgeon to perform a gastroplasty lengthening procedure when necessary, division of adhesions, and accurate dissection of the contents within the peritoneal sac when patients have had previous abdominal surgery [5, 16]. Under most circumstances, a transabdominal approach is acceptable, although we recommend the transthoracic approach when considerable esophageal shortening is demonstrated on barium contrast studies or preoperative endoscopy, or if previous intraabdominal procedures have been performed.
We feel that the preoperative evaluation must include an assessment for esophageal shortening to determine the need to include a gastroplasty lengthening procedure to the reconstruction [5, 14]. We did not utilize gastroplasty as a part of repair with any of our patients, which may lead to future recurrence of herniation among those patients with unrecognized esophageal shortening. For optimal management, the surgeon confronting patients with paraesophageal hiatal hernias should be familiar with a variety of approaches to the surgical management. Therefore, decisions regarding repair of paraesophageal hiatal hernias should be based on the patient’s pathophysiologic condition and not the technical limitations and experience of the surgical team.
A considerable number of studies have accrued that demonstrate that the laparoscopic management of gastroesophageal reflux disease (GERD) in patients with sliding hiatal hernias is safe and effective [17, 18]. Laparoscopic techniques can be readily applied to the management of paraesophageal herniation. Although technically challenging and associated with a variable "learning curve," we have successfully proceeded with the laparoscopic approach. The operative time is acceptable and a mean hospital stay of 3.2 days is considerable shorter than similar patients undergoing open procedures.
The symptomatic evaluation with a visual analog scale and the hiatal hernia scoring system, as described by Jamieson and Duranceau, have shown the laparoscopic approach to be an effective procedure [19]. Correlation of the symptomatic results with the postoperative barium contrast studies and postoperative manometry data indicate these laparoscopic repairs of paraesophageal hernias to be an effective procedure. Longer follow-up is necessary to fully evaluate the effectiveness of this approach to paraesophageal hiatal hernias.
As long as careful preoperative evaluations are performed to exclude esophageal shortening and esophageal carcinoma, the laparoscopic approach to paraesophageal hiatal hernias may prove a safe and effective technique for the management of these complex problems. In this patient population, often consisting of elderly, debilitated patients, avoiding an open procedure may prove beneficial. This is a technically challenging procedure, but as experience is gained and committed follow-up is performed, we believe this approach will provide an excellent option for patients with giant paraesophageal hiatal hernias.
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Footnotes
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Maziak DE, Todd TR, Pearson FG. Massive hiatus hernia: evaluation and surgical management. J Thorac Cardiovasc Surg 1998;115:53–62. 
Swanstrom LL, Marcus DR, Galloway GQ. Laparoscopic Collis gastroplasty is the treatment of choice for shortened esophagus. Am J Surg 1996;171:477–81.
Swanstrom LL, Jobe BA, Kinzie LR, Horvath KD. Esophageal motility and outcomes following laparoscopic paraesophageal hernia repair and fundoplication. Am J Surg 1999;177:359–63.
Johnson AB, Oddsdottir M, Hunter JG. Laparoscopic Collis gastroplasty and Nissen fundoplication. A new technique for the management of esophageal foreshortening. Surg Endosc 1998;12:1055–60.
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4. Discussion
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DR F. GRIFFITH PEARSON (Toronto, Ontario, Canada): Doctor Anderson, Dr Pairolero, members, and guests. The abstract in the program for this paper was incorrect, and indicated that 39 of the 44 cases reported on were type II paraesophageal hernias, with the esophagogastric junction located in its normal anatomic, intraabdominal position. I had thought at the time of reading the abstract that the paper, therefore, added to a very common misconception about paraesophageal hernia that the type II variant is common. In fact, the authors have reversed these figures in the manuscript, and only five of the 44 cases reported were of the true paraesophageal, type II variant. The remainder were sliding hiatal hernias, and this is very much in keeping with our own observations.
We reported our experience with paraesophageal hernias this past May at the annual meeting of the American Association for Thoracic Surgery. This paper has just been published in the January issue of the Journal of Thoracic and Cardiovascular Surgery.1 In our review, 91 of 94 patients were classified as sliding or type III hernias. This observation was based on measurements obtained at endoscopy, manometry, and by evaluation during the operation. This evaluation has a very important bearing on the selection of antireflux repair, because acquired shortening is a common feature of these advanced, long-standing sliding hernias. Acquired shortening is the result of inflammatory changes in the thoracic esophagus, secondary to acute and chronic reflux esophagitis. In our own series of 91 cases, a gastroplasty was added because of acquired shortening to reduce tension on the repair in 75 of 94 cases. In long-term follow-up (mean follow-up 94 months), there were only two failures: both failures occurred after a Belsey Mark IV repair without gastroplasty. Both were reoperated, a gastroplasty added, and good results obtained. A review of the significant publications on paraesophageal hernia is instructive:
"Paraesophageal hernia is a condition of the elderly. The mean age reported in these 6 publications varied from 53 to 69 years. Since most of these cases represent an advanced stage of sliding hiatus hernia, — the largest hernias occur in the most elderly. Organoaxial volvulus inevitably occurs when enough stomach rolls up into the posterior mediastinum. Please note that between 50% and 87% of patients reported using an open antireflux repair for huge hernias with associated organoaxial volvulus,—and the mean age in these 3 publications varied between 64 and 69 years. The incidence of volvulus is not recorded in the papers on laparoscopic repair, — but the mean age in Wiechmann’s paper was 53 years, which probably indicates an earlier stage of herniation.
"The perceived incidence of sliding type III hernia varies enormously in these 6 publications: between 11% and 97%. From an appraisal of the papers, I believe this variation is purely the result of interpretation by the authors,—often based on inadequate information in those papers which report a high percentage of type II hernias.
"Follow up is understandably short for the laparoscopic repairs and relatively long in the series reporting an open operative antireflux repair. The incidence of failure to control reflux,—and the need for reoperation, is significantly lower in the reports from the Mayo Clinic and ourselves,—1% and 2% respectively. Why is this so? I believe that the choice of repair was more selective in these 2 series, and a lengthening gastroplasty to accommodate acquired short esophagus was added in many cases."
I have no doubt that laparoscopic antireflux repair has a secure place in the future. The instrumentation and technical skills continue to improve. Importantly, skilled and experienced laparoscopic surgeons are beginning to recognise the complication of short esophagus and are developing techniques for adding a thoracoscopic and laparoscopic gastroplasty. In 1996, Swanstrom and colleagues in Portland Oregon reported on four cases in which they used a thoracoscopic approach for gastroplasty, and a laparoscopic repair for fundoplication in patients with giant hernia and acquired short esophagus.2
Swanstrom reported experience with this technique of combined thoracoscopic gastroplasty and laparoscopic fundoplication in 21 patients at a meeting of the Pacific Surgical Association in February of 1998.3 John Hunter and associates of Atlanta have reported experience in 11 patients with acquired short esophagus secondary to paraesophageal hernia, who were managed by the Steichien technique of gastroplasty using a laparoscopic approach for fundoplication.4
The paper today was clearly presented and the video illustrated the pathology of the condition well. I would hope, however, that the authors will become more selective in the future, and anticipate the commonly associated complication of acquired short esophagus in these giant hernias. This should reduce their observed recurrence rate and incidence of reoperation.
I have two questions for Dr Wiechmann: What proportion of your patients had preoperative endoscopy? What was the mean follow-up for this group of patients? Thank you for the opportunity to discuss this paper.
DR VICTOR F. TRASTEK (Rochester, MN): I enjoyed your paper. Certainly, as thoracic surgeons become more adept at laparoscopic techniques, the indications for hernia repair and reflux problems broaden. Early results, mortality, and morbidity seem to be comparable with the open procedure. The problem that we need to resolve is long-term results, and that will obviously take more time.
I would like to ask the authors two questions. Taking down the sac is the hardest part of this operation as you pointed out. Did you have any patients who had vagal nerve injuries or postoperative emptying problems? And, could you elaborate more on your follow-up situations, the number of patients followed, and over what period of time? That was unclear from the presentation.
DR NICHOLAS J. DEMOS (Jersey City, NJ): I enjoyed the presentation and Dr Pearson’s comments very much. Since 1990 to 1991, we have been doing thoracoscopic hiatal hernioplasties and routinely added the uncut gastroplasty before fundoplication. Among 30 patients who have been done thoracoscopically, 5 had what you might call paraesophageal or large hernias. Of course, we add routinely the stapling and thus we do the fundoplication around the neoesophagus and that has helped a lot with these large hernias. Thank you very much.
DR JAMES D. LUKETICH (Pittsburgh, PA): I enjoyed the presentation very much. I have two questions. In your single mortality from a perforation, was this a perforation that was recognized at the time of surgery and repaired or was this a delayed perforation that was unrecognized and subsequently became a problem for you?
And, in your three recurrences that required reoperation, did these have a very large diaphragmatic defect? And if so, do you think in retrospect that your repair, your crural approximation, was under tension? And also, I did not see it mentioned, but when you do have a large defect, have you resorted to the use of mesh to avoid crural tension when you are attempting to repair the hernia? Thank you.
DR WIECHMANN: Doctor Pearson, your results are indeed excellent. And our series clearly represents a learning curve. The conversion to the open procedures and the perforations occurred early and our ability to perform this procedure and carefully dissect out the hernia sac, which again is mentioned, I think, as the most difficult part of this procedure, has steadily improved.
Certainly, the need for careful preoperative evaluation of esophageal shortening is absolutely necessary and we need to carefully identify which patients may have esophageal shortening and certainly consider the techniques for gastroplasty using a laparoscopic approach, which you mentioned. To answer your question, all patients had preoperative endoscopy.
To answer the question about postoperative vagal injury, I sense that this is very comparable with the open procedures. Unlike my mentor, Dr Orringer, who, when we would do these complex cases, would seem to always be able to identify the anterior and posterior vagus nerve and keep me away from them, when I have done this operation open, I seem to always carefully identify them, and somewhere in my dissection manage to damage at least one of them. I suspect that this is very comparable with the laparoscopic approach and, in fact, the high incidence of gas bloat that our patients suffered may represent some injury to vagal fibers.
To answer the question about follow-up, our average follow-up was 19 months. Our follow-up extended from 1 to 54 months, and this certainly represents a limitation of our study. To discuss Dr Luketich’s points. The esophageal perforation that was suffered was identified and repaired in the operating room. The patient subsequently releaked and required an esophagectomy and died from complications of sepsis and multisystem organ failure.
The three recurrences, were they obvious? Yes, they were. These were obvious recurrences with large hiatal defects. And could this have been related to tension? I think it almost certainly was. We do not manage large defects with mesh. I think that if the patient does have a large defect and does have significant esophageal shortening, then a gastroplasty procedure, as outlined by Dr Pearson, is certainly the way to proceed.
Once again, thank you.
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References
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Abstract
Introduction
