Original article: general thoracic
Effect of paraesophageal hernia repair on pulmonary function

Presented at the Poster Session of the Thirty-eighth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28–30, 2002.
https://doi.org/10.1016/S0003-4975(02)03718-9Get rights and content

Abstract

Background. Paraesophageal hernias classically present in elderly patients with symptoms of postprandial pain, bloating, dysphagia, and anemia. Most surgeons would advocate repairing paraesophageal hernias whenever they are encountered, however, significant levels of dyspnea or pulmonary dysfunction could previously have led to concerns regarding individual patient suitability for repair. We have noted that patients complaining of dyspnea prior to paraesophageal hernia repair often noted significant improvement following surgery.

Methods. Between 1995 and 2001, 45 patients (mean age 71.5 years) presented with paraesophageal hernias. Patients had preoperative investigations including chest roentgenogram and barium swallow, 100%; upper endoscopy, 96%; manometry, 89%; and 24-hour pH studies, 27%. Operative repair was accomplished with an open Hill repair with intraoperative manometrics. All patients had assessment of pre- and postoperative spirometry, diffusion capacity, dyspnea index, and quality of life assessment.

Results. Presenting symptoms included dyspnea, 84%; heartburn, 71%; dysphagia, 67%; regurgitation, 64%; and anemia, 47%. Type II hernias were found in 2 patients, type III in 33 patients, and type IV in 10 patients. Complications were minimal; mortality was zero. Mean length of stay was 4.7 days (range 3 to 9). Significant improvement in spirometry levels were noted in mean forced expiratory volume in 1 second (FEV1) (preop, 1.87 liters; postop, 2.17 liters; percent improvement, 16%), p < 0.0001; mean forced vital capacity (FVC) (preop, 2.52 liters; postop, 2.89 liters; percent improvement, 14.7%), p < 0.0001; mean percent predicted FEV1 (preop, 75.8%; postop, 88.6%), p < 0.0001; and mean percent predicted FVC (preop, 78.8%; postop, 91.5%), p < 0.0001. An improvement trend was noted in diffusing capacity, which did not reach statistical significance. The degree of improvement was seen to correlate with the size of the hernia. When hernias involved 100% of the stomach, percent improvement in FEV1 of 19.6% and FVC of 19.7% were noted. Two patients who required home oxygen were able to discontinue therapy following surgery. Significant improvements in quality of life scores and dyspnea index were documented.

Conclusions. Elderly patients with paraesophageal hernias are occasionally considered inappropriate candidates for surgical repair on the basis of coexistent medical problems including pulmonary dysfunction. Paraesophageal hernia repair is routinely associated with significant improvement in spirometry values, dyspnea index, and quality of life scores.

Section snippets

Material and methods

The study included patients presenting with type II, III, and IV paraesophageal hernias to Virginia Mason Medical Center between 1995 and 2001. All patients were reviewed to document preoperative symptoms. Preoperative studies included chest roentgenogram (100%), barium swallow (100%), endoscopy (96%), manometry (89%), and 24-hour pH study (27%).

Basic spirometry studies and diffusion capacity measurements were carried out 1 to 4 weeks preoperatively and repeated 1 to 6 months following surgery.

Results

Patients were studied between 1995 and 2001. These included 45 patients, 16 males and 29 females, mean age 71.5 years (range 46 to 91). Presenting symptoms are shown in Table 1. Over 50% of patients presented with symptoms of gastroesophageal reflux disease, dysphagia, and regurgitation. However, 84% complained of some degree of dyspnea preoperatively. Two patients (5%) were on home oxygen preoperatively. Three patients underwent urgent operations following hospitalization for what was thought

Comment

There is a significant body of literature suggesting a relationship between pulmonary symptoms and gastroesophageal reflux disease 1, 2, 3. However, there is very little assessment of the potential ramifications of large hiatal hernias and pulmonary function.

Sliding (type I) hiatal hernias can become very large, but do not often reach the proportions seen with paraesophageal hernias (type II, III, and IV). Patients who present with these hernias are typically elderly and often present with

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