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332 Part III Esophagus
12 radially dispersed regions. e vast amount of data generated by these sensors is then processed and presented in traditional linear plots or as a visually enhanced spatiotemporal tracing that is readily interpreted. is enhanced spatial
resolution allows real-time monitoring of contractile activity
over the entire esophageal length and can be coupled with
impedance measurement so as to determine whether pressure
readings and bolus movement correlate (Fig. 15-13).
An incompetent LES is dened based on the comparison
study between 50 healthy volunteers and patients with symptomatic GERD. An LES is considered defective by having one
or more of the following characteristics: an average LES pressure of less than 6 mm Hg, an average length exposed to the
positive-pressure environment in the abdomen (intra- abdominal
length) of 1 cm or less, and an average overall sphincter length
of 2 cm or less. Achalasia is dened by the manometric ndings
of a hypertensive, nonrelaxing LES with esophageal aperistalsis
(100% failed or simultaneous contractions). Ineective esopha-
geal motility is dened by manometric ndings of either failed
peristalsis of greater than 30% or mean wave pressure of less
than 30 mm Hg. Nutcracker esophagus is dened by peristaltic
contractions that exceed 180 mm Hg within the smooth muscle
portion of the esophagus. Diuse esophageal spasm is dened by
greater than 20% simultaneous contractions. Depending on the
integrity of esophageal peristalsis, the antireux procedure can
be tailored to include either a “oppy” Nissen fundoplication or
partial fundoplication. In our practice, patients with ineective
or failed peristalsis undergo a Dor partial fundoplication.
FIGURE 15-13 High-resolution manometry. Manometric appearances of normal peristalsis, achalasia, hiatal hernia and hypotensive lower
esophageal sphincter (LES), nonrelaxing LES after Nissen, and nutcracker esophagus.
Chapter 15 Gastroesophageal Reux Disease and Hiatal Hernia (Including Paraesophageal) 333
GASTRIC EMPTYING
Delayed gastric emptying causes bloating, dyspepsia, postprandial nausea, and abdominal distension. Previous studies
have demonstrated that GERD is associated with delayed gastric emptying in approximately 40% of patients, but the precise role of gastric emptying in the pathogenesis of GERD is
90
unclear.
It has been established that fundoplication improves
gastric emptying by reducing the storage capacity of the fun-
91–93
dus.
However, persistent delayed gastric emptying can
cause an unsatisfactory outcome after antireux surgery as fundoplication itself can lead to bloating. erefore, a gastric emptying study should be considered for candidates of antireux
surgery with suspicious symptoms such as nausea, vomiting,
and bloating. e gastric emptying study is performed with a
radionuclide-labeled meal. Emptying of solids and liquid can
be assessed simultaneously by having both phases marked with
dierent tracers. After ingestion of a labeled standard meal,
gamma counter images of the stomach are obtained at 5- to
15-minute intervals for 1.5–2 hours. After collection of decay,
the counts in the gastric area are plotted as a percentage of the
total counts at the beginning of the imaging. e gastric emp-
tying half-time (T
of the meal to exit the stomach. Patients with a T
) is dened as the time required for 50%
1/2
more than
1/2
90 minutes are considered to have delayed gastric emptying. It
has been suggested that patients with a T
the upper limit of normal (T
>180 minutes) undergo pylo-
1/2
roplasty at the time of fundoplication.
agement of patients with a T
between the upper limit of
1/2
of more than twice
1/2
91
However, the man-
normal and twice the upper limit of normal (90–180 minutes)
94
remains controversial.
Postoperative bloating can be treated
by reoperation and pyloroplasty, endoscopic dilation of the
pylorus, or endoscopic botulinum toxin injection.
SURGICAL THERAPY FOR GERD
History of the Evolution of
Antireux Surgery
e rst case of successful antireux surgery was reported by
Rudolph Nissen in 1956.
the lower esophagus with the gastric fundus over a large
intraesophageal dilator. Subsequently, Nissen and Rossetti suggested that only the anterior wall of the stomach be
wrapped around the lower esophagus.
procedure has been modied in many ways. To avoid postoperative “gas bloat” syndrome, the partial anterior and posterior fundoplication techniques, in which the fundus encircles
270 degrees of the esophageal circumference, were developed
and reported by Jacques Dor in 1962
43
pet in 1963,
respectively. Donahue et al rst described the
“oppy” Nissen technique, in which the fundoplication was
performed over a large-diameter esophageal dilator.
DeMeester et al further modied the operation by using a
large dilator, limited the length of the fundoplication (2 cm),
95
In this case, Nissen enveloped
96
Subsequently, the
41
and by Andre Tou-
97
en
and completely mobilized the gastric fundus by division of
98
the short gastric vessels.
Since the rst description of successful laparoscopic Nissen fundoplication by Dallemagne
et al in 1991, the laparoscopic approach has been widely
42
accepted.
Several randomized trials have established that
the laparoscopic approach achieves equivalent results with
regard to subjective and objective resolution of GERD, with
less postoperative pain, a shorter recovery period, and lower
complication rate.
99
Patient Selection for Surgery
Most patients have a relatively benign form of GERD that is
responsive to life style and dietary modications and medical
therapy, and do not need surgical treatment. e mainstay
of therapy for GERD is medical management. PPI therapy
is highly eective, resulting in relief of symptoms and healing of esophagitis in more than 80% of patients.
most patients require lifelong treatment and discontinuation
of therapy results in symptomatic relapse within 6 months
in approximately 90% of patients with esophagitis and 75%
55
of patients with NERD.
Additionally, it should be noted
that PPI therapy does not reduce the esophageal injury associated with alkaline reux and never addresses the mechanical
incompetence of the barrier such as a defective LES and a hiatal hernia. A structurally defective LES is the most important
factor predicting failure of medical therapy. Although the
presence of a failed LES and esophagitis has been the primary
indications for surgical treatment, antireux surgery should
be considered in any symptomatic patients with a documented GERD by pH testing or MII-pH regardless of presence of esophagitis and/or a defective LES. is is particularly
true in patients who have PPI-responsive symptoms or persistent symptoms despite maximal PPI therapy. It is important
to note that a good response to PPI therapy is a good indicator of the excellent outcome following antireux surgery.
Young patients, especially women, with documented
GERD are also excellent candidates for surgical treatment.
ey usually require lifelong medical therapy to control their
GERD symptoms. e cost-eectiveness of surgical versus
medical therapy in patients with GERD remains contro-
51,59,100
versial.
Recent studies have suggested that long-term
usage of PPI potentially causes impaired calcium absorption
and osteoporosis, which may be associated with an increased
57
risk of fractures.
is is particularly important for women.82
Patients with esophageal stricture are excellent candidates for
101,102
surgical treatment.
Esophageal stricture is often associated with a structurally defective LES and impaired esophageal contractility. Before proceeding with antireux surgery,
malignancy and a drug-related etiology of the stricture should
be excluded, and the stricture should be dilated enough to
resolve dysphagia. Esophageal manometry is then performed
to evaluate the esophageal motility prior to laparoscopic fundoplication.
Patients with BE commonly have a severe structural
defect of the LES and impaired esophageal motility.
44
However,
56
e
334 Part III Esophagus
presence of BE indicates the presence of GERD. In addition, BE may progress to adenocarcinoma. Antireux surgery may prevent the development of adenocarcinoma,
although there has been no prospective study performed
that supports this supposition because of an extremely low
incidence of adenocarcinoma arising from BE and the resultant inability to adequately power a comparison trial. BE
should be rst treated, followed by antireux surgery. If BE
with high-grade dysplasia and/or intramucosal carcinoma is
found on biopsy specimens, an esophageal resection should
be considered.
Patients with extraesophageal symptoms such as cough,
aspiration, asthma, and progressive pulmonary brosis can also
be good candidates for antireux surgery. Before proceeding
to surgical treatment, it is extremely important to document
the correlation between reux events and symptoms.
Laryngopharyngeal reux, a variant of GERD, may be associated with the development of extraesophageal symptoms.
Because the clinical presentation of laryngopharyngeal reux
is nonspecic and there has been no way to detect laryngeal
events, it has been extremely dicult to demonstrate causality
in the clinical setting. MII-pH could be an eective tool to
make a diagnosis of laryngopharyngeal reux.
83
Principles of Surgical Therapy
a posterior crural closure is performed to enable easy passage
of the esophageal dilator. If adequate esophageal length cannot be achieved secondary to shortening of the esophagus,
wedge gastroplasty as a lengthening procedure should be
considered. Finally, an intraoperative endoscopic evaluation
of the created valve is valuable to conrm the hallmarks of
a successful fundoplication (Fig. 15-14). It should be noted
that the initial fundoplication has the best chance to achieve
the successful outcome.
Procedure Selection
A laparoscopic approach has been widely accepted, and
the laparoscopic Nissen fundoplication is the procedure of
choice for a primary antireux surgery in the majority of
patients with good esophageal motility and normal esophageal length. Previous prospective studies and randomized
controlled studies have shown that the Nissen fundoplication
is an eective antireux surgery with minimal side eects,
which provides long-lasting relief of reux symptoms in over
90% of patients. Patients with a severe esophageal motility
disorder dened by greater than 50% failed swallows, low
peristaltic pressure, or an aperistaltic esophagus are best
treated with a partial fundoplication to avoid the excessive
outow resistance.
e primary goal of antireux surgery is to safely restore
the structurally defective gastroesophageal valve, to prevent
its shortening with gastric distention while preserving the
patient’s ability to swallow normally. To achieve this goal,
several principles regarding the reconstruction of the valve
should be considered. First, the operation should restore
the adequate pressure and length of the distal esophageal
sphincter to prevent reux from the stomach. e eect is
to augment sphincter characteristics and prevent unfolding
of the valve in response to gastric distention. In normal swallowing, a vagally mediated relaxation of the distal esophageal
sphincter and the gastric fundus occurs.
relaxation of the sphincter, only the gastric fundus should be
used to create the fundoplication. e fundoplication should
be placed around the distal esophagus and not the proximal stomach because it does not relax well with swallowing and has poor peristalsis. A deep groove on the surface of
the fundoplication indicates that the repair is too tight and
there should be no hesitation to take the repair down and
begin over. Intraoperative injury to the vagal nerves should
be avoided because it may cause the failure of sphincter
relaxation with deglutition as well as delayed gastric emptying. Second, the fundoplication should not increase the
resistance of the relaxed sphincter to a level that exceeds the
peristaltic pressure of the esophageal body. erefore, preoperative esophageal manometry is important to evaluate the
esophageal motility. A Nissen fundoplication should be no
longer than 3 cm and created over a 60F bougie. After a circumferential mediastinal esophageal mobilization resulting
in 3 cm of tension-free intra-abdominal esophageal length,
85
To achieve adequate
PRIMARY ANTIREFLUX REPAIRS
Laparoscopic Nissen Fundoplication
e laparoscopic Nissen fundoplication is the most commonly
performed antireux procedure in the United States. e key
points of this approach are the following:
•
•
the short gastric and posterior gastric vessels
•
tension-free intra-abdominal esophagus
•
•
•
a 60F bougie
e patient is placed supine and in a split-legged position,
and the surgeon stands between the legs. A ve-port technique
is used: four 5-mm and one 12-mm ports are used. A 5-mm,
30-degree laparoscope is introduced through the 5-mm port
placed in the left upper quadrant. All secondary ports should
be placed under laparoscopic visualization. e second port
(12 mm), which is used for the surgeon’s right hand instruments, is placed 12 cm from the tip of the xiphoid process
and 2 cm below the left costal margin. e third port (5 mm),
which serves as the primary port site for the assistant, is placed
Chapter 15 Gastroesophageal Reux Disease and Hiatal Hernia (Including Paraesophageal) 335
A
C
FIGURE 15-14 Endoscopic appearance of a re-created valve. A. Nissen fundoplication. B. Dor fundoplication. C. Toupet fundoplication. e left
panels represent oblique section of each fundoplication. e right panels represent the endoscopic appearance of the corresponding valves. Endoscopy
shows a “stacked coils” appearing nipple valve in Nissen fundoplication, “S”-shaped ap valve in Dor fundoplication, and an omega-shaped valve in
Toupet fundoplication.
B
within the left anterior axillary line along the costal margin.
e fourth port (5 mm) is created immediately to the left
of the xiphoid process for placement of the Nathanson liver
retractor (Cook Medical, Bloomington, IN) that is used to
expose the hiatal opening and gastrohepatic omentum. e
fth port (5 mm), which is for the surgeon’s left hand instruments, is placed inferior to the right costal margin immediately to the right of the falciform ligament (Fig. 15-15).
e rst step in the hiatal dissection is opening the gastrohepatic omentum and then extending to the right and left
crura to expose the esophagus circumferentially at the hiatus.
In up to 12% of patients, an accessory left hepatic artery, originating from the left gastric artery, will accompany the hepatic
vagal branch. is vessel should be preserved or, when necessary, divided between clips. e relationship between the division of hepatic vagal branch and the dysfunction of gallbladder
336 Part III Esophagus
5 mm
12 mm
5 mm
5 mm
5 mm
FIGURE 15-15 Patient position and port placement.
has been suggested. However, the benet of preservation of
86,103
the hepatic vagal branch remains controversial.
e gastrophrenic attachments over the anterior aspect of the left crus
are divided, and this dissection is further extended so as to
mobilize the angle of His and divide the highest short gastric
vessels (Fig. 15-16). e phrenoesophageal ligament is then
FIGURE 15-17 Dissection of the phrenoesophageal ligament.
opened at the right crus, and the dissection between the crus
and esophagus is carried anteriorly (Fig. 15-17). During this
maneuver, both anterior and posterior vagus nerves should be
identied and preserved (Fig. 15-18). e hiatal dissection is
then carried posteriorly until the union of the right and left
crura is identied and the beginning of the posterior esophageal window is created (Fig. 15-19). Although the necessity of
dividing the short gastric vessels remains controversial,
104,105
several studies have suggested that incomplete mobilization of
106
the fundus can cause postoperative dysphagia.
Division of
the short gastric vessels begins along the greater curvatureof
the stomach, at the level of the lower pole of the spleen (Fig.
15-20). After division of short gastric vessels, the posterior
stomach is exposed, and the posterior pancreaticogastric fold
and posterior gastric vessels are divided to achieve further
mobilization of the fundus and expose the base of the left crus
FIGURE 15-16 Division of the gastrophrenic attachments of the
apex and pillar of the left crus anteriorly, angle of His, and highest
short gastric vessels.
FIGURE 15-18 Identication of the anterior vagus nerve.
Chapter 15 Gastroesophageal Reux Disease and Hiatal Hernia (Including Paraesophageal) 337
FIGURE 15-19 Beginning of the esophageal posterior window.
(Fig. 15-21). A posterior esophageal window is then completely established from the right side, and a Penrose drain is
inserted behind the esophagus and the ends secured together
anterior to the esophagus with several clips. e Penrose drain
facilitates retraction of the esophagus during the mediastinal
dissection (Fig. 15-22).
An extensive mediastinal dissection of the esophagus is
performed circumferentially until at least 3.0 cm of distal
esophagus remains within the abdomen in a tension-free
fashion (Fig. 15-23). Attention must be paid to preserve both
vagus nerves. If an adequate length of intra-abdominal esophagus cannot be obtained even after extensive mediastinal
dissection, a lengthening procedure such as a stapled-wedge
107
Collis gastroplasty should be considered.
During the medi-
astinal dissection, attention should be paid to avoid injury of
FIGURE 15-21 Division of the posterior gastric vessels.
both vagus nerves and mediastinal pleura (Fig. 15-24). If the
pleural cavity is accidentally opened, tension pneumothorax
can be prevented by transabdominal insertion of a 14F red
rubber catheter into the aected pleural space. At the end of
the procedure, the pleural space is evacuated with a Valsalva
maneuver and the catheter is removed. At the completion of
mediastinal dissection, the diaphragmatic crura are approximated using interrupted 0 nonabsorbable suture. e closure
should be snug, but not tight, around the esophagus and
enable facile passage of the bougie (Fig. 15-25).
e fundus of the stomach is brought through the posterior esophageal window. By grasping the greater curvature
of the fundus on either side of the esophagus, a “shoeshine
maneuver” is performed to ensure that there is a proper orientation of the fundus without twisting or torsion (Fig. 15-26). At
FIGURE 15-20 Division of the short gastric vessels.
FIGURE 15-22 Creation of a large retroesophageal space.
338 Part III Esophagus
FIGURE 15-23 At the completion of extensive mediastinal
dissection, an adequate tension-free intra-abdominal esophageal
length was achieved.
this point, an esophageal dilator (60F) is inserted and guided
along the lesser curvature of the stomach under laparoscopic
visualization. A 2.5-cm fundoplication is then performed
around the end of esophagus with 0 nonabsorbable sutures
that incorporate the right and left limbs of the fundoplication
along the greater curvature. At this point, an instrument is
advanced through the fundoplication toward the diaphragm
to ensure the fundoplication is not too tight. Eventually, the
fundoplication is secured with 3 nonabsorbable, unpledgeted
sutures. Sutures should incorporate a full thickness of the
stomach and partial thickness of the anterior esophageal wall,
with care taken to avoid placement into the anterior vagus
nerve (Fig. 15-27). e dilator is then removed and the intraoperative upper endoscopy is performed to conrm the proper
orientation of the valve.
FIGURE 15-25 Completion of the approximation of diaphragmatic
crura.
Laparoscopic Partial Fundoplication
Partial fundoplication is indicated in patients with impaired
esophageal motility. e Dor and Toupet antireux procedures consist of partial anterior and posterior fundoplication,
respectively. Most of the key points are common with those
listed for a Nissen fundoplication. e dierence between a
complete and a partial fundoplication is the structure of a
newly created valve; a “nipple” valve in a complete fundoplication versus a “ap” valve in a partial fundoplication.
DOR FUNDOPLICATION
After mobilization of the distal esophagus and GEJ and hiatal closure, a 60F Bougie is placed as described in the section on Nissen
FIGURE 15-24 Mediastinal dissection. Attention must be paid to
preserve the vagal trunks and prevent the injury to mediastinal pleura.
FIGURE 15-26 Shoeshine maneuver.
Chapter 15 Gastroesophageal Reux Disease and Hiatal Hernia (Including Paraesophageal) 339
without requiring any intervention such as dilation. However,
persistent dysphagia beyond 3 months has been reported in up
to 10% of patients. Bloating and hyperatulence are also common after antireux surgery because patients with GERD tend
to swallow excessive air with saliva in order to neutralized acid
reuxate. Scheduled administration of Simethicone is eective
to reduce gas in the GI tract, improving the symptoms. In addition, it is important to prevent constipation so as to not worsen
bloating. Another common side eect after antireux surgery is
the inability to vomit, but this is rarely clinically relevant. It is
critical to control perioperative nausea so as to prevent retching
with subsequent disruption of the repair.
Studies of long-term outcome following laparoscopic fundoplication have demonstrated relief of typical GERD symptoms such as heartburn, regurgitation, and dysphagia in more
than 90% of patients at the follow-up interval of 2–3 years and
98,108–110
FIGURE 15-27 Completion of the fundoplication.
80–90% of patients at 5 years or more.
fundoplication results in a signicant increase in LES pressure
Laparoscopic
and length, generally restoring these values to normal. Postoperative pH studies indicate that more than 90% of patients
fundoplication. e initial suture of the Dor fundoplication
incorporates the greater curvature side of the gastric fundus 2
cm distal to the GEJ, lateral wall of the esophagus 2 cm proximal to the GEJ, and base of the left crus to re-create the angle of
His. Re-creation of the angle of His is an essential element of the
Dor fundoplication. e greater curvature is then sutured to the
arch of the diaphragm toward the apex of the crura, bringing
the anterior fundus over the anterior wall of the distal esophagus with seven interrupted 0 nonabsorbable sutures. is repair
is carried over to the right crus to the 9 o’clock position. At
completion, the fundoplication should appear smooth without
creases indicating the absence of tension.
TOUPET FUNDOPLICATION
In an identical fashion to the Nissen fundoplication, the
gastric fundus is passed behind the esophagus through the
retroesophageal space after hiatal closure and placement of an
esophageal dilator. e right side of the fundus is sutured to
the right margin of the esophagus with four nonabsorbable
sutures, and the most distal suture is placed to the lesser curvature of the stomach immediately distal to the GEJ. e
right posterior aspect of the fundus is sutured to the right
side of the proximal preaortic fascia. A similar line of sutures
secures the left limb of the fundoplication to the esophagus.
e posterior aspect of the gastric fundus on left is sutured to
the base of the left crus.
normalize acid exposure to the esophagus. A randomized study
with 11-year follow-up demonstrated that the open and laparoscopic approaches for the Nissen fundoplication have similar
long-term subjective symptomatic outcome despite the signicantly higher incidence of incisional hernia and endoscopically
defective valves in the open group; from these data, the authors
dened the laparoscopic approach as the procedure of choice
111
in surgical management of GERD.
ere is a less predictable outcome of atypical symptoms such as cough, asthma, and
laryngitis after antireux surgery, being relieved in only twothirds of patients probably because the documentation of correlation between reux events and atypical symptoms has been
112–114
dicult.
is could be addressed with the introduction
of a reliable esophageal objective testing tool such as MII-pH.
Quality-of-life analyses have become an important part
of surgical outcome assessment, especially for the surgical
treatment of benign disease such as GERD. Currently, both
global and disease-specic questionnaires have been used to
quantify quality of life before and after surgical interven-
115
Most studies have utilized the Short Form 36 (SF-36)
tion.
instrument that is rapidly administered and well-validated.
e GERD Health-Related Quality of Life Scale (GERDHRQL), which is a disease-specic questionnaire, is also commonly used to address symptom severity in GERD. Fernando
et al compared quality of life after antireux surgery with that
of nonoperative management for severe GERD, and showed
that both SF 36 and GERD-HRQL were signicantly superior in patients who underwent laparoscopic fundoplication
compared with those who had medical treatment. ey indi-
Outcome of Antireux Surgery
cated that laparoscopic fundoplication should be considered
for patients who are dissatised with medical treatment.
116
e goal of surgical treatment for GERD is to relieve the symptoms by restoring a mechanically defective gastroesophageal
barrier. is goal should be achieved without inducing post-
Reoperation for Failed Antireux Repairs
operative complications such as dysphagia and gas bloat syndrome. Temporary dysphagia due to postoperative tissue edema
of the wrap is common and generally resolves within 3months
With the increased number of antireux surgeries being
performed, the reoperation for a failed repair has been more
340 Part III Esophagus
frequent. Previous studies have shown that the failure rates
98,117,118
for open fundoplication range from 9 to 30%,
those for laparoscopic approach range from 2 to 17%.
whereas
119,120
Many patients with mild recurrent symptoms can be managed with nonoperative therapy. It has been estimated that
between 3 and 6% of antireux surgeries will require reop-
121
eration.
With the advance of minimally invasive surgical
technique, more reoperations are being performed using a
laparoscopic approach. However, the success rate for redo
surgery does not equal to that of the initial antireux surgery.
Little et al reported that 84% of patients undergoing the rst
redo antireux surgery achieved a satisfactory result, but only
42% of patients with three or more previous reoperations had
118
a satisfactory result.
Although a recent systematic review of
reoperations showed that recurrent reux and dysphagia were
the most frequent indications for redo antireux surgery,
122
the etiology of recurrent symptoms varies considerably and
patients with any persistent symptoms should be evaluated
with objective testing. It is extremely important to identify
the etiology of symptoms in order to choose an appropriate
treatment option. Evaluation includes the repeat of esophageal objective testing such as upper endoscopy, barium
swallow, manometry, pH monitoring, MII-pH, and gastric
emptying. Based on radiographic ndings, several patterns
123
of recurrence have been reported (Fig. 15-28).
Herniation
and disruption of the fundoplication were the most common
122
causes of failure.
esophagus often contributed to repair herniation.
Additionally, inadequately treated short
124
ere are several options for reconstructive antireux
surgery, including redo Nissen or partial fundoplication,
Roux-en Y esophagojejunostomy, and esophagectomy. In
redo fundoplication, it is essential to completely take down
the previous repair in order to reestablish the normal anatomy,
identify the “true” GEJ by medializing the gastroesophageal
fat pat, preserve both vagus nerves, recognize a short esophagus, repair the crura, and re-create the proper fundoplication.
e results of redo antireux surgery are not as good as those
of the primary antireux surgery. However, good-to-excellent
results can be achieved in more than 80% of patients using
minimally invasive techniques at an experienced center.
125,126
HIATAL HERNIA
History
In 1919, Soresi published the rst report on the surgical treatment of hiatal hernia.
racic approach to hiatal hernia repair and 2 years later reported
a series of 111 patients.
between hiatal hernia and gastroesophageal reux and proposed surgical options to correct the defect, namely returning
the stomach to the abdomen and repairing the diaphragmatic
129
hiatus.
and Hill et al
Subsequently, Barrett,
132
ing the cardiophrenic angle in correcting reux symptoms. In
1967, Belsey and Skinner presented data on 1063 patients with
127
In 1950, Sweet described the transtho-
128
Allison established the relationship
130
Hiebert and Sir Belsey,
131
set the stage for the importance of reestablish-
hiatal hernia.
133
e work was the rst to distinguish between a
sliding hiatal hernia and a paraesophageal hernia (PEH). Since
then, further evaluation and subclassication of hiatal hernias
has occurred. From this work, the overriding consensus for the
next several decades was that PEH required surgical repair so
as to prevent strangulation, gastric necrosis, and patient death.
Categories of Hiatal Hernia
ere are four types of hiatal hernia. Type I, sliding hiatal
hernias, account for nearly 95% of all hiatal hernias.
e combination of hiatal enlargement, lengthening of the
phrenoesophageal ligament, and increased intra-abdominal
pressure allows the GEJ to become intrathoracic. Sliding hiatal hernias may be more likely to progress in patients who are
obese, pregnant, or have a chronic cough. Because the GEJ is
displaced from its normal anatomic position, there is concurrent dysfunction of the LES manifesting as decreased resting
pressure. is causes a loss of the angle of His, thus distorting
the esophageal ap valve.
e other three types of hiatal hernias are broadly classied
as paraesophageal. Compared with a type I hernia, which has
no hernia sac, all PEHs are covered circumferentially by a layer
of peritoneum that forms a true hernia sac. Type II PEH is the
136
least common.
Type II hernias are characterized by preservation of the GEJ at its normal anatomic position within in the
abdomen. e phrenoesophageal ligament is preserved, but the
esophageal hiatus is enlarged and the fundus of the stomach is
in the thoracic cavity. When there is proximal displacement
of the GEJ and at least 30% of the stomach above the diaphragm, this is classied as a type III PEH, the most common
type of PEH. When there is herniation of other organs into
the thoracic cavity along with the stomach, this is termed a
type IV PEH. Colon, small bowel, pancreas, spleen, omentum,
and liver can migrate into the true anterior or posterior hernia sac. In addition to obstruction of the stomach, colon, or
small bowel, there is the potential for compromised blood
ow to the organs that are displaced intrathoracically.
most common complaints associated with PEH are related to
mechanical issues caused by the location of the fundus above
the diaphragm while the GEJ is xed in its proper anatomic
position in the abdomen. ese include chest pain or pressure,
obstruction, incarceration, possible strangulation, and pulmonary dysfunction commonly associated with chronic aspiration. Additionally, about 40% of patients with a PEH have
chronic anemia that may be the result of either mucosal venous
engorgement or a Cameron ulcer.
Hiatal hernias, including PEHs, occur most commonly in
women. In the largest published series on treatment of PEH,
75% of patients were female.
senting with PEH are older than 70, possibly because of loss
of elasticity and muscle weakening. is loss of muscle tone
around the diaphragmatic opening allows it to become dilated
more easily. e gastric cardia then pushes into the opening
and may or may not return to its normal anatomic position,
thus further dilating the hiatus. Women may be aected more
87
138
139
About half of all patients pre-
137
134,135
e
Chapter 15 Gastroesophageal Reux Disease and Hiatal Hernia (Including Paraesophageal) 341
A B
C
FIGURE 15-28 Pattern of failure of primary repair: four types of failure. A. Complete disruption; B. Slipped Nissen; C. Malpositioned wrap;
D. Transhiatal herniation. (Reprinted from Hinder RA. Gastroesophageal reux disease. In: Bell RH, Jr, Rikkers LF, Mulholland MW, eds. Diges-
tive Tract Surgery: A Text and Atlas. Philadelphia, PA: Lippincott-Raven Publishers; 1996:19.)
frequently than men because of changes during pregnancy.
Other etiologies that cause increases in intra-abdominal pressures (obesity, constipation, and abdominal ascites) are also
implicated.
D
140
shortening have been identied.
e rst is the apparent
short esophagus, which is longitudinal compression of the
esophagus in the mediastinum, but maintenance of normal
esophageal length. e other two types are truly shortened
esophagus and are classied as reducible and nonreducible. A
reducible short esophagus is foreshortened, but with exten-
PEH and Short Esophagus
sive mediastinal mobilization 2.5 cm of intra-abdominal
esophagus can be obtained. In patients with a nonreducible
Short esophagus is dened as less than 2.5 cm of tension-free
intra-abdominal esophagus. ree types of esophageal
short esophagus, extensive mediastinal mobilization fails to
produce sucient length and an esophageal lengthening