J Thorac Cardiovasc Surg

Massive hiatus hernia: evaluation and surgical management.

Maziak DE. Todd TR. Pearson FG.
University of Toronto, Department of Thoracic Surgery, Ontario, Canada.
OBJECTIVE: Paraesophageal hernias represent advanced degrees of sliding hiatus hernia with intrathoracic displacement of the intraesophageal junction. Gastroesophageal reflux disease occurs in most cases, resulting in acquired short esophagus, which should influence the type of repair selected. METHODS: Between 1960 and 1996, 94 patients with massive, incarcerated paraesophageal hiatus hernia were operated on at the Toronto General Hospital. The mean age was 64 years (39 to 85 years), with a female to male ratio of 1.8:1. Organoaxial volvulus was present in 50% of cases. Clinical presentation in these patients included postprandial pain in 56%, dysphagia in 48%, chronic iron deficiency anemia in 38%, and aspiration in 29%. Symptomatic reflux, either present or remote, was recorded in 83% of cases. All patients underwent endoscopy by the operating surgeon. In 91 of 94 patients, the esophagogastric junction was found to be above the diaphragmatic hiatus, denoting a sliding type of hiatus hernia. Gross, endoscopic peptic esophagitis was observed in 36% of patients: ulcerative esophagitis in 22% and peptic esophagitis with stricture in 14%. A complete preoperative esophageal motility study was obtained for 41 patients. The lower sphincter was hypotensive in 21 patients (51%), and the amplitude of peristalsis in the distal esophagus was diminished in 24 patients (59%). These abnormalities are both features of significant gastroesophageal reflux disease. In 13 recent, consecutive patients with paraesophageal hernia, the distance between the upper and lower esophageal sphincters was measured during manometry. The average distance was 15.4 +/- 2.33 cm (11 to 20 cm), which is consistent with acquired short esophagus. The normal distance is 20.4 cm +/- 1.9 (p < 0.0001). RESULTS: All 94 patients were treated surgically: 97% had a transthoracic repair with fundoplication. A gastroplasty was added in 75 cases (80%) because of clearly defined or presumed short esophagus. There were two operative deaths, and two patients were never followed up. Among the 90 available patients, the mean follow-up was 94 months; median follow-up was 72 months. Seventy-two patients (80%) are free of symptoms (excellent result); 13 (13%) have inconsequential symptoms requiring no therapy (good result); and three patients (4%) are improved but have symptoms requiring medical therapy or interval dilatation (fair result). Two patients had poor results because of recurrent hernia and severe reflux. Both were successfully treated by reoperation with the addition of gastroplasty because of acquired shortening, which was not recognized at the first operation. CONCLUSIONS: Most of these 94 patients had symptoms or endoscopic, manometric, and operative findings that were consistent with a sliding hiatus hernia. There was a high incidence of endoscopic reflux esophagitis and of acquired short esophagus. True paraesophageal hernia, with the esophagogastric junction in a normal abdominal location, appears rare. Our observations were supported by measurements obtained at preoperative endoscopy and manometry, and by findings at the time of surgical repair. These observations support the choice of a transthoracic approach for repair in most patients.

Early experience and learning curve associated with laparoscopic Nissen fundoplication.

Deschamps C. Allen MS. Trastek VF. Johnson JO. Pairolero PC.
Section of General Thoracic Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minn 55905, USA.
BACKGROUND: Laparoscopic approach for hiatal hernia repair is relatively new. Information on the learning curve is limited. METHODS: From January 1994 to September 1996, 280 patients underwent antireflux surgery at our institution. A laparoscopic repair was attempted in 60 patients (21.4%). There were 38 men and 22 women. Median age was 49 years (range 21 to 78 years). Indications for operation were gastroesophageal reflux in 59 patients and a large paraesophageal hernia in one. A Nissen fundoplication was performed in all patients; 53 (88.3%) had concomitant hiatal hernia repair. RESULTS: In eight patients (13.3%) the operation was converted to an open procedure. Median operative time for the 52 patients who had laparoscopic repair was 215 minutes (range 104 to 320 minutes). There were no deaths. Complications occurred in five patients (9.6%). Median hospitalization was 2 days (range 1 to 5 days). Median operative time and median hospitalization were significantly longer in the first 26 patients than in the subsequent 25 patients (248 vs 203 minutes and 2 days vs 1 day, respectively; p = 0.03). Seven of the first 30 patients (23.3%) required laparotomy as compared with two of the second 30 (6.7%) (p = 0.07). Follow-up in the 51 patients who had laparoscopic fundoplication for reflux was complete in 50 (98.0%) and ranged from 7 to 38 months (median 13 months). Functional results were classified as excellent in 34 patients (68.0%), good in 6 (12.0%), fair in 7 (14.0%), and poor in 3 (6.0%). Three patients were reoperated on for recurrent reflux symptoms at 5, 5, and 11 months. CONCLUSIONS: We conclude that laparoscopic Nissen fundoplication can be performed safely. The operative time, hospitalization, and conversion rate to laparotomy are higher during the early part of the experience, but all are reduced after the learning curve.

Esophagectomy for unsuccessful antireflux operations.

Gadenstatter M. Hagen JA. DeMeester TR. Ritter MP. Peters JH. Mason RJ. Crookes PF.
Second Department of Surgery, University of Innsbruck, Austria.
BACKGROUND: Primary antireflux surgery provides excellent symptom relief in most patients. Unfortunately, the results of redo surgery are less predictable. In these patients, esophageal injury from long-standing reflux of gastric contents and operative trauma from previous failed antireflux procedures results in progressive deterioration in esophageal propulsion, poor clearance of reflux episodes, mucosal damage, and, in some cases, stricture formation. For the past 16 years, we have selectively used esophageal resection and replacement instead of another reoperation in these challenging patients. METHODS: Seventeen patients with end-stage esophageal body dysfunction and one or more previously unsuccessful antireflux procedures underwent esophagectomy and reconstruction by colon interposition in 15 patients and jejunum interposition in 2 patients. The indications for esophagectomy rather than a redo antireflux procedure were a global loss of effective esophageal motility in 13 and a nondilatable stricture in four. Their outcome was compared with that of 32 patients with adequate motility and 18 with a similar global loss of motility who had a redo antireflux procedure. Perioperative complications after esophagectomy were recorded, and long-term outcome was assessed by means of a standardized questionnaire at a median of 7 years after the operation. RESULTS: Patients with profound esophageal body dysfunction who underwent esophageal resection had outcomes similar to those with normal motility who underwent a redo antireflux procedure. Those with profound esophageal motility dysfunction who underwent a redo antireflux procedure had a worse outcome than those who underwent resection. Esophageal resection and replacement was performed without mortality or graft failure. All patients who underwent resection stated that their preoperative symptoms were relieved completely (n = 6) or improved (n = 10). Thirteen patients (81%) were able to eat three meals a day, and 12 patients (75%) enjoyed an unrestricted diet. Two thirds of the patients were at or above their ideal body weight, and 88% were fully satisfied with the outcome of the procedure. CONCLUSION: Patients with end-stage esophageal body dysfunction who have had a previous unsuccessful antireflux procedure can be treated by esophageal resection with a high expectation of success.

Pediatric and adult lung transplantation for cystic fibrosis.

Mendeloff EN. Huddleston CB. Mallory GB. Trulock EP. Cohen AH. Sweet SC. Lynch J. Sundaresan S. Cooper JD. Patterson GA.
Department of Surgery, Washington University School of Medicine, St. Louis, Mo, USA.
OBJECTIVE: This paper was undertaken to review the experience at our institution with bilateral sequential lung transplantation for cystic fibrosis. METHODS: Since 1989, 103 bilateral sequential lung transplants for cystic fibrosis have been performed (46 pediatric, 48 adult, 9 redo); the mean age was 21 +/- 10 years. Cardiopulmonary bypass was used in all but one pediatric (age

Proposed revision of the staging classification for esophageal cancer.

Year 1998
Korst RJ. Rusch VW. Venkatraman E. Bains MS. Burt ME. Downey RJ. Ginsberg RJ.
Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
OBJECTIVES: This study analyzed survival with respect to lymph node involvement to develop a new staging system for patients with esophageal cancer that accurately reflects prognosis. METHODS: The records of patients undergoing resection of primary esophageal cancer from 1989 to 1993 were reviewed. The data collected included patient age and sex, tumor histologic characteristics and location, the use of preoperative or postoperative radiation and chemotherapy, the type of resection, the depth of tumor invasion, the number and location of benign and malignant lymph nodes in the resected specimen, the disease status at last follow-up, and the first site of relapse. With an anatomically specific lymph node map, tumors designated in the current American Joint Committee on Cancer system as M1 because of extensive lymph node metastases were reclassified as N2, reserving the M1 category for visceral metastases. Survival was analyzed by the Kaplan-Meier method, and prognostic factors were assessed by log-rank and Cox regression analyses. RESULTS: There were 216 patients (159 men, 57 women) with a median age of 63.5 years. Adenocarcinoma of the distal esophagus or gastroesophageal junction was the most common tumor (127 patients, 59%) and Ivor Lewis esophagogastrectomy was the most frequently performed operation. Both lymph node location (N1 versus N2) and number (0 vs 1 to 3 vs 4 or more) significantly influenced survival. CONCLUSIONS: A new staging system that adds an N2 M0 descriptor and reclassifies stage groupings reflects prognosis more accurately than does the current American Joint Committee on Cancer staging system. The number of positive lymph nodes is also an important stratification factor.

Protein-losing enteropathy after the Fontan operation: an international multicenter study. PLE study group.

Year 1998
Mertens L. Hagler DJ. Sauer U. Somerville J. Gewillig M.
Department of Pediatric Cardiology, UZ Leuven, Belgium.
OBJECTIVE: This multicenter study retrospectively analyzes the data on 114 patients with protein-losing enteropathy after Fontan-type surgery. Special attention was given to the different treatment strategies used and their effect on outcome. METHODS AND RESULTS: In 35 participating centers 3029 Fontan operations were performed. The incidence of protein-losing enteropathy in the survivors was 3.7%. The median age at Fontan-type surgery was 8.2 years (range: 0.6 to 32.9 years). Median age at diagnosis of protein-losing enteropathy was 11.7 years with a median time interval between surgery and diagnosis of 2.7 years (range: 0.1 to 16.4 years). Most patients had edema (79%) and effusions (75%). Hemodynamic data revealed a mean right atrial pressure of 17 +/- SD 5.3 mm Hg with a cardiac index of 2.4 +/- 0.8 L/min/m2. Medical treatment only (n = 52) resulted in a complete resolution of symptoms in 25%, no improvement in 29%, and death in 46%. Surgical treatment (n = 52) was associated with relief of protein-losing enteropathy in 19%, no improvement in 19%, and death in 62%. In 13 patients 16 percutaneous interventions were performed. This resulted in symptomatic improvement after 12 interventions and no improvement after 4 interventions. CONCLUSIONS: We conclude that the current treatment of protein-losing enteropathy after Fontan operation is associated with a very high mortality and morbidity rate. Preventive strategies and new therapeutic approaches are necessary.

Esophageal replacement for end-stage benign esophageal disease.

Year 1998
Watson TJ. DeMeester TR. Kauer WK. Peters JH. Hagen JA.
Department of Surgery, University of Rochester, NY, USA.
BACKGROUND: Benign esophageal diseases constitute a common group of disorders that are generally managed with medical therapy or surgery designed to improve foregut function. A small subset of patients, however, has advanced disease that requires esophageal replacement to achieve symptomatic relief. PATIENTS AND METHODS: One hundred four patients with benign esophageal disease who underwent esophageal reconstruction over a 21-year period (1975 to 1996) were reviewed retrospectively. Dysphagia was the major symptom driving surgery in 80% of the patients. Colon was used to reconstruct the esophagus in 85 patients; stomach, in 10 patients; and jejunum, in 9 patients. Forty-two patients who had lived with their reconstruction for 1 year or more answered a postoperative questionnaire concerning their long-term functional outcome. RESULTS: In the 104 patients, the primary underlying abnormality leading to esophageal replacement was end-stage gastroesophageal reflux (37 patients), an advanced motility disorder (37 patients), traumatic, iatrogenic or spontaneous perforation (15 patients), corrosive injury (8 patients), congenital abnormality (6 patients), or extensive leiomyoma (1 patient). Ninety-eight percent of patients reported that the operation had cured or improved the symptom driving surgery. Ninety-three percent were satisfied with the outcome of the operation. The overall hospital mortality rate was 2%, and the median hospital stay was 17 days. Graft necrosis occurred in 3% of patients, and anastomotic leak occurred in 6% of patients (or 2% of the total number of anastomoses). CONCLUSIONS: Esophageal replacement for benign disease can be accomplished with a low mortality rate and a marked improvement in alimentation. Reconstruction restores the pleasure of eating and is viewed by the patient to be highly successful.

The utility of the pectoralis myocutaneous flap in the management of select cervical esophageal anastomotic complications.

Year 1998
Heitmiller RF. McQuone SJ. Eisele DW.
Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
OBJECTIVE: The majority of cervical esophageal anastomotic complications can be successfully managed nonoperatively. A small group of patients may have anastomotic strictures or leakage and fistula formation that are chronic and resistant to nonoperative therapy. The purpose of this study was to review our experience with the use of the pectoralis myocutaneous flap to treat these patients. METHODS: Since April 1992, four patients have undergone pectoralis myocutaneous flap repair of cervical esophageal anastomotic complications at our institution. Two patients had chronic strictures, one patient underwent prophylactic repair with a pectoralis myocutaneous flap to prevent stricture formation, and one patient had a chronic anastomotic fistula. The pectoralis myocutaneous flap was harvested in the standard fashion. The technique of anastomotic repair is described. The medical records were retrospectively reviewed to determine patient characteristics and our results. RESULTS: Two suture line leaks developed: one small, contained leak required no intervention, and the other resolved with cervical drainage. Pneumonia, seroma at the site of the pectoralis myocutaneous flap donor, transient hoarseness, and partial skin graft loss occurred in one case each. There were no deaths. Hospital stay ranged from 12 to 22 days. A good functional result was obtained in three patients. CONCLUSION: Our results show that pectoralis myocutaneous flap repair of select cervical anastomotic complications is safe and well tolerated even in patients with complicated problems.

Massive hiatal hernias: the anatomic basis of repair.

Year 1998
Altorki NK. Yankelevitz D. Skinner DB.
Department of Radiology, The New York Hospital-Cornell Medical Center, New York 10021, USA.
OBJECTIVES: In the repair of giant hiatal hernias, controversy persists as to whether an antireflux repair is required and whether a Collis gastroplasty is necessary. This study was undertaken to determine the location of the gastroesophageal junction in giant hiatal hernias with an intrathoracic stomach, as well as the outcome after repair without a Collis gastroplasty. METHODS: Fifty-two patients were evaluated for a giant hiatal hernia, of whom 47 underwent surgical correction. Preoperative evaluation included esophagoscopy (n = 45), gastrointestinal series (n = 40), esophageal manometry (n = 20), and 24-hour pH testing (n = 13). The dominant clinical features were acute chest or abdominal pain (72%), heartburn (53%), and gastrointestinal bleeding (49%). The gastroesophageal junction was located in the mediastinum in 77% of patients, in the abdomen in 17%, and was not determined in 6%. Twenty-eight patients (59%) had clinical or objective evidence of reflux. Reduction with an antireflux repair without a gastroplasty was done in 47 (Belsey, n = 28; Nissen, n = 19). An excellent or good result was achieved in 38 patients (90%) with a median follow-up of 45 months. CONCLUSIONS: These results, obtained without a Collis gastroplasty, are equivalent to those obtained by an antireflux repair with an esophageal lengthening procedure. The frequent location of the gastroesophageal junction in the mediastinum suggests that these massive hernias often are the result of progressive enlargement of a sliding component. An antireflux repair is therefore necessary in the majority of patients.