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J Thorac Cardiovasc Surg 1998;115:828-835
© 1998 Mosby, Inc.
GENERAL THORACIC SURGERY |
From the Department of Cardiothoracic Surgeryb and Radiology,a The New York Hospital–Cornell Medical Center, New York, N.Y.
Received for publication May 21, 1997. Revisions requested August 12, 1997; revisions received Nov. 18, 1997. Accepted for publication Nov. 20, 1997. Address for reprints: Nasser K. Altorki, MD, The New York Hospital–Cornell Medical Center, 525 East 68th St., New York, NY 10021.
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.
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