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J Thorac Cardiovasc Surg 1998;115:263
© 1998 Mosby, Inc.

LETTERS TO THE EDITOR

The choice of fundoplication for mixed hiatal hernia and associated anemia

To the Editor:

I congratulate Trastek and associates ¹ for their article calling attention to occult bleeding of massive hiatal hernias caused by gastric erosion. This complication is also prevalent in my experience—27.7%. However, their title, "Diaphragmatic Hernia and Associated Anemia: Response to Surgical Treatment," may lead to confusion. They discuss bleeding in the upper gastrointestinal tract associated not with a diaphragmatic hernia (by rupture) but with hiatal hernias, which is the common denominator of this entity.

Like many others, ^2,3 I agree with them that in instances of mixed massive hiatal hernias a fundoplication should be included in the repair. In my similar 18 cases I too used fundoplication (Belsey type in the majority of cases) for prophylaxis, because in all instances I found a mixed-type hernia with slippage of the gastroesophageal junction into the mediastinum.

On the other hand, dysphagia occurred in 17.02% of patients (n = 47) after their preferred repair, the uncut Collis-Nissen combination. No mention was made of the length of the associated Nissen fundoplication, which probably played a role in the development of this specific complication, necessitating postoperative dilation in three and repair revision in two instances. In my 18 transthoracic repairs of such hernias, I was obliged to perform an esophageal lengthening procedure in only one patient. I was able to perform a tension-free Belsey Mark IV fundoplication in all but one patient.

I believe that combined reconstructions (Collis-Belsey or Nissen) are rarely justified, if ever, in circumstances of uncomplicated hiatal hernias, as postulated many years ago by Ellis. ⁴

Postgraduate Medical UniversityThoracic Surgical ClinicPihenó ut 1
H-1523 Budapest, Hungary References

1. Trastek VF, Allen MS, Deschamps C, Pairolero PC, Thompson A. Diaphragmatic hernia and associated anemia: response to surgical treatment. J Thorac Cardiovasc Surg 1966;112:1340-5.[Abstract/Free Full Text]
   
2. Pearson FG, Cooper JB, Ilves R, Todd TRJ, Jamieson WRE. Massive hiatal hernia with incarceration: a report of 53 cases. Ann Thorac Surg 1983;35:45-51.[Abstract]
   
3. Allen MS, Trastek VF, Deschamps C, Pairolero PC. Intrathoracic stomach: presentation and results of operation. J Thorac Cardiovasc Surg 1993;105:253-9.[Abstract]
   
4. Ellis FH. When should the esophagus be lengthened? Ann Thorac Surg 1982;33:531-3.[Medline]
   

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Kotsis, L. Search for Related Content PubMed Articles by Kotsis, L.