Short esophagus is a disease of the past and the prevention of recurrent hiatal hernia is the challenge of the future

Abstract

Author has nothing to disclose with regard to commercial support. Author has nothing to disclose with regard to commercial support. I read with interest the letter written by Dr Mattioli commenting on the article recently published by Stringham and colleagues.1Stringham J.R. Phillips J.V. McMurry T.L. Lambert D.L. Jones D.R. Isbell J.M. et al.Prospective study of giant paraesophageal hernia repair with 1-year follow-up.J Thorac Cardiovasc Surg. 2017; 154: 743-751Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar Dr Mattioli discusses 3 important sources of debate among experts in the treatment of gastroesophageal disease: (1) shortened esophagus; (2) definition of “giant” hiatal hernia; and (3) the clinical significance of small recurrent hiatal hernia. Shortened esophagus, with peptic stricture as its most common predictor,2Gastal O.L. Hagen J.A. Peters J.H. Campos G.M. Hashemi M. Theisen J. et al.Short esophagus: analysis of predictors and clinical implications.Arch Surg. 1999; 134: 633-638Crossref PubMed Scopus (101) Google Scholar was traditionally one of the most common manifestations of gastroesophageal disease. Thus, Collis gastroplasty was an integral part of antireflux surgery and hiatal hernia repair.3Urschel Jr., H.C. Razzuk M.A. “Collis-Belsey” fundoplication for uncomplicated hiatal hernia and gastroesophageal reflux.Ann Thorac Surg. 1979; 27: 564-566Abstract Full Text PDF PubMed Scopus (3) Google Scholar, 4Pearson F.G. Henderson R.D. Long-term follow-up of peptic strictures managed by dilatation, modified Collis gastroplasty, and Belsey hiatus hernia repair.Surgery. 1976; 80: 396-404PubMed Google Scholar, 5Orringer M.B. Sloan H. Collis-Belsey reconstruction of the esophagogastric junction. Indications, physiology, and technical considerations.J Thorac Cardiovasc Surg. 1976; 71: 295-303Abstract Full Text PDF PubMed Google Scholar Now with the widespread use of proton pump inhibitors and near eradication of peptic strictures, esophageal stricture is a rare finding. However, Collis gastroplasty remains a common procedure in many esophageal centers with a reported prevalence as high as 40% to 66%.1Stringham J.R. Phillips J.V. McMurry T.L. Lambert D.L. Jones D.R. Isbell J.M. et al.Prospective study of giant paraesophageal hernia repair with 1-year follow-up.J Thorac Cardiovasc Surg. 2017; 154: 743-751Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar, 6Zehetner J. Demeester S.R. Ayazi S. Kilday P. Augustin F. Hagen J.A. et al.Laparoscopic versus open repair of paraesophageal hernia: the second decade.J Am Coll Surg. 2011; 212: 813-820Abstract Full Text Full Text PDF PubMed Scopus (96) Google Scholar, 7Luketich J.D. Nason K.S. Christie N.A. Pennathur A. Jobe B.A. Landreneau R.J. et al.Outcomes after a decade of laparoscopic giant paraesophageal hernia repair.J Thorac Cardiovasc Surg. 2010; 139 (404.e1): 395-404Abstract Full Text Full Text PDF PubMed Scopus (183) Google Scholar In a pure paraesophageal hiatal hernia, by definition, the gastroesophageal junction is located intra-abdominally; therefore, short esophagus is not associated with type II hiatal hernia as previously reported by Lugaresi and colleagues8Lugaresi M. Mattioli S. Aramini B. D'Ovidio F. Di Simone M.P. Perrone O. et al.The frequency of true short oesophagus in type II-IV hiatal hernia.Eur J Cardiothorac Surg. 2013; 43: e30-e36Crossref PubMed Scopus (14) Google Scholar in 34 cases with type II to IV hiatal hernia, in which none of the patients with type II had a short esophagus. However, the prevalence of a pure type II hiatal hernia is rare. In our report of 131 large hiatal hernias, a pure type II hiatal hernia was seen in only 4 of 131 (3.1%).9Banki F. Kaushik C. Roife D. Mitchell K.G. Miller III, C.C. Laparoscopic repair of large hiatal hernia without the need for esophageal lengthening with low morbidity and rare symptomatic recurrence.Semin Thorac Cardiovasc Surg. May 29, 2017; ([Epub ahead of print])Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar Others have reported a rate of 8 of 100 (8%).10Luketich J.D. Raja S. Fernando H.C. Campbell W. Christie N.A. Buenaventura P.O. et al.Laparoscopic repair of giant paraesophageal hernia: 100 consecutive cases.Ann Surg. 2000; 232: 608-618Crossref PubMed Scopus (172) Google Scholar As the result of the rarity of a pure type II hiatal hernia, the term “paraesophageal hernia” is often loosely used to describe type III and IV. This use leads to confusion in disentangling the relationship between paraesophageal hiatal hernia and short esophagus in the esophageal literature. Type II paraesophageal hiatal hernia was found only in 6 of 106 (6%)1Stringham J.R. Phillips J.V. McMurry T.L. Lambert D.L. Jones D.R. Isbell J.M. et al.Prospective study of giant paraesophageal hernia repair with 1-year follow-up.J Thorac Cardiovasc Surg. 2017; 154: 743-751Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar in the article by Stringham and colleagues1Stringham J.R. Phillips J.V. McMurry T.L. Lambert D.L. Jones D.R. Isbell J.M. et al.Prospective study of giant paraesophageal hernia repair with 1-year follow-up.J Thorac Cardiovasc Surg. 2017; 154: 743-751Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar and type III and IV in 100 of 106 (94%). Therefore, the use of Collis gastroplasty in that series is similar to that reported from other esophageal centers. Reporting the prevalence of stricture in the series would have been informative to clarify the need for Collis gastroplasty in 66% of patients. The use of Collis gastroplasty may be a reflection of an institutional tradition, but it is clear that the use of Collis gastroplasty has decreased over time.7Luketich J.D. Nason K.S. Christie N.A. Pennathur A. Jobe B.A. Landreneau R.J. et al.Outcomes after a decade of laparoscopic giant paraesophageal hernia repair.J Thorac Cardiovasc Surg. 2010; 139 (404.e1): 395-404Abstract Full Text Full Text PDF PubMed Scopus (183) Google Scholar In our report of 131 large hiatal hernias, none had stricture and Collis gastroplasty was required in none.9Banki F. Kaushik C. Roife D. Mitchell K.G. Miller III, C.C. Laparoscopic repair of large hiatal hernia without the need for esophageal lengthening with low morbidity and rare symptomatic recurrence.Semin Thorac Cardiovasc Surg. May 29, 2017; ([Epub ahead of print])Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar We further reported a series of 101 type IV hiatal hernias, and none had stricture or a Collis gastroplasty.11Victoria Chang M, Garwood G, Roife D, Kaushik C, Miller CC, Banki F. Laparoscopic type IV hiatal hernia repair with toupet fundoplication: clinical outcomes and lessons learned. Poster Presentation, Western Surgical Association, 125th Annual Meeting, Scottsdale, Arizona, November 4-7, 2017.Google Scholar Therefore, short esophagus, once a common manifestation of gastroesophageal reflux disease, may become the disease of the past, and Collis gastroplasty, once a basic component of antireflux surgery, may become a historical procedure. Dr Mattioli and I are in agreement that pure type II hiatal hernias are definitely not associated with a short esophagus, and this clear distinction should be emphasized when we discuss paraesophageal hiatal hernias as a whole. “Giant” paraesophageal hiatal hernia is commonly used to describe the condition in which more than 30% of the stomach extends into the chest. For the surgeon, the term may be not only a definition of the size but also a marker of the complexity of paraesophageal hiatal hernias as they get larger. As more stomach herniates into the chest, the risk of mechanical complications such as perforation, volvulus, and bleeding increases. In parallel, there is an increase in the degree of complexity of the case, with more mediastinal dissection and longer duration of operation, which in the past required open procedures via laparotomy, thoracotomy, or even a thoracoabdominal approach. In addition, larger hernias tend to occur in older patients with more associated comorbidities, and performing a laparotomy or thoracotomy resulted in higher morbidity in this group of patients. Now, with the development and refinements of laparoscopic techniques, many centers report the safe laparoscopic repair of these large hernias with good outcomes even in an aging population. Therefore, the large hernia and the corresponding surgical repair may not seem as gigantic as the name once implied. Although it was previously believed that the majority of patients with small recurrent hiatal hernia are asymptomatic,12Dallemagne B. Kohnen L. Perretta S. Weerts J. Markiewicz S. Jehaes C. Laparoscopic repair of paraesophageal hernia. Long-term follow-up reveals good clinical outcome despite high radiological recurrence rate.Ann Surg. 2011; 253: 291-296Crossref PubMed Scopus (133) Google Scholar and even the recurrent hiatal hernia was defined as transdiaphragmatic herniation of stomach of more than 2 cm,13Oelschlager B.K. Pellegrini C.A. Hunter J.G. Brunt M.L. Soper N.J. Sheppard B.C. et al.Biologic prosthesis to prevent recurrence after laparoscopic paraesophageal hernia repair: long-term follow-up from a multicenter, prospective, randomized trial.J Am Coll Surg. 2011; 213: 461-468Abstract Full Text Full Text PDF PubMed Scopus (281) Google Scholar more recent reports suggest that recurrent hiatal hernia of any size should be considered as a poor result. The reports of Stringham and colleagues1Stringham J.R. Phillips J.V. McMurry T.L. Lambert D.L. Jones D.R. Isbell J.M. et al.Prospective study of giant paraesophageal hernia repair with 1-year follow-up.J Thorac Cardiovasc Surg. 2017; 154: 743-751Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar and Lugaresi and colleagues14Lugaresi M. Mattioli B. Daddi N. Di Simone M.P. Perrone O. Mattioli S. et al.Surgery for type III-IV hiatal hernia: anatomical recurrence and global results after elective treatment of short oesophagus with open and minimally invasive surgery.Eur J Cardiothorac Surg. 2016; 49: 1137-1143Crossref PubMed Scopus (5) Google Scholar add weight to this emerging consensus. I agree with Dr Mattioli that the merit of the article is its focus on small hiatal hernia of less than 2 cm, because they are more symptomatic as we previously thought and they should be followed closely. The repair of large paraesophageal hiatal hernia has shifted from management of a short esophagus and complications of open procedures to a laparoscopic approach, without the need for Collis gastroplasty, with low morbidity and short length of stay. The prevention of recurrent hiatal hernia of any size remains an important challenge and should be the main goal in the refinement of hiatal hernia repair. We may need to shift our thinking and realize that paraesophageal hiatal hernias may not be as giant, the esophagus may not be as short, and small recurrent hiatal hernias may not be as asymptomatic as we once believed. Why consider a paraesophageal hernia giant and a long esophagus short? Definitions and results of surgery for paraesophageal hiatal herniasThe Journal of Thoracic and Cardiovascular SurgeryVol. 155Issue 3PreviewI read with much interest the article by Stringham and colleagues1 published in the August 2017 issue of the Journal. I was intrigued by some of their interpretations of the terminology, which clash with what I had been taught about gastric hiatal hernias in my residency years, in fact many years ago. Full-Text PDF Open Archive