Effect of paraesophageal hernia repair on pulmonary function.
BACKGROUND
Paraesophageal hernias classically present in elderly patients with symptoms of postprandial pain, bloating, dysphagia, and anemia. Most surgeons would advocate repairing paraesophageal hernias whenever they are encountered, however, significant levels of dyspnea or pulmonary dysfunction could previously have led to concerns regarding individual patient suitability for repair. We have noted that patients complaining of dyspnea prior to paraesophageal hernia repair often noted significant improvement following surgery.


METHODS
Between 1995 and 2001, 45 patients (mean age 71.5 years) presented with paraesophageal hernias. Patients had preoperative investigations including chest roentgenogram and barium swallow, 100%; upper endoscopy, 96%; manometry, 89%; and 24-hour pH studies, 27%. Operative repair was accomplished with an open Hill repair with intraoperative manometrics. All patients had assessment of pre- and postoperative spirometry, diffusion capacity, dyspnea index, and quality of life assessment.


RESULTS
Presenting symptoms included dyspnea, 84%; heartburn, 71%; dysphagia, 67%; regurgitation, 64%; and anemia, 47%. Type II hernias were found in 2 patients, type III in 33 patients, and type IV in 10 patients. Complications were minimal; mortality was zero. Mean length of stay was 4.7 days (range 3 to 9). Significant improvement in spirometry levels were noted in mean forced expiratory volume in 1 second (FEV1) (preop, 1.87 liters; postop, 2.17 liters; percent improvement, 16%), p < 0.0001; mean forced vital capacity (FVC) (preop, 2.52 liters; postop, 2.89 liters; percent improvement, 14.7%), p < 0.0001; mean percent predicted FEV1 (preop, 75.8%; postop, 88.6%), p < 0.0001; and mean percent predicted FVC (preop, 78.8%; postop, 91.5%), p < 0.0001. An improvement trend was noted in diffusing capacity, which did not reach statistical significance. The degree of improvement was seen to correlate with the size of the hernia. When hernias involved 100% of the stomach, percent improvement in FEV1 of 19.6% and FVC of 19.7% were noted. Two patients who required home oxygen were able to discontinue therapy following surgery. Significant improvements in quality of life scores and dyspnea index were documented.


CONCLUSIONS
Elderly patients with paraesophageal hernias are occasionally considered inappropriate candidates for surgical repair on the basis of coexistent medical problems including pulmonary dysfunction. Paraesophageal hernia repair is routinely associated with significant improvement in spirometry values, dyspnea index, and quality of life scores.
Low
Donald E
DE
Section of General Thoracic Surgery, Virginia Mason Medical Center, Seattle, Washington 98101, USA. donald.low@vmmc.org
Simchuk
Eric J
EJ
D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D005541:Forced Expiratory Volume; D006551:Hernia, Hiatal / Q000503:physiopathology* / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D014797:Vital Capacity