Paraesophageal Hernia Repair Boosts Lung Function

COLORADO SPRINGS – Improvements in pulmonary function tests and subjective complaints of breathlessness appear to be underappreciated benefits of the surgical repair of giant paraesophageal hernias.

Symptom assessment of these patients has generally focused on reflux and dysphagia, but these hernias also have adverse impacts on pulmonary function. Repair most benefits patients who are older, have bigger hernias, and worse baseline pulmonary function, said Dr. Philip W. Carrott Jr., of Virginia Mason Medical Center, Seattle.

"Patients with giant paraesophageal hernia and coexistent dyspnea or positional breathlessness should be reviewed by an experienced surgeon for elective repair, even when pulmonary comorbidities exist," Dr. Carrott concluded at the annual meeting of the Western Thoracic Surgical Association.

He based this advice on a single-center, retrospective, cohort study involving 120 patients who had pulmonary function tests preoperatively and again at a median of 106 days after surgery.

The overall group averaged 10% increases over baseline (P less than .001) in forced vital capacity (FVC), forced expiratory volume in 1 second (FEV₁), vital capacity, and volume-adjusted mid-expiratory flow (IsoFEF25-75), as well as a 2.9% increase in the diffusing capacity of the lung (DLCO).

The larger a patient’s hernia as expressed by percent intrathoracic stomach (ITS) on preoperative contrast studies, the greater the improvement in pulmonary function tests after surgery. Hernia size was the strongest predictor of improvement. For example, forced vital capacity improved by an average of 4.7%, compared with reference values in patients with the smallest hernias as expressed in a percent ITS of less than 50%, as compared with a 6.0% gain in patients with a preop 50%-74% ITS, a 9.1% improvement in those with 75%-99% ITS, and a 14.9% gain in FVC in patients with 100% ITS.

The postoperative improvement in lung function increased with each decade of patient age.

Patients with the worst preoperative lung function tended to have the biggest hernias – and the greatest objective and subjective improvements after surgery. For example, 36% of subjects had a reduced baseline FEV₁ not more than 75% of the reference value. Their vital capacity improved by 0.45 L, as compared with 0.23 L in patients without a reduced baseline FEV₁. And their DLCO improved by 1.23 mL CO/min/mm Hg, compared with just 0.23 in patients whose baseline FEV₁ was more than 75% of the reference value.

Of 63 patients who reported preoperative dyspnea, 47 (75%) noted subjective improvement in their respiratory function after hernia repair. Intriguingly, so did 30 of 57 patients (53%) not complaining of dyspnea at baseline.

Dr. Carrott and his fellow researchers postulate that restoring efficient diaphragmatic function is just part of the explanation. "The stomach probably has a paradoxical motion during respiration, such that the abdominal positive pressure is pushing against the negative effect of the lungs and chest wall," he said.

Study participants averaged 74 years of age, with a median of four preoperative symptoms. The most common were heartburn in 59%, early satiety in 54%, dyspnea in 52%, dysphagia in 47%, chest pain in 40%, and regurgitation in 39%.

Major comorbidities included pulmonary disease in 29% of subjects, heart disease in 35%, and obesity in 39%. An open Hill repair with no hiatal reinforcement was performed in 99% of patients, and 97% of the operations were elective.

Despite the substantial prevalence of comorbid conditions, there was no operative mortality. The mean length of stay was 4 days. One-third had complications, including six cases of arrhythmia, four instances of nausea delaying discharge, three cases of pneumonia, and two cases each of ileus, wound infection, or delirium.

Discussant Dr. Sean C. Grondin observed that paraesophageal hernia is a relatively common disease in the practice of most thoracic surgeons. And although the study provides some support for the notion that surgical repair may improve pulmonary function, its retrospective nature and only moderate size render it less than fully convincing.

"I think it still falls a little short just yet of providing conclusive evidence. At this time I would caution surgeons from telling patients that they’ll get a definitive improvement in their dyspnea after paraesophageal hernia repair, although it’s certainly a possibility," said Dr. Grondin of the University of Calgary (Alta).

Dr. Ross M. Bremner of St. Joseph’s Hospital and Medical Center, Phoenix, commented that: "I’ve long been telling my patients who have their entire stomach in the chest that they’re likely to get some improvement in their pulmonary function from repair. Now at least I have some data to show them they can get at least 10%-15% improvement."

Dr. Carrott reported that he had no disclosures.

COLORADO SPRINGS – Improvements in pulmonary function tests and subjective complaints of breathlessness appear to be underappreciated benefits of the surgical repair of giant paraesophageal hernias.

Symptom assessment of these patients has generally focused on reflux and dysphagia, but these hernias also have adverse impacts on pulmonary function. Repair most benefits patients who are older, have bigger hernias, and worse baseline pulmonary function, said Dr. Philip W. Carrott Jr., of Virginia Mason Medical Center, Seattle.

"Patients with giant paraesophageal hernia and coexistent dyspnea or positional breathlessness should be reviewed by an experienced surgeon for elective repair, even when pulmonary comorbidities exist," Dr. Carrott concluded at the annual meeting of the Western Thoracic Surgical Association.

He based this advice on a single-center, retrospective, cohort study involving 120 patients who had pulmonary function tests preoperatively and again at a median of 106 days after surgery.

The overall group averaged 10% increases over baseline (P less than .001) in forced vital capacity (FVC), forced expiratory volume in 1 second (FEV₁), vital capacity, and volume-adjusted mid-expiratory flow (IsoFEF25-75), as well as a 2.9% increase in the diffusing capacity of the lung (DLCO).

The larger a patient’s hernia as expressed by percent intrathoracic stomach (ITS) on preoperative contrast studies, the greater the improvement in pulmonary function tests after surgery. Hernia size was the strongest predictor of improvement. For example, forced vital capacity improved by an average of 4.7%, compared with reference values in patients with the smallest hernias as expressed in a percent ITS of less than 50%, as compared with a 6.0% gain in patients with a preop 50%-74% ITS, a 9.1% improvement in those with 75%-99% ITS, and a 14.9% gain in FVC in patients with 100% ITS.

The postoperative improvement in lung function increased with each decade of patient age.

Patients with the worst preoperative lung function tended to have the biggest hernias – and the greatest objective and subjective improvements after surgery. For example, 36% of subjects had a reduced baseline FEV₁ not more than 75% of the reference value. Their vital capacity improved by 0.45 L, as compared with 0.23 L in patients without a reduced baseline FEV₁. And their DLCO improved by 1.23 mL CO/min/mm Hg, compared with just 0.23 in patients whose baseline FEV₁ was more than 75% of the reference value.

Of 63 patients who reported preoperative dyspnea, 47 (75%) noted subjective improvement in their respiratory function after hernia repair. Intriguingly, so did 30 of 57 patients (53%) not complaining of dyspnea at baseline.

Dr. Carrott and his fellow researchers postulate that restoring efficient diaphragmatic function is just part of the explanation. "The stomach probably has a paradoxical motion during respiration, such that the abdominal positive pressure is pushing against the negative effect of the lungs and chest wall," he said.

Study participants averaged 74 years of age, with a median of four preoperative symptoms. The most common were heartburn in 59%, early satiety in 54%, dyspnea in 52%, dysphagia in 47%, chest pain in 40%, and regurgitation in 39%.

Major comorbidities included pulmonary disease in 29% of subjects, heart disease in 35%, and obesity in 39%. An open Hill repair with no hiatal reinforcement was performed in 99% of patients, and 97% of the operations were elective.

Despite the substantial prevalence of comorbid conditions, there was no operative mortality. The mean length of stay was 4 days. One-third had complications, including six cases of arrhythmia, four instances of nausea delaying discharge, three cases of pneumonia, and two cases each of ileus, wound infection, or delirium.

Discussant Dr. Sean C. Grondin observed that paraesophageal hernia is a relatively common disease in the practice of most thoracic surgeons. And although the study provides some support for the notion that surgical repair may improve pulmonary function, its retrospective nature and only moderate size render it less than fully convincing.

"I think it still falls a little short just yet of providing conclusive evidence. At this time I would caution surgeons from telling patients that they’ll get a definitive improvement in their dyspnea after paraesophageal hernia repair, although it’s certainly a possibility," said Dr. Grondin of the University of Calgary (Alta).

Dr. Ross M. Bremner of St. Joseph’s Hospital and Medical Center, Phoenix, commented that: "I’ve long been telling my patients who have their entire stomach in the chest that they’re likely to get some improvement in their pulmonary function from repair. Now at least I have some data to show them they can get at least 10%-15% improvement."

Dr. Carrott reported that he had no disclosures.

COLORADO SPRINGS – Improvements in pulmonary function tests and subjective complaints of breathlessness appear to be underappreciated benefits of the surgical repair of giant paraesophageal hernias.

Symptom assessment of these patients has generally focused on reflux and dysphagia, but these hernias also have adverse impacts on pulmonary function. Repair most benefits patients who are older, have bigger hernias, and worse baseline pulmonary function, said Dr. Philip W. Carrott Jr., of Virginia Mason Medical Center, Seattle.

"Patients with giant paraesophageal hernia and coexistent dyspnea or positional breathlessness should be reviewed by an experienced surgeon for elective repair, even when pulmonary comorbidities exist," Dr. Carrott concluded at the annual meeting of the Western Thoracic Surgical Association.

He based this advice on a single-center, retrospective, cohort study involving 120 patients who had pulmonary function tests preoperatively and again at a median of 106 days after surgery.

The overall group averaged 10% increases over baseline (P less than .001) in forced vital capacity (FVC), forced expiratory volume in 1 second (FEV₁), vital capacity, and volume-adjusted mid-expiratory flow (IsoFEF25-75), as well as a 2.9% increase in the diffusing capacity of the lung (DLCO).

The larger a patient’s hernia as expressed by percent intrathoracic stomach (ITS) on preoperative contrast studies, the greater the improvement in pulmonary function tests after surgery. Hernia size was the strongest predictor of improvement. For example, forced vital capacity improved by an average of 4.7%, compared with reference values in patients with the smallest hernias as expressed in a percent ITS of less than 50%, as compared with a 6.0% gain in patients with a preop 50%-74% ITS, a 9.1% improvement in those with 75%-99% ITS, and a 14.9% gain in FVC in patients with 100% ITS.

The postoperative improvement in lung function increased with each decade of patient age.

Patients with the worst preoperative lung function tended to have the biggest hernias – and the greatest objective and subjective improvements after surgery. For example, 36% of subjects had a reduced baseline FEV₁ not more than 75% of the reference value. Their vital capacity improved by 0.45 L, as compared with 0.23 L in patients without a reduced baseline FEV₁. And their DLCO improved by 1.23 mL CO/min/mm Hg, compared with just 0.23 in patients whose baseline FEV₁ was more than 75% of the reference value.

Of 63 patients who reported preoperative dyspnea, 47 (75%) noted subjective improvement in their respiratory function after hernia repair. Intriguingly, so did 30 of 57 patients (53%) not complaining of dyspnea at baseline.

Dr. Carrott and his fellow researchers postulate that restoring efficient diaphragmatic function is just part of the explanation. "The stomach probably has a paradoxical motion during respiration, such that the abdominal positive pressure is pushing against the negative effect of the lungs and chest wall," he said.

Study participants averaged 74 years of age, with a median of four preoperative symptoms. The most common were heartburn in 59%, early satiety in 54%, dyspnea in 52%, dysphagia in 47%, chest pain in 40%, and regurgitation in 39%.

Major comorbidities included pulmonary disease in 29% of subjects, heart disease in 35%, and obesity in 39%. An open Hill repair with no hiatal reinforcement was performed in 99% of patients, and 97% of the operations were elective.

Despite the substantial prevalence of comorbid conditions, there was no operative mortality. The mean length of stay was 4 days. One-third had complications, including six cases of arrhythmia, four instances of nausea delaying discharge, three cases of pneumonia, and two cases each of ileus, wound infection, or delirium.

Discussant Dr. Sean C. Grondin observed that paraesophageal hernia is a relatively common disease in the practice of most thoracic surgeons. And although the study provides some support for the notion that surgical repair may improve pulmonary function, its retrospective nature and only moderate size render it less than fully convincing.

"I think it still falls a little short just yet of providing conclusive evidence. At this time I would caution surgeons from telling patients that they’ll get a definitive improvement in their dyspnea after paraesophageal hernia repair, although it’s certainly a possibility," said Dr. Grondin of the University of Calgary (Alta).

Dr. Ross M. Bremner of St. Joseph’s Hospital and Medical Center, Phoenix, commented that: "I’ve long been telling my patients who have their entire stomach in the chest that they’re likely to get some improvement in their pulmonary function from repair. Now at least I have some data to show them they can get at least 10%-15% improvement."

Dr. Carrott reported that he had no disclosures.