John M. Streitz

Paraesophageal hiatal hernia: Is an antireflux procedure necessary?

Between January 1970 and October 1992, 119 patients underwent 126 repairs of a paraesophageal hiatal hernia at the Lahey Clinic. Seven patients with a recurrent hernia required reoperation. Of the procedures, 19 (15%) included an antireflux procedure because of severe reflux symptoms and objective evidence of reflux demonstrated by grade 2 esophagitis on endoscopy, manometric evidence of a hypotensive lower esophageal sphincter pressure (< or = 10 mm Hg), positive results on 24-hour pH monitoring, or all three methods. Follow-up ranged from 6 months to 18 years with a median of 61.5 months, and the results of 115 operations were analyzed. Symptomatic results were good to excellent after 96 (83.5%) of these 115 operations. Thirteen symptomatic paraesophageal hernias recurred in 12 patients (one recurrence per 58 patient-years of follow-up). Severe reflux symptoms accompanied by endoscopic evidence of esophagitis developed in 2 patients who had not undergone an antireflux procedure at the time of repair of the hernia. We conclude that an antireflux procedure is rarely required in patients undergoing repair of a paraesophageal hiatal hernia and should be employed only when objective evidence of reflux is seen preoperatively.

Objective assessment of gastroesophageal reflux after short esophagomyotomy for achalasia with the use of manometry and pH monitoring

The role of an antireflux procedure as an adjunct to esophagomyotomy for achalasia remains a subject of controversy. Little objective documentation exists of this operations effect on sphincteric competence and the degree of postoperative gastroesophageal reflux. This report of esophageal manometry and 24-hour pH monitoring on 14 patients with esophageal achalasia whom we had previously treated by a short esophagomyotomy without an antireflux procedure provides such documentation. Esophagomyotomy reduced lower esophageal sphincter pressure by 12% to 71% (mean 41%) from a preoperative mean of 26.7 mm Hg to a postoperative mean of 14.6 mm Hg. The number of postoperative episodes of acid reflux per patient in 24 hours was fewer than 29 (normal < 49) in 13 patients, with a median of 12 episodes for the entire group. Esophageal acid exposure, measured as percentage of total time with pH less than 4.0 (normal < 4.5%), was below 4.5% in 10 patients, six of whom had values less than 1%. Among the four patients with values greater than 4.5%, only one had a temporal correlation of symptoms with an episode of acid reflux. Multivariate analysis showed that esophageal acid exposure time correlated only with the level of residual lower esophageal sphincter pressure during the relaxation phase of deglutition. A pressure less than 8 mm Hg was predictive of normal acid contact time (p < 0.001). Mean lower esophageal sphincter pressure, percent reduction in lower esophageal sphincter amplitude, postoperative vector volume, and length of the lower esophageal sphincter did not significantly correlate with amount of esophageal acid exposure. We conclude that a short esophagomyotomy without an antireflux procedure results in a competent lower esophageal sphincter in most patients. Increased esophageal acid exposure, when it occurs, is due to slow clearance of esophageal acid from relatively few reflux episodes and is more likely to occur when there is a high residual pressure during deglutition after myotomy. These findings suggest that the addition of an antireflux procedure to a short esophagomyotomy would not be expected to improve clinical results.

Current concepts concerning the nature and treatment of Barrett's esophagus and its complications

Current concepts regarding the nature and the treatment of Barretts esophagus and its complications are reviewed. The columnar-lined lower esophagus is being increasingly recognized as an acquired condition caused by gastroesophageal reflux. Many patients are asymptomatic. Barretts esophagus occurs in about 10% to 15% of patients with reflux esophagitis. The diagnosis depends on endoscopy and biopsy. Complications are common and include ulceration, stricture, dysplasia, and adenocarcinoma. Esophagitis, ulceration, and stricture can usually be treated medically. Surgical approaches are discussed for patients whose condition is refractory to medical therapy. The premalignant nature of Barretts epithelium is well recognized, and strategies for surveillance and resection are discussed. Survival after resection of adenocarcinoma in Barretts esophagus is not appreciably different from that of other carcinomas. Surveillance with endoscopy offers the best chance for early detection and cure.

Iatrogenic paraesophageal hiatus hernia

Between January 1970 and January 1990, 101 patients with paraesophageal hiatus hernias were operated on at the Lahey Clinic Medical Center. Thirteen patients had hernias that were identified as being iatrogenic in origin, a prevalence of 13%. Ten hernias were secondary to antireflux procedures, and esophagomyotomy, esophagogastrectomy, and placement of an Angelchik prosthesis accounted for one case each. Symptoms did not differ substantially from those of patients with primary hernias. Incarceration occurred in 2 patients, but neither sustained strangulation. The pathogenesis was most frequently disruption of a previous hiatal closure. Other etiological factors included disruption of the phreno-esophageal membrane by operative dissection, postoperative gastric dilatation, and failure to recognize esophageal shortening or an existing hiatal defect. Abdominal repair was usually possible, but 3 patients required thoracotomy for reduction. There has been one known recurrence during a median follow-up of 41 months.

Polyuric Urinary Tract Dilatation with Renal Damage

Polyuria of diabetes insipidus and psychogenic polydipsia can produce massive dilatation of the urinary tract in the absence of any mechanical obstruction. Renal failure in these cases is rare. We report the second case of nephrogenic diabetes insipidus with nonobstructive hydronephrotic renal damage. Temporary suprapubic drainage restored renal function to normal and decreased the upper tract dilatation. Renal function has been preserved for more than 10 years. Surgical intervention beyond temporary vesical drainage is unnecessary.

Repair of Aortoesophageal Fistula After Aortic Grafting

This report describes repair of an aortoesophageal fistula caused by a previously placed thoracic aortic graft. The diagnosis was made by esophagoscopy. The repair consisted of femoral-to-femoral cardiopulmonary bypass, excision of the old graft, placement of a new graft, esophagectomy, cervical esophagostomy, gastrostomy, and later reconstruction by cervical esophagogastrostomy.

Fatal hypoxemia following mitral valve replacement.

Patency of the foramen ovale is a common condition. In certain clinical settings it permits the development of right-to-left intracardiac shunting. A case is described of sudden, fatal hypoxemia due to shunting through a patent foramen ovale immediately following mitral valve replacement.

Subfascial implantation of implantable cardioverter defibrillator generator

The automatic cardioverter defibrillator generator is a relatively large unit, which has most often been implanted in a subcutaneous pocket. In a consecutive series of 120 primary implantations, we employed a subrectus fascia pocket that has resulted in a cosmetically superior result with a 0.8% incidence of system infection. The technique of subfascial implantation is described.

The Impact of Close Surveillance of Barrett’s Esophagus Patients on the Results of Esophagogastrectomy for Carcinoma

The risk of malignant degeneration in patients with Barrett’s esophagus (BE) is well known. However, the potential benefits of close surveillance of such patients in terms of the early detection of cancer and the results of esophagogastrectomy following its early detection remain poorly documented. This study was undertaken to determine whether or not there are clearly identifiable benefits from close surveillance of patients with benign BE.