Paraesophageal Hernia Repair Can Boost Lung Function
BY BRUCE JANCIN
Elsevier Global Medical News
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 adversely affect pulmonary function. Repair most benefits patients who are older, have bigger hernias, and have 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 said 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. Indeed, hernia size was the strongest predictor of improvement. For example, FVC 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 preoperative 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 per 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.
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%.
An open Hill repair with no hiatal reinforcement was performed in 99% of patients, and 97% of the operations were elective.
COMMENTARY
Dr. Richard Fischel, FCCP, comments: Despite this study’s retrospective nature and moderate sample size, the data reinforce what many surgeons have been noting anecdotally for years. The fact that the largest improvement was seen in the sickest patients coincides with other studies of respiratory function such as the national emphysema treatment trial or NETT, which addressed a larger population in a prospective study. In this study, all cases were done with an open surgical technique and one can only wonder if the results may have been even better had a laparoscopic approach been utilized. This study can be useful to surgeons discussing elective repair of paraesophageal hernia with their patients, especially those with impaired respiratory function, while being cautious to avoid any “promise” of improved lung function.
