Thorax (1957), 12, 181.

AN OPERATION FOR HIATUS HERNIA WITH SHORTOESOPHAGUS

BY

J. LEIGH COLLISFrom tile Queen Elizabeth Hospital, Birminghan

(RECEIVED FOR PUBLICATION MARCH 29, 1957)

The patient with a hiatus hernia and a markedlyshort oesophagus presents a problem for whichthere is not at present a generally accepted line oftreatment. There are gross macroscopic changesin the oesophagus and they tend to give rise tosevere pain and dysphagia. The shortening of theoesophagus makes the problem unsuitable fortreatment by the standard operations for hiatushernia, while some of the suggested treatments,such as oesophago-jejunostomy, are so formidablethat they are unsuitable for the frail and oftenaged subjects.Anatomical and physiological investigations

which were published in 1954 led me to refashionmy operative technique for the problem of hiatushernia generally (Collis, Kelly, and Wiley, 1954).These investigations and the experience with themodified technique demonstrated certain pointswhich seemed to have a special bearing on thedifficult problem of the patient with a shortoesophagus.

Evidence was put forward in that paper to showthat some infants with a hiatus hernia lose theirsymptoms before they lose the radiologicallydemonstrable hiatus hernia. It was suggested thatthis was due to the development of tone in thecrural fibres so that gross reflux from the stomachbelow the diaphragm is controlled. The smallamount of reflux which remains is sufficient toallow fluid to enter the gastric pouch above thediaphragm, but the force of the reflux is weak andcan be controlled by the sphincter action at thecardia. If these children are followed up, it willbe seen that further complete power to controlreflux at the hiatus will usually be developed andwhen this is effected the hernia will in most casesremain reduced. This reduction does not alwaystake place, but if the control at the hiatus is goodthe condition is very difficult to demonstrate radio-logically and can only be shown at oesophago-scopy. This state of affairs is often referred to asa gastric-lined oesophagus.

This situation holds dangers for the patients inlater life, but is compatible with many years ofeither symptom-free existence or a state of onlytrivial trouble. It seemed reasonable to wonder ifsomething along similar lines could not be arrangedfor patients with established short oesophagus andfree reflux.The essential part of the refashioned operation

described in 1954 was that an acute angle ofimplantation between the stomach and the oeso-phagus should be formed. This is effected bysuturing the two limbs of the right crus above andin front of the oesophagus. As a result of this,the point around which the oesophago-gastricjunction angulates is lowered, with the effect thatthe angle automatically becomes more acute. Theoperative technique was fully described and it isonly necessary to add that it has continued to givegood results.The point of particular importance here is that

the operation was used on some cases in whichthe oesophagus was short, and as a result thecardia could not be returned to the hiatus. Theresults in this group were not perfect, but it wasclear that in many cases reflux could be controlledand symptomatic relief given. The weakness ofthis procedure was a technical one, in that therewas too much bulk tissue occupying the oeso-phageal hiatus, so that a satisfactory anglebetween the stomach above the diaphragm andthat below could not be produced.The suggestion that is now being made is that

gastric tissue can be used to form the connectingtube between the lower end of the short oeso-phagus and the main body of the stomach withinthe abdomen. In view of the possible disadvan-tages of the use of this tissue it is desirable tohave a clear knowledge of the physiological secre-tions of the part involved. In 1934 Bergerdescribed a careful study of the distribution ofthe parietal cells of the stomach which are the

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J. LEIGH COLLIS

FRc. .-Fhis diagram is taken from the paper by Berger. The inaltlbodv of the stomacih is shaded black and is rich in parietal cellswhicih produce HCI. Relatise to this thie shaded area at thiecalrdia only has 50(). of the parietal cells.

main source of hydrochloric acid. Fig. I is re-produced ftronm Berger's paper to show the arrange-ment. From this it will be seen that the areaadjacent to the cardia has only a limited supplybut that milost ot the lesser curve is well supplied.A series of sections was made from gastric tissueto confirm this statement.Another important work on this subject was pro-

duced by Billenkamp in 1929. He made a specialstudy of the magenstrasse in 1 5 different species,including man, and he found that the mucosaof this area was thinner in man than other partsof the stomach and that it was practically devoidof peptic glands.

It would seem that the area of the cardia andlesser curve has a definite power of producingacid bitt that it is deficient in its power to producepepsin.

GENERAL PLAN or OPERATIONIn view of the experience from congenital

defects in this area and the work of Berger (1934)and Billenkamp (1929), it seems reasonable to pItforward a plan for using a gastric connecting linkbetween the short oesophagus above and the mainbody of the stomach below the diaphragm, pro-vided that certain precautions are taken.

First, it is necessary to use onlv gastric tissuLeof the magenstrasse. Secondly, an cffective Xalveaction must be obtained so that refluLx is preventedfrom the main body of the stomach into the coti-necting link and oesophagus above. Thirdly. itseems desirable that as narrow a tube of stomachas possible is used so that the amount ol gastricsecretion should be minimal.

TECHNIQUE OF OPERAT ION

The patient is placed on his right side xith hiswhole body rotated a little backwards. Anabdomino-thoracic incision is made froimi theiinibilicus to the edge of the trapzzitls along theline of the seventh or eighth rib The chestand abdomen are opened bv resection ot onie ot-other of these ribs. It is found desirable toremove a segment of the costal margin. Theincision in the diaphragm should be made as tai-laterally as possible so as to minimize the nuLimbetof filaments of the phrenic nerve which are CLut.For the same reason it should only be taken to aipoint half an inch short of the central tendoin.[his is important to ensure generally good functionin the diaphragm after this operation. A smallamount of lateral weakness is not a disadvantage.The mediastinum is dissected so as to demon-

strate the short oesophagus and stomach pouch.In sonie cases it will be found that so muich extrt.length of oesophagus can be obtained by thisdissection to effect a standard plastic repair. Whenthis cannot be achieved the gastric pouch is care-fully cleared of vascular attachments so that itssurface is smooth and clean. In order to do thisit is useful to be able to inspect the stomach frombelow and to bring extra stomach up into the chest.When this stage is completed the anaesthetist

passes a No. 9 (English gauge) stomach tube fromthe mouth into the intra-abdominal part ot thestomach. Parker-Kerr clamps are then applied asshown in Fig. 3. The distal ends of these clampsare brouiiht as close as possible to the simallstomach tube and lesser curve. The object of thisis to make certain that the tube of stomach at thispoint will be as narrow as possible. The stomachis incised between the clamps and the free cuffsewn up before the clamps are removed.

After removing the clamps the suture line isinvaginated. The position now is as shown inFig. 4. The part of the stomach pouch to the leftis now returned below the diaphragm and has theeffect of enlarging the fundus. Above the dia-phragm a portion of the pouch remains which willfrom now on be referred to as the "connectingtube."

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HI/A T(S H/ERVNIA

FIG. 2.-This is a diagrammatic representation of the condition underconsideration. A hiatus hernia is present with a short oesopha-gus. A broad neck of gastric tissue occupies the diaphragmatichiatus.

AFTEf' DIV/S/ONANVD SLSUTURF

FIG. 4.-This shows the position after the clamps have been removedand the stomach incised. The pouch of the hiatus herniasnow been divided into two parts. First there is the part alongthe lesser curve which is the connecting tube, and secondly thereis the part to the left which is going to be given back to the fundus.

POS/ TION/FOR

CLAMPS

LOWER PARTRETURNVED TOABDOMENV

FIG. 3.-The parallel dark lines show the position in which the clamps FIG. 5.-The oesophagus and the connecting tube only remain aboveare placed. The lower end of the clamp is brought as close as the diaphragm. Only a narrow neck of gastric tissue is now inpossible to the lesser curve. When the clamps are on, the the diaphragmatic hiatus. Around this narrow tube a satis-gastric pouch is divided by them into two halves. factory plastic repair of the fibres of the right crus can be

performed.

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The last phase of the operation is the plasticrepair as described earlier in Thorax (Collis,Kelly, and Wiley, 1954). It is done from belowthe diaphragm. The under surface of the fibresof the right crus are dissected clean of everythingexcept peritoneum, which is carefully preserved.The limbs of the right crus are now suturedtogether above and in front of the connectingtube. This produces an acute angle between theconnecting tube and the main body of thestomach. As the diaphragm is closed the stomachis included in two of the stitches in order to retainthe connecting tube and oesophagus in position.The chest and abdomen are closed with inter-costal drainage for 48 hours.

RESULTSFig. 6 is a typical example of the type of case

for which this operation has been done. Fig. 7shows the same case after gastroplasty. The con-necting tube can be seen. A good angle of im-plantation into the stomach had been producedand no regurgitation could be induced at bariumswallow examination.The operation has been carried out on nine

patients between April, 1955, and September, 1956.Seven were women and two were men. Their ageswere between 50 and 70 in seven of the patients.The other two were aged 31 and 37 years. Allhad gross symptoms. Dysphagia was prominentin seven patients and one had had many oeso-phagoscopies for dilatation. At oesophagoscopyoesophagitis was marked in all cases, with ulcera-tion noted in five. The oesophageal length wasbetween 29 and 34 cm. It is to be noted that thegrossest forms of short oesophagus have not beentreated this way so far.

After operation one of the patients who wasapparently making good progress died with acoronary thrombosis. He was aged 67. In thefirst case, in a woman aged 31, reflux was not satis-factorily controlled, and although she is improvedher condition is not considered satisfactory. Thepost-operative result in the other seven is excellent.A check barium swallow has been done in all ofthese between eight and 12 months from operationand in six no reflux could be produced. In oneonly slight reflux occurred. At the same periodafter operation these patients were also checkedby oesophagoscopy and the complete absence ofoesophagitis and stricture was noted. No patienthas required post-operative oesophagoscopy anddilatation. This is in spite of the previous dilata-tions required in one case. It is to be noted thatin the immediate post-operative period markeddysphagia was present in most patients and that

FIG. 6.-This is a barium swallow film to show the type of case forwhich the operation has been done, i.e., an irreducible hiatushernia with a short oesophagus. There is marked narrowing atthe cardia and the patient had gross dysphagia.

FIG. 7.-This is the same patient as shown in Fig. 6. A gastroplastyhas now been performed. The connecting tube can clearly beseen with the cardia in about the same position as before opera-tion. It is to be noted that the narrowing at the cardia hasgone and this is in spite of no post-operative dilatation.

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OPERATION FOR HIATUS HERNIA WITH SHORT OESOPHAGUS 185

01APHRAGM --

FIG. 8.-The incision has been made and the wound opened. The incision in the diaphragmis shown, and it will be seen that it stops short of the edge of the central tendon.

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FIG. 9.-The mediastirnsm has now been dissected to show the stomach pouch and cardia.

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186 J. LEIGH COLLIS

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FIG. 10.-The small stomach tube is now in position and the Parker-Kerr clamps have beenplaced on the stomach pouch. The tips of these clamps are brought as close as possible tothe lesser curve.

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Fic,. 12.-The clamps have been re-moved and the double layer ofinvaginating suittures has been in-serted. The gastric pouch has nowbeen divided into two parts. Tothe right is the connecting tube andto the left is the part which willbe retturned bclow the diaphragnito acid to the suize of the fundus.

COIVNECTINGTUBE

FG-.13.-Only the connecting tube now. remains aboe thedeiaphragm-n.It I ies in the nmedias-niuin a ndl gives extra I ength to t he oesophagusso that the plastic repair at The hiatus ws ill be able to fte dorenwitliout tfznsion.

Ft. 14. -The diaphragrmi is nowsretracted upwsards so thlatl theplastic repair of the hiatuscani be done frorti the tindersurface. A ltong line o1f-Liitiires has becin placed be-isccrn the vtso limtlbs ot theright1 Lruis. above and in fronttlf the stubstitutec for thekiesophaguLS. the coinniiectingtutbe. Bv doing this thevoint aroLund w.uhich the gutangLilates is lowered by thesutJurC line. The fundiLs withhailf of the gastric poLuchadded to it is secn on the1et

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J. LEIGH COLLIS

it often continued for three weeks from operation.Some slight difficulty in swallowing was oftenpresent after this, but in all cases it steadilyimproved. Some degree of immediate post-operative dysphagia is regarded as desirable andit is felt that if it is not present the operation hasnot been done properly.Only one major post-operative complication

occurred. This was a left subphrenic abscess witha leak from the suture line. The whole conditionsubsided spontaneously with drainage of the pus.The improvement of the general health of these

patients has been remarkable and has resulted intheir suffering less from other coexistent diseases.One patient had suffered for many years fromnarcolepsy and another from Parkinsonism. Thesymptoms of both conditions have becomeremarkably less.

CONCLUSIONSThe operation, which is called gastroplasty, is of

considerable magnitude, but is still much smallerthan oesophago-jejunostomy, and is well toleratedeven by old and weak patients. It leaves the diges-tive arrangements near normal and there is noproblem afterwards with nutrition. Excellentresults have been obtained in seven patients, butthe unsatisfactory state in the first case must betaken as a warning of the need to narrow the con-necting tube sufficiently so that a really good angleof implantation can be obtained. The procedurehas not been used on the very short oesophagiwhere the cardia is in the region of the aortic archor above. The reason for this is conservatism, andit is felt that results justify its use for these also.

Attention has been drawn to the spontaneousrelief of dysphagia after this operation. By thisit is intended to suggest that many strictures whichare generally believed to be fibrous are in factmainly produced by reflex spasm. In these caseswhen the irritation of reflux has been removedand the oesophagitis has subsided the dysphagiawill no longer be present. While putting thisforward as an observed fact it is fully appreciatedthat in some strictures fibrous change is presentand it is anticipated that oesophagoscopy may wellhave to be done for dilatation in some cases in thefuture.

SUMMARYAn operation is described for the condition of

hiatus hernia with short oesophagus.The method involves the use of a small portion

of stomach as a connecting link between the oeso-phagus above and the main body of the stomachbelow the diaphragm.The results of the use of the procedure in nine

patients are described.The operation is referred to as a gastroplasty.

I am particularly indebted to Dr. J. C. A. Raison,of the Thoracic Surgical Unit, Warwick, for help inthis work. My thanks are also due to Mr. L. Dee,clinical photographer to the Queen Elizabeth Hospital,Birmingham.

REFERENCES

Berger, E. H. (1934). Amer. J. Anat., 54, 87.Billenkamp, H. (1929). Beilr. path. Anal., 82, 475.Collis, J. L., Kelly, T. D., and Wiley, A. M. (1954). Thorax, 9, 175.

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