Prevalence of Kyphoscoliosis Among Patients with Giant Paraesophageal Hernia: Proposed Pathophysiology and Clinical Significance
Matthew J. Schuchert*1, Prasad Adusumilli2, Chris C. Cook1, Brian L. Pettiford1, Joshua P. Landreneau1, Ricardo S. Santos1, James D. Luketich1, Rodney J. Landreneau1
1Heart, Lung and Esophageal Surgery Institute, University of Pittsburgh Medical Center, Pittsburgh, PA; 2Thoracic Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
Background: Kyphoscoliosis, more common among women, is seen in approximately 4% of the octogenarian population of the United States. We hypothesized that patients with kyphoscoliosis are affected with a reduced intra-abdominal volume and progressive laxity of the musculature of the diaphragmatic hiatal sling mechanism leading to an increased risk of hiatal hernia formation and progression over time.
Methods: We retrospectively reviewed the clinical history and roentgenographic data of 341 paraesophageal hernia patients over the last 4 years. The prevalence of kyphoscoliosis among this patient cohort, and the outcomes of surgical management were compared to paraesophageal hernia patients without kyphoscoliosis.
Results: Ninty-three of the 341 patients (27%) were found to have significant kyphoscoliosis (mean age 74; 85% female). Laparoscopic repair of paraesophageal hernia with fundoplication was performed in 91% of these patients. There was one mortality (aspiration pneumonia) and 15% major postoperative morbidity. Mean length of hospital stay was 8 days (range 2-71). Prolonged stays were related mainly to marginal pulmonary status. Surgical outcomes among patients with or without kyphoscoliosis are compared in the Table. The presence of kyphoscoliosis was associated with increased major perioperative morbidity and length of stay following paraesophageal hernia repair.
Conclusion: The prevalence of kyphoscoliosis was nearly 30% among patients with paraesophageal herniation. This frequently under-appreciated condition may contribute to the development and progression of type I “sliding” hiatal hernias into type III “mixed” paraesophageal hernias. Surgeons approaching paraesophageal hernia repair in this setting should be aware of the increased morbidity and postoperative care required in managing these patients.
Clinical Significance of Kyphoscoliosis in Paraesophageal Hernia Patients
| PARAESOPHAGEAL HERNIA PATIENTS WITH KYPHOSCOLIOSIS | PARAESOPHAGEAL HERNIA PATIENTS WITHOUT KYPHOSCOLIOSIS | |
| NUMBER OF PATIENTS (n) | 93 | 248 |
| AGE (mean) | 74 | 67 |
| LENGTH OF STAY (mean days) | 8 | 3 |
| MAJOR COMPLICATIONS (%) | 15 | 6 |
