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Introduction: The clinical management of patients with large type III paraesophageal hiatal hernia (PEH) in both elective and urgent circumstances has become quite common. Repair of PEH now accounts for 30-50% of fundoplications in high volume centers. Given the primary focus on hernia repair, and not gastro-esophageal reflux (GERD), the utility of esophageal motility in patients with PEH is unclear. Furthermore, the availability of esophageal motility testing, emergent presentation of patients and complex anatomy making catheter placement difficult, all limit the routine use of preoperative motility. The aim of this study was to characterize preoperative esophageal function in patients with PEH and to determine the prevalence of esophageal dysmotility which might impact surgical approach.
Methods: Eighty patients (mean age 64.5 ±11.9 years; mean BMI 30.7 ±5.8; 65% female), with endoscopic and/or radiographic type III hiatal hernia, who underwent preoperative High Resolution Manometry (HRM) from December 2006 to October 2011 formed the study population. All studies were analyzed using current esophageal body motility classifications and current analysis software (ManoViewTM v2.0.1). Assessment of the lower esophageal sphincter (LES) was possible in 21 patients (26%) in which the catheter was passed through the diaphragmatic crura into the intra-abdominal cavity. All manometry parameters were referenced to normal-values previously established in our institution.
Results: Esophageal body function including wave propagation and circular muscle strength was normal in 35/80 (44%) of patients. A simultaneous/spastic contraction pattern (distal latency <4.5sec and/or contractile front velocity >9cm/s) was present in 14/80 (17.5%) and abnormal contraction strength (overall distal contractile integral <500mmHg●cm●s, weak peristalsis with peristaltic defects and/or frequent failed peristalsis) in another 14 (17.5%). Manometric evidence of functional outflow obstruction (elevated intra-bolus pressure and/or elevated 4-second integrated relaxation pressure) was present in 29/80 (36.3%) of patients. One patient met the manometric criteria for Achalasia. Manometric evidence of the sliding component of the PEH was present in 17/21 (81%) with a mean length of 4.1±2.1 cm. Overall LES length was short in 14/21 (67%) patients, 19/21 (91%) had a shortened intra-abdominal segment and 2/21 (10%) were hypertensive at rest.
Conclusion: Significant abnormalities of esophageal body function are present in a large percentage (56%) of patients with paraesophageal hiatal hernia. Nineteen percent have severely compromised circular muscle strength. These data suggest that HRM should be included in the preoperative evaluation of patients with PEH whenever possible.