Digestive Diseases and Sciences, Vol. 40, No. 1 (January 1995), p. 191

LETrERS TO THE EDITOR

ACID-SUPPRESSION DID NOT ENHANCE HEALING OF GASTRIC ULCER ASSOCIATED

V¢ITH PARAESOPHAGEAL HERNIA AFTER HERNIAL REDUCTION

To The Editor: Paraesophageal herniation of the stomach is com-

plicated in about 20% of patients by a gastric ulcer at the point of diaphragmatic indentation of the herniated stomach (1-3). However , the causes of gastric ulcer associated with a paraesophageal her- nia (GUPH), as well as a gastric ulcer in general, are not known. Clinical experience suggests that man- agement of GUPH requires surgical correction of the hernia and no specific antiulcer surgery is re- quired (1, 3). We have previously shown that re- turning the stomach to its normal position without any postoperative medical therapy promotes heal- ing of the ulcer within 6-12 months of surgery (3). Whether postoperative medical therapy can en- hance the healing process is not known. Therefore, we report our recent experience with three patients with GUPH who received acid-suppression therapy after surgical correction of the hernia.

Two patients (both 56-year-old men) presented with a history of melena and one (55-year-old woman) with an episode of hematemesis. The diag- nosis was established by means of contrast radiog- raphy and endoscopy. All three patients had a GUPH located at the point where the lesser curva- ture of the herniated stomach abuts the hiatus. All patients had an abdominal repair by using the iden- tical technique as in our previous series (3). The repair consisted of hernial reduction, excision of the sac, anterior crural repair, and anterior gastropexy. A concomitant partial anterior fundoplication was employed in two patients because of coexisting gastroesophageal reflux. Postoperat ive therapy consisted of either 150 mg ranitidine twice daily (two patients) or omeprazole 20 mg daily (one pa- tient) continuously until complete healing of GUPH was confirmed. Postoperatively these three patients were endoscoped at two-month intervals. Healing of the ulcer was demonstrated in the patient receiv- ing omeprazole eight months after surgery, and in the two patients receiving ranitidine eight and 12 months after surgery. These healing times were

similar to the GUPH cases reported by us following surgical correction of the hernia without acid- suppression therapy (3). In the two patients receiv- ing ranitidine, occult bleeding and mild anemia were present within four months of surgery.

This experience indicates that postoperative acid- suppression therapy had no effect on the healing of GUPH after surgical correction of a paraesophageal hernia. This suggests that the role of the "mechan- ical" factor in GUPH is more important than in other ulcer disease. These ulcers were located at the point where the lesser curvature of the herni- ated stomach rides over the hiatus. The mechanical pressure exerted at this point may interfere with arterial supply and venous drainage, thus causing ischemia. It has been shown that stress-induced spasm of muscularis mucosae and consequent com- pression of arteries feeding the gastric mucosa may also play an important role in ulceration (4). Return- ing the herniated portion of the stomach to its nor- mal position promotes healing of the GUPH.

The reasons for the slow healing of GUPH are unknown. Our impression is that these ulcers are larger (3). The healing of larger ulcers seems to require more time, but there are no controlled stud- ies on this point.

SRDJAN RArdC, MD, PHI), FACS PREDRAG PESKO, MD, PHD

MIHAILO DUNJIC, MD ZORAN GERZlC, MD, PHD

Institute of Digestive Diseases Belgrade University School of Medicine

Belgrade 11000, Yugoslavia

REFERENCES

1. Hill LD, Tobias JA: Paraesophageal hernia. Arch Surg 96:734-744, 1968

2. Walther B, DeMeester TR, Lafontaine E, Courtney JV, Little AG, Skinner DB: Effect of paraesophageal hernia on sphinc- ter function and its implications on surgical therapy. Am J Surg 147:111-116, 1984

3. Rakic S, Pesko P, Dunjic M, Gerzic Z: Healing of gastric ulcer associated with paraesophageal hernia after hernial re- duction. Am J Surg 163:443-445, 1992

4. Piasecki CK, Thrasivoulou C: Spasm of gastric muscularis mucosae might play a key role in causing focal mucosal ischemia and ulceration. Dig Dis Sci 38:1183-1189, 1993

Digestive Diseases and Sciences, Vol. 40, No. 1 (January 1995) 0163-2116/95/0100-0191507.50/0 © 1995 Plenum Publishing Corporation

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