Healing of Gastric Ulcer Associated With Paraesophageal Hernia After Hernial Reduction

Srdjan Rakic, MD, rw, Predrag Pesko, MD, Mihailo Dunjic, MD,

ZOran Gerzic, MD, PbD, Belgrade, Yugoslavia

From the Institute of Digestive Diseasq Department of Surgery, Bel- grade University School of Maiicine Clinical Center, Belgrade, Yuge slavia.

Requests for reprints should be addressed to Srdjan Rakic, MD, Institute of Di@stivc Dbemes, Deparbmt of Surgery, Koste Todoro- vica6,Bclgnuk11ooo,Yugu5lavia.

Manuubipt submitted May 14,1991, and acnzptal in revised form Au-t 7,199l.

P araesophageal hemiation of the stomach is frequent- ly complicated by a gastric ulcer brought on by vas-

cular stasis, poor gastric emptying, and pressure on the gastric wall from the diaphragm [I 1. Management of this ulceration does not require antiulcer surgery but does mandate surgical correction of the hernia, which pro- motes healing of the ulcer [ 1,2]. It has been reported that the ulcer heals within 2 to 6 weeks of the surgery [3]. We reviewed our experience with paraesophageal hernia in order to assess the therapeutic efficacy of restoring the stomach to the abdomen on ulcer healing, with the em- phasis on the dynamics of the healing process.

Thirty-four patients with paraesophageal herniation of the stomach were treated at the Institute of Digestive Diseases, Belgrade University Clinical Center, Belgrade, Yugoslavia, over a lo-year period ending December 3 1, 1989. The mean age was 58.7 years (range: 33 to 79 years). In all patients, the diagnosis was established by means of contrast radiography and endoscopy. A gastric ulcer at the point of diaphragmatic indentation of the herniated stomach (figure 1) was identified in eight pa- tients (23%), whose mean age was 58.1 years (range: 50 to 72 years). All eight patients underwent surgical treat- ment through the transabdominal approach by a Collis type of repair for a paraesophageal hiatus hernia (hernial reduction, excision of the sac, and anterior crural repair) [4]. In addition, several fmation sutures were routinely placed along the gastric fundus to the esophagus and diaphragm. An anterior gastropexy was also employed in six patients to minimize the risk of hernial recurrence. Two patients who had a mixed type paraesophageal and sliding hernia underwent concomitant antireflux proce- dure because of coexisting gastroesophageal refhtx (a short Nissen fundoplication and a posterior partial fundo- plication). No specific antiulcer surgery was performed in the entire series.

All patients were both radiologically and endoscopic- ally examined at 3-month intervals during the first year after operation and annually since then. The control ex- aminations were completed in six patients. Two patients in whom a persistent ulcer was later demonstrated 9 months after surgery missed a regular control examina- tion 6 months after surgery, which later proved not to influence the overall results. All endoscopies were per- formed by the authors, and all radiologies by the same two radiologists. The classification of data relied primari- ly on the findings of endoscopy. Mean follow-up was 20 months (range: 12 to 36 months). No medical antiulcer therapy was employed during the follow-up period.

All patients had an unremarkable postoperative course, and the average hospital stay was 10 days. At follow-up, all patients had a satisfactory symptomatic

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Fl@ire 1. Gastrointestinal barium contrast study showing para- esophageal ham& and gastric ulcer at the point of diaphgmatic indentation of ths herniated stomach.

Figure 2. Gastrointestinal barium contrast study 6 months after hemiil repair in patient shown in Figure 1 demonstrates persist- ing ulcer.

FIgwe 3. C3astr~ntestinal ‘barium contrast study 9 months after hernial repair in patlent shown In Fm 1 and 2 demonstrates healing of tha ulcer.

result, and no hernial recurrence was observed. No pa- tient experienced pain, and only one patient complained of occasional distress. A persistent gastric ulcer, however, was detected in all patients at the first examination 3 months after operation. Ulcer was typically located above the incisura angularis of lesser curvature of the returned stomach. At the second examination 6 months after oper- ation, healing of the ulcer was demonstrated in only two patients, whereas, in six, the ulcer persisted (Figure 2). Healing of the ulcer was demonstrated in another three of the remaining six patients at the examination 9 months after operation (Figure 3). One year after surgery, ulcer healing was demonstrated in the last three patients with previously persisting ulcer. Neither major bleeding nor anemia occurred during the presence of the ulcer craters or in the remaining follow-up. There were no other ulcer complications or ulcer recurrences over the follow-up pe- riod. No significant difference in ulcer healing according to the type of repair was demonstrated in thii small series.

Gastric ulcer is a well-recognized complication of paraesophageal hemiation of the stomach, which was shown to occur in 23% of the patients in our series. Since ulceration is brought on by a mechanical problem, con- servative management cannot correct the underlying

HEALING OF GASTRIC ULCER AFTER HERNIAL REDUCTION

pathophysiologic defect and will not allow healing of the ulcer. Surgical correction of this condition is therefore mandatory, and there is general agreement that returning the stomach to its normal position restores adequate gas- tric drainage and promotes healing of the ulcer and that no specific antiulcer surgery is required [I-3]. This proved to be true in our series as well.

More pertinent to this discussion, however, is whether the healing process is as rapid as it is generally considered to be [Z-3]. Well-documented studies on this issue are lacking, and in only one report, which is repeatedly cited, has it been stated that the ulcer usually heals within 2 to 6 weeks of surgery 131. Contrary to this, we have observed no healing of ulcer within 3 months of hernial correction. The healing process in thii series was slower, requiring between 6 to 12 months. As no ulcer complications were

observed in this period, medical antiulcer therapy seems not to be necessary from this standpoint. Whether postop erative antiulcer medical therapy might enhance the healing deserves evaluation.

REFERENCES 1. Treaty J, Jam&on GG. Para-oesophageaf hernias. In: Jam&on GG, editor. Surgery of the oesophagus. Edinburgh: Churchill-Liv- ingstone, 1988: 149-57. 2. Mercer CD, Velasco N, Hill LD. Paraesophageal hernia. In: Hill LD, Kozarek RA, McCalum RW, Merccr CD, editors. The esoph- agus: medical and surgical management. Philadelphia: WB Saun- ders Company, 1988: 148-56. 3. Hill LD, Tobias JA. Paraesophageal hernia. Arch Surg 1968; 96: 735-44. 4. Colfii JL. Surgical control of reflux in hiatus hernia. Am J Surg 1968; 115: 465-71.

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