Changes in lung volumes and gas trapping in patients with large hiatal hernia

The effect of surgical repair of hiatal hernia (HH) on pulmonary function: a systematic review and meta-analysis

PURPOSE

Hiatal hernia is renowned for the symptom of reflux, and few physicians associate a hiatal hernia with pulmonary issues. It is widely acknowledged that a hiatal hernia can be treated with surgery. However, less is known about how the surgical procedure would benefit pulmonary function. Thus, the aim of this study was to determine whether surgical repair can improve pulmonary function in patients with hiatal hernias.

METHODS

We registered the protocol on the PROSPERO (International Prospective Register of Systematic Reviews) platform (no. CRD42022369949). We searched the PubMed, Embase, Cochrane Library, and ClinicalTrials.gov databases for cohort studies that reported on the pulmonary function of patients with hiatal hernias. The quality of each cohort study was evaluated using the Newcastle-Ottawa scale (NOS). We then calculated mean differences (MDs) with 95% confidence intervals for these continuous outcomes. Each study's consistency was appraised using the I² statistic. The sensitivity analysis was performed using the trim-and-fill method. Publication bias was confirmed using the funnel plot visually and Egger regression test statistically.

RESULTS

A total of 262 patients from 5 cohorts were included in the meta-analysis. The quality evaluation revealed that, of these 5 papers, 3 received 8 NOS stars out of 9 stars, 1 received 9, and the other received 7, meaning all included cohort studies were of high quality. The results showed that surgical repair for a hiatal hernia significantly improved forced expiratory volume in 1 s (FEV1; weighted mean difference [WMD]:0.200; 95% CI 0.047-0.353; I² = 71.6%; P = 0.010), forced vital capacity (FVC; WMD: 0.242; 95% CI 0.161-0.323; I² = 7.1%; P = 0.000), and total lung capacity (TLC; WMD: 0.223; 95% CI 0.098-0.348; I² = 0.0%; P = 0.000) but had little effect on residual volume (RV; WMD: -0.028; 95% CI -0.096 to 0.039; I² = 8.7%; P = 0.411) and the diffusing capacity carbon monoxide (DLCO; WMD: 0.234; 95% CI -0.486 to 0.953; I² = 0.0%; P = 0.524).

CONCLUSION

For individuals with hiatal hernias, surgical repair is an efficient technique to improve respiratory function as measured by FEV1, FVC, and TLC.

Laparoscopic fundoplication for para-oesophageal hernia repair improves respiratory function in patients with dyspnoea: a prospective cohort study

Background

Dyspnoea in patients with a para-oesophageal hernia (PEH) occurs in 7% to 32% of cases and is very disabling, especially in elderly patients, and its origin is not well defined. The present study aims to assess the impact of PEH repair on dyspnoea and respiratory function.

Methods

From January 2019 to May 2021, all consecutive patients scheduled for PEH repair presenting with a modified Medical Research Council (mMRC) score ≥ 2 for dyspnoea were included. Before and 2 months after surgery, dyspnoea was assessed by both the dyspnoea visual analogue scale (DVAS) and the mMRC scale, as well as pulmonary function tests (PFTs) by plethysmography.

Results

All 43 patients that were included had pre- and postoperative dyspnoea assessments and PFTs. Median age was 70 years (range 63–73.5 years), 37 (86%) participants were women, median percentage of the intrathoracic stomach was 59.9% (range 44.2–83.0%), and median length of hospital stay was 3 days (range 3–4 days). After surgery, the DVAS decreased statistically significant (5.6 [4.7–6.7] vs. 3.0 [2.3–4.4], p < 0.001), and 37 (86%) patients had a clinically significant decrease in mMRC score. Absolute forced expiratory volume in one second (FEV1), total lung capacity, and forced vital capacity also statistically significantly increased after surgery by an average of 11.2% (SD 17.9), 5.0% (SD 13.9), and 10.7% (SD 14.6), respectively. Furthermore, from the subgroup analysis, it was identified that patients with a lower preoperative FEV1 were more likely to have improvement in it after surgery. No correlation was found between improvement in dyspnoea and FEV1. There was no correlation between the percentage of intrathoracic stomach and dyspnoea or improvement in PFT parameters.

Conclusion

PEH repair improves dyspnoea and FEV1 in a statistically significant manner in a population of patients presenting with dyspnoea. Patients with a low preoperative FEV1 are more likely to have improvement in it after surgery.

Paraesophageal hernia repair with laparoscopic Toupet fundoplication: impact on pulmonary function, respiratory symptoms and quality of life

BACKGROUND

Paraesophageal hiatal hernia (PEH) is characterized by protrusion of intra-abdominal organs into the posterior mediastinum. Respiratory symptoms and reduced pulmonary function have been described as possibly related to lung compression.

OBJECTIVE

To assess the effect of laparoscopic Toupet fundoplication (LTF) for PEH repair on pulmonary function, measured with pulmonary function tests (PFTs), and respiratory symptoms.

METHODS

Retrospective, single-center, cohort study (November 2015-2020). All patients that completed pre- and postoperative (12 months) PFTs assessment were included. The gastroesophageal reflux disease health-related quality of life (GERD-HRQL), reflux symptom index (RSI) and short form-36 (SF-36) were used.

RESULTS

Overall, 71 patients were included. The median age was 67.1 years and the majority were females (78.8%). Baseline PFTs were within normal limits in 91% of patients. At 12 month follow-up, total lung capacity (TLC) (4.77 vs. 5.07 L; p = 0.0251), vital capacity (VC) (2.97 vs. 3.31 L; p = 0.0065), forced expiratory volume in one second (FEV1) (2.07 vs. 2.44 L; p < 0.001) and forced vital capacity (FVC) (2.78 vs. 3.19 L; p < 0.001) were significantly improved. No significant differences were found for diffusing capacity of lung for carbon monoxide (DLCO) (17.09 vs. 17.24; p = 0.734), and FEV1/FVC (0.77 vs. 0.77; p = 0.967). Interestingly, improvements were more pronounced in patients with large PEH (type IIIb and IV). At 12 month follow-up, both gastrointestinal and respiratory symptoms were significantly improved and 94% of patients were satisfied with the operation. The GERD-HRQL (18.1 ± 7.9 vs. 4.01 ± 2.4; p = 0.001), RSI (37.8 ± 9.7 vs. 10.6 ± 8.9; p < 0.001) and all SF-36 items were improved.

CONCLUSIONS

LTF for the treatment of PEH is safe and seems to be effective up to 12 month follow-up with improved lung volumes, spirometry values, quality of life, gastrointestinal and respiratory symptoms.

Impact of Paraesophageal Hernia Repair on Respiratory Function: A Systematic Review

Background and Objectives: Surgical repair of hiatal and paraesophageal hernia is widely accepted for the treatment of gastroesophageal reflux symptoms. The respiratory benefit of this surgery is less clear. The objective of this review is to quantify the benefit to pulmonary function and subjective dyspnea of paraesophageal hernia repair with the aim of refining the indications and contraindications for elective paraesophageal hernia repair.

Methods: Articles were gathered from systematic searches of the Medline Complete Database via the Creighton University Health Sciences Library literature search services. Publications with both pre and postoperative pulmonary function data or both pre and postoperative subjective dyspnea data with regards to surgical paraesophageal hernia repair were included.

Results: Six studies were included in this review. The majority of studies in this review show improvement in pulmonary function postoperatively with regards to FEV1, FVC, and VC when stratified by % intrathoracic stomach (ITS), particularly in groups >50% ITS. No significant change was seen in postoperative DLCO or FEV1/FVC.

Conclusion: Paraesophageal hernia repair has shown to improve pulmonary function both objectively and subjectively. This review was limited by the paucity of literature on the subject as well as the lack of a standardized method for measurement of %ITS.

Critical appraisal of the impact of surgical repair of type II-IV paraoesophageal hernia (POH) on pulmonary improvement: A systematic review and meta-analysis

BACKGROUND

Paraoesophageal hernia (POH) comprising type II-IV hiatal hernia often presents with pulmonary symptoms such as shortness of breath. However, impact of surgical repair on improvement in pulmonary symptoms is unclear.

OBJECTIVE

This systematic review and meta-analysis aimed at characterising impact of POH repair on patient reported improvement in pulmonary symptoms.

METHODS

This systematic review identified studies reported pulmonary symptoms in patients with undergoing surgical repair for Type II-IV POH from 1st January 2001 to 1st December 2018. Primary outcome was improvement in pulmonary symptoms. Secondary outcomes were improvement in other patient-reported outcomes such as heartburn, regurgitation, chest pain, and dysphagia and intraoperative and postoperative outcomes.

RESULTS

This systematic review identified 27 studies (n = 4428 patients) reporting assessment of pulmonary symptoms. However, only 21 studies (n = 2902 patients) reported preoperative and postoperative pulmonary symptoms and hence these were included in the final meta-analysis. There was significant improvement in pulmonary symptoms following POH repair (OR: 8.40, CI_95%: 4.91-14.35, p < 0.001), with improvement in all types of POH. Rates of overall and major complications were 16% and 5%, respectively. Rates of conversion, 30-day mortality, reoperation and recurrence were 2%, 1% 4% and 12% respectively.

CONCLUSION

This review demonstrates that POH repair is associated with improvement in pulmonary symptoms with acceptable low laparoscopic conversion rates, morbidity, mortality and recurrence rates.

Who gets a PEG? An analysis of simultaneous PEG placement during elective laparoscopic paraesophageal hernia repair

INTRODUCTION

Percutaneous Endoscopic Gastrostomy (PEG) is an infrequent adjunct in elective paraesophageal hernia repair (PEHR). Guidelines denote that PEG "may facilitate postoperative care in selected patients." Though there is sparse literature defining which patients may benefit. The purpose of this study is to determine factors associated with simultaneous PEG placement during PEHR and their subsequent outcomes.

METHODS

The NSQIP database was queried from 2011 to 2016 for patients undergoing elective laparoscopic PEHR. Cases were excluded if PEHR or fundoplasty was not the primary procedure, a concomitant bariatric procedure was performed, or if the primary surgeon was not a general or cardiothoracic surgeon. Groups were Propensity Score Matched for age, BMI, and ASA Class.

RESULTS

15700 patients were identified, 371 who underwent simultaneous PEG placement (2.4%). Non-PEG patients were matched at a 5:1 ratio, producing 1855 controls. PEG patients had higher rates of pre-operative dyspnea (OR 1.45, p = 0.0110), pre-operative weight loss (OR 2.87, p = 0.0001), and lower pre-operative albumin (3.92 vs. 4.01, p = 0.0129). PEG patients had more intra-operative contamination (mean Wound Classification 1.54 vs. 1.38, p < 0.0001) and longer case durations (170 vs. 148 min, p < 0.0001). PEG patients had longer lengths of stay (3.4 vs. 2.5 days, p = 0.0001), rates of superficial SSI (OR 5.82, p = 0.0012), peri-operative transfusions (OR 2.68, p = 0.0197), and pulmonary emboli (OR 3.61, p = 0.0359).

CONCLUSION

Patients undergoing simultaneous PEG during PEHR are more likely to have respiratory symptoms, markers of malnutrition, and intra-operative factors indicative of more technically challenging cases. These patients have longer hospitalizations, higher rates of superficial SSI, and more pulmonary emboli.

The effect of obesity on lung function

INTRODUCTION

There is a major epidemic of obesity, and many obese patients suffer with respiratory symptoms and disease. The overall impact of obesity on lung function is multifactorial, related to mechanical and inflammatory aspects of obesity. Areas covered: Obesity causes substantial changes to the mechanics of the lungs and chest wall, and these mechanical changes cause asthma and asthma-like symptoms such as dyspnea, wheeze, and airway hyperresponsiveness. Excess adiposity is also associated with increased production of inflammatory cytokines and immune cells that may also lead to disease. This article reviews the literature addressing the relationship between obesity and lung function, and studies addressing how the mechanical and inflammatory effects of obesity might lead to changes in lung mechanics and pulmonary function in obese adults and children. Expert commentary: Obesity has significant effects on respiratory function, which contribute significantly to the burden of respiratory disease. These mechanical effects are not readily quantified with conventional pulmonary function testing and measurement of body mass index. Changes in mediators produced by adipose tissue likely also contribute to altered lung function, though as of yet this is poorly understood.