Postgrad Med J: first published as 10.1136/pgmj.42.494.765 on 1 December 1966. Downloaded from POSTGRAD. MED. J. (1966), 42, 765. ARTIFICIAL IN THE DIAGNOSIS AND TREATMENT OF HIATUS N. GEFFEN, M.B., Ch.B., D.M.R.D.,* B. MAISEL, M.D. Departments of Radiology and Surgery, New York Hospital -Cornell Medical Center, New York

THE ANATOMY and physiology of the distal oesopha- extent of herniation, but after studying 300 cases of gus is well established and the radiological boundar- hiatus hernia by cinefluorography, Campeti, Geffen, ies of hiatus hernia are well defined so that Charles and Watson (1962), believed that the uncertainty in diagnosis is now unnecessary. symptoms were related to the tone of the lower Nevertheless, correlation between the radiological oesophageal sphincter. If the sphincter was hypo- evidence of hiatus hernia and the symtomatology is tonic and overcome, oesophageal reflux would incomplete. Large may exist with minimal occur and this produced symptoms. If the sphincter or no symptoms; conversely, severe symptoms often was hypertonic then dysphagia could result. Such accompany minor radiological changes. a classification, however, though functionally The true incidence of hiatus hernia is unknown, useful, presupposed that the symptoms were all and varies with the techniques employed and in the due to oesophageal reflux and this is clearly an Protected by copyright. selection of patients. The radiological incidence over-simplification. Symptoms may also result from varies from 1 % to 20% (Kirkland and Hodgson, congestive, ulcerative and inflammatory changes in 1947), to 73.3 % (Schatzki, 1932). Edmonds the oesophagus or gastric loculus, early stricture (1957) reports an incidence of 3.3%, Hafter (1958). formation, motor dysfunction of the oesophagus 12.5% and Stein and Finkelstein (1960), 50% in and a lower oesophageal ring. 100 consecutive examinations in adults. It has been The symptoms of hiatus hernia may be confused suggested that approximately half the patients with with those of peptic ulcer, disease, or hiatus hernia are asymptomatic and in a further even cardiac disease, and in many cases though an 250% there is often doubt as to whether the hiatus anatomical defect may be demonstrated, the hernia is directly responsible for symptoms (Moersch, difficulty in establishing a diagnosis is so great that 1963). doubt is left as regards treatment. Palmer (1955) Akerlund (1926) originally classified the radio- in correlating symptomatology with hiatus hernia found 17 distinct symptom-complex logical appearances into Type 1 - the congenitally patterns and short oesophagus and or with thoracic stomach; Clerf, Shallow, Putney and Fry (1950) in a group of cases diagnosed as http://pmj.bmj.com/ Type 2 - the para-oesophageal type; and Type 3 hiatus hernia found, on - the remainder, in which the distal variants may completion of investigation, an error in diagnosis of be accompanied by identical symptoms. Allison 35 % in 110 cases, in which the disease was confused (1951) considered that sliding and para-oesophageal with carcinoma, achalasia, peptic ulcer, myocardial hernias gave rise to different symptoms and had a disease and . This difficulty in diagnosis different prognosis. Barrett (1954) simplified the is, of course, compounded by the coincidental disease of these other organs, and may add to classification into (A) - sliding hiatus hernia; (B) - any - symptoms already the result of hiatus hernia. para-oesophageal hernia; (C) mixed; and this on October 1, 2021 by guest. appears a practical classification, though true Palmer emphasised the association of diseases para-oesophageal is probably rare, the majority of sometimes described as 'Saints triad' (hiatus hernia, these being of the mixed type. cholecystitis, coli), and found this association in 17% of 381 patients. When doubt It is probable that the symptoms associated with existed as to which feature was responsible for hiatus hernia are produced by interference with the symptoms, than a retrospective analysis of the sphincteric mechanism at the distal oesophagus. results of treatment suggested that in these patients Tumen, Stein and Schlansky (1960) graded their the least relief was obtained from cholecystectomy series of hiatus hernias according to the size and and the greatest satisfaction accrued from repair of the hiatus hernia. Edmonds found coincidental *Present address:-Department of Radiology, College of disease in 120% of 204 cases of hiatus hernia. Physicians, and Surgeons of Columbia University, In this clinical dilemma some method of assessing Francis Eelafield Hospital, New York. the likely results of surgery would be valuable and Postgrad Med J: first published as 10.1136/pgmj.42.494.765 on 1 December 1966. Downloaded from 766 POSTGRADUATE MEDICAL JOURNAL December 1966 a technique for predicting the outcome of surgery between 1950 - 1962, and of these 12 were examined would clearly resolve many of the difficult problems. using cinefluorography. The patients were divided Under these circumstances, a method of imitating into two groups:- the end result of surgery might be expected to predict the value of operation and we have used Diagnostic (Group A) artificial pneumoperitoneum in this respect. In 36 patients whose average age was 58 years, (the Artificial is a well-established youngest 14 months and the oldest 85 years) artificial pneumoperitoneum pneumoperitoneum was induced and the result noted. method of treating pulmonary tuberculosis and has (Table 1). All had symptoms such as , belching, also been used as a pre-operative measure to stretch dysphagia, regurgitation, haematemesis, etc., which the abdominal wall prior to surgery for giant could be directly attributable to hiatus hernia. In many, ventral hernia (Mason, Kootz and Graves, radiological and other examinations provided evidence of 1956; associated lesions (cholelithiasis, , peptic 1954). Maisel and others described the technique ulcer, cardiac disease) and often there was considerable which we have used and its usefulness in the pre- doubt as to the significance of the hiatus hernia in operative preparation of patients undergoing total causing symptoms. In some cases artificial pneumoperi- has been assessed (Weedon and Maisel, toneum was instituted after failure of the medical gastrectomy treatment. After artificial pneumoperitoneum, 21 1958; Maisel, Cooper and Glenn, 1956). They have patients were relieved of their symptoms and this was also used it as an aid in the differential diagnosis regarded as a positive test. All the patients were treated where myocardial insufficiency and hiatus hernia by operation, with satisfactory results in 20; one patient have been confused (Maisel and Horger, 1956), and had a reccurrence of the hernia eight months after operation. In 15 patients the artificial pneumoperitoneum in the treatment of debilitated geriatric patients with had no effect on symptoms, a negative test, and in eight hiatus hernia (1958). Berry, Holbrook, Langdon of these another diagnosis was subsequently made. and Matthewson (1955) reported similar experiences (Table 1.) In seven cases, however, though reduction of in 10 cases of hiatus hernia with good results in the hernia had no effect on symptoms, no other cause was Protected by copyright. nine, and the present report summarises the found. experience over a period of 12 years by one of us Therapeutic (Group B.) (BM) in the use of this technique for diagnosis and In 38 patients whose average age was 76 years, it was therapy in hiatus hernia. decided to assess the therapeutic value of artificial pneumoperitoneum for associated debilitating disease, principally cardio-pulmonary disease which made the Methods and Results elderly patients unsuitable for surgical treatment or in 74 with hiatus of cases where surgery was refused. Treatment consisted of patients hernia, irrespective 850- 1500 ml. of air given at intervals of two weeks, type, and associated diagnostic or therapeutic though sometimes treatment was interrupted for several problems were studied at the New York Hospital months to assess the efficiency of the procedure. All

TABLE 1 74 PATIENTS TREATED WITH PNEUMOPERITONEUM http://pmj.bmj.com/ GROUP A. GROUP B. 36 Patients treated as a diagnostic test 38 Patients treated without plan for (Average Age- 58 years). hiatal hernioplasty (Vis-a-tergo poor in each). 1. 21 Positive tests and hernioplasty performed: (Average age - 76 years) 20 are well 1 recurrent hernia with symptoms 1. 37 Patients were well during therapy 2. 1 Patient continuous on October 1, 2021 by guest. 2. 15 NegativeNegative tests: pneumoperitoneumrequires (a) 2 sustained coronary occlusions (850pneumoperitoneumcc. of air) at (one of these fatal) 2 weekly intervals (b) 1 retroperitoneal Hodgkin's disease (c) 2 cancer of pancreas at autopsy (d) 2 chronic cholecystitis and cholelithiasis relieved by cholecystectomy (i) 10 year follow up (ii) 6 months follow up (e) 1 cancer of stomach at autopsy (f) 7 had no symptoms associated with No cause found, even in retrospect Postgrad Med J: first published as 10.1136/pgmj.42.494.765 on 1 December 1966. Downloaded from December 1966 GEFFEN AND MAISEL: Artificial Pneumoperitoneum 767 forms of medical treatment were withheld during the therapy. In all cases the hernia was reduced with alleviation of the most distressing symptoms. All patients remained well and the only complications of treatment were temporary, including occasional epigastric distress, shoulder pain or vomiting which was alleviated by a mild sedative and subsided within two or three days. In one case, however, the artificial pneumo- was responsible for the precipitation of an . One patient was maintained in this manner for six years. The initial pneumoperitoneum was induced in hospital and thereafter refills were carried out on an out-patient basis at the pneumoperitoneum clinic.

Discussion These results show that the induction of an artificial pneumoperitoneum provides a useful diagnostic test in patients who suffer from hiatus hernia associated with other lesions, and where there is no doubt regarding the role of the hernia in contributing to the symptomatology. In all cases where the symptoms improved after artificial pneumoperitoneum, subsequent treatment of the hernia surgically showed excellent results except for Protected by copyright. one patient who had an early recurrence of the hernia. In contrast, half of the patients who failed to respond to artificial pneumoperitoneum were subsequently found to be suffering from associated disorders, not all of which were apparent at the time the test. of diagnostic There were seven FIG. 1. - The large para-oesophageal hernia has been patients, however, where the test was negative, but reduced, the abdominal segment of the oesophagus no other explanation of the symptoms could be lengthened, and the hernial sac stays filled with air. found. The efficacy of this diagnostic test is perhaps confirmed by the results of treatment in patients not abdominal pressure resulting from the artificial considered suitable for surgery. The maintenance pneumoperitoneum may even cause an abnormally of artificial pneumoperitoneum in 38 patients has long delay in emptying of the oesophagus. This shown satisfactory results in all but one. occurred in one of our cases and was relieved by The technique is simple and safe and can be the withdrawal of 300 ml. of air. After reduction of http://pmj.bmj.com/ relied on to alleviate the most distressing symptoms. the hernia, the preformed peritoneal sac stays Moreover, artificial pneumoperitoneum has not filled with air (Figs. 1 and 2). produced clinically recogniseable interference with A mechanism of the production of cardiopulmonary function, nor has it complicated has been suggested by Banyai (1939). He measured the operative and post-operative management of a negative pressure in the immediate subdiaphrag- these patients. On the contrary, the great amount matic portions of the diaphragm presumably as a of space beneath the stretched and elevated left result of the transmitted negative intrathoracic on October 1, 2021 by guest. diaphragm may facilitate the repair of the diaphragm pressure. This negativity exerts an upward force on and manipulation of the stomach and oesophagus. the upper abdominal organs. The artificial increase The anatomical and physiological effects of in intra-abdominal pressure will accumulate in the artificial pneumoperitoneum have been studied upper part of the in the erect or semi- experimentally (Maisel, 1955). In dogs its main erect position and neutralise the effects of this effects are an increase in the size of the peritoneal negativity and its upward force. The degree of cavity and in the erect position an elevation of the visceroptosis and elevation of the diaphragm will diaphragm and a visceroptosis of the upper ab- depend on the phase of respiration, tonicity and dominal organs including the stomach. These integrity of the abdominal wall and diaphragm, size effects result in a lengthening of the abdominal of the , variable status of the segment of the oesophagus, and so reinforces the lungs and pleura and the presence or absence of continence of the sphincteric mechanism (Nagle pleuro-pulmonary or peritoneal . There and Spiro, 1961; Wolf, 1960). The increased intra- will of course be no hernial reduction if the hernia Postgrad Med J: first published as 10.1136/pgmj.42.494.765 on 1 December 1966. Downloaded from 768 POSTGRADUATE MEDICAL JOURNAL December 1966

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FIG. 3.-Small sliding hernia partially reduced, but :iiii.·iiircili::··:iit# improvement of symptoms. .I.,.:l;i.iiii.iai;iii..::'';'" Summary :i ii ''''''';··:··:·,r:; Artificial pneumoperitoneum affords an effective FIG. 2.-Another case alleviated by pneumoperitoneum. and safe method for the management of hiatus Stomach in the normal position. Liver and spleen hernia in the aged and poor surgical risk patient displaced downward. Abundant air under both and as a and test in the diaphragms and in the hernial sac (outlined by diagnostic therapeutic arrows). younger patient to distinguish between symptoms from cardiac, gall bladder and other gastro- is incarcerated or peri-oesophageal adhesions are intestinal disease from those due to hiatus hernia. present. My grateful thanks in the preparation of this paper Para-oesophageal and mixed type hernias are to Mr. C. G. Clark, Reader, University Department of intraperitoneal. They will be more uniformly Surgery, Leeds, for his helpful advice and editorial reduced than sliding hiatus hernias which have a assistance. http://pmj.bmj.com/ small sac of peritoneum on the left side only. The right side includes the bare area of stomach and is REFERENCES devoid of peritoneum. In large sliding hiatus AKERLUND, A. (1926): Hernia Diaphragmatica Hiatus hernias, both sides will be covered by peritoneum Oesophagei vom Anatomischen und Rontgenolo- and artificial pneumoperitoneum can be expected to gischen gesichtspunkt, Acta radiol. (Stockh.), 6, 3. relieve them (Fig. 3) ALLISON, P. R. (1951): Reflux , Sliding Hiatal In the or the air will move Hernia and the Anatomy of Repair, Surg. Gynec. supine prone positions, Obstet., 92, 419. on October 1, 2021 by guest. to the anterior and posterior abdominal walls BANYAI, A. L. (1939): Visceroptosis during Artificial respectively resulting in a return of the original Pneumoperitoneum Treatment, Radiology, 33, 751. under the The increased BARRETT, N. R. (1954): Hiatus Hernia, Brit. J. Surg., negativity diaphragm. 42, 231. positive abdominal pressure will then be a potent BERRY, W. C., HOLBROOK, J. P., LANGDON, E. A., and force in the return of the hernia to its original MATTHEWSON (1955): A Study of Hiatal Hernia Using thoracic position. In addition, in the supine Pneumoperitoneum, U.S. Armed Forces Med. J., 6, the increased will be 1715. position positive pressure CAMPETI, F. L., GEFFEN, N., CHARLES, R., WATSON, transmitted to the hernia and if this force is J. S. Jnr. (1962): Small Hiatal Hernia, a Cinefluoro- sufficient to overcome the sphincteric mechanism, graphic Analysis. Presented at 10th International oesophageal reflux will result. The importance of Congress Radiology, Montreal. Book of Abstracts, the erect or semi-erect in or p. 264. position diagnosis CLERF, L. H., SHALLOW, T. A., PUTNEY, F. J., and therapy by artificial pneumoperitoneum is thus FRY, K. E. (1950): Esophageal Hiatal Hernia, J. Amer. emphasised. med. Ass., 143, 169. Postgrad Med J: first published as 10.1136/pgmj.42.494.765 on 1 December 1966. Downloaded from December 1966 GEFFEN AND MAISEL: Artificial Pneumoperitoneum 769 EDMONDS, V. (1957): Hiatus Hernia, Quart. J. Med. MOERSCH, H. J. (1963): Medical Management of Some (NS), 26, 445. Common Esophageal Disorders, N.Y.St.J. Med., 63, HAFTER, E. (1958): Hiatal Hernia, Amer. J. dig. Dis. 398. (N.S.), 3, 901. NAGLE, R., and SPIRO, H. M. (1961): Segmental Response KIRKLAND, B. R., and HODGSON, J. R. (1947): Roent- of the Inferior Esophageal Sphincter to Elevated genologic Characteristics of , Intragastric Pressure, , 40, 405. Amer. J. Roentgenol., 58, 77. PALMER, E. D. (1955): Saints Triad (Hiatus Hernia, KOONTZ, A. R., and GRAVES, J. W. (1954): Preoperative Gall Stones, and Diverticulosis Coli) The Problems of Pneumoperitoneum as an Aid in the Handling of Properly Directing Surgical Therapy, Amer. J. dig. Ann. 759. Dis., 22, 314. Gigantic Hernia, Surg., 140, SCHATZKI, R. (1932): Die Hernien des Hiatus Oeso- MAISEL, B., COOPER, W., and GLENN, F. (1956): Pneumo- phagus, Dtsch. Arch. klin, Med.. 173, 85. peritoneum in the Management of Esophageal Hiatus STEIN, G. N., and FINKELSTEIN, A. (1960): Hiatal Hernia, Hernia, J. Amer. med. Wor. Ass., 11, 299. Roentgen Incidence and Diagnosis, Amer. J. dig. MAISEL, B. (1958): The Role of Pneumoperitoneum in Dis. (N.S.), 5, 77. the Non-Surgical Treatment of Esophageal Hiatal TUMEN, H. J., STEIN, G. N., SCHLANSKY, E. (1960): X-Ray Hernia, Amer. Rev. Tuberc., 78, 623. and Clinical Features of Hiatal Hernia, Gastroenterol- MAISEL, B. (1955): Pneumoperitoneum in Preoperative ogy, 38, 873. Preparation for Total Gastrectomy: Experimental WEEDEN, W. M., and MAISEL, B. (1952): Pneumo- Study, Surg. Gynec. Obstet., 100, 595. peritoneum as an Adjuvant in the Preoperative MAISEL, B., and HORGER, E. (1956): Pneumoperitoneum Preparation of the Patient for Total Gastrectomy, as a Diagnostic-Therapeutic Test, J. Amer. med. Ass., N. Y.St. J. Med., 52, 448. 160, 868. WOLF, B. S. (1960): The Esophagogastric Closing MASON, E. E. (1956): Pneumoperitoneum in the Manage- Mechanism Role of the Abdominal , ment of Giant Hernias, Surgery, 39, 143. J. Mt. Sinai Hosp., 27, 404. Protected by copyright. http://pmj.bmj.com/ on October 1, 2021 by guest.