[Surgical treatment of paraesophageal hiatal hernia with total intrathoracic volvulus of the stomach].

UNLABELLED: From 1971 to 1993, we operated 44 patients, 34 females and 10 males with a paraoesophageal hernia in which the entire stomach entered the thorax. Mean age of the patients was 70 years. Seventeen patients underwent emergency surgery for strangulated hernia leading to complete ghastric occlusion, gastric bleeding or necrosis (3 cases). Only 2 patients had a past history of gastro-oesophageal reflux. The following techniques were used: abdominal access in all cases, saccular resection, closure of the widened hiatus or of a left sided hernial hiatus, anterior gastropexy suturing the greater curvature to the abdominal on the left. Several patients were in precarious clinical situations and had to be treated under local or regional anaesthesia alone. Two patients had partial necrosis of the stomach and were treated by partial gastropexy. There were no deaths or major complications. Incomplete recurrence was noted in one patient 2 years after the initial procedure.

IN CONCLUSION: 1) abdominal access is much preferable; 2) an antireflux procedure is only indicated when the patients have signs of gastro-oesophageal reflux; 3) most complications are not due to the hernia itself but to gastric volvulus. Consequently, simple reduction of the hernia followed by anterior gastroplexy under local anaesthesia can give excellent results in patients in precarious clinical situations and argues against major operation with general anaesthesia; 4) due to the gravity of paraesophageal hernia, a surgical solution is required as soon as diagnosis has been confirmed.