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Invited Critique |

What Do the Esophagus and a Jump Rope Have in Common?  Comment on “Effects of Large Hiatal Hernias on Esophageal Peristalsis”

Jeffrey H. Peters, MD
Arch Surg. 2012;147(4):357-358. doi:10.1001/archsurg.2012.154.
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The association of hiatal hernia and foregut disease emerged in the late 19th century and its association with esophageal mucosal injury, in the 1930s to 1950. The functional consequences of hiatal hernia, however, remain incompletely understood. Roman et al1 have contributed considerably to the understanding of hiatal hernia; this article continues that trend. It is useful to consider the sphincter (LES) and esophageal body separately to simplify interpretation of the data. Large hiatal hernias have long been shown to lower LES pressure because the CD are an important component of the normal high-pressure zone. The effect of hernia on sphincter relaxation (IRP) is less well studied, although experience with paraesophageal hernias would suggest that complex hernias may impair relaxation. As Roman et al emphasize, however, interpretation is complex. The LES residual pressure is measured in reference to intra-abdominal gastric pressure and a catheter coiled in a large hernia will alter the calculation. This article nicely discusses the complexities of this issue, although detail of the individual patient anatomy in those with elevated IRP is absent, which does not help answer the question of causation. The data and discussion of abnormalities of the esophageal body are also revealing. Roman et al seem to be arguing that although abnormalities in power and coordination of the esophageal body are common, particularly rapid contractions/spasm, they may be “artifactually” altered by shortening and loss of anchoring of the esophagus. This conclusion is premature, as the motility abnormalities may have important symptomatic consequences. Roman et al do not relate dysphagia in patients with or without abnormal propagation speeds. Finally, manometric abnormalities do not directly measure the true function of the esophagus, which is the movement of solids and liquids from the pharynx to the stomach. Surely the next step is to relate HRM findings to symptoms and/or their improvement following hernia repair.

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