ESOPHAGEAL HIATUS HERNIA WITH SPECIAL REFERENCE TO ENDOSCOPIC DIAGNOSIS SEIBI KOBAYASHI, M.D. Department of Internal Medine Aichi Cancer Center Hospit

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1 \ -1 Symptoms and Associated Endoscopic Esophagitis in Esophageal Hiatus Hernia \ - 2 Gastroscopic and Radiologic Correlation Gastroenterological Endoscopy

2 ESOPHAGEAL HIATUS HERNIA WITH SPECIAL REFERENCE TO ENDOSCOPIC DIAGNOSIS SEIBI KOBAYASHI, M.D. Department of Internal Medine Aichi Cancer Center Hospital There are two methods available to the endoscopic identification of esophageal hiatus hernia : esophagoscopic approach to identify a hernia sac between the gastroesophageal junction and hiatal opening (direct method) and gastroscopic approach to presume herniation of the gastric mucosa through the hiatus by looking upon the cardial opening inside the stomach (indirect method). 1) Direct method by A total of 40 patients were found to have an esophageal hiatus hernia among 2200 esophagoscopic examination with a fiberoptic instrument : slidingg type, by employing the retroflexion (U-turn) method for Type 4 : Cardial orifice hidden by radiating folds, 38: paraesophageal type, 1 : mixed type 1. The incidence of esophagitis associated with an esophageal hiatus hernia was very high and noted in 24 (60%) of the 40 patients. 2) Indirect method by gastroscopy. Several shapes of the cardial orifice were recognized observing the cardia during gastrscopic examination. The shapes of the cardial orifice to the stomach were classified as follows. Type 1 : Tightly closed cardial orifice. Type 2 : Triangular shaped cardial orifice. Type 3 : Folds radiating towards cardial orifice. especially from posterior wall. Type 5 : Entire fundus shows collapse, and cardial orifice is hidden by collapsed f undal mucosa. 1) Ortega, J. A.: New Criterion in the Esophagoscopic Diagnosis of Sliding Type Hiatal Hernia. Am. J. Gastroenterol. 57:410415, ) Schachter, H. and Kobayashi, S.: The gastroscopic retrof lexion method in the diagnosis of sliding esophageal hiatus hernia. Gastrointest. Endosc. 17: 78 ` 80, Type 6 : Small hole seen beside tube at cardial Using these classification of cardial types, we found 4 instances of radiologic hiatus hernia in the group of 133 patients having an endoscopic Type 1 cardia, 7 of 103 with Type 2, 9 of 21 with Type 3, 7 of 9 with Type 4, 2 of 2 with Type 5, and in 24 of 32 with Type 6. Of 64 patients classified as having cardial Type 3 through 6, approximatery 66% showed

radiologic hiatus hernia on routine examination. On the other hand, in 38 (84%) of 45 patients having a radiologically demonstrated hiatus hernia excluding "suspicious" gastroscopy.

3 radiologic hiatus hernia on routine examination. On the other hand, in 38 (84%) of 45 patients having a radiologically demonstrated hiatus hernia excluding "suspicious" there was agreement of retrof lexion In conclusion, while the usefulness of retrof lexion (U-turn) gastroscopic examination as compared with other methods for detecting esophageal hiatus hernia remains to be evaluated, observations using this technique allow description of typical cardial mucosal fold patterns and suggest a significant correlation between those and the erpsence or absence of radiologically demonstrated hiatus hereia. Schachter, H. and Kobayashi, S. The gastroscopic retroflexion method in the diagnosis of sliding esophageal hiatus hernia. Gastrointestinal Endoscopy , 1970.

4 ENDOSCOPIC DIAGNOSIS OF THE SLIDING HIATUS MISAO HERNIA YOSHIDA Institute of Gastroenterology Tokyo Women's College of Hiatus hernia is the constant or recurrent protrusion of parts of the stomach through the hiatus of the diaphragm into the thorax. Hiatus hernia can be classified into three types; (1) Sliding hiatus hernia; (2) Paraesophgeal hiatus hernia; (3) Mixed hiatus hernia. In our esophagoscopic examinations ( ), we found 238 cases of sliding hernias and only one case of mixed hernia. On endoscopic diagnosis sliding hernia, we must reveal elevated esophagogastric mucosal junction with gastric mucosa extending as a sac from the esophagogastric mucosal junction to the diaphragmatic pinchcock. Severe sliding hernia was found in 31 cases; 15 % of all sliding hernias. The position of the esophagogastric mucosal junction was at 32.5 cm from the upper incisors on average. The length of the hernia from the esophagogastric junction to the diaphragmatic pinchcock was 6.1 cm on average. We found reflux esophagitis in almost every case and found stricture in 54 % of them. Moderate sliding hernia was found in 51 cases ; 21 % of all sliding hernias. The esophagogastric mucosal junction was at 34 cm from the upper incisors on average. The length of the hernia was 4.1 cm on average. Stricture was found in 6 % of them. Slight sliding hernia was found in 149 cases; 62 % of all sliding hernias. We found the esophagogastric mucosal junction at 38 cm from the upper incisors on average. Ref lux esophagitis was found in 33 % of them. The length on the hernia was 2 cm on average. Ther foundd no stricture. Reflux esophagitis was found in 53 % of all sliding hernias, stricture was found in 9.2 %. Surgical treatment was performed in only 1.7 % of all For the improved diagnosis of the sliding hernia, we used a esophagof iberscope which is able to flex 200 degrees in one direction at the top of the instrument. With this f iberscope we observed the shape of the cardia of the sliding hernia and classified the Gastroenterological Endoscopy

findings of the cardia into three types; (1) TYPE-I; large diaphragmatic hiatus with gastric mucosal fold concentrating to the border of the hiatus was found without forming nomal cardial lip.

5 findings of the cardia into three types; (1) TYPE-I; large diaphragmatic hiatus with gastric mucosal fold concentrating to the border of the hiatus was found without forming nomal cardial lip. The esophagogastric mucosal junction can be observed at the top of the hernia. (2) TYPE- U ; moderate size oval hiatus was found without forming normal cardial lip. Esophageal mucosa and the esophagogastric mucosal junction can be seen at the middle portion of the hernia. (3) TYPE- ID ; Loose cardial orifice was found under near the maximal intragastric pressure. The esophagogastric mucosal junction can be seen just inside and slight orl the cardial orifice. Severe hernia has TYPE-1 moderate hernia has TYPE- U, and slight hernia has TYPE- V cardial shape. Small reversible sliding hernia can be missed on esophagoscopy without abdominal compressiotn. Following the esophagoscopy, we observed the cardia under near the maximal intra gastric pressure and the relation between the cardial orifice,f hernia and the esophagogastric mucosal junction. this method is very useful! especially on diagnosis of the slight sliding hernia.

6 Second Surgical Department, Chiba Univ. School of Medicine THE CLINICAL EVALUATION ON THE INTRA- LUMINAL PRESSURE AND ph MEASUREMENT OF ESOPHAGEAL HIATAL HERNIA TSUYOSHI HIRASHIMA We experienced 177 cases of esophageal hiatal hernias between 1965 and 1974 in our Department. According to Zaino's classification. 173 cases were in the type of sliding hernia, one case was of paraesophageal hernia and 3 cases were of combined form. On the age distribution, there were 79 cases, that is 44.6% between 60 and 69 years of age, there were 38 cases that is 21.5% between 70 and 79 years of age and there were 28 cases, that is 15.8% between 50 and 59 years of age. There were more cases in the aged group. On sex difference, there were 71 male and 106 female. Concerning on the complaints, heartburn was the most in the incidence; 55 cases that is 47.4 %. The difficulty of swallowing was the second ; 38 cases that is 32.8 %. There were 25 operated cases. The reduction, closure and fixation was performed on 17 cases, that was the most in incidence. The resection of gastric fundus was done on 4 cases, fundplication on 2 cases and esophagocardiac plasty with gastric patch was on one case. The follow-up result was the best in the reduction, clcsure and fixation. We performed the measurement of esophageal intraluminal pressure on swallowing and resting states, and also in the combination with ph measurement, roentgenogram and electromyogram. The results were summarized as follows ; 1) The combined measurement of intra-luminal pressure and roentgenogram. We devised the induction tube for resting pressure measurement, in marking with lead and enamel line every one cm for each 5 cm orally and distally from the side hole. We measured the point of respiratory revarsal and then fixed the side hole with PRR. We made roentgerogram in this state, and we knew correctly the difference and length between the point of physiological attachment of diaphragm and the slided stomach. 2) The resting pressure of esophagocardiac junction. We noticed here 2 types of resting pressure curves, Gastroenterological Endoscopy

7 that is the mono-phasic and di-phasic peaks in the lower pressure zone. In the mean value of normal lower pressure zone, the pressure of PRR was 8.1 cm and the length was 3 cm. On the mean value of 7 cases of 19 cases of mono-phasic type, there was an elongation of HPZ. In the mean value of 7 cases of di-phasic type, both of the peaks were lower than the normal. Those findings of elongation of high pressure zone and di-phasic character were interpreted as the disociative phenomen of extrinsic and intrinsic constriction mechanism. The di-phasic type suggested the existence of the severe functional disturbance of esophagocardiac function. In the cases of di-phasic type, there were shown endoscopically erosion and ulcer due to ref lux esophagitis. 3) The combined measurement of resting pressure and ph. The normal ph curve rose sharply in accordance with PRR, while that of hiatal hernia cases differed in several centimeters or rose only gradually. In this method of combined measurement, we accomplished a quantitative measurement. 4) The measurement of swallowing pressure. In the measurement of swallowing pressure simaltaneously on 3 or 6 points, we recorded and recognized the following characteristics; the appearance of negative wave orally to the lower high pressure zone and the late appearance of 'positive wave. In this discussion we evaluated the diagnostic value of the measurement of esophageal intra-luminal pressure under the combined methods. We concluded that these were valuable as a diagnostic method for determining the operative indication and suggesting the operative method from the functional point of view.

8 ESOPHAGEAL HIATAL HERNIA YOSHIYA KUMAGAI M.D. Dept. of Surgery School of Medicine Keio University Untill April 1975 about 10, 000 adult people regis- trated in our system. Esophageal diaphragmatic sliding hiatal hernia is a common disorder in American and Europian people, but in Japanese the incidence of this disease has been considered to be very low. In fact very few literature discussed about the frequency of hiatal hernia in Japanese people. Incidence of the hiatal hernia in Japanese people was studied by the retro-spective long time follow up mass survery group. Material and Methods film study on the Eight years ago in Keio Cancer Detective Center the mass survey of upper G-I X-ray series had been started upon the people who were registrated able to receive continuous examination every year. to be All of the 8 years follow up films of the 520 people who had been registrated 8 years ago in our system and had been receiveing continuous follow up study of X -,ray G-I reries, were examined retrospectively by 2 doctors under the established criteria in order to determine if the people have hiatal hernia or not. 17 people were eliminated, who had been post operative state from the begining or operated upon cancer of the stomach (2 cases) or upon other disorders within these 8 years. Gastroenlerological Endoscopy

9 X-ray findings were classified into following three groups grade V. irreducible hernia, grade II. reducible hernia, and grade I. minimal hernia or doubtful hernia. Results 2 people had grade V (0.4%) irreducible hernia. 28 people had grade U(5.9%) reducible hernia and 49 people grade T (9.7%). minimal or doubtful hernia were group. 424 non hernia group were also studied as a control Ulceration of the esophagus and duodenum were found in 72 hernia group 10.0 %, and this incidence was higher than in control group (4.2 %). The incidence of upper G-I diverticulum in people with grade II. & III. hernia was 37.5% (11 out of 30). In control group upper G-I diverticulum co-incided only 4.5% (19 out of 424). The incidence of esophageal erosion or ulceration for which the treatment should be done in the people with grade U. & V, hernia, was 10%. (by the esophagoscopic study) Discussion and Conclusion The incidence of the diaphragmatic hiatad hernia in Japanese people was discussed and it was not lower than in American or Europian people. Diaphragmatic sliding hiatal hernia found 6 % in normal adult in our examination, but only for 10 % of them the treatment of esophagitis were necessary. It will be suggested that hiatal herniation should not be considered as clinical disease in Japan but only a state of the gastro-esophageal deformity.

11 TUS HERNIA SPINAL DEFORMITY AND ESOPHAGEAL HIA- HIROYOSHI KOIZUMI, TATSUO WADA, EIJI ARITA 1st Department of Surgery Yokohama City University, School of Medicine Department of Surgery Yokohama Minami Kyosai Hospital Since the installation of clinic of the esophageal diseases in September, 1969 till in April, 1975, 368 cases have been encountered in this clinic. Among them, in 14 cases was observed the esophageal hiatus hernia. In all 14 cases, in 12 cases was recognized the compression fracture of the spinal column, in 2 cases due to the trauma and in 10 cases due to the osteoporosis. The sites of the fracture were found between the 6 th. thoracic and the 3 rd. lumbar vertebrae, in 6 cases it was recognized at the level of the 12 th. thoracic vertebra. In 4 cases was observed the kyphosis ; in the other 4 cases the scoliosis ; in the last Gastroenterological Endoscopy

12 4 cases was recognized the kyphoscoliosis. Among them, in 5 cases weer adopted the corsets. From the above described findings, the spinal deformity might be suspected to be the triggering factor for the occurrence of the esophageal hiatus hernia. Of the relationship between the spinal deformity and the esophageal hiatus hernia, quite a few, if any, papers have been issued. Henry. L Bockus reported that the kyphosis of the spinal column pulled down the rib with resulting in descendence of the diaphragma below the normal position. Concerning this point, further consideration must be added in future to the previous excellent works. Ç Á Œ¾ \ Manometric Diagnosis of Hiatus Hernia \ Department of Medicine University of Chicago Charles S. Winans, M.D.

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