81 yo man for consideration of hiatus hernia repair to treat dyspnoea

Background

• Large hiatus hernia – involving entire stomach and some omentum
  • Reflux controlled on PPI – no GI symptoms
  • Nocturnal dry cough

Issues

• Fibrotic lung disease 
  • Retired mine worker
  • Regular Respiratory review: 
  • NYHA class 3 dyspnoea, 50m on flat 
  • PFT’s – TLCO 39% FEV1 70% pred 
  • Commenced antifibrotic medication day before perioperative review
• Dyspnoea 
  • Limiting quality of life for patient – no longer able to garden
  • Independent in ADL’s
  • Dynamic component?
    • Objectively better functional capacity than reported by respiratory team – NYHA class 2/3
    • DASI 5 METS, walked from carpark to clinic without stopping including stairs
• Ejection systolic murmur noted on examination – not previously documented. No recent echocardiograms

Discussion

• Difficult to ascertain how much dyspnoea is attributable to hiatus hernia:
  • Multifactorial dyspnoea may not improve with this surgery
  • Possible it is attributable to underlying fibrotic disease.
• Patient and family undecided – only keen to proceed if surgery likely to improve dysapnoea
• Recurring question for in PIG
  • Systematic review paper found – 262 patients (see attached )
  • Results showed Improved FEV1 but not residual volume or DLCO
• Echocardiogram required to assess degree of LA compression and AV structure/function
• Article: Hernia (2023) 27:839–848 https://doi.org/10.1007/s10029-023-02756-5

Plan

• Echocardiogram
• Continue antifibrotic medication for 3 months until next respiratory review 
• Re-review in perioperative clinic prior to decision whether or not to proceed