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OPERATIONS FOR HIATUS HERNIA

PERHAPS the biggest problem associated with themanagement of hiatus hernia arises from the extreme

variability of the disability it causes. Dyer andPridie 1 investigated 95 symptom-free subjects anddemonstrated hiatal herniation in 33%, thoughreflux occurred in only 5 cases; but when gastro-oesophageal reflux is present there is increasing evidencethat repair of the hernia will diminish or abolishthe symptoms of heartburn and retrosternal pain 2-6

(though there is disagreement about how this relief isobtained).The simplest surgical treatment is reduction of the

hernia and tightening of the hiatus behind the oeso-phagus, thereby refashioning the gastro-oesophagealangle and restoring the subdiaphragmatic oesophagealsegment. The results of this procedure vary consider-ably in different surgical hands; the recurrence-rate ofherniation is usually 10-30%, and an even greaterproportion have radiologically demonstrable reflux. 7Yet there have been few attempts to compare different

surgical approaches. Magarey has reviewed theresults obtained in 101 patients in whom a slidinghiatus hernia was repaired by the same surgeon usingthree different operations. The earlier patients (64)underwent transthoracic or transabdominal repair andthe later cases (37) were treated by fixation of thegastric lesser curve to the anterior abdominal wall asdescribed by Boerema.9 The Boerema procedure isperformed through an upper abdominal incision, andthe lower oesophagus is mobilised until at least 5 cm.can be drawn into the abdomen. Posterior suture of thecrura was sometimes omitted, the important step beingthe fixation of 5 cm. or more of the lesser curve of thestomach to the anterior abdominal wall so that theoesophagus is held down into the abdomen undertension. The fundus of the stomach is left free to rollup under the diaphragm and restore the gastro-cesophageal angle. Since similar repair of the hiatuswas achieved equally by the thoracic and abdominalapproaches these two groups were combined, and thepostoperative results at 6 months to 5 years later werecompared with those of the Boerema procedure byquestionary. At 6-12 months and at 1-2 years therewere significantly fewer failures in the Boerema

group, and none were encountered after 2 years,

though the number of patients was inadequate forthese later follow-up results to be conclusive. Sympto-matic relief did not correlate closely with radiologicalfindings, and it is clear that the benefit to the patient ofsurgical repair of hiatus hernia cannot be judged frombarium-meal examinations Even so, after 2 yearsmore than half of the patients undergoing thoracicrepairs had recurrent herniation, compared with a thirdin the Boerema group.

1. Dyer, N. H., Pridie, R. B. Gut, 1968, 9, 696.2. Allison, P. R. Surgery Gynec. Obstet. 1951, 92, 419.3. Harrington, S. W. ibid. 1955, 100, 277.4. Cross, F. S., Smith, G. V., Jr., Kay, E. B. J. thorac. cardiovasc.

Surg. 1959, 38, 798.5. Barrett, N. R. Br. med. J. 1960, ii, 247.6. Wooler, G. H. Gut, 1961, 2, 91.7. Atkinson, M. Br. med. J. 1967, iv, 218.8. Magarey, C. J. Br. J. Surg. 1972, 59, 432.9. Boerema, I. Surgery, St. Louis, 1969, 65, 884.

10. Edwards, D. A. W., Phillips, S. F., Rowlands, E. N. Br. med. J.1964, ii, 714.

The success of surgical repair of sliding hiatushernia has yet to be explained. The explanationsoffered are at variance with observations on the roleof the lower oesophageal sphincter in resisting thepressure gradient between abdomen and thorax; andthe disturbing implication to be drawn from the

experiments of Cohen and Harris 1 was that operativereplacement of the sphincter to a position below thediaphragm cannot be expected to affect its competencein controlling reflux. Yet, as Edwards et al. 10 point out,hiatus hernia is very much a disease of symptoms, andif the superiority of the Boerema procedure be con-firmed its simplicity has much to commend it, and theabdominal approach confers the advantage of allowingother operative procedures to be performed in addi-tion to hiatus repair. Nevertheless, reservations remain.Retrospective studies and the type of review in whichpatients are asked by questionary to state their currentsymptoms and to recall their preoperative conditionare always a little suspect. There is still great scopefor a controlled trial of surgical procedures andapproaches to answer the difficult question of what isthe best treatment for hiatus hernia.

RETAINING WOMEN DOCTORS

THE day of a woman doctor’s wedding may be agloomy one for the Department of Health. The ratioof women to men in the medical schools is rising, andthe Department is worried about the number of womenwho leave the National Health Service after marriage.Its first efforts were directed at creating more part-timejobs for women with domestic commitments, and thesewere quite successful; now an imaginative scheme hasbeen announced aimed at the many women who,though unable at present to take on any regularprofessional duties, would like to return to medicalpractice eventually. In the past, many such women havebeen permanently lost to medicine.The Women Doctors’ Retainer Scheme 12 will be open

to women (and possibly some men) under 55, workingless than two sessions or the equivalent a week, whoare prevented by domestic commitments from doingmore. A member of the scheme will be paid a E50retainer annually, and for this she will be expected tokeep up medical registration and membership of amedical defence organisation, read a professionaljournal, attend at least 7 " education " sessions a year,and do at least 12 " service " sessions a year. The idea isthat she will maintain her professional skills and train-ing so that, when free, she will be able to go back intomedicine without a break. The scheme will be run

by regional boards, which will have to ensure thatsuitable service sessions are available. The scheme isnot open-ended-membership will be reconsideredannually-but no-one is likely to be eliminated withoutthe recommendation of the regional postgraduatecommittee. Most women who want eventually to goback into medicine will be able to fulfil the minimumcriteria, at least.

11. Cohen, S., Harris, L. D. New Engl. J. Med. 1971, 284, 1053.12. Women Doctors’ Retainer Scheme. Department of Health and

Social Security and Welsh Office. H.M. (72)42.