PART 1: ANATOMY The aim of this work was to improve operative technique in the control of gastric reflux in hiatus hernia by more exact anatomical knowledge. During dissections to establish the nerve supply of the crura (Collis, Satchwell, and Abrams, 1954) it became obvious that there were points in the anatomy of the area which had not been fully described and were not generally appreciated. It seemed reasonable to presume that the anatomical arrangements were designed for a functional result and that deductions could be made from this study about the mechanism of the oesophageal hiatus. MATERIALIn preparing the previous paper on the nerve supply of the diaphragm, 14 Fig. 7. The overlap below the hiatus presents the usual pattern, but all the fibres forming the lower muscle band come from the left crus. They cross over in a scissor-like fashion, a similar band coming on 4 April 2019 by guest. Protected by copyright.
Anatomy to the surgeon is mainly of interest when it concerns parts that he ordinarily meets. In this respect the diaphragm has only attained an important place in the last 15 years. Before this the abdominal surgeon seldom saw it from below, while his thoracic counterpart was not particularly interested when his main attention was concentrated on the lung. The surgery of the oesophagus has brought these two fields together and has given a new importance to the detailed study of this structure.Our attention was drawn to the importance of. the nerve supply of the crura because of the possibility that the branch to the left half of the right crus might be interfered with during the repair of a hiatus hernia. In order to ascertain if this danger did exist we searched the literature, but no description of the nerve supply of these parts could be found. Much information was obtained about the nerve supply of the diaphragm as a whole, and it was noted that the main controversy had centred around whether or not the phrenic nerves were the sole motor innervation of its musculature. This is an important point which must be settled before confining attention to the phrenic nerve. There is a widely held view that failure to paralyse the diaphragm by a phrenic crush may sometimes be due to the nerve supply reaching the diaphragm by other routes, such as the intercostal nerves. This surgical opinion had much support from earlier anatomical authorities, but would seem to have been completely refuted by the work of Schlaepfer (1926), Jansen (1931, and Strauss (1933).Working on a dog, Schlaepfer sectioned the left phrenic nerve, and after two years killed the animal. All the muscle of the left half of the diaphragm had atrophied and was replaced by fibrous tissue. The line of demarcation between the normal and atrophic areas was clear cut, and he made especial note that this was the case posteriorly. He concluded that the phrenic nerve provided the sole motor supply of the diaphragm. Jansen carried out similar degeneration experiments on goats, and again found that no other nerve supply to the diaphragm existed. The interest in the work of Strauss arises from the fact that he confirmed that the above experiments applied to man. He examined diaphragms from patients who had been treated by phrenic evulsion, and demonstrated that without exception atrophy included the whole of the appropriate side. He also made careful dissections of the nerves and showed that they each divide into three branches, which he followed to the fine filaments only visible with a hand lens. He traced these nerves to the periphery of the diaphragm, and also dissected the intercostal nerves in relation to the attachment of this structure. In this way he proved to his own satisfaction that no branches of the intercostal nerves entered the diaphragm.LOCAL SUPPLY OF THE CRURA It seemed clear from the published work that the nerve supply to the crura could only come from the phrenic nerves, but it was also apparent that no information was available about how t...
The incidence of oesophagitis has been determined in 108 patients with sliding hiatus hernias using endoscopic, histological, and radiological criteria. Particular consideration has been given to the relationship between inflammatory disease and clinical symptoms. All the patients were attending a thoracic surgical clinic and the spectrum of disease encountered was fairly severe; over half of the cases had established strictures when first seen. The incidence of oesophagitis based on endoscopic evidence was 76-9%. while inflammatory change was noted on biopsy in 56 2% and at barium swallow in 58-3% of the patients. Oesophagoscopy proved to be the most satisfactory method of assessment; biopsy specimens were either inadequate or correlated poorly with other criteria while barium swallow was of diagnostic value only in severe oesophagitis. The main symptoms were pain, heartburn with regurgitation, dysphagia, and bleeding. Dysphagia was common due to the preponderance of patients with strictures, while obvious bleeding was very uncommon. Endoscopic oesophagitis was found in 75% of the patients with specific retrosternal pain and in 600O, of those with heartburn and regurgitation. The inability to equate heartburn with oesophagitis is emphasized. The incidence of inflammatory change in patients with dysphagia was 8722% ; nearly all the cases in this group showed stricture formation.Gastro-oesophageal reflux occurs in most patients with symptomatic hiatus hernia and may produce an inflammatory reaction of varying severity in the lower oesophagus. There is no agreement, however, on the frequency with which this reaction occurs nor on the influence it may have on clinical symptoms. In the past, many of the symptoms in hiatus hernia patients have been loosely attributed to reflux oesophagitis without adequate objective evidence. This study was undertaken firstly to determine the incidence of
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