The Association of Cancer of the Stomach and Oesophagus with Herniation at the Oesophageal Hiatus of the Diaphragm

Hiatal insufficiency, followed by sliding oesophago-gastric hiatal herniation, is common, usually interferes with the valvular mechanism at the lower end of the gullet and so leads to reflux oesophagitis. The association of cancer of the oesophagus and stomach with sliding hiatal herniation is too common to be due to chance. Ninety-six cases collected from the literature are reviewed and 12 new ones added. Reflux oerophagitis and ulceration associated with sliding hiatal hernia may predispose to the development of oeso-phageal tumours, but it is unlikely to be the major factor involved. Massive stomach tumours (such as leiomyosarcomas) may occasionally, by their bulk and pressure, assist in the formation of a hernia in the presence of a lax hiatus. The predominance of adenocarcinomas of the gullet in association with hiatal hernias is likely to be due to a variety of factors. The two commonest of these would seem to be (1) that a small lower portion of the oesophagus is frequently lined by glandular epithelium which, at this constricted site, is particularly liable to malignant disease, and (2) that there is preferential spread in the submucous lymphatics of the oesophagus by tumours arising at the cardia. As both these tumour types develop in the hiatal tunnel, they tend to cause dilatation and produce irritation, both of which pre-dispose to herniation. Rarely, large portions of the gullet may be lined by gastric mucosa, because the cardia is congenitally situated within the thorax. In more cases, portions of the oesophageal mucosa may fail to undergo normal squamous transforma-tion before birth, providing an opportunity for true adeno-carcinomas of the oesophagus to occur with normally placed cardio-oesophageal junctions. There has been a high incidence of hiatus hernia even with this group in the cases so far reported. This may be due to some special tendency to hiatus insufficiency when the oesophagus is lined by gastric mucosa, but is probably no more than a reflection of medical interest at the present time, since adenocarcinomas of the oesophagus occur quite frequently without associated hernia and any lower oesophageal tumour promotes the tendency to herniation in the presence of a lax hiatus by causing irritation and reflex oesophageal contraction.