Hiatal hernia and GERD

Gastro-Esophageal Reflux (GERD) and Hiatal Hernia information

GERD is very common, as evidenced by the numerous commercials on television promoting various antacids for the treatment of GERD symptoms. It is important to point out up front that these medications (Pepcid, Zantac, Prilosec, Nexium, Protonix, etc) treat the symptoms of reflux, namely heartburn. These medications do not actually stop reflux. They merely make the material that is refluxing less acidic, and thus, in most cases, less symptomatic. GERD is a plumbing problem. It is the abnormal, or excessive, amount of flow of gastric contents back into the esophagus. This typically manifest as heartburn, and acid taste in the mouth, and sometimes regurgitation. Other symptoms that can be due to GERD (atypical symptoms) are coughing, chest pain/pressure, chronic throat clearing, asthma, hoarseness and difficulty swallowing. These are in the atypical category because they can have other causes as well.

Before going further about GERD, let me address Hiatal Hernia
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The hiatus of the diaphragm is where the esophagus goes from the chest to the abdomen. And a hiatal hernia (or paraesophageal hernia) is when the stomach, and less commonly other organs, have herniated through this opening. Hiatal hernias are common, and in most cases do not require any treatment. A hiatal hernia can make GERD more likely, but not everyone with GERD has a hiatal hernia and not everyone with a hiatal hernia has GERD. Hiatal hernias are in most cases repaired as part of the surgical treatment for GERD. Sometimes patients can have large (at least greater than 5 cm) enough hiatal hernias to have symptoms unrelated to reflux. This can come from entrapment of the stomach and stomach contents above the diaphram, manifest as chest pain or pressure, usually while eating. It often will respond to standing up and walking, allowing the contents to empty out of the stomach that is trapped above the diaphragm, and this allows eating to resume. Sometimes this can result in nausea and retching. In rare cases the stomach can become trapped and twisted above the diaphragm resulting in severe pain, and requires emergency decompression or surgery. Another, often missed, symptom of a large hiatal hernia is unexplained anemia. Sometime ulcers (Cameron’s ulcers) in the stomach at the level of the diaphragm are visible on endoscopy, but often the anemia is due to chronic blood loss at this site in the absence of visible erosions. Over my years of practice I have performed many hiatal hernia repairs, often of very large hernias, and sometimes large recurrent (they had a prior surgical repair) hiatal hernias. I use a biologic (your body will absorb and replace it over time) mesh to reinforce my closure of the hiatus around the esophagus. Repair of very large or recurrent hiatal hernias is more difficult that routine anti-reflux surgery, and takes longer. While the risk of requiring conversion to an open operation is higher for these cases, of the many that I have performed, I have never had to do that.

Now back to GERD;
GERD should be initially treated by behavioral modifications. These generally include weight loss, sleeping with the head of the bed elevated, avoiding acidic foods, avoiding eating within 4 hours of going to bed and weight loss (yes, I know I listed it twice). Medical treatment for GERD symptoms should start with H2 blockers such as Zantac and Pepcid, and elevating to PPIs, such as Prilosec and protonix, if those fail. The PPIs where made to be taken short term. And while many patients have taken these medications long term without a problem, recent studies are showing some increased risks associated with long term PPI use.

 

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Failure of medical treatment, or the desire to avoid long term PPI use is an indication for surgical treatment of reflux, in a patient suitable for such a procedure.

Who is suitable for anti-reflux surgery? Right off the bat let me say that those who would be high risk for general anesthesia, and those that have a body mass index (BMI) of 40 or greater (BMI Calculator) are not good candidates for this surgery. And if you are referred to me for this, I will most likely not have anything more to offer you.
There are diagnostic tests used in the evaluation of those considering antireflux surgery and include an upper endoscopy (EGD), which is required of every patient. Other tests that may be used are, a barium esophagram, esophageal manometry, and ambulatory pH probe.

 

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I use the latter three tests only selectively for patients who have difficulty swallowing (esophageal manometry), who have only atypical symptoms (pH probe), and for those with unclear anatomy (barium esophagram).

Surgery for Reflux

The standard surgical treatment for GERD is some form of fundoplication, which translates to the folding of the fundus of the stomach against the lower esophagus. This is most commonly done in the form of a Laparoscopic Nissen Fundoplication. Laparoscopic meaning it is performed through multiple (5 to be precise) small incisions using long instruments and a camera, as opposed to a large midline incision. Nissen is the last name of the surgeon the came up with the idea. In this procedure and hiatal hernia that is present is repaired, and the fundus of the stomach is sutured to itself around the lower esophagus. A common variation to this procedure is to perform a partial fundoplication (named after a surgeon as well, Toupet). There have been a number of variations on this procedure over the years developed to mitigate some of the potential side effects of this surgery, but Laparoscopic Nissen Fundoplication remains the most “popular” procedure for the treatment of reflux. Over my years in practice I estimate that I have performed close to 400 of these procedures.
A newer approach that I have been utilizing is the Trans-oral Incisionless Fundoplication (TIF) procedure. This is also done in the operating room under general anesthesia, but instead of making incisions, it is a device that is placed through the patients mouth and passed into the stomach using an endoscope. This forms a partial fundoplication, very similar to what is formed laparoscopically. It tends to have a faster recovery, but cannot be used on patients with any significant hiatal hernia.

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In either case, the post-operative stay is 1 night in the hospital. The next day patients are discharged home on a liquid diet for 2 weeks, and then advanced to a more normal diet over the next 6 weeks. Please refer to the post-op instructions for more details.

The operative risks of TIF and laparoscopic fundoplication are similar to some degree. They are bleeding, infection, injury to the surrounding structures (intestines, liver, stomach, esophagus and spleen), DVT and cardiopulmonary risks of general anesthesia (which are increased if you already have heart or lung disease). These complications are all, thankfully quite uncommon.
Post-operative risks are pain, dysphagia (trouble swallowing), bloating, increased flatulence, recurrent reflux or hiatal hernia, and the need for further procedures.

For more information about GERD and specifically the TIF procedure please go to: www.GERDhelp.com

Laparoscopic Anti-Reflux (GERD) Surgery Patient Information from SAGES