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Acid Reflux and Hiatal hernia

Dr. Jossart narrates a 5:17 second slide show tutorial on acid reflux and hiatal hernias with short videos. Slide 1: GERD is the flow of acid from the stomach up into the esophagus and even up to the back of the throat. It is more common in obesity, during pregnancy, some medications, smoking and with certain foods and beverages. Symptoms of GERD include heartburn, sour taste, worsening symptoms when lying down, burping, food getting stuck, hoarseness, coughing, worsening asthma and upper abdominal pain. Symptoms can often be controlled for some time with dietary changes and weight loss. For those whose symptoms are not controlled, antacid medications can treat symptoms effectively. Some patients will have a hiatal hernia that contributes to the symptoms and the medications do not control the symptoms well enough. These patients may want to consider surgery to repair the hiatal hernia. Complications of GERD include scarring, bleeding and even cancer of the esophagus. It is important to prevent these by treating GERD with medications, surgery and monitoring with endoscopy. Slide 2: A hiatal hernia is when the top of the stomach starts to migrate into the chest through a natural hole in the diaphragm that has enlarged over one’s lifetime. This hole is known as the hiatus. This hole slowly enlarges and let’s the stomach slide or move upward into the chest and this often makes acid reflux worse. Hiatal hernias are a spectrum of symptoms and size. A hiatal hernia can be small with just an inch or two of stomach sliding into the chest or very large with the entire stomach in the chest. Some patients may have no symptoms at all. Some may just have mild heartburn. Some patients may have symptoms of vomiting that may be a sign that the stomach is twisted or stuck in the chest (paraesophageal hiatal hernia). We often use the words incarcerated and strangulation to explain what is happening. Slide 3: These images are photographs taken during surgery of different sizes or types of hiatal hernias. A small hiatal hernia with only an inch or two of stomach sliding into the chest. A moderate sized sliding hiatal hernia with the top third of the stomach sliding into the chest. In incarcerated hiatal hernia with the top third of the stomach stuck in the chest. A giant paraesophageal hiatal hernia with the entire stomach in the chest. The Upper GI x-ray reveals a moderate sized hernia above the diaphragm and between the lungs. Slide 4: Indications for having surgery to repair the hiatal hernia include breakthrough symptoms on medications, worsening symptoms such as vomiting and food blockages and very large or giant paraesophageal hiatal hernias that are at risk for incarceration and volvulus. The operation is always done through 5 small incisions with a small risk of needing a larger incision. Patients usually leave in less than 23 hours but some frail or elderly patients with larger hernias may need to stay longer. You are walking within hours after surgery, you can take a shower the next day and the first week at home is light duty. No bedrest! You must be up and about. Some people will even return to light duty work within a few days. The diet for the first week is any type of liquid or pureed foods to allow for a week of healing. After one week, you slowly introduce regular foods in to your diet. Slide 5: Videos. Slide 6: There are numerous types of repairs that are historically associated with the surgeons who described their unique method. These include Nissen, Hill, Dor, Toupet, Rosetti, Belsey Mark IV and others. This slide reveals a simple closure of the hiatus around the esophagus and additional sutures can be placed to secure the stomach in the abdomen. This is called a cardiopexy. A Nissen Fundoplication involves wrapping stomach around the esophagus to create an area of compression or narrowing that prevents the reflux or symptoms of GERD. The type of surgery chosen depends on the size of the hernia, the patient’s symptoms and preferences and can be discussed in detail during an office visit. Slide 7: The usual risks or complications of abdominal operations such as bleeding and infection are very low. Side effects such as difficulty swallowing and bloating are usually due to bad dietary decisions and usually improve over the first few months. Recurrence is the most common problem with all hernia operations. The hiatal hernia repair generally has a 5 year recurrence of 20%. That means 20% of patients would need it repaired again within 5 years. This is more likely in patients who gain weight, large hernias, smoke, repetitive heavy lifting, traumatic events and patients who need to take oral steroids. Dr. Jossart’s 9 year recurrence rate is much lower than the 20% generally mentioned as it is less 4%.