Is surgery the best option for a hiatal hernia?
The oesophageal hiatus is an opening in the diaphragm (the muscle that separates the abdomen from the chest) through which the esophagus (the tube that carries food from the mouth to the stomach) enters.
Occasionally, certain health issues affect the hiatus, causing acid reflux whereby the stomach contents flow in the opposite direction back up the esophagus. There are several treatment options, including hiatal hernia surgery.
Hiatal issues in order of frequency
- Gastroesophageal reflux disease (acid reflux). Frequent passage of acid from the stomach into the esophagus, due to a malfunctioning sphincter at the hiatus.
- Diaphragmatic hernia. Displacement of the abdominal viscera towards the thorax. The significant upward abdominal pressure causes compression of the lungs and heart.
- Visceral obstruction. May lead to volvulus, rotations or compression in the digestive tract, and requires immediate intervention in acute disorders.
What causes a hiatal hernia?
Sometimes, if the hiatus increases in size, it may lead the stomach to bulge through it, causing a hiatal hernia. This may happen due to excessive upward abdominal pressure, or due to other factors such as obesity, breathing difficulties or age.
- Atypical: They appear in the larynx and can be summarized as itching or irritation of the throat, coughing, respiratory discomfort, etc.
- Typical: Heartburn; a burning sensation along the esophagus that may be accompanied by chest pain and food regurgitation.
If a patient should notice any of the above symptoms, it is recommended they immediately see a specialist. The first test is a blood test, and this would typically be followed by:
– Esophageal manometry: This measures the pressure exerted by the esophagus for food to progress through it. It serves to rule out other diseases and evaluate other possible disorders.
– Esophageal pH-metry: This measures the volume of gastric acid that travels in the opposite direction towards the esophagus. It permits for the severity of the reflux to be quantified.
– Gastroscopy: An endoscopy of the upper gastrointestinal tract. This procedure may find lesions and ulcers caused by the gastric acids that need to be quantified. It also helps identify a possible Barret’s esophagus, a lesion that could lead to cancer.
There are medications such as H2 blockers (ranitidine) or proton-pump inhibitors (omeprazole) that help eliminate the troublesome symptoms of a hiatal hernia. These medications, as well as avoiding fats, spices, alcohol, coffee and tobacco, help combat the symptoms but do not eliminate the condition. Eliminating a hiatal hernia requires a simple laparoscopic surgery to place the stomach back into the abdomen and close the esophageal hiatus. Finally, a tie-shaped knot is made in the upper stomach area around the esophagus to strengthen the lower esophageal sphincter. This technique is known as Nissen Fundoplication.
This operation is indicated for:
- Patients whose symptoms do not improve with medication, especially food regurgitation.
- Young patients who do not want to continue indefinitely with the medication.
- Patients with respiratory problems, such as pulmonary aspiration or pneumonia.
- Patients with serious esophagus issues, such as narrowing, scarring, ulcers or Barret’s esophagus.
- Patients with a paraesophageal hernia or giant hiatal hernia, which allows the stomach to move up through the chest or twist the stomach.