Patients with Hiatal Hernias/ Reflux

Director Metabolic Medicine and Surgery Institute

Florida Hospital Celebration Health

Overview

Consequence of hiatal herniaTreatment Method of repair: anterior vs posterior Laparoscopic vs robotic TechniqueSpecial scenariosConsequence of hiatal hernia after foregutsurgery

medical vs surgical management

104 pts randomized

93 pts available for analysis at 3 years

surgical pts:

more heartburn free days

improved quality of life

treatment failures: 11.8% surgery vs 16% medical

24 hour pH monitoring at 3 years: no difference

Surg Endosc. 2011 Aug;25(8):2547-54. Epub 2011 Apr 22.

A randomized controlled trial of laparoscopic Nissen fundoplication versus proton pumpinhibitors for the treatment of patients with chronic gastroesophageal reflux disease(GERD): 3-year outcomes.Anvari M, Allen C, Marshall J, Armstrong D, Goeree R, Ungar W, Goldsmith C.

conclusion: no difference in objective measures but statistically significantdifference in subjective measures and quality of life scores

surgical technique

meta-analysis of randomized clinical trials7 eligible studies 683 patients: posterior vsanterior fundoplicationShort term: reflux and symptomatic heartburn lessfor posterior repair, but dysphagia score higherlong term: dysphagia scores become comparablebut difference in reflux and symptomaticheartburn persist

Ann Surg. 2011 Jul;254(1):39-47.Laparoscopic anterior versus posterior fundoplication for gastroesophageal reflux disease:systematic review and meta-analysis of randomized clinical trials.Broeders JA, Roks DJ, Ahmed Ali U, Draaisma WA, Smout AJ, Hazebroek EJ

conclusion: posterior fundoplication is superior forsymptom control and there is no difference indysphagia in the long term

Laparoscopic vs robotic approach

50 patients randomized to laparoscopic (LNF) vsrobotic nissen fundoplication (RNF)no difference in operative time, blood loss, peri-operative complications, post-operative painscores, hospital staysno difference in reduction of esophageal acidexposure and increase in LES sphincter tone

Br J Surg. 2006 Nov;93(11):1351-9.

Randomized clinical trial of standard laparoscopic versus robot-assisted laparoscopic Nissenfundoplication for gastro-oesophageal reflux disease.Draaisma WA, Ruurda JP, Scheffer RC, Simmermacher RK, Gooszen HG, Rijnhart-de Jong HG, Buskens E, Broeders IA

conclusion: no benefits of robotic vs laparoscopicapproach in terms of clinical outcomes (small series)

Trocar Placement

AssistantCamera

5 mm8mm 5mm

technique

special scenarios

large/giant/intrathoracic

somewhat synonymous for type III hiatal herniaherniation of >30% of stomach (no uniformdefinition)incidence unclearmanagement debatableelective vs observationmesh vs no mesh

Large intrathoracic hernias

The New York Statewide Planning and Research Cooperative System(SPARCS) administrative database over 5 year period (53 per 1 millionpeople)Approx 1000 pts admitted each year with primary diagnosis ofintrathoracic stomach53% coded as emergent admissions66% of the emergent admissions discharged without surgical interventionemergent admissions vs elective admissions

data supports early elective repair

Surg Endosc. 2010 Jun;24(6):1250-5. Epub 2009 Dec 24.

A population-based analysis of emergent vs. elective hospital admissions for an intrathoracic stomach.Polomsky M, Hu R, Sepesi B, O'Connor M, Qui X, Raymond DP, Litle VR, Jones CE, Watson TJ, Peters JH.Source

higher mortality (5.1% vs 1.1%)higher costlonger length of stay

giant hiatal hernias

retrospective review 662 pts laparoscopic repairmean age: 70mean percent of stomach herniation: 70%

J Thorac Cardiovasc Surg. 2010 Feb;139(2):395-404, 404.e1. Epub 2009 Dec 11.

Outcomes after a decade of laparoscopic giant paraesophageal hernia repair.Luketich JD, Nason KS, Christie NA, Pennathur A, Jobe BA, Landreneau RJ, Schuchert MJ.

giant hiatal hernias

radiographic recurrence: 15.7%reoperations: 3.2%30 day mortality: 1.7%quality of life scores: excellent in 90%

giant hiatal hernia

giant hiatal hernia

giant hiatal hernia

42 yo femaleBMI 43GERD, asthma

gastric bypass after repair of gianthiatal hernia

hiatal hernia

patient information

52 yo female45 kgprogressive dysphagia for solids and nowsometimes liquidshas had multiple prior endoscopic interventions

achalasia

heller myotomy with Dorfundoplication

post-op x-ray

clinical significance after foregutsurgery

case study

58 yo female with h/o gastric bypasssevere epigastric pain with eating extensive workup negative for possible etiologygastric bypass reversed secondary to severe painwith eatingpain intermittent after reversal, then becamechronic againendoscopy and barium studies unremarkable

Obesity Surg. 2010 Mar;20(3):386-92. Epub 2009 Oct 24.Diagnosis and treatment of atypical presentations of hiatal hernia following bariatric surgery.Flanagin BA, Mitchell MT, Thistlethwaite WA, Alverdy JC.

Pritzker School of Medicine, The University of Chicago, Chicago, IL60637, USA.

AbstractBariatric surgery dramatically alters the normal stomach anatomy resulting in a significant incidence of hiatal hernia and gastroesophageal refluxdisease. Although the majority of patients remain asymptomatic, many complain of severe heartburn refractory to medical management and additionalhighly atypical symptoms. Here, we describe the diagnosis and treatment regarding four cases of symptomatic hiatal hernia following bariatric surgerypresenting with atypical symptoms in the University Hospital, USA. Four patients presented following laparoscopic Roux-en-Y gastric bypass orduodenal switch/pancreaticobiliary bypass (DS) with disabling and intractable midepigastric abdominal pain characterized as severe and radiating tothe jaw, left shoulder, and midscapular area. The pain in all cases was described as paroxysmal and not necessarily associated with eating. All fourpatients also experienced nausea, vomiting, and failure to thrive at various intervals following laparoscopic bariatric surgery. Routine workup failed toproduce any clear mechanical cause of these symptoms. However, complimentary use of multidetector CT and upper gastrointestinal contrast studieseventually revealed the diagnosis of hiatal hernia. Exploration identified the presence of a type I hiatal hernia in all four patients, with the stomach staplelines densely adherent to the diaphragm and parietal peritoneum. Operative intervention led to immediate and complete resolution of symptoms. Thepresence of a hiatal hernia following bariatric surgery can present with highly atypical symptoms that do not resolve without operative intervention.Recognition of this problem should lead to the consideration of surgery in cases where patients are dependent on artificial nutritional support andwhose symptoms are poorly controlled with medication alone.

atypical symptomsdebilitating epigastric pain unrelated to eatingother symptoms included nausea and vomitingcomprehensive evaluation negative for obviousmechanical causesymptoms immediately and completely resolved afterhiatal hernia repair

consequence

Obesity Surg. 2010 Jun;20(6):702-8. Epub 2009 Sep 12.

Clinical utility of endoscopy and barium swallow X-ray in the diagnosis of sliding hiatal hernia in morbidly obese patients: a study before and aftergastric bypass.Fornari F, Gurski RR, Navarini D, Thiesen V, Mestriner LH, Madalosso CA.

GASTROBESE, Rua Uruguai, 1555, 99010112, Passo Fundo, Rio Grande do Sul, Brazil. fernandofornari@gmail.com

AbstractBACKGROUND: The main clinical consequence of sliding hiatal hernia (SHH) is gastroesophageal reflux disease (GERD). Endoscopy and bariumswallow X-ray are commonly used to diagnose SHH. We aimed to assess the clinical utility of endoscopy and X-ray in the diagnosis of SHH in morbidlyobese patients before and after gastric bypass (GBP).

METHODS: Ninety-two patients underwent reflux symptoms evaluation, upper gastrointestinal endoscopy, and barium swallow X-ray before and 6months after banded GBP. The performance of endoscopy in diagnosing SHH was assessed, taking X-ray as reference. Endoscopy and X-ray weretested as predictors of SHH with GERD.

RESULTS: SHH was more prevalent when characterized by X-ray than endoscopy either before (33% vs. 17%; P = 0.017) or after GBP (26% vs. 7%; P= 0.001). Endoscopy showed low sensitivity (<or=40%) and high specificity (>or=94%) in diagnosing SHH. Before GBP, more patients with SHH hadGERD compared to patients without SHH using either X-ray (83% vs. 58%; P = 0.016) or endoscopy (94% vs. 61%; P = 0.009). After GBP, only patientswith radiologic evidence of SHH showed higher prevalence of GERD compared to patients without SHH (50% vs. 26%; P = 0.037). SHH patients alsoreported weekly or daily vomit more often than patients without SHH (59% vs. 32%; P = 0.026).

CONCLUSIONS: In morbidly obese patients, X-ray is superior to endoscopy in diagnosing SHH either before or after banded GBP. In patients treatedwith this technique, the utilization of X-ray may help in the management of reflux symptoms and frequent vomit.

hiatal hernia in bariatric patients

33% of patients found to have hiatal hernia on bariumswallow pre-op

26% of patients found to have persistent hiatal herniaon barium swallow 6 months postop

these patients had greater frequency of vomiting

summary

consequence of hiatal hernia is reflux and surgery is aneffective treatment optionrobotic approach shows no clinical outcomes advantagesversus laparoscopic approach, but studies are limited andthere are obvious technical advantages to the surgeongiant hiatal hernias should be electively repairedone must consider the whole patient and all of thevariables in choosing the appropriate interventionhiatal hernias can have a far greater clinical consequenceafter foregut surgery, and therefore, one should be moreaggressive in repairing hiatal hernias in this setting

thank you