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Hiatal and Paraesophageal Hernia Treatment Options //
Robotic Hiatal and Paraesophageal Hernia Surgery |
Hiatal and paraesophageal hernia surgery is commonly performed to close the hernia defect and reposition the hernia contents in the correct position. If reflux is present then an anti-reflux procedure is warranted.
This procedure which is selected based on specific characteristics of all the tests performed to establish a diagnosis entails wrapping a small amount of your own stomach around the esophagus to prevent slippage of the hernia contents back into the chest and reinforce the valve and prevent reflux if present. Many times to prevent recurrences we may consider using a dissolving matrix to reinforce the diaphragm to prevent recurrences. If you do not have reflux and depending on testing we may consider partial wraps as apposed to a full wrap.
This procedure does not typically reduce your intake and most patients will continue to tolerate the same amount of food after surgery. However, for 3-4 weeks we have you on a specific diet plan to avoid having issues with the valve. As such some patients have noted some weight loss up to 25lbs after surgery which will usually return unless you attempt to keep it off.
The surgical procedure typically takes 1 1/2 to 2 hours to complete and the majority of patients go home on a liquid diet the same day. We typically recommend stopping and anti-reflux medications after surgery as these should no longer be indicated. We routinely perform this procedure robotically through 5 very small abdominal incisions. There are no restrictions on activity or lifting after surgery but we recommend not engaging core muscles for up to 6 weeks. We also do not make recommendations on when you should go back to work. However, we advise you use common sense and listen to your body.
The majority of patients with reflux prior to surgery should after surgery have no return of symptoms even while they are off their reflux medications and no longer need to follow the reflux diet. Therefore, you can indulge a little. We continue to encourage however a healthy lifestyle and diet plan.
Most patients who have this procedure continue to not require medications for reflux at 10 years.
Most patients with heartburn, chest-pain, and regurgitation of food will no longer have these issues on a routine basis after the procedure. However, like any regular person that overeats you can have occasional heartburn. This is normal but should not be routine.
Full Wrap
Partial Wrap
Robotic LINX |
The LINX procedure is similar to the more conventional Anti-reflux surgery and is used in the setting of reflux and a hiatal or paraesophageal hernia. Similar to the conventional approach this is performed robotically and we still need to fix a hiatal or paraesophageal hernia. However, instead of using a small part of your stomach to strengthen your valve we would use a magnetic ring.
This procedure which is selected based on specific characteristics of all the tests performed to establish a diagnosis.
This does not typically reduce your intake and most patients will continue to tolerate the same amount of food after surgery. However, for 3-4 weeks we have you on a specific diet plan to avoid having issues with the valve. But because we need you to "exercise" the magnetic valve we do start you on regular food soon after surgery. This may feel uncomfortable at first but typically improves with time. Some patients have noted some weight loss up to 15lbs after surgery which will usually return unless you attempt to keep it off.
Similar to the conventional procedures described above the emphasis of this approach continues to be focused on the repair of the hernia and reduction of the contents back into the abdomen from the chest. We do recommend reinforcement of the diaphragm with a dissolving biosynthetic matrix to avoid recurrences.
The surgical procedure typically takes 1 to 1 1/2 hours to complete and the majority of patients go home on the same day. We typically recommend stopping and anti-reflux medications after surgery as these should no longer be indicated. We routinely perform this procedure robotically through 5 very small abdominal incisions. There are no restrictions on activity or lifting after surgery although we do would like you to avoid core training for 6 weeks. We also do not make recommendations on when you should go back to work. However, we advise you use common sense and listen to your body.
The majority of patients after surgery have no return of symptoms even while they are off their reflux medications and no longer need to follow the reflux diet. Therefore, you can indulge a little. We continue to encourage however a healthy lifestyle and diet plan.
There is no significant long-term data on this device but compared to the conventional anti-reflux procedure there is less bloating based on most current studies. There is however more difficulty with swallowing early on that does typically resolve.
This procedure is our recommended procedure in the setting of prior sleeve gastrectomy for weight loss.
Endoscopic Reflux Procedures |
Endoscopic Anti-reflux procedures are designed for specific patients and are part of the discussion of best approach. The TIF procedure (Transoral Incisionless Fundoplication) has the best outcome of all endoscopic anti-reflux procedures. This is performed through the mouth without incisions and we use a special device to reconstruct the valve between the esophagus and the stomach.
This procedure is ideal for patients who have reflux and no longer want to take medications or perform lifestyle modifications.
This approach will not address the hernia and therefore would not be recommended in the setting of a hiatal or paraesophageal hernia.
Medication |
There are a variety of medications for the management of reflux. These range from over the counter medications to prescription medications. However, these medications will not address the hernia so would only provide symptom relief in the setting of reflux.
These medications should be taken under careful monitoring of a trained specialist as there maybe side effects to long term use of these medications and correct diagnostic workup should be performed to ensure you are on the right medications and are on it for the right reasons.
The 4 main types of medications which are all antacids work by different mechanisms to block the acid excretion of your stomach or neutralize it.
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Tums/Rolaids: These medications work by neutralizing the acid by using an ingredient that work quickly on the acid secreted into the stomach. These medications have minimal side effects and are good for occasional symptoms usually with heavy meals. Typically, most patients take these medications knowing they will have symptoms or soon after having symptoms.
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Zantac and H2 blockers: These medications block the release of acid into your stomach and take slightly longer to work but last longer. Therefore, they are ideal for patients with some underlying daily symptoms that are mild. They do block acid production and side effect profiles are slightly worse than Tums and Rolaids.
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Proton Pump Inhibitors (PPI's): This is the major drug group used to treat symptomatic reflux. Drugs in this group include Omeprazole, Nexium, Dexilant, Prilosec among others. These drugs have been associated with bone loss, cardiovascular issues, and potentially mental acuity changes.
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Carafate, Gaviscon: These drugs work by coating the stomach and esophagus and are given prior to meals for onset of action. They do require and acidic environment for activation. Although Gaviscon is over the counter Carafate requires a prescription and due to having Aluminum can only be used for a brief period.