Hiatal Hernia And Gastroesophageal Reflux

The overall management of patients who present with dysphagia or heartburn must include, of course, a cardiovascular history and examination since the suspicion of ischemic cardiac disease or other myocardial dysfunction must always be in mind.

The esophageal problems that may result in dysphagia or heartburn can include carcinoma, gastroesophageal reflux or motility disorders (including achalasia or diffuse esophageal spasm). The preoperative evaluation of patients who present with suspected esophageal motility disease or gastroesophageal reflux should always include esophagoscopy (with biopsy if necessary); a 24-hour pH probe study; and manometry. An upper GI study may be helpful on occasion, although it is redundant. If the above three studies are done well, they will give all the information an upper GI study can provide and much more.

The 24-hour pH probe monitor determines with high sensitivity and specificity the presence of gastroesophageal reflux. This is much more difficult to evaluate using the upper GI barium swallow. An upper GI barium swallow which reveals a hiatal hernia is not at all synonymous with gastroesophageal reflux. Not all patients who have hiatal hernias have gastroesophageal reflux. In fact, only about 10% of patients with hiatal hernias have clinical gastroesophageal reflux. Also it should be noted that the barium swallow is not a specific test either. Reflux of barium into the esophagus can be observed in 25% of normal subjects and the inability to demonstrate reflux in an upright position does not exclude the presence of GE reflux.

The 24-hour esophageal pH monitoring test is performed by placing a pH electrode 5 cm above the upper border of the lower esophageal sphincter as measured manometrically. A normal diet is given with the exception that food or liquid with a pH less than 5 or greater than 7 is excluded. At the completion of the monitored period, the probe is advanced into the stomach to document the pH of the gastric contents. Patients are instructed to record symptoms over the 24 hours and this is then reviewed on the pH probe continuous strip. Acid reflux is identified whenever the pH in the esophagus drops to 4 or below. The 24-hour esophageal pH monitoring is the most accurate way to measure gastroesophageal reflux.

In the work-up suspected gastroesophageal reflux with symptoms of heartburn and/or dysphagia, a careful history and physical examination is done followed by esophagoscopy, manometry and 24-hour pH testing. If these reveal esophageal reflux, medical management is indicated for a period of 6 weeks until the next evaluation.

Medical management includes the following: H2 blockers, antacids, and abstinence from alcohol and smoking (i.e. these are all the same medical management maneuvers used for peptic ulcer disease). In addition, the patient should sleep in an upright position, i.e. by placing shock blocks at the head of the bed. If the patient's symptoms have not resolved in 6 weeks, surgery may be indicated. This may be of several different types, the most commonly being a Nissen fundoplication.

Indications for performing surgery for gastroesophageal reflux includes the following: persistent esophagitis; bleeding; ulceration; severe dysplasia found on endoscopic biopsy; stricture; or recurrent aspiration. Although controversial at the present time, the presence of Barrett's esophagus does not mandate prophylactic anti-reflux procedure but should be followed closely.

Procedures

The operations available for anti-reflux include the Nissen fundoplication, the transthoracic Belsey Mark IV procedure, the Hill fundoplication, or an intra-tho-racic Nissen fundoplication. Advances in laparoscopic technique have permitted endoscopic Nissen fundoplication as well.

The standard abdominal Nissen fundoplication is performed with the patient placed supine, and a standard upper midline incision is made. The greater curvature of the stomach is mobilized taking the short gastric arteries. A size 40 Maloney dilator is passed through the gastroesophageal junction from above and mobilized distal esophagus and proximal stomach is wrapped using the mobilized fundus of the stomach in a 360° fashion (Fig. 17.5). Interrupted sutures are then passed through the seromuscular coat of the stomach through the muscle area of the esophagus, then back out through the other side of the stomach. This is done for about a 2-3 cm length. It should be sufficiently loose that the gloved finger is able to be passed up through the repair between the fundus and the esophagus. Some people perform a tacking maneuver of the fundoplication down to the pre-aortic fascia, i.e. modified Hill procedure, however this is not necessary. The hiatal hernia defect is repaired with interrupted sutures.

One of the complications of a Nissen fundoplication is the gas-bloat syndrome which may result from too tight of a wrap or injury to the vagus nerves. The treatment is pyloroplasty drainage procedure.

For the transthoracic Belsey Mark IV, a lateral thoracotomy is performed at the 7th or 8th intercostal space. After complete mobilization of the cardia of the stomach, the lower 4 cm of the esophagus is cleared of connective tissue. Mattress sutures are placed between the gastric fundus and the muscle layers of the esophagus (Fig. 17.6). After these mattress sutures are tied, a second row of mattress sutures is placed between the muscle coat of the esophagus, the gastric fundus and the crus of the diaphragm. Before these sutures are tied, crural sutures are placed to narrow the esophageal hiatus; this results in an effective anti-reflux mechanism. It should be noted that the wrap is only 270° rather than the 360° Nissen fundoplication.

The Hill procedure for gastroesophageal reflux is a conceptually simple operation. It is basically a crural plication added to a posterior gastropexy. The crura of the diaphragm is approximated over the distal esophagus. A posterior gastropexy

Diaphragm Crura

Fig 17.5. Nissen fundop-lication procedure. The fundus of the stomach is wrapped 360° about the esophagus. Reprinted with permission from McFadden DW, Zinner

MJ. Benign disease of the esophagus. In: Ritchie Jr. WP, Steele Jr. G, Dean RH, eds. General Surgery. Philadelphia: J.B. Lippincott Co, 1995: p. 80.

is performed from the cardia of the stomach down to the median arcuate ligament, i.e. pre-aortic fascia. This effectively stabilizes the lower esophageal sphincter, tightens the esophageal hiatus and limits gastroesophageal reflux.

There may be instances where the disease is so severe that the esophagus is actually shrunk, the stomach is permanently fixed in the chest, and the stomach cannot be reduced into the abdomen. In this case, an esophageal lengthening procedure may be necessary. This is commonly done with an addition of a Collis procedure to either the Nissen or the Belsey Mark IV. In this case a staple gun is used to cut down on the greater curvature side of the stomach, forming a neo-esophagus. The fundus of the stomach can then be wrapped about the neo-esopha-gus either in a 360° fashion for Nissen fundoplication either within the abdomen or within the chest, or it may be used in a 270° fashion as in a Collis-Belsey Mark IV done transthoracically.

What is the management of severe stricture of the esophagus? This is an indication for an anti-reflux procedure. After endoscopy and biopsy to ensure that this is not a malignant stricture, dilation of the stricture should be performed with progressively larger bougies followed by an anti-reflux procedure. It should be noted that there may be instances of nondilatable stricture which may require esophagectomy and replacement of either a part of or usually the entire esophagus. This is an ideal situation for a transhiatal esophagectomy with a cervical esophagogastric anastomosis.

Herbal Remedies For Acid Reflux

Herbal Remedies For Acid Reflux

Gastroesophageal reflux disease is the medical term for what we know as acid reflux. Acid reflux occurs when the stomach releases its liquid back into the esophagus, causing inflammation and damage to the esophageal lining. The regurgitated acid most often consists of a few compoundsbr acid, bile, and pepsin.

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