It is estimated that 10% of adult population in the USA have hiatus hernias with the onset in the early fifth decade of life.
Hiatus hernias occur where the gullet (oesophagus) enters the neck of the stomach because the upper part of the stomach migrates into the chest (sliding type). This positioning allows acid and stomach contents to reflux into the gullet causing the familiar symptoms of heartburn, regurgitation of bile and food content, a bad taste in the mouth and throat, and inappropriate burping. In some patients, these symptoms can occur in the absence of a hiatus hernia.
Instead, the cause is a weakness of the muscles around the lower end of the gullet: gastro-oesophageal reflux disease (GORD) or gastro- esophageal reflux disease (GERD). GORD tends to occur in a much younger population. A less common type of hiatus hernia is where the stomach rolls up along side the gullet into the chest, there may be few or no symptoms (rolling type).
Do I need an operation for this condition?
Not usually. Fortunately, these symptoms can be well controlled in most patients with medication. Indications for surgery are failure to control symptoms through medication, the wish by the patient to avoid long-term medication, the development of complications of reflux, the presence of abnormal stomach lining in the gullet (Barrett’s oesophagus).
If I have an operation what is the success rate of curing my symptoms?
Operations to correct hiatus hernias and GORD have a high success rate (95% patient satisfaction after one year), providing the patients are properly counselled and selected correctly. The poor record of open hiatus hernia surgery in the past and effective medication has stopped many clinicians from referring patients for consideration of the surgical option. With an improved understanding of how the condition occurs and the use of objective assessments to assess the severity of the condition, better selection of patients for surgery has resulted in vastly improved results.
Do I need any investigations to help in the decision making for surgery?
Yes. Success rates are now high because of adequate preoperative investigations. Three key tests are needed: endoscopy (a telescope test under sedation to assess the lining of the upper gastrointestinal tract and to confirm the diagnosis); barium swallow to observe the dynamics of how your gullet moves in response to swallowing); and oesophageal function tests (to monitor the amount of acid exposure and measurement of the pressures in different parts of the gullet). An objective decision whether surgery will benefit you or not will be discussed with you by your specialist.
Which approach will be used?
A laparoscopic (keyhole) technique will be used in most patients. In Australia, the United States and Europe where this is an extremely common problem, laparoscopic repair of hiatus hernia is becoming almost as common place as laparoscopic gallbladder surgery.
The essence of the operation has two components: 1) the defect in the diaphragm where the gullet enters the abdomen is tightened by stitches and; 2) the upper part of the stomach is loosely wrapped around the gullet to stop the acid and contents of the stomach refluxing into the gullet. This operation is called a floppy Nissen fundoplication and is the one advocated at the HKHC. There are many variations in the techniques used to repair hiatus hernias but none have shown overwhelming superiority over the Nissen fundoplication.
Many large studies support its safety and wider spread adoption by surgeons trained in this highly specialised technique. You will be in hospital for 3 to 4 days and should not require any of your previous medication after the operation.
Are there any complications after surgery?
All patients experience some difficulty in swallowing for the first 1-4 weeks. The first week is limited to a strictly fluid and soft diet. Swallowing improves with time and should be normal in most patients by 3 months. Rarely does persistent difficulty occur. Damage to the nerves around the gullet may result in diarrhoea. A contrast swallow examination is performed on the day after surgery to ensure that there has been no damage to the gullet. Both these potential latter complications can be minimised by careful surgical dissection. Because the operation is designed to prevent both gas and food refluxing into the gullet you may experience more bloating and passage of flatus than usual.