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Medical Edge Newspaper Column from Mayo Clinic

HIATAL-HERNIA PATIENTS CAN BE CURED THROUGH MINIMALLY INVASIVE SURGERY

DEAR MAYO CLINIC: I am a 79-year-old woman with a large hiatal hernia that is causing me to aspirate. I have moderate emphysema, too. Is surgery an option for me? Is there anything else that will help prevent aspiration? — Oklahoma City

ANSWER: A hiatal hernia occurs when a portion of the stomach, or the entire stomach in some cases, protrudes through the opening (hiatus) in the muscular diaphragm through which the esophagus (swallowing tube) normally passes. The stomach winds up in the chest, above the diaphragm, instead of in the abdomen where it is normally located.

The resulting symptoms depend on what part and how much of the stomach ends up in the chest. Small hiatal hernias generally cause few problems other than mild and short-lived bouts of “reflux” — backflow of food and gastric juices — commonly known as heartburn. Larger hernias can cause chronic heartburn, chest pain, swallowing difficulties, the sensation of feeling full after beginning a meal and shortness of breath. Aspiration, a condition whereby reflux migrates high enough to enter the windpipe and lungs, causing irritation of the vocal cords and lungs, can also occur in hiatal hernia cases. This is especially true when lying down at night to sleep.

People who experience frequent episodes of aspiration can suffer from hoarseness, shortness of breath and recurrent pneumonia. The respiratory effects, unpleasant enough by themselves, can exacerbate your emphysema symptoms, which already include shortness of breath and irritable airways.

Simple “self care” measures can help reduce the degree and frequency of heartburn and aspiration. The three most important measures are: limiting the amount of eating and drinking in the hours prior to bed; raising the head of your bed; and avoiding belts or tight-fitting clothes, especially in the evening.

Medications may also ease heartburn and limit aspiration. Over-the-counter antacids can help to neutralize acidity in the stomach and esophagus. H2 (histamine) blockers reduce the amount of acid secreted by your stomach, whereas proton pump inhibitors block acid production and allow time for damaged esophageal tissue to heal. Prokinetic agents can help the stomach to empty in the right direction more rapidly so that there is less volume available to reflux into the esophagus.

Keep in mind, however, that while these medications may offer some symptomatic relief, they do not treat anatomy-related symptoms. Surgery is usually offered to patients who have symptoms and who are candidates for surgery by virtue of their overall state of health. Age by itself is not a reason to exclude the possibility of surgery, as symptomatic hiatal hernia patients are typically over the age of 65 and many of them make excellent surgery candidates, with equally excellent outcomes.

The operation to deal with your type of hiatal hernia usually involves: 1) lengthening the esophagus to reduce the tension when returning your stomach back down into your abdomen; 2) making the opening in your diaphragm (through which the esophagus normally passes) smaller; and 3) anchoring a one inch length of esophagus in the abdomen below the diaphragm muscle. The latter objective is usually accomplished by loosely wrapping the floppy upper part of the stomach around the lower, intraabdominal portion of the esophagus — a process called fundoplication or antireflux procedure.

Traditionally, this operation has been done through an incision in either the abdomen or left side of the chest. Now, however, a minimally invasive (laparoscopic) approach — in which the surgeon works with small instruments and a fiber-optic camera to produce several small incisions in the abdomen — is employed. In addition to faster recovery and diminished postoperative discomfort, a minimally invasive laparoscopic procedure may permit more patients — who may have not been candidates for conventional open surgery — to undergo surgical repair.
— Stephen D. Cassivi, M.D., M.Sc, FACS, Division of General Thoracic Surgery, Mayo Clinic, Rochester, Minn.

Additional Resources:
Treatment of Hiatal Hernias
Other Web Resources

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Medical Edge from Mayo Clinic is an educational resource and doesn’t replace regular medical care. To e-mail a question, go to www.mayoclinic.org, or write: Medical Edge from Mayo Clinic, c/o TMS, 2225 Kenmore Ave., Suite 114, Buffalo, N.Y., 14207. For health information, visit www.mayoclinic.com.