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Hiatal Hernia & GERD

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Hiatal Hernia & GERD Hiatal Hernia & GERD Lisa M. Brown, MD, MAS Assistant Professor of Thoracic Surgery University of California, Davis Health Case Study • 45 year old woman with hiatal hernia discovered during workup for heartburn • Her symptoms include heartburn increasing in severity over the past 5 years and occasional regurgitation • She has no dysphagia Case Study: Psychosocial History • Cigarette Smoking • Former Smoker, quit 10 years ago • 10 pack years • Living Status • Lives alone • Functional Status • Independent • ECOG Score • 0 Symptoms • Heartburn, regurgitation Proton Pump Inhibitors (PPIs) • Yes, Omeprazole • Partial relief PPI Mechanism of Action Histamine H2 Acetylcholine Receptor Antagonists Muscarinic Muscarinic Antagonists M3 Receptor Histamine Gastrin CCK H Receptor 2 2 Receptor + K+ Parietal H + + H K PPI Cell ATPase Acid Gastric Gland Lumen Proton Pump Inhibitors (PPIs) • Omeprazole (Prilosec) (available OTC) • Esomeprazole (Nexium) (available OTC) • Lansoprazole (Prevacid) • Rabeprazole (AcipHex) • Pantoprazole (Protonix) • Zegrid (Omeprazole with sodium bicarbonate) (available OTC) Case Study: EGD • Z-line at 40 cm from the incisors • Biopsy without intestinal metaplasia • Hiatal hernia and normal mucosa in the stomach • The duodenal mucosa was normal Kamal A, et al. Best Practice & Research Clinical Gastroenterology.2010;24(6):799-820 Barrett’s Esophagus • Premalignant condition • Chronic injury from GERD • Mucus-secreting columnar cells replace reflux-damaged esophageal squamous cells (metaplasia) • The only known precursor of esophageal adenocarcinoma • A small % of patients with BE will develop cancer • More than 90% of patients with cancer have no prior history of BE • It is unclear why some patients with BE progress to cancer Barrett’s Esophagus • At least 1 cm of salmon-colored mucosa proximal to the GEJ • Biopsy confirmation of intestinal metaplasia Columnar Squamous Epithelium Epithelium (Intestinal Metaplasia) GEJ GEJ Goblet Cell Barrett’s Esophagus • Classification • No dysplasia • Indefinite for dysplasia • Low-grade dysplasia • High-grade dysplasia Spechler SJ, Souza RF. NEJM 2014 Aug 28;371(9):836-45 Barrett’s Esophagus pH Testing pH Testing Yes DeMeester score 58.4 Case Study: Manometry Lower Esophageal Sphincter Region Esophageal Motility Landmarks Number of swallow evaluated 12 Proximal LES (from nares/cm) 42.0 Chicago Classification LES length (cm) 4.0 % failed 0 Esophageal length (LES-UES centers/cm) 23.3 % weak 0 Intraabdominal LES length (cm) 0.0 % ineffective 0 Hiatal hernia? Yes % panesophageal pressurization 0 LES Pressures % premature contraction 0 Pressure measurement method eSleeve, IRP % fragmented 0 Basal (respiratory mean)(mmHg) 20 (13-43) % intact 100 Residual (median)(mmHg) 6 (<15.0) Manometry • Yes, Normal • LES resting pressure: 20 mmHg • % of failed swallows: 0% Case Study: Imaging Barium Swallow • No abnormality of the swallowing function • Configuration and motility of esophagus are normal • Small sliding hiatal hernia • Trace amount of elicited gastroesophageal reflux to the level of the mid-esophagus • IMPRESSION • Small sliding-type hiatal hernia • Small volume gastroesophageal reflux occurs with provocative maneuvers. Imaging • Yes • Type of imaging: Barium Swallow/Upper GI Hiatal Hernia Type • Type I • Sliding hiatal hernia • 95% of all HH • Type II • Paraesophageal hernia • Type III • Combination of Types I and II • Type IV • Herniation of additional organs Hiatal Hernia Size • Not always documented • May be documented in the following reports: • Esophagogastroduodenoscopy (EGD) • Esophagram / Barium Swallow • Chest or Abdominal CT scan Hiatal Hernia Size and Type • Hiatal hernia size (cm): Missing Data • Hiatal hernia type: I Case Study: Operation • Hernia repair status: Primary repair Case Study: Procedure Approach • Laparoscopic Operative Details • Fundoplication: Yes / Complete • Gastroplasty: No • Mesh: No • Relaxing Incision: No Fundoplication Normal Nissen Anatomy (Complete) Dor Toupet (Partial) (Partial) Tension Free Hiatal Hernia Repair • Axial Tension • Along the length of the esophagus • Shortened Esophagus • Intra-abdominal length <2cm • Radial Tension • Between diaphragmatic crura Bradley DD et al. Surg Endosc 2015;29:796-804 Gastroplasty • Shortened Esophagus • Most commonly from GERD • Inflammation • Edema ----> Fibrosis • Can extend transmurally (full thickness) • Repeated cycles of injury and repair • Contraction of collagen in scar • Circumferential -> peptic stricture • Longitudinal -> short esophagus Horvath KD et al. Ann Surg 2000;232(5):630-40 Gastroplasty (Collis) Horvath KD et al. Ann Surg 2000;232(5):630-40 Mesh Oelschlager BK et al. Ann Laparosc Endosc Surg 2017;2:50 Relaxing Incision: Right Greene CL et al. Surg Endosc 2013;27:4532-38 Relaxing Incision: Left Greene CL et al. Surg Endosc 2013;27:4532-38 Diagnosis Primary Procedure Case Study: Follow Up • Alive at 30 days • Postoperative course was unremarkable • Tolerating soft diet without dysphagia or heartburn • Off of Omeprazole • No radiographic recurrence, symptom recurrence, endoscopic intervention nor re-operation.
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