Lisa M. Brown, MD, MASAssistant Professor of Thoracic Surgery

University of California, Davis Health

Hiatal Hernia & GERD

• 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

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

Gastrin

CCK2Receptor

PPI

AcetylcholineMuscarinic AntagonistsMuscarinic

M3 Receptor

Histamine H2Receptor Antagonists

Histamine

H2 Receptor

Parietal Cell

H+K+

ATPase

H+ K+

Acid

Gastric GlandLumen

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

SquamousEpithelium

Columnar Epithelium(Intestinal Metaplasia)

Goblet CellGEJGEJ

Spechler SJ, Souza RF. NEJM 2014 Aug 28;371(9):836-45

Barrett’s Esophagus• Classification

• No dysplasia• Indefinite for dysplasia• Low-grade dysplasia• High-grade dysplasia

Barrett’s Esophagus

pH Testing

pH Testing

YesDeMeester score 58.4

Case Study: ManometryLower Esophageal Sphincter RegionLandmarksProximal LES (from nares/cm) 42.0LES length (cm) 4.0Esophageal length (LES-UES centers/cm) 23.3Intraabdominal LES length (cm) 0.0Hiatal hernia? Yes

LES PressuresPressure measurement method eSleeve, IRP

Basal (respiratory mean)(mmHg) 20 (13-43)

Residual (median)(mmHg) 6 (<15.0)

Esophageal MotilityNumber of swallow evaluated 12Chicago Classification% failed 0% weak 0% ineffective 0% panesophageal pressurization 0% premature contraction 0% fragmented 0% intact 100

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

Nissen(Complete)

Toupet(Partial)

Dor(Partial)

Normal Anatomy

Tension Free Hiatal Hernia Repair

Bradley DD et al. Surg Endosc 2015;29:796-804

• Axial Tension• Along the length of the

esophagus• Shortened Esophagus

• Intra-abdominal length <2cm

• Radial Tension• Between diaphragmatic

crura

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