Hiatal Hernia Repair – After Gastric Sleeve
A hiatal hernia is a comorbid condition that may occur in obese individuals. Despite being a leading weight loss surgery in the United States, gastric sleeve surgery has been associated with gastro-esophageal reflux (GERD) resulting in heartburn. It can either aggravate an existing problem or cause it to develop de novo. A hiatal hernia has however been implicated as one of the predisposing factors for developing GERD, thus, necessitating repair.
What is a hiatal hernia?
The chest cavity, which contains the heart and lungs, is separated from the abdominal cavity by a dome-shaped muscular structure known as the diaphragm. The diaphragm is the primary muscle of inspiration. Its contraction and relaxation is the major factor in maintaining respiration, though there are other accessory muscles of respiration that are important as well. Structures such as esophagus that serves as a passage for food from the throat to the stomach pierce this diaphragm to enter the abdominal cavity from the thoracic cavity. The hole in the diaphragm that affords a passage to the esophagus is known as esophageal hiatus.
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A hiatal hernia is an abnormal condition in which organ(s) in the abdomen such as stomach; intestine; or omentum protrudes through the esophageal hiatus into the thoracic cavity. It can be congenital but most common among the elderly and those who are obese.
The consequence of stomach protrusion is gastro-esophageal reflux disease which is characterized by regurgitation of acidic stomach contents into the esophagus. Patients may experience heartburn, excessive belching and sour taste of acid at the back of the tongue. They may also have difficulty with swallowing due to the disruption of the normal junction between the esophagus and the stomach. Other manifestations include chest pain, difficulty with breathing, palpitation and intestinal obstruction.
The symptoms of reflux often subside with the use of antacids and drugs that suppress gastric acid production. However, a definitive diagnosis can be made by doing an upper gastrointestinal endoscopy. This procedure involves the passage of a flexible tube with a camera through the mouth into the esophagus, stomach, and duodenum to see the cause of the reflux. This also helps rule out other causes of heartburn such as peptic ulcer. Another diagnostic procedure is the barium swallow study.
Why repair a hiatal hernia after gastric sleeve surgery?
Reflux symptoms may fail to resolve following medical management with antacids or gastric acid suppression. However, when they are partially due to a hiatal hernia, they may persist. Other features of a hiatal hernia such as chest pain, difficulty with breathing are also not amenable to antacids as they are caused by the anatomical disruption.
When to repair a hiatal hernia
The repair of a hiatal hernia can be done before, during or after gastric sleeve surgery. Many surgeons have different views about the effect of a hiatal hernia repair on gastric reflux. Results have shown that repair of a hiatal hernia may not lead to resolution of reflux symptoms. This finding can be explained by the fact that reflux symptoms after gastric sleeve surgery are not solely due to the anatomical disruption caused by a hiatal hernia. Other causes of reflux include increased intragastric pressure due to less compliance and removal of part of the lower esophageal sphincter fibers during surgery.
Also, some surgeons believe that reflux and other symptoms of a hiatal hernia may resolve after significant weight loss with a reduction in intra-abdominal pressure. Nevertheless, if the symptoms persist after gastric sleeve surgery, a repair may be indicated.
The repair of a hiatal hernia following gastric sleeve surgery may result in resolution of specific symptoms. During this repair, the stomach is returned into the abdominal cavity, and the diaphragmatic defect around the esophagus is repaired. A mesh can also be utilized for closing this defect. This repair will prevent the abdominal contents such as stomach from protruding back into the chest cavity. Palpitation due to irritation of the vagus nerve by the protruding stomach as well as difficulty with swallowing may resolve.
Another major surgical procedure that must be performed along with hiatal hernia repair is fundoplication. The surgery involves the wrapping of the fundus of the stomach around the junction of the stomach and the esophagus. This will help increase the competency of the esophageal sphincter leading to resolution of the reflux.
A hiatal hernia is a common problem in obese people. Some of the symptoms may resolve after gastric sleeve surgery, but when they persist, a repair of this anatomical abnormality may become necessary.