Episode 89: Hiatal Hernias and other Diaphragmatic Hernias | Hernia Talk Live Q&A

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Speaker 1 (00:00:00):

Hi everyone, it’s Dr. Towfigh. Welcome to Hernia Talk Live, our weekly question answer session. My name is Dr. Shirin Towfigh. I am your hernia and laparoscopic surgery specialist. Many of you are joining us by Facebook as a Facebook live at Dr. Towfigh. Some of you follow me on Instagram and Twitter at hernia doc and thanks for following me and watching and sharing everything on YouTube. At the end of this show, we will have this posted on YouTube for all of you all to see. Today we have a very great guest because we’re getting a little bit outside of the typical hernias that we talk about. We have Dr. Caitlin Houghton. She is a foregut surgery specialist at USC where I used to work, university of Southern California. Very, very famous institution for hiatal hernias and forge surgery in general. You can follow her on Facebook at Dr. Houghton or on Twitter, Kate Houghton 13. And please give a warm welcome to Dr. Houghton. How are you?

Speaker 2 (00:01:04):

Hi, I am good. How are you?

Speaker 1 (00:01:06):

Good. So many of people on this already know my first job was at USC and of course everyone knew about for good surgery and Dr. De who was a chairman at the time, the Alcock’s, Jeff,

Speaker 2 (00:01:26):

Hey again, yours

Speaker 1 (00:01:27):

Peter, Jeff Peters was a program chair at the time, also very well known foregut surgery. I took my first sages course at USC for, I don’t know if they still have their foregut surgery case courses when I was a resident. So you have quite a legacy behind you at USC and now you are one of the premier robotic surgeons there and you do a lot of hiatal hernia surgeries and foregut surgeries. So I’m really excited to have you because I don’t answer a lot of questions about hiatal hernias.

Speaker 2 (00:01:59):

Yeah, well thanks for having me. Yeah, I’m excited to talk about this topic because it’s often has a lot of patients are often confused about the information out there and yeah, I’m really excited to kind of see what patients are wanting to know and shed some light on the disease process of hiatal hernias, which is also a lot of times correlates with acid reflux as well. So sometimes they go hand in hand. So there may be questions. Yeah, maybe talking about acid reflux hiatal hernias and we can talk about why those things tend to be treated similarly.

Speaker 1 (00:02:37):

Yeah, absolutely. So maybe you can just quickly tell us what is a hiatal hernia? Because a lot of people call my office because they have a hiatal hernia. They’re like, okay, hernia surgeon hiatal hernia. But it’s, it’s not technically an abdominal wall hernia. It’s a little bit deeper. So maybe you can explain what’s the hiatus, why is it called hiatal hernia?

Speaker 2 (00:03:00):


Speaker 1 (00:03:01):

What you do is different than the average general surgeon.

Speaker 2 (00:03:04):

Yeah. So the a hiatal hernia is basically a hernia in the diaphragm. So the muscle that separates the chest from the abdomen and a hernia basically is just a hole. So anytime there’s a hole somewhere in the body, it’s called a hernia. But depending on that, where it is when you have differences. So a hiatal hernia, there’s the hiatus of the diaphragm, that’s a natural hole in the diaphragm to let the esophagus pass from the chest cavity to the abdomen. But it’s considered a hernia when stomach pushes up through that hole up into the chest. So then now you have stomach up in the chest where it shouldn’t belong. The difference between kind of abdominal wall hernia and foregut or the hiatal hernia is that often you need to go to a foregut specialist or someone that, and what that means, basically foregut is just a fancy word for esophagus and stomach. Someone that works in that area because that area is right behind the heart and it’s sandwiched between the lungs and the heart and the aorta or the major blood vessels and the body. And you’re working in a small space to try and get that stomach back into its normal position. So often it takes a specialist to do that type of hernia surgery.

Speaker 1 (00:04:30):

And who are those specialists? If someone wants to see, can they go to a general surgeon or do they have to be specialized?

Speaker 2 (00:04:38):

Yeah, so there are lots, many tracks for doing this type of hernia, but you could be a general surgeon and kind of focus your practice in the foregut area or the hiatal hernia area. So a lot of general surgeons or a subset I should say of general surgeons do this procedure. But as a patient, often what I would look for is someone that does these often because that’s an area of critical structures I would say, or a lot of anatomy that is high risk in a way. So you want someone that does a lot of these procedures and is very well versed in that area. So usually that is someone who’s has a M I S or minimally invasive surgery fellowship is a good way to kind of see, yeah, oh did they do that kind of fellowship? That means they specialized in this area you for a year afterwards, just focused on doing that kind of thing.

Speaker 2 (00:05:42):

And sometimes it’s lumped with minimally invasive or and bariatric together. Sometimes that fellowship covers both. And then often there’s kind of centers of excellence as well. So more and more this idea of a digestive diseases center, center of excellence comes up and those are kind of within a hospital system. Often they designate a certain hospital, a certain group to be their specialist and have this kind of accreditation of being a center of excellence. So that’s also something to look for as a patient if you want to make sure that you’re going to an experienced surgeon.

Speaker 1 (00:06:28):

Yeah, that’s interesting. I didn’t know they had a center of excellence for that. The question is, is a hiatal hernia the same as an epigastric hernia?

Speaker 2 (00:06:36):

No, actually. So an epigastric hernia is still in the abdominal wall. So anything that the abdominal wall we talk about, anything visible that you can see evolved on when you look down at your abdomen. An epigastric is just that area between where the bone, the ribcage is high on the abdomen, that’s called the epigastric region. Hiatal hernia is deeper on the inside.

Speaker 1 (00:07:01):

Yeah, I’ll fix the epigastric

Speaker 2 (00:07:03):

Hernias. Yeah,

Speaker 1 (00:07:05):

Fix the hiatal

Speaker 2 (00:07:06):

Hernias. Exactly. Yeah,

Speaker 1 (00:07:08):

It’s definitely a different, I mean the anatomy is the conceptually it’s the same, like you said, it’s a whole, but it’s always a hole where a major organ, the stomach goes through in your situation with the hiatal hernias. Whereas abdominal wall, it’s usually fat. It can be small intestines, often not other organs.

Speaker 2 (00:07:31):

The other major difference, which is that in the abdominal wall you can completely close that hole cause you don’t have to have anything going through there. So you completely close that hole and then can cover that with Mesh. Yeah. Whereas in a hiatal hernia, you need to leave a small defect, you need to leave the hole so the esophagus can still come through. And so that poses some challenges where you have to close it enough so that it doesn’t come, hopefully doesn’t come back, but not too much that you know can have problems with swallowing or something like that in that area. Cause you are closing around the esophagus.

Speaker 1 (00:08:12):

So just to clarify, the anatomy goes, the food goes in your mouth, it goes behind your throat, it goes down the esophagus, which is just a simple long tube and then that’s really behind your heart. And then it transitions into the stomach right around what they call the breast bone, I guess below the breast bone. And if you have any problems with the area, usually the pain is around that area, right? Well, somewhere between the breasts and lower.

Speaker 2 (00:08:43):

So it can be in the upper abdomen, right under the rib cage. Sometimes it goes a little bit towards the right side. Patients can have heartburn. That’s also one of the major symptoms of a hiatal hernia is kind of heartburn. We can talk about why that is. Other minor things can be feeling that food gets stuck or regurgitation of food. Let’s say you’re, you eat and then you bend over to tie your shoe and blah, you have a little bit of something come into your mouth that’s called regurgitation and that can be a symptom. It’s kind of hard because some of these symptoms can overlap other things and it’s not always a hiatal hernia, but some of those things, if you have acid reflux or that regurgitation food kind of feels like it’s come coming up, those can be signs of a hiatal hernia. But often in other times they can be completely asymptomatic and patients don’t even know they have them.

Speaker 1 (00:09:40):

That was going to be the next question, which is how do you know if you have a hiatal hernia? So what percentage of people with hiatal hernias actually have symptoms?

Speaker 2 (00:09:50):

Probably a, I would say the major symptom is acid reflux. But their acid reflux can happen with or without a hiatal hernia. And symptomatic, I would say probably about 60% of patients with a hiatal hernia are symptomatic. A lot of, whoa, most people are the issue. What I think if is that you all people can tend to, if those symptoms come on gradually, you can make minor little changes and not really realizing that, oh, I’m not, I’m making minor changes in my day. Not easy eating spicy food as much or not eating late at night so that I don’t feel, I don’t get woken up in the middle of the night with acid reflux. There’s little changes that people make and they don’t kind of associate it. So I would say more people are symptomatic than not. But there are about 40% that aren’t, probably wouldn’t know. Is

Speaker 1 (00:10:46):

It a US problem? Are there a lot of hiatal hernias or acid reflux in India or China or Africa?

Speaker 2 (00:10:54):

Yeah, no, I don’t think it’s just a US problem. I think it’s probably a little bit more prominent here just because of things that we think can contribute to a hiatal hernia. And this is not everything. Some of it is genetic and we know that it can run in families. Okay. But other times it’s anything that increases abdominal pressure. So being overweight, having carrying a lot of your weight in the abdomen, heavy lifting, but maybe those are kind of speculations of why you get it. Most patients, however, with a hiatal hernia, the research shows that they actually have a difference in their collagen in the muscle of the diaphragm itself that predisposes them to have stretching of that hole so that more so stomach is more likely to get up there. So there is a genetic component as well.

Speaker 1 (00:11:51):

When I talk to my hernia patients, I do a full history and always ask ’em about acid reflux or look for hiatal hernias on their imaging because it’s all the same family. And it sounds like factors for hiatal hernias are very similar for other hernias, obesity, chronic cough, anything that increases your abdominal pressure. Nicotine, has that been shown to have a higher risk? It is for hernias,

Speaker 2 (00:12:20):

Not necessarily. I haven’t heard that one. For hiatal hernias specifically.

Speaker 1 (00:12:24):

And then straining to have a bowel movement like constipation. Men when they have enlarged prostate, they’re restraining next to the bladder and then yeah, definitely obesity is a big one. And also in the groin and else belly button where you can get hernias, there have been studies that show this kind of mismatch of collagen. So you tend to have the weaker collagen, not so much of the stronger, more mature collagen. And when the collagen is laid down, it’s not as perfectly laid in these perfect patches and so they don’t have the strength that you expect. So can you explain while you’re answering all the questions before I’m getting into them? Okay. So the last question was about what is hiatal hernia? How’s it different than other hernias? We discussed that the next is about surgery. So you’re a surgeon and I assume you’re talking to patients about whether they need surgery and what the pros and cons are. But how do I know if my hiatal hernia needs repair?

Speaker 2 (00:13:33):

So often before, often before a patient gets to a surgeon, they’ve had some workup done. They know they have a hiatal hernia. And often we know that because either they’re symptomatic and they’re with acid, let’s say it’s symptomatic with acid reflux. And so their GI Dr. May do a scope or an endoscopy with a look with a camera down through the esophagus into the stomach and they notice a hiatal hernia. So that’s one way people can know that they have a hiatal hernia. And so that’s one way people get to me. Others are they find it on a CT scan that they were getting for something else. So those are some more of the asymptomatic patients that have large hiatal hernias.

Speaker 2 (00:14:24):

Every patient that comes in our door for a surgical consult, if they have a hiatal hernia, we kind of want to know we need a little bit of a workup before we say, yes, you’re a candidate for surgery. So not all hiatal hernias do require surgery. A lot of them do. However, because the hiatal hernia or, well, there’s a valve between the esophagus and stomach that prevents acid reflux and prevents injury to the esophagus from acid. So often if that valve is up in the chest, it’s not working appropriately. So it can contribute to some of those symptoms which although acid reflux can be treated with antacids or medication and other things, if the hiatal hernia is there, you’re never really going to solve the problem. Yeah, cause it’s a mechanical or structural issue.

Speaker 2 (00:15:23):

So we want to know do you have acid reflux? How bad is it? Does the hernia affect your daily life? And some of the testing we do is an endoscopy. Sometimes we do a quantitative or a pH test to see how much acid is really coming into your esophagus. And oftentimes we’ll do some kind of imaging or x-ray study where you drink some dye and we watch it go through to know to screen for the motility of esophagus. So if we’re considering you for surgery, we want to know that your esophagus squeezes well cause we’re going to, part of the hernia surgery, which I’m going to describe in a minute, is recreating a valve between the esophagus and stomach. And we do that because once we bring the esophagus out of the chest and it’s now down in the proper place in the abdomen, that sphincter muscle that usually would protect you from acid reflux, it doesn’t work anymore.

Speaker 2 (00:16:23):

It just kind of loses its function from being up in the chest. So two parts of the surgery if you are a candidate is that we bring the stomach down in the right place. There’s a hole in the diaphragm that I told you was too big and we need to narrow that down so it’s just big enough for the esophagus to come through. So we stitch that diaphragm up and then the second part of the surgery is to reinforce the valve and there’s options for that. And your surgeons will go over what the best options for you, how tight you reinforce it based on how well your esophagus or your anatomy can squeeze food down past a valve. So that’s kind of the basics. A lot of if you have a large hiatal hernia and large is relative. So I would say if it’s measured like four to seven centimeter, four to 10, anything above, well anything above six I would say is large, moderate I would say is probably a four to six range.

Speaker 2 (00:17:28):

And then small hiatal hernias are probably in the two to four range. All of them can be symptomatic. You could have a huge hernia and be asymptomatic, have a really small hernia and have all the symptoms in the world. It doesn’t necessarily correlate, but often if patients have large hernias, we want to get those fixed because there’s some complications of having your stomach up in your chest. It doesn’t belong there. No, it doesn’t belong there. You can get shortness of breath, it can twist. There’s something, we’d rather have it down in the abdomen where it should be. So we prevent some of those complications. And then for the smaller ones, we and the moderate ones we’re looking to make, see if they’re symptomatic and if they’re symptomatic, we consider fixing those for patients.

Speaker 1 (00:18:21):

Good. So the next question, and this is a good leeway into it, is what are the symptoms of a hiatal hernia? Can you get discomfort under the breast that moves to the center of the chest that then becomes spasms from both sides of the ribs, then severe pain and nothing seems to help including ice or heat. This only came on when sitting or driving in the car.

Speaker 2 (00:18:43):

Yeah, so that’s kind of a thing. Some symptoms overlap, so yeah, I mean could that be a symptom of a hiatal hernia? Yeah, you could have this pain or shortness of breath or positional discomfort.

Speaker 1 (00:19:01):


Speaker 2 (00:19:02):

Can I say a hundred percent without doing any testing that is a hiatal hernia? No, but it could be and it requires that type of symptom requires maybe some workup. An X-ray study would be a simple thing to start with just to see if your anatomy is normal, if that’s suspected.

Speaker 1 (00:19:23):

So the same follow up is once the bad pain comes in, I’ve had two episodes where I felt that like a fist size knot in my chest about three inches in size and the next time I happened, it seemed to be a six inch area. I finally got to a doctor and he wants to do an endoscopy, which I’ve had in the past and I know I have a hiatal hernia, but it’s been many years. I also have acid reflux. Three doctors said they don’t think a hiatal hernia would cause the symptoms I have.

Speaker 2 (00:19:54):

It’s hard to, pain is a hard symptom to directly correlate to something. We know that a hiatal hernia can cause discomfort. It can cause discomfort in the chest and patient, the thing that’s patients experience their symptoms and their body a little differently. Yeah. So could it be what I would say to a patient that has a hiatal hernia, has acid reflux and is experiencing that type of pain discomfort, listen given, let’s say the workup says that you’re a pretty good candidate for surgery, let’s fix that abnormal anatomy and there’s a good chance that pain does go away. And if it doesn’t, then we fix your anatomy. You don’t have acid reflux, you don’t have to worry about the hernia. And we could consider, then we have to think about other things that could be contributing to the pain or discomfort. But there’s, after kind of teasing and talking to a patient and asking specific questions, often we can tease out whether it’s probable that that would be something that could happen from acid reflux.

Speaker 1 (00:21:07):

Part of the teasing. So if you do endoscopy, which is camera down the throat looking at the esophagus and the stomach and it’s clean, yeah, you have a hiatal hernia, but there’s no inflammation, there’s no burning, there’s no acid kind of evidence of esophagitis, which is kind of burning or inflammation of the lining. Does that imply that you don’t have pain from a hiatal hernia or can you have pain from a hiatal hernia and have a normal endoscopy except for the hiatal hernia?

Speaker 2 (00:21:35):

Yeah, that’s probably a little more rare to have that intense pain from a hiatal hernia. Not to say it can’t happen, but it’s a little more rare. The other thing that I would say is on a simple endoscopy and you let’s say the mucosa or the lining of the anatomy looks normal, oftentimes if patients are complaining of symptoms that sound like they’re from acid reflux or from a hiatal hernia, that’s when I would do a pH test to actually put a probe inside the esophagus to monitor how much acid is coming up. And it gives us a score. The Demeester score, we talked about Tom, the Demeester, he developed that he’s from USC, but it gives you a score to say, yeah, actually you know you have a hiatal hernia, although it’s not causing a lot of visual injury, you actually have a lot of reflux and that may be worth getting fixed. So there’s a lot of little nuances and in tailoring the surgery to a patient’s needs.

Speaker 1 (00:22:41):

So that probe is a, so a pH probe is outpatient study, correct?

Speaker 2 (00:22:47):

Yes. So it’s actually, it’s a wireless, it’s like the size of a little pencil eraser. And during an endoscopy we clip it into the esophagus about six centimeters above where your valve is or should be. And then you have a wire monitor that you wear and it tracks it wirelessly for four days and then you bring back the monitor and we’re able to see a tracing of how often and give you a score that tells us if you’ve had acid reflux or not. That’s helpful and if you helpful. Yeah, and it’s a really great test because it’s for those patients that maybe have a small hiatal hernia but not a lot of injury from reflux visually. And it can kind of clarify if those symptoms are from reflux or if it’s something else for us.

Speaker 1 (00:23:35):

And then what if they just take a bunch of ant acids and is that a good predictor of whether their hiatal hernia is the cause of their pain?

Speaker 2 (00:23:45):

So if you take antacid, so antacids are basically a medication that we give to patients that have acid reflux to decrease the amount of heartburn or how much acid is in their stomach and can decrease the acid in your stomach. They’re great for a lot of patients, they work really well and it takes away your symptoms and you can kind of live your normal life. But often patients are on these medications chronically and continuing to take them and take them and take them and they’re not quite, they’re helping their symptoms, but they’re not making them go away and they’re still having nagging symptoms on a daily basis. Those, that’s what we call breakthrough symptoms. So if you’re on the medication that you should be on and you’re still having symptoms, even if maybe they’re not as bad some pa, then we need to look into maybe we should get it fixed surgically.

Speaker 2 (00:24:46):

There are patients that just don’t want to be on medications every day of their life and have a hiatal hernia and need or want to get it fixed. And we talk to patients like that as well. There’s a lot of media about antacids being bad for you, the risk for an individual is pretty small for a healthy individual. The risk of the antacids even being on them longer. Some people are on ’em for five, 10 years. I think the label says three months only, but people are on these and they’re controlling their symptoms for many years. And there’s a a lot of fear I think from the media recently and I, yes, there are some side effects and depending on what your other medical issues, it might be an issue for you versus someone else. But overall they’re relatively safe and the risk of surgery has some risk to it too. So it’s always kind of weighing the benefit and the risk of staying on a medication versus the risks, inherent risk of surgery.

Speaker 1 (00:25:56):

So yeah, 10, 20 years ago there were studies showing concern that if you’re on these anti ulcer medications for a long time, you can get gastric cancer, kind of like a elevating gastro levels and so on. But I think the more recent studies show that that was not the case. Do you know anything about the risk of gastric cancer with Nexium? Yeah, Pepcid,

Speaker 2 (00:26:20):

Most of ’em are. There’s not a risk of gastric cancer. There was one, a zantec was taken off the market for a little while and I think they changed the formula and I think it’s back, but Zantac was off for a while because of a known risk that was proven. But all the rest of ’em, I don’t think that I’ve seen that come up again as a risk of them. Yeah.

Speaker 1 (00:26:45):

Okay. The next question is, do asymptomatic congenital hiatal hernias exist? And if yes and you have it, will it worsen with time and become symptomatic if you ignore it?

Speaker 2 (00:26:56):

It can. Yeah. So they do exist and they can be asymptomatic. We kind of think that most hernias over time are likely going to get larger. Okay. But would you agree with that statement?

Speaker 1 (00:27:12):

Yeah. We don’t know how fast that trajectory is. It could be one exactly. 10 years or

Speaker 2 (00:27:16):

20, exactly. So we just don’t know how long for each patient that’s going to take. So what I would say is if you know have a hiatal hernia and it’s asymptomatic and surgery is not really needed for you because you’re, you’re not having any bad side effects from the hernia, I would put that patient on a surveillance type of program where they get an imaging study or some kind of study periodically. It might be three years, it might be five years depending on how big the hernias to start with. If it’s really small and the symptoms don’t change, we can just periodically look at it to, because we don’t know how fast it could change and it might not change for a really long time and that patient may not need surgery. If it’s a large hernia, when we find out about it, most of the time I’m probably going to recommend that we fix that hernia while someone’s kind of young and healthy and before it gets worse. Because if it’s already large that 6, 7, 8, 9 centimeter range, then likely fixing it early is going to be a better strategy.

Speaker 1 (00:28:25):

Next question is about imaging. So what’s the best imaging for a hiatal hernia outside of endoscopy?

Speaker 2 (00:28:32):

Yeah, I mean I would say an endoscopy is the best. Well, it gives you a lot of information from the inside, whether the hiatal hernia, how big it is, you can measure it, you can see if you’re having injury on the mucosal side from it. The other thing often we get is called a video esophagal or an esophagal, and that’s drinking some dye and watching it go through that, that often is also done in conjunction and during the workup and making for a patient, they’ll get that and an endoscopy and that is to kind of see the configuration in real time. When you swallow, does your esophagus move bright? Is the dye that we have you drink going down, hitting a point, kind of refluxing back up? Is it going through normally? What’s happening? Yeah, what’s happening dynamically, which we can’t see when you’re asleep.

Speaker 2 (00:29:29):

And we just put a scope in there. And then some subset of patients will also need a study, which I guess this is kind of getting into the details, but some will need a manometry, which is a study that actually looks at the squeezing of the esophagus. So function if, yep, we need to know if we are considering that someone for surgery and let’s say on their imaging study on that x-ray study, it looks like their esophagus may not squeeze very well. We want to know whether it does or doesn’t. And so sometimes we need a functional study where we have a probe in there and then have patients follow and it gives us measurements of the actual pressures of the esophagus so we can decide whether tight to reinforce a valve for that sphincter. Can

Speaker 1 (00:30:23):

You see a hiatal hernia on CT scan or a CAT scan?

Speaker 2 (00:30:27):

You can, yeah. Yes, you can see it. And sometimes that’s how a patient finds out about it because they get a CT scan for something else and they’re like, oh, we see a hiatal hernia there. And honestly oftentimes it’s downplayed at that point. You may be told and you’re like, oh, don’t worry about it. It’s small, nothing to do about that. And that can be true, but at the same time, if you’re having symptoms from it or if it’s a over a certain size, that may not be true for everyone. Or if that’s

Speaker 1 (00:30:58):

Why you got the CT scan because you’ve got this weird pain in the upper abdomen. Like a knife, like sharp pain in the, yeah, yeah, that’s

Speaker 2 (00:31:07):

Probably, and there’s nothing else on there. It’s probably from the hiatal hernia. Yeah. And then

Speaker 1 (00:31:15):

The video esophagal where they drink the contrast and you watch it go down from your esophagus to your stomach and if it reflexes up, does that mimic what happens when you take food in?

Speaker 2 (00:31:28):

Yeah, it does. They’ll do liquid and then often they’ll give you a little tablet as well, but will simulate more solid. So it’s kind of what happens with liquids, what happens with the solid and it, yeah, it does. It’ll mimic what happens when you swallow food or liquid.

Speaker 1 (00:31:45):

Okay, cool. So we already talked about the genetic component there. It does run in families just like other hernias,

Speaker 2 (00:31:54):

Right? Yeah, yeah, absolutely. Okay. Yeah, it does. So we think that there is a genetic component. I think we touched on that with kind of that collagen depth. The collagen can be a different type. You’re not going to know that a patient, you’re not going to know if your collagen is different. That’s more of a kind of something that’s been studied in the past, but patient’s not going to necessarily know if you have more of one type of collagen than the other.

Speaker 1 (00:32:24):

And for regular hernias, not only does it run in families, we’ve been able to show that it’s actually a stronger link if a female in your family has it than a male. It’s something that I started seeing in my patients where there was a stronger genetic link if it was a mom than a dog, even though women tend to are less likely to have abdominal wall hernias than men. But what do you see in hiatal hernias? Is it more common in men or women?

Speaker 2 (00:32:56):

Not necessarily, no. Well, I guess they do say in that it’s slightly more in men. They do, I guess they should rephrase. Yes, they tend to say that it’s more likely in men and more likely in that kind of 50 year old age group. But that being said, I don’t always, in my experience, that’s not necessarily what I see. I see a pretty equal distribution, honestly, of men and women and yeah. That’s interesting that you found that about the female’s bloodline. I guess I haven’t necessarily seen that in hiatal hernias, but I don’t know that I’ve been kind of maybe been that observant either. So yeah,

Speaker 1 (00:33:39):

It’s less common in women, but if it isn’t a female, that bloodline is stronger to be passed on. Yeah, yeah,

Speaker 2 (00:33:45):

That’s interesting. Yeah.

Speaker 1 (00:33:47):

Okay. Going back to, let’s start with a little bit nonsurgical stuff. So most of the symptoms from a hiatal hernia are acid reflux or GERD by gastro reflux disease. Although you did hint on obstruction and other really bad complications that can occur probably in the larger hernias. But is there a way to naturally cure a hernia osteitis or to at least treat the symptoms without using prescription medication

Speaker 2 (00:34:20):

Or Yeah, I would say there’s no way to cure a hiatal hernia. That’s a structural abnormality in your body and you could try and prevent it from getting worse. But honestly, and that can work. So some of the strategies to try and prevent it from getting worse would be to keep any that intraabdominal pressure down. So losing weight, trying to avoid extreme constipation or heavy lifting, coughing if you have a major coughing issue, anything that increases abdominal pressure we think can contribute to making hiatal hernias worse. One thing I want to caution is that I wouldn’t, I’m not saying stop exercising, you’re, you’re safe. Most patients with hiatal hernia are going to exercise and it’s not going to change it. I’m talking about really heavy weightlifting where you’re really increasing the intraabdominal pressure. And I think that there are ways to decrease the symptoms, avoiding certain foods, acidic foods can help some patients and avoiding your triggers, eating, not eating late at night because when you lay down, if you don’t have a valve in place, then that can kind of flow more easily up into the esophagus. There are some, I don’t know. Yeah, there’s not a lot of natural kind of remedies. There are some on

Speaker 1 (00:35:56):

TikTok there about

Speaker 2 (00:35:56):

Acid reflux. I know there’s hundred

Speaker 1 (00:35:58):

Requires a lot of them.

Speaker 2 (00:35:59):

I know there are hundreds and hundreds. I don’t know if they’re proven. That’s the thing. And if you have a structural abnormality, it’s probably what I often tell patients is you’re probably not changing the amount of reflux that’s coming up because your valve is abnormal so that you’re going to have reflux, but you can change how you respond to, you may not change the acid reflux or the amount, but an acids make the secretions less acidic, so you’re not feeling it as much.

Speaker 1 (00:36:35):

Have you heard about the vinegar? They say you should have apple vinegar.

Speaker 2 (00:36:39):

Cider vinegar. Yeah. Yeah. I mean I’ve heard that and I don’t know, I’ve seen no scientific studies that would prove that that’s true.

Speaker 1 (00:36:50):

Yeah, yeah, though. And then what about carbonated drinks and coffee and tea that’s caffeinated? Are all those can kind of exacerbate reflux? Right, because

Speaker 2 (00:37:04):

Yeah, they can. So caffeinated, I mean it’s like everything good that you want to eat. If you think about fat, chocolate, caffeine, over eating, overstuffed meals, tomato sauce for a Italian good, Italian meals, wine, those can all kind of make acid reflux worse. And man, you could avoid everything, but patients tend to have certain triggers that may make their reflux worse and avoiding some of those can help. Yeah. So yeah, I mean there’s a lot of different foods that can kind of contribute to acid reflux. Carbonated I think is more about the stretching of the bubbles and the gas and over distension of the stomach, which can, if you think about if you increase the pressure within the stomach with that gas, then you’re likely pushing more upwards on the chest. And

Speaker 1 (00:38:02):

If you’re constantly burping, does that imply you have a hiatal hernia?

Speaker 2 (00:38:07):

Not necessarily it. I mean, in one patient, yes, you may have one, another patient you may not. So it’s not one of those typical symptoms, but it can a lot of symptoms in an individual for one person, it could happen. Could that be that you have increased burping? You could, but it’s not indicative, I would say, of a hiatal hernia.

Speaker 1 (00:38:33):

Got it. Let’s talk about surgery. So you already embarked on mentioning a little bit just the whole concept, which is it’s a hole, you got to close the hole and there are different surgical approaches. You are a big proponent of robotic surgery. We had a whole session robotic surgery last week with Andrea. Oh yeah, that was really, really fun. We’ve had a couple others in the past too about just robotics, just fun talks. I love robotic surgery because it’s fun, but I’m, I’m not one that promotes it for every single thing. Some people always do robotic surgery, some do nothing. And others, I’m kind of in between. But I know that you are a big component of robotic surgery and that’s a lot of what you do. So is it fair to say that if you have the opportunity to either have laparoscopic or robotic surgery, that you should choose that option as opposed to open surgery assuming that you’re offered both?

Speaker 2 (00:39:34):

Yes, for sure. And actually most foregut procedures, if you’re going to go and see a surgeon for elective repair, it’s going to be minimally invasive, meaning small incisions, it’s going to be laparoscopic or robotic. There are not a lot, I would say almost no one is doing those open electively. If you’re in emergent situation where you come in and there’s a big issue because something happened in the stomach, those are rare cases, those maybe will be done open. But in the elective setting, meaning it’s planned, it’s 99% of the time going to be offered a minimally invasive approach. So either laparoscopic or robotic, I do mostly robotic. And I think surgery is, there’s, technology is kind of entering the world of surgery more and more. What I like about robotic surgery is we’re operating in a small space, the diaphragm is small and we have to go through the small space to dissect in the chest and bring the hernia down.

Speaker 2 (00:40:50):

And there’s critical structures there. So for me, really the benefit of robotics during the surgery is visualization and stability of the camera. It takes out tremor. And then the other thing is you have these wristed instruments, so I can kind of use a wristed instrument to get in tight spaces, whereas traditional laparoscopy, it’s straight sticks. So I often say it’s operating with chopsticks. We’ve gotten really good at that. We’ve trained that way for years and years and years. And in order to offer minimally invasive surgery, we can do very complex surgeries that way. And there are expertly skilled surgeons that, and that’s the way I was trained. I was trained laparoscopically. But the robot kind of gives us our freedom and our flexibility back, which I really like to keep surgery as precise as possible. And then as far as the patients, I do see a little less pain, a little less, their incisions hurt a little bit less. They tend to bounce back from surgery just a little bit better. And so I really do think it’s for area, I do think it’s benefit.

Speaker 1 (00:42:04):

And then when you do repair and abdominal wall hernias, we use Mesh and it’s, I believe we are overusing Mesh, but it is a very critical tool that we have in trying to fix abdominal wall hernias, especially the larger ones. What is the role of Mesh for the hiatal, for the hiatus and hiatal hernias?

Speaker 2 (00:42:26):

Yeah, so Mesh is, I hesitate to say a controversial talk topic in hiatal hernias, but it’s debated, I should say. Yeah, it’s not controversial. It’s debated. And the reason it’s debated is because based on our scientific literature, there were papers early on when we started using Mesh that said it helped recur reduce recurrence rates, so reduce how often those hernias came back in the same individual. And so initially everyone was like, oh my gosh, this is so great. We can reduce this hernia from coming back by using this Mesh. The issue was that that was true for the first six months to a year after surgery, but then if you followed those patients at five or 10 years, the patients who got Mesh or didn’t have Mesh had the same kind of rate of recurrence or that hernia coming back. And so long term, it didn’t pan out to prevent a hernia from coming back.

Speaker 2 (00:43:31):

That’s so weird. So I will use it selectively. I’ll use it when the diaphragm, you can think about a hole being narrow or teardrop shape or it can be a big oval. And so if there’s some tension or there’s some, I’m pulling sewing up the diaphragm and there’s kind of some tension on it, I like to reinforce with Mesh because it’ll kind of allow, protect that area for the short term and that first six months to a year while the tissue is weakened and it gives it extra structural support. So I will use it in those patients. I know that long-term predict who may get a recurrent hernia or who won’t, the recurrence rate, I’m just going to jump into this because it might be a follow-up question about, okay,

Speaker 1 (00:44:27):

It’s already been asked. Yeah,

Speaker 2 (00:44:28):

What is, yeah, why do they, yeah, and what is the recurrence rate? So nationally, I would say the recurrence rate is like 20%, and that sounds high, high, but we’re fixing kind of reconstructing an area that moves and it’s dynamic and you have to leave a hole. So it’s kind of this arts. And the caveat to that is that about 20%, right? That’s the number that’s thrown out there in centers that do, these are expert centers or so an expert hands, that rate goes down a little bit. It’s about 15%. And then there’s also, it breaks down between the patients who have recurrence that need it repaired or a recurrent surgery or another surgery to help repair it. And usually that’s about five to 10. Any quoted five to 10% at five to 10 years after the initial surgery.

Speaker 1 (00:45:28):

But the majority of those people that recur don’t necessarily need another surgery. They just need maybe new medication or modification or lifestyle.

Speaker 2 (00:45:36):

So sometimes those are asymptomatic recurrences, so patients don’t even know about it. But we like to follow our patients and make sure that this is a durable surgery. So we tend to follow patients over time sometimes. So sometimes we find ’em that way and a lot of times it’s big, the patients that tend to be more at risk for her recurrence are the ones that have a big hernia on the outset onset and maybe have some of those external factors like intraabdominal pressure or genetics could not be on our side. And those are a little riskier, have a little more of recurrence rate than the smaller ones. But they tend to, if they come back, they tend to come back smaller. So if you had a six, seven centimeter, I mean this isn’t all the time. It’s kind of the rule thumb, they’ll usually, they’ll come back and be like maybe one to two centimeters. So we find it radiographically or on imaging and then we have to tease out whether it’s symptomatic or actually causing any issue for the patient.

Speaker 1 (00:46:44):

So I’ve learned is that we actually have really great medications nowadays and most of what used to be prescription is now over the counter like Prosec, Nexium, Pepcid, these are all prescription when I was a resident or even came out after I was a resident and now they’re over the counter medications. So in terms of symptom control and acid reflux kind of medical treatment, those medications seem to be pretty damn good. Do you notice that that’s reduced the need for surgery? And that’s one question. And then the second question is what are the risks of this hiatal hernia surgery?

Speaker 2 (00:47:28):

Yeah, the medication is good for a lot of patients. The one thing I worry about honestly is that it’s so available an acid reflux, I mean it seems like it’s just an annoyance, but what a lot of patients don’t know is that acid reflux is actually the number one precursor to esophageal cancer and left untreated or left undertreated without kind of medical supervision. It can progress because you could be taking the medication and not feeling anything, not feeling the symptoms of heartburn anymore. And yet on the inside you could have major issues. And so I caution like, yes, they are great and they could might work really well for you for a long time. But I also think that you should work with a medical provider to make sure you’re not in a higher risk subset of patient with acid reflux. The prevalence of hi esophageal cancer has gone up tremendously in the last 25 years.

Speaker 2 (00:48:29):

And I don’t know that, I mean, don’t think that’s very common knowledge that there’s a direct link between acid reflux and esophageal cancer not to scare patients. Most patients will never get that. It’s not, but that’s why I caution against just treating it over the counter on your own and making sure that you’re working with a medical provider, even if the medication is what you end up needing. The surgery is not, I would say it’s not very risky in kind of expert hands and patient and surgeons that are doing this often the surgical risk is pretty minimal. It’s minimally invasive, small incisions, what you’ll probably be quoted minimal risk of really minimal risk of bleeding, minimal risk of injury. The biggest risk I would say is there’s always some risk of anesthesia with any procedure and things like that, but it’s so small. Yeah, so that’s the thing.

Speaker 2 (00:49:31):

I think the biggest risk is that we need to know we tailor the surgery for what you need. So the cookie cutter surgeon that’s going to say, anyone with acid reflux that comes through my door needs one procedure, ENT say, or pay fun application or one thing, I worry that then we’re not tailoring to the patient’s needs. So in our institution we like to get those studies and really talk to a patient about multiple options. Those options sometimes are using your stomach and wrapping around. And we can wrap all the way around 360. We can wrap it partially, which is a two 70 wrap and that’s called a two fun application. We have a device called a links, which is a magnetic ring that can help reinforce the valve on that. There’s even an endoscopic option where you can go in and through a scope like we did when we were looking to see if you have a hiatal hernia and reinforce the valve from the inside.

Speaker 2 (00:50:35):

And there’s all little, whether you’re a candidate for one or the other kind of, there’s little nuances that make you a candidate for one versus another, but the swallowing afterwards can be an issue. The most common side effects of the procedure, which is what you know want to balance is gas float or feeling kind of gassy because you’ve reinforced this valve and so you can’t burp their vomit as well anymore. So most of that goes downwards so you patients can feel gassy afterwards. And then the risk of weak dysphagia, which is a fancy word for kind of trouble swallowing this, you eat food now you have this really robust, nice valve but preventing reflux from coming up. But it can be difficult to get the food down. That’s about 10% of patients can have some degree of dysphagia. Most of the time that’s in the recovery phase.

Speaker 2 (00:51:40):

After surgery in the first three months where you’re not used to having a valve, now you have a really strong valve, their swelling, the scar tissue and that all we know is we heal. That swelling goes away. The scar tissue remodels and softens, the diaphragm stretches a little bit. So often there that subset of patients that can have problems initially after surgery slowly gets better over time and nothing has to be done. There’s a small subset of patients that struggle more than that and may need some kind of treatment like a dilation where you stretch the valve out afterwards to try and break up the scar tissue to help them swallow better. But it’s important to know ahead of time kind of what your anatomy is doing so we can try and prevent that as much as

Speaker 1 (00:52:36):

Possible. And what’s your thought about applying weight loss surgery for people that are obese and have hiatal hernia, acid reflux, et cetera? What are your thoughts on that?

Speaker 2 (00:52:50):

I think it’s a great idea. Honestly, patients that are obese, let’s say are overweight and have hiatal hernias. If we just fix the hiatal hernia but do nothing about that excess weight, then you still have all that abdominal pressure that’s going to make you a little higher chance of having a recurrent hernia, that hernia come back and need to have another procedure down the line, which is not good. And then we want to try and prevent that if we can. And then we also know that a gastric bypass surgery, which is the same surgery that you can get for weight loss, is great for endstage reflux. So even in normal weight, individuals that have severe reflux, if they’ve gotten, let’s say a surgery for it and this and they recured and they still have horrible reflux and we’ve tried other things, then our last resort is for those, or not last but is a gastric bypass, that is a great anti-reflux surgery.

Speaker 2 (00:53:54):

So often if a patient is in the category that could qualify for bariatric surgery and have a hiatal hernia, I often kind of have a conversation to them about, hey, we could A, fix your hernia, get your acid reflux control in the best way possible, give you a least amount of recurrence rate or chances of it coming back and kind of treat some of those other comorbidities that often are other medical conditions that often are associated with being overweight like sleep apnea or diabetes, some of those other things. We can treat the whole patient instead of just chip shotting, oh, this is for this and this is for that. So I think it’s a great thing to consider.

Speaker 1 (00:54:42):

Someone’s asking about the links, the ring you put around, does it always require general anesthesia?

Speaker 2 (00:54:51):

It does because it’s surgical procedure and we always need to fix you. We fix the hernia and then we put the links on, even if we just put the links on because we’re going intra abdominally, we do have to have general anesthesia.

Speaker 1 (00:55:08):

And then a question about medications. Some patients are very sensitive to medications, they have allergies to everything they have mast cell activation syndrome and so on. So is there a way to compound their medications for acid reflux to, or should they go straight to surgery? What if you don’t tolerate the medications?

Speaker 2 (00:55:32):

Yeah, I mean if you don’t tolerate the medications, then surgery is, it’s an option for those patients. And we do have patients like that where they just can’t tolerate the medications and structurally they have an abnormality and we can fix that. And then I would say otherwise, dietary lifestyle changes can be tried, like I said, kind of eating less at night or earlier before bedtime, not lying flats, sleeping, propped up. I mean, those things can help reduce symptoms. They might not make ’em go away completely, but if you’re not quite ready or can’t not severe enough for maybe surgical intervention, you could go that route too. But often surgery is something you consider. If your valve is really abnormal, then it can definitely help prevent those symptoms and lead to a better quality of life.

Speaker 1 (00:56:32):

Yeah, I think where the takeaway points that you mentioned is really key, which is not to ignore your acid reflux. If it’s due to a mechanical problem, the door is open for things to move up, which is a high hernia, then you may require surgery or some other more drastic measures than just popping some Tums or taking pups in. And then if you’ve ignoring your acid reflux for years and years and years, you’re at risk of burning that lining. And esophageal cancers something that you brought up and for whatever reason the rate’s going up. Do we know why the rate’s going up?

Speaker 2 (00:57:13):

We don’t know for sure. We know that there’s a link and there are more PAT patients with acid reflux. One of the theory theories, which I don’t know that it’s necessarily been proven, but is that patients are taking the medication but they’re ignoring, they’re not following up with medical providers. So there’s one paper that shows that if you take anti-AIDS twice a day, that actually your cancer risk goes up. And that’s not because the anti cause cancer because those patients think they’re doing the right thing, they don’t feel it anymore, so they think they’re fine. And yet, even though you don’t feel it sometimes it can still be causing injury on the inside. That’s why I really think working with a medical provider is important when treating this dynamic disease. And it’s, the thing about GERD and hiatal hernias is that there’s no one answer, which I think you probably have heard me say, there’s this spectrum. So it’s this whole spectrum of disease from moderate to severe, and we really have to tease out where you, your disease state is so that we can recommend surveillance and medications or you’re going to be fine in reassurance or surgical intervention.

Speaker 1 (00:58:38):

Yeah, yeah, exactly. And it’s true as well for hernias, but I think that when you go to a specialist or a center of excellence, they’re probably more adapted, kind of tailoring it to the needs. Same with hernias. I just saw a patient early today, and she’s actually from another state, and they do have great hernia surgeons, but she went to this group that called themselves a hernia center, but they really only do one operation and she’s female, so that’s a different operation she has. She’s thin so that there’s a different algorithm for thin patients, for females, for the type of hernia that she had, and her nerve should not be cut. Well, they always cut the nerves. She doesn’t need Mesh, they always use Mesh.

Speaker 1 (00:59:32):

She kind of understood that maybe she needs something tailored to her. Yeah, that’s why I feel like the same is true for most operations, but I think hiatal hernia surgery, one of the reasons I don’t do it is I wasn’t trained at usc. I worked there. So it was very clear that as a general surgeon, you get trained to do them, but it’s really very specialized to be able to not harm patients and not make them crippled by doing too tight or too loose of a repair. But highly, I don’t offer it because you do so much better at it than I would ever do. So it’s just not fair to kind of say I do all hernias when really I think four gut surgery is, it’s a hernia technically, but it’s really foregut anatomy and forge mechanics are very different than abdominal wall.

Speaker 2 (01:00:31):

Yeah, I mean I think that that is a specialized region of the body, and I like what you said about kind of tailoring it, and I would caution if you go to someone and you know, get one surgery every patient, you’re, instead of kind of the doctor kind of figuring out what a patient needs is, like I do this one thing. So every patient that comes to me as a candidate for this one thing, and that just doesn’t work. I think in today’s medic medical world where we have options and we really need to try and use them.

Speaker 1 (01:01:10):

Yeah, totally agree. Well, I told you before we started, the hour goes by really quickly.

Speaker 2 (01:01:15):

It does it.

Speaker 1 (01:01:17):

We’re all done. We had so much fun.

Speaker 2 (01:01:18):

Yeah. Well, thank you so much. I mean, it’s such a passion to treat patients and in this area of the body, and it is so nuanced, and I dedicate most of my practice to really learning these nuances. So I really hope that our patients and our community has learned something and get the help they need. So thank you. I love it so much.

Speaker 1 (01:01:42):

But I love bringing on people like you that really love what they do and are really good at it. So thank you for joining me. I know you have family and work and everything else they get to, so I do appreciate you volunteering your time to help answer all the questions that were submitted today, which were great, and also answer the questions and also going to clarify what’s best for these very unique hernias that occur for our patients.

Speaker 2 (01:02:12):

Yeah, absolutely.

Speaker 1 (01:02:13):

So on that note, everyone thank you. We will see you next week with another guest. I really love having everyone on, and thanks to everyone for joining. I will see you later, and I hope to see you at Sages pretty soon. Yeah.