Rita Knotts, MD, and Justin Henning, MD, on Diagnosing and Treating Hiatal Hernia

Drs Rita Knotts and Justin Henning discuss the diagnosis and treatment—including surgical options—for hiatal hernias. 

Rita Knotts, MD, is an assistant professor at NYU Langone Health and a practicing gastroenterologist with the NYU Langone Center for Esophageal Health in New York City. Justin Henning, MD, is a clinical assistant professor of surgery at NYU Langone Health.

Any views and opinions expressed are those of the authors and or participants, and do not necessarily reflect the views policy or position of the Gastroenterology Learning Network or HMP Global, its employees and affiliates.

Hello everyone. I'm Rita Knotts, an assistant professor of medicine at NYU Langone Health at our Center for Esophageal Health. I specialize in esophageal diseases, and today I'm here with my surgical colleague also at NYU Langone Health, who's a clinical assistant professor of surgery at the Center for Esophageal Health within our division of surgery, Dr. Justin Henning.

Dr Henning:

Hi, Rita. Thanks for having me.

Dr Knotts:

Welcome. So today we're going to talk about hiatal hernias and what we do with them in clinical practice. So I'm going to start off by asking Dr Henning, can you tell us a little bit more about the types of hiatal hernias that we may encounter in clinical practice every day?

Dr Henning:

Sure. So there are a couple types of hiatal hernias, but the quick and easy way to break them down is that by far the most common type are what are called type 1 or sliding hiatal hernias. And what that refers to is the junction of the stomach and the esophagus intermittently sliding up and down, above and below the diaphragm, over the course of the day with changes in intraabdominal pressure. And what we know is that that predisposes to gastroesophageal reflux disease. Less common are what are called paraesophageal hernias, which are different variations of larger hiatal hernias where the junction of the stomach and the esophagus is in a fixed position above the diaphragm with some additional amounts of part or all of the stomach plus or minus additional intraabdominal organs. And the type depends on how big and in what orientation those other organs may be.

Dr Knotts:

So that was a wonderful description, but hiatal hernias are pretty commonly seen in clinical practice. As you mentioned, type 1 or sliding hiatal hernias are seen pretty routinely on endoscopy or on imaging, but not all of them require repair. So can you tell us a little bit more about when you get involved in the clinical picture as a surgeon or when a repair is required?

Dr Henning:

Sure. So the short answer is, when is repair required, is never; it is a patient-driven, symptom-driven discussion. This is an elective intervention, but we do have some kind of standard indications for when we talk about fixing a hiatal hernia in general, that is done for patients who have severe what we call pathologic reflux disease. That requires additional specialized testing to make that diagnosis, which we can talk a little bit about. But in general, we recommend surgery for patients who have uncontrolled esophageal reflux despite kind of maximal medical interventions; that refers to patients with breakthrough heartburn despite PPI or maybe to patients whose heartburn is really well controlled but who still have gross regurgitation and the feeling of things coming back up. That can be patients who are perfectly well controlled on PPI and have no persistent symptoms, but who don't want to be on medications lifelong or long-term or have side effects of medications that they can't tolerate or don't want to deal with. And then lastly, we frequently see patients who have complications of reflux disease, bad esophagitis, strictures, or evidence of Barrett's esophagus, which we know is associated with significant long-term reflux.

Dr Knotts:

So you're absolutely right. We typically have a very good collaboration between our GI service and our surgical counterparts because we want to make sure that patients are good and reasonable candidates. So that requires us on the gastrointestinal side to do a certain degree of testing to ensure that these patients really and truly have pathologic GERD so they have optimal outcomes postoperatively. And so at our center we frequently get referred for testing or we refer or we do further testing on these patients. And this could include a high-resolution esophageal manometry initially to start off with, to make sure that patients have adequate motility or don't have a major motility disorder prior to entering into a surgical procedure.

And very importantly, we also do pH testing. And so esophageal pH testing can consist of 2 different types or 2 different options. The first is what we're starting to consider more of our gold standard at this point is a 96-hour wireless pH capsule that we place endoscopically. And this measures esophageal acid exposure over that 4-day period. It also measures symptom correlation over that time. And among another type of testing also includes pH impedance testing, which is an intranasal catheter that's typically placed after we place a manometry catheter that measures total acid exposure as well as impedance events over a 24-hour period. But these tests help us again to ensure that patients truly have pathologic GERD because we do know that 20% of these patients may actually have an alternative functional esophageal condition like functional heartburn or reflux hypersensitivity. So it's really important that a multidisciplinary approach is used in a lot of these patient cases.

So can you tell us a little bit more about, we talked about hiatal hernias, but frequently with hiatal hernia repair we do, or you do, antireflux surgeries. So can you tell us a little bit about that and what your experience is, what type of antireflux surgeries there are out there and which patients do the best with each one?

Dr Henning:

Sure. So there are several options. In general, the repair of a hiatal hernia is only a portion of the surgical control of reflux disease. What that entails is almost always a minimally invasive surgery, anywhere from 5 to 7 small incisions and then laparoscopic or increasingly commonly robotic surgery, with the goal of reducing the hiatal hernia and bringing the junction of the stomach and the esophagus back down into the abdominal cavity with at least 3 centimeters of distance from the diaphragm to the GE junction. Once that is done, we sew the diaphragm closed to make the pleural diaphragm nice and snug around the distal esophagus because we know that that contributes to the antireflux barrier. And then once that is done, we do something additional to augment the strength of that lower esophageal sphincter complex at the gastroesophageal junction.

Traditionally that was done with a fundoplication, a surgical wrap of the stomach around the bottom of the esophagus. There are multiple variations of that surgery. The one that most people are common with is what's called a Nissen fundoplication, which is a 360-degree wrap of the stomach around the esophagus. This works exceptionally well at stopping reflux, but it has a pretty significant side effect profile. Things like dysphagia, inability to belch or vomit, and gas and bloating with a significant increase in flatulence. And in general, that surgery is increasingly uncommon. And the reason for the Nissen kind of falling out of favor in the setting of those side effects is that we have very good data that says that doing a fundoplication but only wrapping the stomach partially around the esophagus in a 270-degree orientation called a Toupet or even less than that to some degree, gives the exact same amount of antireflux control on objective pH testing and quality of life surveys for patients, but with significantly decreased side effect profiles.

A newer technology that's also available is what's called a Linx or a magnetic sphincter augmentation, which is a ring of magnetized beads that get implanted on the lower esophagus at the exact same position that a fundoplication would be placed at, except that rather than using the stomach to encircle the esophagus, it's a ring of pliable magnetized beads that can expand to allow food to pass through. This technology has been around for 15 years or so. The outcomes are really good. Patients have good control of reflux afterwards with the main side effect being dysphasia that usually can be managed with endoscopy and dilations and is a self-limited process postoperatively.

Dr Knotts:

Yeah, I was going to say, are there candidates that you think are better for one than the other?

Dr Henning:

So yeah, so in general, to be a better candidate for a Linx than a fundoplication, we do need to know that you have kind of normal swallowing mechanism. So most institutions require you to have a manometry prior to a Linx placement to make sure that there is no evidence of subclinical ineffective esophageal motility that could patients at a higher risk of having significant dysphagia postoperatively. That being said, no studies have shown that that necessarily makes a difference, and the most common reason that someone would have dysphagia after Linx is that they had dysphagia before their surgery. So it's really an individual discussion with the patients about what they want, what risks they're willing to accept as far as a side effect profile, and whether or not they are willing to have an implantable device, a foreign body placed around their esophagus.

Dr Knotts:

And of course, at our center we do manometry on almost all of these patients prior to them going to the operating room. But more and more we've also been including endoFLIP as a part of our preoperative evaluation and it can help us assess if there's a major motility disorder there as well. And it could be a particularly helpful tool in the small subgroup of patients that really can't even tolerate a manometry. So I think it's going to be interesting to see how that plays overall in our algorithm in the future.

And so I just have one additional question for you. So when you're in the office with these patients before surgery, are there certain things that you take into consideration? We mentioned a few factors like their symptoms, but maybe we can comment on or maybe we can discuss a few other factors like BMI or any other things that you think would help you to restratify a patient to assess their postoperative outcomes when you're in the office with them.

Dr Henning:

Sure. So the first thing that I discuss with patients is that reflux and GERD gets blamed for all kinds of symptoms, right?

Dr Knotts:

Right! That's correct.

Dr Henning:

And very commonly symptoms that are blamed on GERD are not due to reflux. So we are always very cautious about predicting improvement in symptoms that we would consider atypical. Things like globus sensation, laryngopharyngeal reflux voice hoarseness, the sensation of things stuck in the throat, chronic cough, asthma, those kind of symptoms are much less likely to respond to an antireflux operation than the typical symptoms of heartburn regurgitation. Secondly, if patients don't have good symptom control or any improvement at all on PPI, we're a little more skeptical that surgery is the right thing for them. Is reflux really what's driving their symptoms? And those two areas are where pH testing and symptom association really is important to know and to be able to counsel patients how much better they can anticipate being.

As far as BMI goes, that is always a conversation with the obesity epidemic that we're experiencing in general. Outcomes of antireflux surgery are not as optimal in patients with a BMI over 35. We know that those patients just don't do as well in the long term. And the reason for that is mainly due to the risk of recurrent hiatal hernia due to the increased intra-abdominal pressure. So in general, we try to avoid operating on those patients. Medical weight loss, diet and exercise, all the new medications may be good adjuncts to try to help with weight loss and get them to a point where they would be a better candidate for surgery. Or there is always the possibility of referrals to bariatric surgery, to talk about surgical weight loss, including gastric bypass, which is actually an exceptionally effective antireflux operation in addition to being a weight loss operation and is always there as an option for patients in whom that's the right thing.

Dr Knotts:

Which I think is sometimes underrecognized. Well, thank you so much, Dr Henning, for this awesome conversation about hiatal hernias and when we operate on these patients. This was really helpful and I'm sure that these bullet points are going to translate well and give people a lot of great information about when they should refer for surgery. So we would love to thank you for being with us today.

Dr Henning:

Thanks, Rita for having me. It's been a pleasure.