Foregut

A hernia is a condition where an organ protrudes through an opening or area of weakness into a space where it should not be. Hiatal hernias occur when the stomach herniates, or pushes into, the chest from the abdomen. The exact cause of hiatal hernias is unknown. They are mostly caused by weakening of the muscles of the diaphragm around the esophagus. Other causes that increase the intra-abdominal pressure such as pregnancy, obesity, chronic coughing or strain can contribute to the formation of hiatal hernias.
There are four types of hiatal hernias.

• A Type I hiatal hernia, also called a sliding hiatal hernia, is the most common type and accounts for over 90% of hiatal hernias. The gastroesophageal junction (GEJ), where the esophagus and stomach meet, has “slid” into the chest cavity rather than sitting in the abdominal cavity where it should be.
• A Type II hiatal hernia, also called a paraesophageal hernia, occurs when the stomach herniates through the hiatus alongside the esophagus. In the type II or “pure” paraesophageal hernia, the GEJ remains below the hiatus in the abdomen. If more than 30 percent of the stomach herniates into the chest, it is called a giant paraesophageal hernia. Type II hiatal hernias make up less than 5 percent of all cases.
• Type III hiatal hernias are mixed hernias in which the gastroesophageal junction is herniated above the diaphragm and the stomach is herniated alongside the esophagus. The majority of paraesophageal hernias are type III.
• In type IV hiatal hernias, other organs in addition to the stomach (colon, small intestine, spleen) also herniate into the chest.

Some hiatal hernias do not cause any symptoms or problems. The most common symptoms associated with ones that do are heartburn, regurgitation, difficulty swallowing, chest pain, anemia, chronic cough. Although there appears to be a link between hiatal hernias and gastroesophageal reflux disease (GERD or heartburn), one condition does not necessarily cause the other. People can have a hiatal hernia without having GERD, and others can have GERD without an hiatal hernia.

Depending on the type of hernia and symptoms, hiatal hernia treatment can range from close observation to surgery. Patients with a small hiatal hernia who have no symptoms do not require any treatment and can be observed closely. The treatment of large sliding hiatal hernias and paraesophageal hernias often requires surgery to correct the anatomy, reduce the hernia and repair the opening in the diaphragm (crural opening). During surgery the stomach is brought back to its normal anatomical position below the diaphragm and the hiatus is closed to a normal size.
Hiatal hernia repair is usually performed using advanced minimally invasive surgery. This includes laparoscopic (using a thin camera and small incisions) or robotic (using a thin camera and instruments attached to a robot controlled by the surgeon) techniques. Using these techniques, surgery is performed using small (5 to 10 millimeter) incisions. The advantages of minimally invasive surgery include less pain, improved cosmesis, and a more rapid recovery and return to activities. Patients are typically discharged from the hospital the day after surgery. Your surgeon will discuss the best approach of hiatal hernia repair for you.

When you eat, food travels from your mouth to your stomach through a tube called the esophagus. At the lower end of the esophagus is a small ring of muscle called the lower esophageal sphincter (LES). The LES acts like a one-way valve, allowing food to pass through into the stomach. Normally, the LES closes after swallowing to prevent backup of stomach juices, which have a high acid content, into the esophagus. GERD occurs when the LES does not function properly allowing acid to flow back and burn the lower esophagus. This irritates and inflames the esophagus, causing heartburn and eventually may damage the esophagus. A few patients may develop a condition in which there is a change in the type of cells in the lining of the lower esophagus, called Barrett’s esophagus. This is important because having this condition increases the risk of developing cancer of the esophagus.
Some people are born with a naturally weak sphincter (LES). For others, however, fatty and spicy foods, certain types of medication, tight clothing, smoking, drinking alcohol, vigorous exercise or changes in body position (bending over or lying down) may cause the LES to relax, causing reflux. A hiatal hernia is found in many patients who suffer from GERD. This phenomenon can contribute to the development of acid reflux.

If you have symptoms of heartburn or GERD, you may need to undergo diagnostic tests such as a barium swallow, upper endoscopy, esophageal function testing (manometry) or an ambulatory pH monitoring to determine treatment options.

In many cases, changing diet and taking over-the-counter antacids can reduce how often and how harsh your symptoms are. Losing weight, reducing or eliminating smoking and alcohol consumption, and altering eating and sleeping patterns can help. Recommendations include avoidance of overeating, eating small portions, not eating within 3 hours of going to sleep, and sleeping with the head of bed elevated.

Patients who do not respond well to lifestyle changes or medications or those who do not wish to continually require medications to control their symptoms, may consider undergoing a surgical procedure. Surgery is very effective in treating GERD. The goal of anti-reflux surgery is to repair a hiatal hernia, if present, and to restore the lower esophageal sphincter by reinforcing this “one-way valve” which is meant to prevent acid reflux.