Surgical Management of GERD & Hiatal Hernia

SURGICAL
MANAGEMENT
OF GERD AND
HIATUS HERNIA
MALAIKA KHAN
MUHAMMAD WASIL KHAN

OBJECTIVES
•Anatomy of the esophagus and its sphincters
•Aetiology of GERD
•Clinical presentation of GERD
•Clinical approach and management of GERD
•Recent Advancements

ANATOMY OF ESOPHAGUS
● Esophagus is a muscular tube about 10
inches, long extending from the
hypopharynx to the stomach.
● The esophagus lies posterior to the
trachea and the heart and passes
through the mediastinum and the hiatus,
an opening in the diaphragm, in its
descent from the thoracic to the
abdominal cavity.
● The esophagus has no serosal layer;
tissue around the esophagus is called
adventitia.

SUB SITE DESCRIPTION
● CERVICAL: Lower end of the pharynx (level of 6th
vertebra or lower border of cricoid cartilage) and
extends to the thoracic inlet (suprasternal notch); 18 cm
from incisors.
● THORACIC:
● Upper: from thoracic inlet to level of tracheal
bifurcation; 18-23cm
● Mid: from tracheal bifurcation midway to
gastroesophageal junction; 24-32cm
● Lower: midway to tracheal bifurcation and
gastroesophageal junction to GE junction.
Including abdominal esophagus, 32-40cm.
● ABDOMINAL: lower part of thoracic esophagus; 32-
40cm

Esophageal sphincters
Chaudhry, S.R. and Bordoni, B. (25 July 2022) Anatomy, thorax, esophagus - In: StatPearls [Internet].
Treasure Island (FL): StatPearls. Available at: https://www.ncbi.nlm.nih.gov/books/NBK482513/
UPPER ESOPHAGEAL SPHINCTER:
● Also called pharyngoesophageal sphincter.
● Allows single direction voluntary passage of food
● Striated muscle sphincter which is produced by
the cricopharyngeus muscle.
● It is a high-pressure zone located in between the
pharynx and the cervical esophagus. The
physiological role of this sphincter is to protect
against reflux of food into the airways as well as
prevent entry of air into the digestive tract

Lower Esophageal Sphincter (LES):
•located at the gastroesophageal
junction.
•prevents gastric contents from refluxing
into the lower esophagus.
•Impaired contraction or reduced tone of
the LES leads to reflux
Chaudhry, S.R. and Bordoni, B. (25 July 2022) Anatomy, thorax, esophagus - In:
Stahttps://www.ncbi.nlm.nih.gov/books/NBK4825tPearls [Internet]. Treasure Island (FL): StatPearls. Available
at: 13/

PATHOPHYSIOLOGY
Antunes, C., Aleem, A. and Curtis, S.A. (2022) Gastroesophageal reflux disease - statpearls - NCBI bookshelf. StatPearls
Publishing, Treasure Island (FL). Available at: https://www.ncbi.nlm.nih.gov/books/NBK441938/
Badillo, R., & Francis, D. (2014). Diagnosis and treatment of gastroesophageal reflux disease. World Journal of
Gastrointestinal Pharmacology and Therapeutics, 5(3), 105-112. https://doi.org/10.4292/wjgpt.v5.i3.105
Frequent transient LES relaxations (TLESRs) result in exceeding the intragastric pressure
more than LES pressures permitting reflux of gastric contents into the esophagus
Prolonged exposure to the refluxate, which consists of both acidic gastric contents
(hydrochloric acid and pepsin) and alkaline duodenal contents (bile salts and pancreatic
enzymes) leading to mucosal damage. GERD can be classified as non-erosive reflux disease
(NERD) or erosive reflux disease (ERD) based on the presence or absence of esophageal
mucosal damage seen on endoscopy.
21% of patients with GERD were noted to have impaired esophageal peristalsis leading to
decreased clearance of gastric reflux resulting in severe reflux symptoms and mucosal
damage

RISK FACTORS
Antunes, C., Aleem, A. and Curtis, S.A. (2022) Gastroesophageal reflux disease - statpearls - NCBI
bookshelf. StatPearls Publishing, Treasure Island (FL). Available at:
https://www.ncbi.nlm.nih.gov/books/NBK441938/
•Motor abnormalities
•Anatomical factors like >> Hiatal hernia and Obesity
•Age ≥ 50 years,
•Connective tissue disorder
•Excess alcohol intake/smoking
•fatty or spicy meals
•Pregnancy
•postprandial supination
•Medications

SYMPTOMS
Antunes, C., Aleem, A. and Curtis, S.A. (2022) Gastroesophageal reflux disease - statpearls - NCBI
bookshelf. StatPearls Publishing, Treasure Island (FL). Available at:
● Heartburn
● Regurgitation
● Epigastric pain
● Dyspepsia
● Chronic cough
● Wheeze
● Hoarseness
● Non cardiac chest pain
● Laryngitis
● Otitis media
● Dental erosions

DIAGNOSIS
Badillo, R., & Francis, D. (2014). Diagnosis and treatment of gastroesophageal reflux disease. World Journal
of Gastrointestinal Pharmacology and Therapeutics, 5(3), 105-112. https://doi.org/10.4292/wjgpt.v5.i3.105
● 24-hour pH studies:only modality allowing
direct measurement of esophageal acid
exposure, reflux episode frequency and
association between symptoms and reflux
episodes. It is typically used to evaluate
patients with persistent symptoms despite
medical therapy, particularly those without
endoscopic evidence of GERD, in order to
confirm the diagnosis

● Upper GI endoscopy: also allows for
biopsies of concerning lesions (e.g.,
Barrett’s metaplasia, strictures or
masses).most patients with typical
symptoms of GERD will have no
endoscopic evidence of GERD on
esophagogastroduodenoscopy.
Therefore, an upper endoscopy is not
required for the diagnosis and is
mostly performed for evaluation of
GERD associated complications
● Esophageal Manometry: preoperative
testing for exclusion of significant
motility disorders such as achalasia
or scleroderma
● Upper GI contrast-enhanced studies

MANAGEMENT
● Lifestyle Modification
● Pharmacological therapy ; PPIs/ H2 receptor antagonist
● surgery

NICE Guidelines:
● Offer people with GERD a full-dose PPI for 4 or 8 weeks.
● If symptoms recur after initial treatment, offer a PPI at the lowest dose
possible to control symptoms. Offer H2RA therapy if there is an inadequate
response to a PPI.
● Offer full-dose PPI for 8 weeks to heal severe esophagitis, taking into account
the clinical circumstances.
● If initial treatment for healing severe esophagitis fails, consider a high dose of
the initial PPI, switching to another full-dose PPI, or switching to another high-
dose PPI, taking into account the person's clinical circumstances
● Do not routinely offer endoscopy to diagnose Barrett’s esophagus, but
consider it if the person has GORD
Gastro-oesophageal reflux disease and dyspepsia in adults (2019). Available at:
https://www.nice.org.uk/guidance/cg184/resources/gastrooesophageal-reflux-disease-
and-dyspepsia-in-adults-investigation-and-management-pdf-35109812699845

NICE Guidelines:

Badillo, R., & Francis, D. (2014). Diagnosis and treatment of gastroesophageal reflux disease. World
Journal of Gastrointestinal Pharmacology and Therapeutics, 5(3), 105-112.
https://doi.org/10.4292/wjgpt.v5.i3.105
Anti-reflux surgeries:
1. Total (Nissen) Fundoplication
2. Partial Fundoplication
3. Laparoscopic Fundoplication
4. Hill procedure
5. Partial gastrectomy with Roux-en-Y gastric bypass
Endoscopic therapies:
1. magnetic sphincter augmentation (MSA) done via LINX
Reflux Management System.
2. Transoral incisionless fundoplication (TIF)
3. Stretta Procedure

SURGICAL MANAGEMENT
OF HIATAL HERNIA
02

HIATAL HERNIA
A hiatal hernia is a medical condition in which the upper part of the
stomach or other internal organ bulges through an opening in the
diaphragm.
The diaphragm is a muscular structure that assists in respiration and has
a small opening, a hiatus, through which the esophagus passes prior to
connecting to the stomach. This is called the gastroesophageal junction
(GEJ).
In a hiatal hernia, the stomach pushes through that opening and into the
chest and compromise the lower esophageal sphincter (LES).
This laxity of the LES can allow gastric content and acid to back up into
the esophagus and is the leading cause of gastroesophageal reflux
disease (GERD).
While small hiatal hernias are often asymptomatic and can typically be
managed medically, large hiatal hernias often requires surgery.
FIGURE: NETTER’S ATLAS OF HUMAN ANATOMY

CLASSIFICATION
● Type I (sliding type), which represents more than
95% of hiatal hernias, occurs when the GEJ is
displaced upwards towards the hiatus.
● Type II is a paraesophageal hiatal hernia, which
occurs when part of the stomach migrates into the
mediastinum parallel to the esophagus.
● Type III is both a paraesophageal hernia and a
sliding hernia, where both the GEJ and a portion
of the stomach have migrated into the
mediastinum.
● Type IV is when the stomach, as well as an
additional organ such as the colon, small
intestine, or spleen, also herniate into the chest.
Smith RE, Shahjehan RD. Hiatal Hernia. [Updated 2022 Aug 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls
Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK562200/

Representative images of anatomy (Row A),
barium swallow (Row B) and endoscopic views
(Row C) of features of Type I or sliding hiatal
hernia (Column 1), Type II PEH (Column 2), Type
III PEH (Column 3) and Type IV PEH (Column 4).
Pane Bi: asterisk – sliding hiatal hernia. Pane Bii:
True paraesophageal hernia adjacent to GEJ.
Separation between GEJ and diaphragm noted,
consistent with a small adjacent hiatal hernia.
(White arrow) Barium tablet present. (Black
arrows) Widened hiatus. Pane Biii: White Arrow:
Gastroesophageal junction; Black arrows:
Widened diaphragmatic hiatus. Pane Biv:
Herniated, intrathoracic stomach with herniation of
duodenum. This stomach is flipped in an
organoaxial rotation. Pane Ci: Sliding hiatal
hernia. Pane Cii: Separate PEH present,
herniated through laxity in phrenoesophageal
membrane. Lax diaphragmatic hiatus also
present. Pane Ciii: Image taken from the
diaphragmatic hiatus (black arrows). Herniation of
GEJ noted with large adjacent fundus/PEH (white
asterisk). Pane Civ: Coronal computed
tomography (CT) image of an intra-thoracic
stomach with herniated loops of colon (white
arrows). GEJ, gastroesophageal junction. PEH,
paraesophageal hernia

ETIOLOGY
● Hiatal hernias may be congenital or acquired.
● There is an increased prevalence in older people.
● It is believed that muscle weakness with loss of flexibility and elasticity with age
predisposes to the development of a hiatal hernia.
● This may cause the upper part of the stomach to not return to its natural position below the
diaphragm during swallowing.
● Other predisposing factors have been identified, such as elevated intraabdominal pressure.
This typically is a result of obesity, pregnancy, chronic constipation, and chronic obstructive
pulmonary disease (COPD).
● Trauma, age, previous surgeries, and genetics can also play a role in the development of a
hiatal hernia

EPIDEMIOLOGY
● Approximately 55%-60% of individuals over the age of 50 have a hiatal hernia.
● However, only about 9% have symptoms, and it depends on the type and competency of
the lower esophageal sphincter.
● The vast majority of these hernias are type I sliding hiatal hernias.
● Type II, paraesophageal hernias, only make up about 5% of hiatal hernias.
● There is also an increased prevalence in women, which could be attributed to increased
intraabdominal pressure during pregnancy.
● Hiatal hernias are most common in Western Europe and North America and are rare in
rural Africa.

EVALUATION
The preoperative work-up in a patient being considered for operative treatment will help confirm
the diagnosis, exclude other pathologic entities, and direct the operative intervention.
● Endoscopy: This is an essential step in the evaluation of patients with GERD and a
suspected hiatal hernia who are being considered for surgery. This study can exclude other
diseases, such as tumors, and can document the presence of esophageal injury.
● Manometry: This study is used to rule out primary motility disorders such as achalasia,
which can mimic the symptoms of reflux. Patients with primary motility disorders often
require a partial fundoplication as opposed to a Nissen.
● pH monitoring: The 24-hour pH test is the gold standard for diagnosing acid reflux. In this
study, a probe is placed 5cm above the GE junction and measures the amount of acid to
which it is exposed. This data is then quantified into a number called the DeMeester score.
A score of 14.7 or above indicates significant gastroesophageal reflux.
● Esophagography: The esophagogram provides valuable information in terms of the
anatomy of the esophagus and proximal stomach. Anatomic abnormalities such as tumors
or strictures may also be discovered during this study.

INDICATION FOR SURGERY
1. Symptomatic hiatal hernia: Surgery is often recommended for patients with symptomatic
hiatal hernia who experience persistent symptoms despite medical management, such as
medication and lifestyle changes.
2. Complications of hiatal hernia: Surgery is indicated when complications arise from a hiatal
hernia, such as recurrent or severe GERD, esophagitis, Barrett's esophagus, stricture
formation, bleeding, or respiratory complications like chronic cough, asthma, or recurrent
pneumonia.
3. Large paraesophageal hernia: Surgery is typically recommended for large paraesophageal
hernias, where a significant portion of the stomach has migrated into the chest alongside
the esophagus.
4. Young patients: Surgery may be considered in young patients with hiatal hernia and
associated symptoms to provide long-term relief and reduce the need for lifelong
medication.
5. Failed medical management: If medical therapy fails to control symptoms or if patients are
unable to tolerate long-term medication use, surgical intervention may be considered as an
alternative treatment option.
Kahrilas PJ, Kim HC, Pandolfino JE. Approaches to the diagnosis and grading of hiatal hernia. Best Pract Res Clin Gastroenterol.
2008;22(4):601-614. doi:10.1016/j.bpg.2007.11.001

INTERNATIONAL GUIDELINES
1. American Society for Gastrointestinal Endoscopy (ASGE):
They provide guidelines and recommendations related to
gastrointestinal disorders, including hiatal hernia.
2. European Association for Endoscopic Surgery (EAES):
EAES offers guidelines and recommendations for
minimally invasive surgery, which may include hiatal hernia
repair.
3. Society of American Gastrointestinal and Endoscopic
Surgeons (SAGES): SAGES provides guidelines and
expert consensus statements on various gastrointestinal
surgical procedures, including hiatal hernia repair.
4. British Hernia Society (BHS): BHS may offer guidelines
specific to the management of hiatal hernia in the United
Kingdom.
5. The European Society of Gastrointestinal Endoscopy
(ESGE): ESGE provides guidelines and recommendations
related to gastrointestinal endoscopy and associated
conditions.

PARAESOPHAGEAL HERNIA
Paraesophageal hernias can present
with a gastric volvulus due to the laxity
of the stomach's peritoneal
attachments and subsequent rotation
of the gastric fundus. This is
considered a surgical emergency.
Current recommendations are for
operative repair of all symptomatic
paraesophageal hernias as well as
completely asymptomatic large hernias
in patients less than 60 years old and
otherwise healthy.
https://stanfordhealthcare.org/medical-conditions/digestion-and-metabolic-health/paraesophageal-hernias.html

NISSEN FUNDOPLICATION
Nissen fundoplication (360-degree wrap): This involves completely wrapping the GEJ using the
fundus of the stomach.
● This is usually done with a 52 french bougie in place to ensure appropriate approximation
without the wrap being too tight. The initial steps involve dissection of the short gastric vessels
off the greater curvature of the stomach to mobilize the fundus.
● The phrenoesophageal membrane over the left crus is fully dissected, and the crural fibers are
identified. For the right crural dissection, the lesser omentum must be opened, and the right
phrenoesophageal membrane mobilized.
● It is important to preserve the anterior and posterior vagi during this dissection.
● A Penrose drain is typically placed around the esophagus to assist in mobilization and creation
of the wrap.
● The wrap is created over a length of 2.5 to 3 cm using 3-4 interrupted permanent sutures. Once
the wrap is complete, the 52 french bougie is removed, and the wrap is anchored to the
esophagus and hiatus. This helps prevent herniation and slippage.

https://www.sages.org/publications/patient-
information/patient-information-for-
laparoscopic-anti-reflux-gerd-surgery-from-
sages

PARTIAL FUNDOPLICATION
When esophageal motility is poor, a partial fundoplication is typically the procedure of choice. The
two most common partial fundoplications are the Dor procedure, which is an anterior wrap, and the
Toupet procedure, which is a posterior wrap. As opposed to the complete 360-degree wrap
performed with a Nissen, these two procedures involve creating a 180 to 250-degree wrap. The
thought is that a partial wrap will help prevent obstruction in the esophagus when motility is a
concern.

https://tofs.org.uk/what-is-oa-tof/surgery-for-oa-tof/post-operative-procedures/fundoplication/

https://www.s
howa-u-kt-
ddc.com/en/
poef/

LINX
(LINX®) is made up of a series of magnetic beads that are
interconnected by a titanium wire and allow for expansion
depending to the applied pressure. The device is placed around
the esophagogastric junction and applies magnetic force in order
to enhance the antireflux barrier function. When the beads are
closed, this magnetic force is approximately 40 g, however when
fully distanced they apply much less force, approximately 7 g. As
a result, the device allows the bolus during swallowing to pass the
esophagus and it also allows the release of elevated gastric
pressure, which is associated with belching or vomiting. On the
other hand, it is highly unlikely that during digestion or at rest, the
stomach would generate enough force to open the device.
Consequently, the LINX® device augments the LES at rest and
prevents inappropriate transient relaxation.
LINX® Reflux Management System in chronic gastroesophageal reflux: A novel effective technology for restoring the natural barrier
to reflux - ResearchGate. [accessed 28 May, 2023]

https://www.researchgate.net/figure/The-LINX-Reflux-Management-System-encircling-the-distal-esophagus-in-
the-closed-position_fig1_243970498 [accessed 28 May, 2023]

ESOPHYX
Transoral incisionless fundoplication (TIF) using the EsophyX™
system has been introduced as a possible alternative for the
treatment of gastroesophageal reflux disease (GERD).
Designed to reconstruct the gastroesophageal flap valve
(GEFV) and restore its function as a reflux barrier, the EsophyX
Device is used during the TIF® procedure to create a 3 cm,
270° esophagogastric fundoplication.
The EsophyX device utilizes proprietary tissue manipulating
technology to deploy 20+ SerosaFuse fasteners that evenly
distribute force across the entire circumference of the wrap –
and all accomplished under direct endoscopic visualization with
a flexible endoscope in the central lumen of the device.
https://www.endogastricsolutions.com/providers/tif-2-0-procedure/esophyx-device/

STRETTA
Esophagus reconstruction with the Stretta® device
uses low-frequency heat to reshape the ring of
muscles in your lower esophagus (lower esophageal
sphincter). This helps restore your natural reflux
barrier.This endoscopic therapy is safe, effective,
durable, and repeatable if necessary and serves an
unmet need for many GERD sufferers. Stretta could
be effective in decreasing esophageal sensitivity to
acid and in decreasing the gastro-esophageal
junction compliance, which in turn contributes to
symptomatic benefit by decreasing refluxate volume.
Triadafilopoulos G. (2014). Stretta: a valuable endoscopic
treatment modality for gastroesophageal reflux disease. World
journal of gastroenterology, 20(24), 7730–7738.
https://doi.org/10.3748/wjg.v20.i24.7730

Hiatal hernia
recurrences after
laparoscopic
surgery: exploring
the optimal
technique
Akmaz B, Hameleers A, Boerma EG, Vliegen RFA, Greve JWM, Meesters B, Stoot JHMB. Hiatal hernia recurrences after laparoscopic surgery:
exploring the optimal technique. Surg Endosc. 2023 Feb 13. doi: 10.1007/s00464-023-09907-w. Epub ahead of print. PMID: 36781470.

Outcomes of
Bariatric
Surgery With
Concomitant
Hiatal Hernia
Repair Using
an Absorbable
Tissue Matrix
Love MW, Verna DF, Kothari SN, Scott JD. Outcomes of Bariatric Surgery With Concomitant Hiatal Hernia Repair Using an Absorbable
Tissue Matrix. Am Surg. 2023 Feb;89(2):293-299. doi: 10.1177/00031348211023450. Epub 2021 May 31. PMID: 34058829.

Håkanson BS, Lundell L, Bylund A, Thorell A. Comparison of Laparoscopic 270° Posterior Partial Fundoplication vs Total
Fundoplication for the Treatment of Gastroesophageal Reflux Disease: A Randomized Clinical Trial. JAMA Surg. 2019;154(6):479–
486. doi:10.1001/jamasurg.2019.0047

https://www.researchgate.
net/publication/343086037
_Efficacy_and_patient_sati
sfaction_of_single-
session_transoral_incision
less_fundoplication_and_l
aparoscopic_hernia_repair

VIDEO TIME YAY!
https://www.youtube.com/watch?v=tIm0aLB2n28

“A knowledge of healthy and diseased actions is not less
necessary to be understood than the principles of other
sciences. By and acquaintance with principles we learn
the cause of disease. Without this knowledge a man
cannot be a surgeon. ... The last part of surgery, namely
operations, is a reflection on the healing art; it is a tacit
acknowledgement of the insufficiency of surgery. It is
like an armed savage who attempts to get that by force
which a civilised man would by stratagem.”
—John Hunter, 1728-1793, Surgeon, St
George’s Hospital, London, UK

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