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Dr. Mike Smith (Host): Reflux disease and hiatal hernias are pretty common, but they can cause a lot of discomforts. Welcome to The GW HealthCast. I'm Dr. Mike Smith, and today's topic, The Latest on GERD and Hiatal Hernia Surgery. My guest is Dr. Karim Trad. Dr. Trad is a Clinical Professor with The George Washington University School of Medicine and Health Sciences and Vice President for the hospital medical staff and is affiliated with The George Washington University Hospital. Dr. Trad, welcome to the show.

Dr. Karim Trad (Guest): Thank you. Thank you for having me.

Host: How about a nice little rundown first. What is GERD? This is what people I think mostly know as reflux disease. What is that? And then, tell us a little bit about hiatal hernias.

Dr. Trad: Very good. GERD, as you alluded to, is referred by most people by the word reflux. In fact, it stands for gastro-esophageal reflux disease. GERD is actually a combination of conditions. To just think of it as a single entity is a mistake. That's the first mistake. In fact, heartburn is the most common manifestation, and that is the one that's easily recognized by people. It is quite commonly treated by over-the-counter medications and things of the sort.

The GERD, however, can be a lot more complicated than that. In some instances, it is actually difficult to diagnose. Heartburn and regurgitation are the classic symptoms of GERD — regurgitation not to be confused with vomiting. Regurgitation is actually just acid taste in the mouth, usually at night when patients are lying down. Those are the classic symptoms.

And then you have what we refer to as the atypical symptoms or laryngeal-pharyngeal reflux. That's a heavy word, but we have an acronym for it. It's LPR or silent reflux. Patients present with a lot of symptoms that are sometimes not recognized even by healthcare professionals and are really tough to treat. For instance, chronic cough, clearing of the throat, globus — sensation which is the feeling of a foreign body in your throat like you swallowed something and it's stuck — and dysphagia, which is difficulty swallowing.

Hiatal hernias, on the other hand, are an anatomic defect at the junction between the esophagus and the stomach. The esophagus is this long, tubular organ that's supposed to take the food and the saliva from your mouth into the stomach, and it crosses the diaphragm, which is a muscle separating the abdomen from the chest. At that junction between the esophagus and the stomach, there's a sphincter. There is a kind of a valve that prevents the acid from going in the other direction — from refluxing, in other words, from the stomach up into the esophagus. A hiatal hernia is nothing but the part of the stomach moving up into the chest. As a result, this whole mechanism where you have a one-way valve, as I described, is now a two-way street, and there is really no barrier to prevent the acid from going from the stomach into the esophagus.

Now, to make things complicated, the hiatal hernia can be present without reflux, and conversely, you can have reflux without the hiatal hernia. Most of the time, they go hand-in-hand, but not always.

Host: I see. So, there is a connection between them that a lot of patients that you see do present with both the reflux disease and also the hiatal hernia.

Dr. Trad: Correct.

Host: I guess let me ask you this first before we get into how we're going to treat this and talk a little bit about the surgery. When should somebody who suffers from heartburn or some of that regurgitation you mentioned at night when they're lying down — when should somebody finally say, "Enough is enough. I should go get this checked out"?

Dr. Trad: That's an excellent question. I think that any patient or any person who finds themselves unable to manage this condition by the usual what we call lifestyle modifications — avoiding eating late, and certain food items, and trying to lose weight is one of those strategies — but if you're taking medications, and you're popping these pills for whatever it is — PPIs, or Zantac, or whatever — even if these things are over-the-counter, and you're finding yourself dependent then you probably should seek a professional for help.

For two reasons, one, you don't have to live in this miserable situation. Number two, you could be negligent in terms of missing out or missing some potentially more serious condition that we can talk about like Barrett's Esophagus, which is a pre-malignant condition that is associated in 10% of cases with GERD. If you have severe reflux, you're better off seeking professional help and undergoing a series of tests to truly identify exactly what is going on.

Host: Yeah, I'm glad you brought that up too. I just want to summarize and reiterate for the listening audience here that if you are suffering from reflux and you're trying all of these different things, and nothing seems to work — you're becoming dependent on these pills — it's important to go get checked out because in some cases, there can be some changes from all of that acid in your esophagus. That's called Barrett's Esophagus, and that is associated with an increased risk of esophageal cancer, so it's important to go ahead and follow Dr. Trad's advice here. Get checked out.

Now, when somebody finally comes to you, the expert, how do you work this up? How are you going to diagnose GERD? How are you going to rule in or rule out a hiatal hernia?

Dr. Trad: There are two types of specialists that are going to take care of GERD. You have the Gastroenterologist who will usually treat medically with medications and that sort of thing, and on our side, the surgeons, we usually see patients once the pain arises and they're being considered for surgery. Let me emphasize here, and it's extremely important, surgery is not needed or recommended for the great majority of cases. It's really for the minority of cases that we would consider surgery. For instance, patients who as I mentioned might have developed pre-malignant changes in their esophagus, patients who don't respond to the medical treatment even when optimize and when the proper doses are given, or when they continue to have these kinds of side-effects.

To answer your question more accurately, what are the tests? There is a whole battery of tests that can be used. The first test and the easiest one is to get the barium swallow. If there is any suspicion of a hiatal hernia, it's a quick test. It's not particularly expensive, and it will give a lot of information about the presence of a hiatal hernia, and even reflux can be witnessed on this test. The patient stands, swallows some barium — it actually doesn't taste that bad as is wrongly reported. They take a bunch of X-rays, which takes five or ten minutes, and you're done. This will show the hiatal hernia, if present, and so you would be closer to having a diagnosis.

Then you have what we call the gold standard, which is an endoscopy. It's putting a lighted tube in the mouth into the esophagus and the stomach, and that allows the endoscopist to look at the lining of your esophagus, at the lining of your stomach to see whether there's a hiatal hernia, whether there's esophagitis, which is inflammation of the lining of the esophagus, and possibly if there is Barrett's Esophagus. There is no other test that will give you the diagnosis of Barrett's, which is the pre-malignant condition we've been talking about.

Host: Right.

Dr. Trad: Endoscopy is absolutely mandatory for somebody who has that problem. Otherwise, you may be again missing a pre-malignant condition. I want to emphasize Barrett's doesn't necessarily give you symptoms so you can't really go by the response to the symptoms. Even if you're responding well to PPIs, but you're requiring them on a daily basis on the long-term you should undergo an endoscopy.

Host: Right. Just so the audience knows — PPI, those are Proton Pump Inhibitors, very common medications prescribed for reflux disease. They just kind of block acid. Let's say somebody has had the workup, the GERD is confirmed, there is a hiatal hernia, they're not responding. There are some of those pre-malignant changes in the esophagus. They come to you, and surgery is recommended. What most people are going to want to know at this point, Dr. Trad, is, is this surgery going to work, and is it going to provide relief? What do you think?

Dr. Trad: It's a very good question. It's a crucial question. I will tell you that in patients in whom the diagnosis has been confirmed, and in well-selected patients, the surgery works very, very well. Also, it has to be performed well. It's a functional operation. We are rearranging the anatomy, so it has to be done very accurately and usually, it is operator-dependent. People with a lot of experience obviously have better outcomes.

Even with the presentation that you just put up, we do additional tests. For instance, we make sure that the esophagus itself is functioning properly. We do a test called manometry, which does pressure measurements inside the esophagus because we're looking at the motility. If we're going to go rebuild the valve that we were talking about — if patients have a poor esophageal function, poor motility in the esophagus, they might end up with another set of problems, with difficulty swallowing, for instance. If patients are well-selected and the operation is well-executed, it is a very, very successful operation that I would say in the upwards of 90% — with the long-term studies, patients have shown satisfaction. And importantly, more than 80% are able to get completely off their medication.

There is some concern now with the Proton Pump Inhibitors having some side-effects, especially if they're taking them very long-term. There are side-effects, such as osteoporosis and there are some reports that they might cause some chronic kidney failure and that sort of thing. To the patient, it gives you the opportunity to no longer take the medication in the great majority of cases. And truly, to fix the problem at the root, which is to recreate that native valve that has ceased to function by rebuilding it.

The way we perform the operation is done in a minimally-invasive way. It's done laparoscopically through small incisions. If there is a hiatal hernia we fix it, meaning we bring the stomach where it belongs inside the abdomen, and then we create a valve using the top part of the stomach to recreate the valve precisely at the same location where that native valve has failed. That then prevents reflux.

Host: Right. Dr. Trad, at the end of the day here, if patients are selected appropriately, and there's a good experience with the surgeons like you at George Washington University Hospital, the outcomes can be quite significant, even people getting completely off medications, which as you point out is very, very important. Dr. Trad, I want to thank you for all the work that you're doing and thank you for coming on the show today. You're listening to the GW Healthcast. Please visit GWDocs.com to get connected with Dr. Trad or another provider, or call 1-888-4GW-DOCS to schedule an in-person or virtual appointment.  I'm Dr. Mike Smith. Thanks for listening.