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Melanie Cole, MS (Host): Welcome to UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole. And joining me today to highlight hiatal hernias and GERD options for surgical management is Dr. Crystal Johnson-Mann. She's an Assistant Professor in the Department of Surgery at the University of Florida College of Medicine.

Dr. Johnson-Mann, it's a pleasure to have you join us today. And I'd like you to start by speaking about the relationship of GERD to hiatal hernia. Explain the different mechanisms for GERD. And while you're doing that, I'd like you to describe because these two are very intrinsically linked, the effect of obesity on GERD and hiatal hernia development.

Dr Crystal Johnson-Mann: Yeah, sure. So first, thank you for having me. So, GERD is a complex disease process. There are certainly motility disorders that can precipitate the onset of GERD symptoms, such as gastroparesis, sort of in the absence of a hiatal hernia. There's also the hiatal hernia sort of onset. And so, essentially, how hiatal hernias can contribute to the onset of GERD symptoms is along the lines of anatomical changes. So, ordinarily, your junction between your esophagus and your stomach should sit basically below the diaphragm. Over time, for various reasons, age, changes in collagen deposition, other factors like obesity, over time, small hernias can develop, but maybe something that is not recognized or has enough of an impetus for workup. Lots of people are walking around with some occasional GERD symptoms. And so, when I say GERD symptoms, it's symptoms like heartburn, which is that sensation of acid or burning in your esophagus, sort of retrosternal burning. And then, of course, there's some other symptoms like water brash, which our patients describe as the sort of acidy taste in the back of their mouth sometimes when they wake up. Some people feel their GERD actually happening, the gastroesophageal reflux, and some people do not. And that is because there are variances in one's sensitivity of the esophagus.

But regardless, when there is displacement of the gastroesophageal junction into the chest, there is a pressure gradient that is different between the abdominal cavity, which is positive pressure, and the chest, which is negative pressure; and thus, GERD can be precipitated at that point.

The options kind of come in, typically medical management. Dietary and medical management behavioral changes is first line. So if people tend to eat very heavy meals before laying down at night, that's a problem, because it's not allowing things to empty out of your stomach. And so, oftentimes, people will need to space out dinner time before bedtime by a few hours.

If there are triggers such as caffeine, alcohol, both of which will relax your lower esophageal sphincter, actually, and can precipitate reflux, so cutting down on caffeine or cutting it out, cutting down on alcohol use and/or removing it, and also chocolate, which contains caffeine, and this also includes tea, any caffeinated beverages or food items should be reduced in their volume. And also, some people describe triggers as citrusy or tomato-based food products can trigger symptoms and elimination of those can greatly improve their symptoms.

When we're considering hiatal hernia repairs and that sort of thing, having a small sliding hiatal hernia in and of itself is not an indication for having surgical interventions. We talk about going there in the setting of symptoms that are not controlled by medication, so maximal medical therapy, which would be PPI therapy and the institution of dietary and behavioral changes. So if people do all those things and they're not having relief and they're still miserable, that's when we're talking about surgical therapy. When people are on the younger side, we do know that proton pump inhibitor therapy over the long-term does increase the risk for osteopenia and osteoporosis. So, younger patients may opt to pursue surgical therapies, more so than someone in their older years, just thinking about the length of time that one would need to be on medical therapy.

When we are talking about how obesity specifically plays a role, this is something we oftentimes find small sliding hiatal hernias, which is a type 1 hiatal hernia. And a sliding hiatal hernia is when you're just displacing your GE junction into the chest, essentially. So, we're changing the anatomic location from being in the abdomen into the chest. They become paraesophageals when you have the stomach going into the mediastinum around the esophagus. And you can have a combination of a sliding and a paraesophageal, which is a type 3, which is actually fairly common.

But back to obesity and the mechanisms behind that. So, obesity in and of itself increases the intraabdominal pressure such that you then can actually overcome your body's natural anti-reflux mechanisms. So, a common analogy that I use for our patients is when women of childbearing age are pregnant, and oftentimes women who are pregnant experience heartburn symptoms. That's usually resolved when they're no longer pregnant, and it's because that increased intraabdominal pressure related to the growing fetus is released once they deliver. So usually, it will resolve, not always. If there's an anatomical issue such as a small hiatal hernia, it doesn't always resolve, but oftentimes it will. And in obesity, you have this constant intraabdominal pressure that is pushing up against the diaphragm around the opening where the esophagus comes through. And over time, that can create a small hiatal hernia, which, like with any hernia, over time, all hernias will enlarge if given enough time and pressure. So, something may start off as very small and actually become ultimately fairly large.

The issue comes in, though, when we're dealing with our patients with obesity, is what can we offer them? And so, the historical take on how we go after the surgical management of hiatal hernias and GERD varies based on BMI. So, the standard teaching for hiatal hernias in the setting of GERD is to do a hiatal hernia repair, which is usually transabdominal, working in the mediastinum to mobilize the stomach and the esophagus from the mediastinum, close the diaphragm, and then do a fundoplication, of which there are typically two types employed for this purpose, either a Nissen, which is a 360-degree fundoplication, or a Toupet, which is a partial wrap in 270 degrees.

I personally only perform Toupets. And this is because there's a lower risk of dyspepsia symptoms, so specifically dysphagia, gas bloat syndrome, people like to be able to burp and vomit should they need to. When you compare, there's a great study out of one of our surgical society, SAGES, that kind of looked at the long-term symptoms and resolution comparing Nissen's and Toupet long-term. And what you see basically head to head, there are some slight differences. So, a Nissen fundoplication, again the complete wrap, has a higher risk of dyspepsia symptoms, so gas bloat syndrome, dysphagia, et cetera. But they also have a slightly higher long-term acid control. Conversely, a Toupet has a lower risk of having these sort of chronic dyspepsia symptoms. But you are trading that for a slightly lower risk of long-term acid control. So, it's a risk-benefit ratio, but I will tell you patients really are quite miserable when they do have those dyspepsia symptoms. So, it's almost worth that trade off. But these are things that I discuss with the patients.

When it comes to patients with obesity, we know, generally speaking, around a BMI of 35 is when you start to see a change in any sort of hernia recurrence risk, whether it be a ventral abdominal hernia recurrence risk or, in this case, a hiatal hernia. And so, typically, when our patients have class 2 and up obesity, there's a few options. One, weight loss, whether that's medically-assisted with any number of the anti-obesity medications on the market or just the standard diet exercise plan, if that has worked for them in the past. It doesn't always work for patients in this setting.

The alternative option is doing a hiatal hernia repair with the then concomitant Roux-en-Y gastric bypass, depending on the BMI. So, BMI is right around 35 don't need to be quite this extreme. BMI is a 40 and up who may not have access to medical weight loss or who have struggled with their weight for a very long time and are really interested in a very durable option to solve both problems, that's where bariatric surgery comes in.

Melanie Cole, MS: Wow. There's so much to think about. Dr. Johnson-Mann, what insights or advice would you offer your fellow physicians or surgeons who are less familiar with some of the nuances you just discussed of the surgical management and that shared decision-making? If you were to offer them that advice, what would you say?

Dr Crystal Johnson-Mann: Sure. So, a couple of things, and I'll go on my soapbox as a bariatric surgeon for a moment here. One, if you have a patient, I'm starting with the patients with obesity aspect. If you have a patient with obesity and a hiatal hernia, understand that obesity is a very chronic and complex disease process. And the biggest thing in that sort of situation, if someone has very symptomatic GERD, plus or minus whether or not they also have a hiatal hernia, the best option for them would be to talk to a bariatric surgeon. Bariatric surgeons have the skill set to not only do foregut operations, but also any wide array of bariatric operations and/or manage complications of bariatric procedures.

But the best service for that specific patient population would likely be undergoing bariatric procedure at a comprehensive bariatric surgery program. Now, when you have someone who has chronic heartburn, GERD symptoms, not responding to medical management, sometimes this is because they don't respond to the medical management because maybe their metabolism of those particular medications is either slow, so they're not going to respond well, or they're what we call an ultra-rapid metabolizer. There's a genetic test that we usually employ in those situations to see, and those people in that case are never going to get relief from maximal dose therapy. And so, those people absolutely need to be referred to a surgical center to consider hiatal hernia repair and/or fundoplication.

The biggest thing I would also say is there is a very low incidence in the population, less than 1% of Barrett's esophagus, which is a direct correlation of abnormal acid exposure to the distal esophagus. However, Barrett's esophagus can arise and shift into dysplasia, which increases one's risk of developing esophageal adenocarcinoma. And we know the esophageal adenocarcinoma is directly related to acid reflux exposure. So, I would say for people who have had chronic heartburn symptoms for years, at a minimum, they should have an endoscopy just to make sure they don't have something else going on that they don't have a hiatal hernia. And then, they could talk to a surgeon about the pros and cons of undergoing surgical intervention. Should that patient desire that? Should it be something that's on the table? But you also don't want to miss things like Barrett's esophagus, which needs to be surveilled.

Melanie Cole, MS: Do you have any final thoughts as we wrap up? This is a fascinating episode. You've given us such great information. You're an excellent educator. So, what would you like to say as final thoughts and the key takeaways from this episode today?

Dr Crystal Johnson-Mann: The key takeaways are just that GERD management is complex, and there's a variety of surgical options that are available. But some of the surgical options that we can proceed with depend on the patient and their specific situations. And so, that's where having someone or a center where you have a lot of different options for GERD management, and someone who's comfortable with offering any of those options and/or a program that's comfortable with offering multiple options is key for the patient to have their complete understanding of the options that are available for them.

Melanie Cole, MS: Thank you so much, Dr. Johnson-Mann, for sharing your expertise today. And to learn more about this and other healthcare topics at UF Health Shands Hospital, please visit innovation.ufhealth.org. Or to listen to more podcasts from our experts, you can always visit ufhealth.org/medmatters. That concludes today's episode of UF Health MedEd Cast with UF Health Shands Hospital. Please remember to subscribe, rate and review UF Health MedEd Cast on Apple Podcasts, Spotify, iHeart and Pandora. I'm Melanie Cole. Thanks so much for joining us today.