Esophageal Kinking, Heartburn and Hiatal Hernia Surgery
Once or twice a year a GERD patient presents to Houston Heartburn and Reflux Center with heartburn and sometimes dysphagia following hiatal hernia repair and Nissen fundoplication performed around the Houston area. Recently, I have treated two patients with similar presentation following sleeve gastrectomy and hiatal hernia repair. GERD and dysphagia workup in these cases typically starts with upper endoscopy and UGI. The UGI is quite informative as it shows kinking of the distal esophagus. Distal esophagus passage from intra-thoracic to intra-abdominal location across the hiatal opening should be smooth with no angulation of kinking. Kinking occurs secondary to poor esophageal mobilization during hiatal hernia repair and aggressive posterior closure of hiatal opening. Consequently, the esophagus takes a 90-degree angle turn at the hiatal opening that leads to post-operative dysphagia and poor acid reflux control. In some cases, I have seen an S shaped distal esophagus on UGI whereby the posterior hiatal closure pushed the esophagus up and the fundoplication pushed it back down leading to severe esophageal outflow obstruction and dysphagia.
The solution to this problem is redo hiatal hernia surgery with proper distal esophageal mobilization and adequate posterior crural approximation. This area is highly dynamic as it constantly stretches and contracts to push food into the stomach. Hiatal hernia repair when properly performed respects the physiologic properties of the gastro-esophageal junction. Consequently, hiatal hernia repair should not be associated with esophageal angulation and outflow obstruction.
Of note, in sleeve gastrectomy cases, narrowing at the incisura angularis leads to proximal stomach dilation. The back pressure created from distal gastric obstruction may also lead to distal esophagus kinking independent of hiatal hernia repair. These cases of severe acid reflux disease require redo hiatal hernia repair and sleeve to gastric bypass conversion to bypass functional obstruction at the incisura angularis.