Fundoplication, Hiatal Hernia Repair and Esophageal Dysmotility
Natalie from Houston sent us this question: Do you recommend fundoplication in a patient with severe esophageal dysmotility and a paraesophageal hiatal hernia? Or is repairing the hernia the best that can be done?
Your question is common and quite relevant. Why add a fundoplication to hiatal hernia repair especially in the setting of severe esophageal dysmotility? You are obviously concerned about post-fundoplication dysphagia (difficulty swallowing food).
Let me start by debunking a common myth about hiatal hernias. It is commonly thought that a hiatal hernia causes acid reflux. In reality, acid reflux causes a hiatal hernia to develop. The esophagus is made of two layers of muscle (longitudinal and circular muscles) that are spirally arranged around the mucosa (the inner lining of the esophagus). Chronic acid reflux causes the esophageal muscles to contract upward away from acid. This upward movement of the esophagus slowly drags the stomach through the hiatal opening. As a result, a hiatal hernia develops and continues to grow in size as long as acid reflux is not stopped. From this perspective, Natalie, a hiatal hernia is a consequence of untreated acid reflux rather than the cause. Of course, a hiatal hernia displaces the lower esophageal sphincter and weakens the anti-reflux barrier thus contributing to acid reflux. However, the root cause of acid reflux is not just hiatal hernia. Indeed, the etiology of acid reflux is multifactorial and remains poorly understood. By the way, as the esophagus retracts into the mediastinum in response to acid reflux, esophageal motility weakens. Most acid reflux patients have esophageal dysmotility. Esophageal dysmotility contributes to acid reflux by preventing effective acid clearance from the esophagus. Hence, both hiatal hernia and esophageal dysmotility are caused by acid reflux and both contribute to acid reflux creating a viscous circle that feeds on itself. For this reason, acid reflux is a chronic and progressive disease. GERD symptoms get worse and hiatal hernia size increases with time.
The purpose of hiatal hernia repair is to restore normal anatomy. A number of surgeons commonly attribute hiatal hernia repair to simply closing the hiatal opening. Such an approach, however, is not sufficient. In reality, the primary purpose of hiatal hernia repair is to bring down the distal esophagus and lower esophageal sphincter from the mediastinum into their original intra-abdominal position. Closing the hiatal opening without dissecting and mobilizing the distal esophagus is a useless operation. Restoring anatomy, however, does not recreate the missing anti-reflux barrier that led to hiatal hernia formation in the first place. Herein comes the role of fundoplication. Wrapping the gastric fundus (upper part of stomach) around the distal esophagus reliably stops acid reflux. The fundoplication cannot be performed unless the distal 4 cm of esophagus is present in the abdomen. For this reason, proper hiatal hernia repair i.e. distal esophageal mobilization, must be achieved to be able to perform a durable and reliable Nissen fundoplication. A poorly performed hiatal hernia invariably results in slipped Nissen fundoplication. The mechanism of action of Nissen fundoplication is multifactorial and is not well understood. Nissen fundoplication does not mechanically reinforce the lower esophageal sphincter like LINX device. Indeed, we currently perform a floppy and short fundoplication to prevent post-operative dysphagia. Even in the setting of severe esophageal dysmotility, a floppy and short fundoplication is associated with very low dysphagia rate. At Houston Heartburn and Reflux Center, our post-fundoplication dysphagia rate is zero.
In summary, fundoplication surgery in addition to hiatal hernia repair are both needed to restore the anti-reflux barrier. When properly performed, hiatal hernia surgery with Nissen fundoplication offer the most reliable cure for acid reflux.