Patients who suffer from GERD and also have a hiatal hernia can suffer debilitating symptoms. The condition is a result of dysfunction of the normal valve mechanism at the junction of the esophagus and stomach, often associated with hiatal hernia of variable degree. When the stomach is displaced into the chest it can cause nausea, vomiting, shortness of breath due to lung compression, pain after eating or a progressive inability to swallow food.
Candidates for laparoscopic surgical treatment are patients who do not respond to medications for reflux, or who do not want to take medications for the rest of their lives, or who develop side effects from medications. An estimated 30% to 50% of patients do not respond to medication for GERD and related issues, and for this group of patients there is no other meaningful treatment besides surgery.
Other candidates include people who have complications of GERD such as stricture, Barrett’s esophagus or suffer from so-called extra-esophageal reflux — caused by irritation by gastric content of the voice box or lungs and presenting with throat burning, hoarseness, chronic cough and asthma-like symptoms.
For those who suffer from both GERD (reflux) and hiatal hernia, Dr. Averbach and Dr. Hamdallah offer the most advanced laparoscopic treatment: fundoplication. This procedure involves repairing hiatal hernia with fundoplication the essence of which is a construction of a gastric wrap around the distal esophagus to re-create a disrupted valve mechanism. There are two main variants of this procedure: Nissen fundoplication, or a complete 360 degree wrap, and Toupet Fundoplication, or a 270 degree wrap.
The former (Nissen) is widely known and is associated with 5% to 10% of side effects such as dysphagia (difficulty swallowing), gas-bloat syndrome and the inability to burp.
The Toupet, or partial fundoplication, preserves distensibility of the esophagus by creation of partial wrap and therefore reduced risk of dysphagia, bloating, and other side effects more common to the Nissen fundoplication are minimized or avoided. At the same time, relief for heartburn and regurgitation is excellent. Dr. Averbach is proud of offer laparoscopic Toupet fundoplication, a state-of-the-art surgical approach which has a very good track record in terms of controlling symptoms and improving quality of life.
A small group of patients suffer paraesophageal or giant hiatal hernia (intrathoracic stomach when more than 30% of the stomach herniates into the chest). Symptomatic patients are also treated with laparoscopic fundoplication with hiatal hernia repair. The presence of large hiatal hernia is associated with more severe symptoms and can cause the stomach and other organs strangulation within the hernia. This group of patients has only one reliable treatment option – laparoscopic hiatal hernia repair with or without mesh and Toupet fundoplication.
The Toupet procedure is also utilized for the treatment of a condition called Achalasia. This disease presents with similar symptoms and is caused by the inability of the esophagus to contract and push food down into the stomach. At the junction with the stomach, the esophageal muscles lose their ability to relax for food bolus passage, creating a stricture-like narrowing. The only long-term, effective treatment for this condition is Heller’s myotomy, or incision of the scarred, non-relaxing muscle. This procedure is also combined with partial fundoplication for better functional results.
For those patients who suffer from morbid obesity in addition to GERD/hiatal hernia, Dr. Averbach offers additional treatment options. Because it is known that in obese patients results of anti-reflux surgery are inferior and are associated with higher rate of failure, we offer consultation and often recommend bariatric surgery – primarily gastric bypass – to resolve symptoms with adequate weight loss in 90% to 95% of patients.