Heartburn is a symptom people get when there is a reflux of gastric contents up into the oesophagus. Within the oesophagus the gastric fluid can cause inflammation. A valve at the junction of the oesophagus is designed to prevent this reflux. The potency of this valve depends on the pressure within the muscle sphincter, the angulation of the oesophagus entering the stomach and the presence of the oesophagus below the diaphragm. With a hiatus hernia the opening of the diaphragm is stretched up allowing the stomach to pass up into the chest. This causes the valve to become inefficient and allows the reflux of gastric juices into the oesophagus. Hiatus hernia on its own does not cause symptoms.

A less common form occurs where the gastro-oesophageal junction remains below the diaphragm but the fundus of the stomach rolls through the hiatus into the chest.

In most instances the symptoms of gastro-oesophageal reflux disease (GORD) is treated medically. The symptoms of reflux disease can be acidic taste in the mouth (water breath), difficulty in swallowing (dysphagia), pain on swallowing, hoarseness and a cough. Asthma can be associated with reflux. Changes in the lining of the oesophagus can lead to Barrettes oesophagus which does have a pre-malignant potential.

Simple lifestyle changes may result in lessening of symptoms. Other avenues are medications which reduce the gastric acidity. If symptoms persist then surgery may be necessary. Surgery is designed to enhance the effectiveness of the lower oesophageal sphincter (valve). Before surgery is contemplated confirmation of normal muscle activity in the oesophagus needs to be made.

Diagnosis of this condition is made with x-ray or endoscopy. Biopsy is needed to confirm the presence of inflammation or other changes. Ph monitoring to ensure the acidity in the oesophagus occurs when symptoms are present. The decision to undergo surgery is dependent on the level of symptoms.

Surgery can be performed laparoscopically or as an open procedure. The aim is to wrap the top of the stomach (fundus) around, to a variable degree to lower part of the oesophagus. The defect in the diaphragm (the hiatus) in many instances will also be closed.

Initially some difficulty in swallowing may occur due to oedema or due to swelling of the area involved in the surgical procedure. This usually passes off within a month.

More information about the procedure is contained in the RACS patient education pamphlet.Picture courtesy of RACS and MI-tec Publishing. The complete patient education pamphlet is available from your surgeon.