Fixing a Fatal Hiatal Hernia
Using minimally invasive techniques, two top surgeons collaborate—with excellent results.
Marie McHose of Monroe Township, now 75, started feeling the effects of a hiatal hernia about a decade ago. She felt pressure and pain in her chest, and a computed tomography (CT ) scan in 2006 revealed the problem. A hiatal hernia is common, but in some instances, as with Mrs. McHose, it can progress to a rarer and more dangerous condition known as a paraesophageal hernia. When hers did so, she needed surgery to repair the potentially fatal disorder. Fortunately for her, minimally invasive techniques have rendered this once difficult surgery much easier for older patients, who make up most of the cases, to weather successfully.
In a hiatal hernia, the stomach pushes through the hiatus, an opening in the diaphragm through which the esophagus passes as it connects to the stomach. Usually only the top section of the stomach, where it joins the esophagus, slides through. If the hiatal opening stretches, though, more of the stomach can push through—that’s known as paraesophageal hernia. It can cause more severe symptoms, including severe acid reflux, chest pain, upper abdominal pain, shortness of breath and difficulty swallowing. There is also a risk for stomach obstruction or ischemia, in which blood supply to the stomach is cut off. That requires emergency surgery.
Mrs. McHose had no idea of this as she tried to live with her symptoms for years. “I took a lot of Tums and Pepcid,” she says. But her condition grew worse, and over the past three years she would feel heaviness in her chest and pain radiating to her left shoulder after meals—once it was so severe she was tested for a heart attack. A pulmonary specialist treated her breathing problems with inhalers, with no success. Finally, he ordered another CT scan.
“He said, ‘No wonder you are having trouble breathing—your stomach is pressing on your heart and left lung!’” she recalls.
She spoke to several surgeons, including Frank Borao, M.D., chief of Esophageal and Bariatric Surgery at Monmouth Medical Center. “He was my second opinion, but because of his enthusiasm and knowledge and the fact that he does a lot of these surgeries, I thought he would be the surgeon for me, even though he is an hour away from where I live.”
Another important factor in her decision is the fact that Dr. Borao is the most experienced surgeon in the state of New Jersey for paraesophageal hernia repairs. He works in tandem with Anthony Squillaro, M.D., a thoracic surgeon. “Having two surgeons working together made a big difference to me,” she says. “And both were very good about answering my calls and questions.”
Dr. Squillaro and Dr. Borao work together on more than 90 percent of each other’s patients. “It’s a two-man operation—he helps me and I help him,” Dr. Squillaro says. “That’s a big factor in keeping operative times down and in achieving the good results we get.” So is the fact that they have performed more than 800 of these surgeries since 2002, which he says is probably the largest on the East Coast and among the most in the country.
Another big factor is the development of laparoscopic techniques for this procedure. “In the old days, we had to cut people open with big incisions,” says Dr. Squillaro. “Most of these patients are elderly, so that was very hard on them. Also, the diaphragm is very thin and weak at the hiatus, so the rate of recurrence after repair was around 30 percent. As a result, primary care physicians used to discourage this surgery.”
Now, however, surgeons need to make four tiny incisions of 5 millimeters, and one of 12 millimeters, to insert ports for their instruments. They use “long, skinny tools,” he says, to pull the stomach back through the diaphragm. Then they stitch the opening closed and reinforce it with a bio-mesh that encourages the body’s own cells to grow onto it, further reinforcing the closure. The next step is a procedure called fundoplication. The surgeon wraps the upper part of the stomach entirely around the esophagus. “This acts as an extrinsic sphincter to stop reflux, because the natural sphincter has been damaged by having a hernia for so long,” he says.
The entire procedure takes about an hour and a half and is performed with the patient under general anesthesia. The patient is kept in the hospital for two days so that the doctors can run gastrointestinal tests to ensure that everything is working properly.
Recovery at home involves a week or so on a liquid diet, then a week or two on soft food purees. “We want a slow progression to solid food, because we don’t want vomiting,” says Dr. Squillaro. That could damage the repairs. Heavy lifting or putting pressure on the diaphragm is discouraged for about two months for the same reason. “It takes that long for everything to heal inside,” says the doctor. “Once we get past that time, most patients don’t have a recurrence.” Indeed, these two surgeons have a recurrence rate of less than 15 percent.
Marie McHose had her procedure September 10, and by the end of November reported that she felt “much better than I have felt in the last five years.” She can eat whatever she wants, has more energy and appears noticeably healthier to her husband Joe, 78, and their many children, grandchildren and great-grandchildren. “I am very pleased with both doctors and what they did,” she says.
“The public and area physicians need to know that there is a better way to fix this now,” Dr. Squillaro says. “There are a lot of people out there who could benefit from this surgery. They need to know that the problem can now be treated much more effectively than it was before.”
To learn more about the comprehensive gastrointestinal surgery program at Monmouth Medical Center, call 732.923.6070.