Sheraz Markar recently hosted an online Expert Speak Talk for Heartburn Cancer UK. Sheraz, a practicing oesophageal gastric surgeon and HCUK Trustee, provided a window into how he thinks about hiatus hernia, both in terms of the symptoms that patients present with, but also how he diagnoses it, and the workup of patients for consideration of surgery.
Sheraz explained some of the nuances around surgery, as he believes it’s important for patients to start to be educated about potential options with surgery, so they can talk in a realistic fashion to their operating surgeons.
The three main things Sheraz spoke about were:
- What is a hiatus hernia?
- What symptoms does it cause?
- How we repair it, the pathway and what you can expect from surgery and the outcomes that we see with surgery down the line.
We hope you enjoy reading this very informative transcript of the hour-long session in this blog post. If you would like to watch the event please head over to our Expert Speaker events page to see the full video recording.
Types of Hiatus Hernia
When we talk about a para-oesophageal hiatus hernia, we’re talking about four main types of hernia. Your normal anatomy is where you have your gullet (oesophagus, foodpipe) and your food comes down your gullet and it hits your stomach, which sits mainly in your abdomen. And then the food is mixed up with all the acid and all the other enzymes in your stomach and then travels into the small bowel.
- Type one hiatus hernia is a relatively small hernia, there the junction between the gullet and the stomach has slipped into the chest and patients typically would present with symptoms of reflux with this type of hernia, because you basically end up with a pressure differential between your stomach and your oesophagus. The acid, which should sit inside your stomach, sometimes refluxes backup. And when we talk about small hiatus hernias, that’s really what we’re talking about with a type one or a sliding hiatus hernia.
- A type two hiatus hernia is where the top part of the stomach, the fundus of the stomach, the uppermost part, has sort of slipped in parallel to the oesophagus. The junction between the gullet and the stomach sits below the diaphragm, but part of the stomach has just popped up into the chest, typically less than five centimetres of stomach is in the chest. This also causes symptoms of reflux, but you may get some other symptoms associated with that, such as regurgitation or pain actually in some patients.
- The third type of hiatus hernia is whereby most of the stomach is sitting in the chest. So both the junction between the gullet and the stomach, and also some of the stomach is sitting in the chest and typically more than 50% of the stomach sitting in the chest. This is typically known as a giant para-oesophageal hernia and patients present with reflux, but they also present with difficulty with swallowing, sometimes pain on swallowing, and sometimes vomiting as well. It’s type three hernias which can present in an emergency, whereby the stomach is stuck in the chest and it’s not coming down and it’s causing severe pain. And in those situations, we worry about the blood supply to the stomach in an emergency setting.
- Type four is where another organ has herniated with the stomach – it can be the small bowel or the colon, or sometimes the pancreas as well can go up, or rarely the spleen, but also the spleen in some situations can go up as well.
Symptoms of Hiatus Hernia
When we see patients in the clinic its key to identify symptoms attributable to the hiatus hernia. Typical symptoms would be things like reflux or heartburn typically with a small size hiatus hernia.
Other things people get are regurgitation, or difficulty or pain on swallowing. And patients also sometimes get chest pain associated with the hiatus hernia. More rarely, people do present with things like shortness of breath or anaemia with a large parasympathetic hernia, a type three hernia.
Patients can get erosions of the stomach called Cameron erosions, which can bleed from time to time. This is when the stomach passes through the diaphragm, and it scratches the stomach, causing it from bleeding to causing ulcers, which can cause it to bleed from time to time. That can cause anaemia in some patients and can cause lethargy, which you would expect with a hiatus hernia, or a giant parasympathetic hernia as well. A fair number of patients are presenting with this shortness of breath or bleeding with anaemia, or sometimes with blood in the stool.
One of the things that I have researched was around quality of life and symptoms patients have. With parasympathetic hernia, I showed there’s a whole host of what patients present with, but in fact, we use one quality of life tool, which is GORD, health-related quality of life, which is primarily focused on just identifying patients who have reflux. So whilst we can talk about all of these other symptoms patients have with parasympathetic hernia, in actual fact, we’re really only focusing on reflux when we try to evaluate outcomes from surgery.
This led to some work and we went through a consensus process and developed a new tool, which is focused on para-oesophageal hernias and the symptoms – we capture heartburn and reflux, but also feelings such as difficulty in getting solid fluids, and food down, difficulty in getting liquids down, chest pain after meals, shortness of breath after meals, and early feeling of fullness or what we call satiety for patients. And we’re able to grade these on how often they occur for a patient, and also how much they feel that this is impacting their quality of life.
This tool now will be implemented in the UK in a national study, and we will collect this data for patients both before and after surgery in a longitudinal fashion to really understand how patients’ symptoms evolve with potential surgical treatment.
Seeing Hiatus Hernia Patients in Clinic
When I see a patient in my clinic I need to understand what the dominant symptom the patient has – does the patient have symptoms or not, and how big is the hernia?
The history is absolutely key to identifying the dominant symptom of the patient, and Are on any medical therapy, like a proton pump for example, and whether or not that’s making any benefit to their symptoms at all.
Patients will have three investigations before they have an anti-reflux operation or a para-oesophageal hernia repair:
- The first is an upper GI endoscopy, and primarily – the most important thing is to rule out cancer in these patients, but we’re also looking for any inflammation of the oesophagus caused by reflux or trying to document the size of the hiatal hernia as we talked about.
- The second is a barium swallow to give a view from the outside -to look at the anatomy of the hiatus, the size of the hernia, and potentially the emptying of the stomach. If the stomach doesn’t empty very well, if it’s sitting most of it in the chest, then that’s a good indication potentially to operate on the patient.
- The third is pH manometry, where we look at the correlation between how much acid a patient says they’re having symptomatically, versus an objective test, where a pH probe sits at the end, at the bottom of your gullet and we measure how often the patient is objectively experiencing reflux. The second aspect we get from this test is motility – how well does your lower oesophageal, your lower oesophagus, contract and that becomes important when we start to think about the operation.
Most surgeons, before a patient undergoes a hiatal hernia, perform three tests – an endoscopy, a CT scan, and a contrast imaging (barium swallow). If you’re a patient and you come to see a surgeon, you are most likely going to have those three investigations, and maybe pH manometry.
Surgical Options for Hiatus Hernia
There are three main components to an operation when we talk about it, and I think it’s important for patients when they see their surgeon to understand that the surgeon will vary their practice, and it will vary from surgeon to surgeon.
In summary, there are three main principles to consider for surgical options.
- The first is crural repair, which is where you have a hole in the diaphragm. How do you repair that hole, whilst maintaining enough space for the oesophagus to sit there, and enough for food to go down? How do you make the hole smaller, so that the stomach doesn’t fly back up?
- The second is, how do you fix the stomach inside the tummy so that it doesn’t go back into the chest? Should you try to strengthen the lower oesophageal sphincter or the junction between the stomach and the gullet, to make it a bit stronger to prevent reflux in the future, and also potentially to bulk up that area, to prevent the stomach from going back up into the chest.
- How safe is this operation for patients? A very large study was conducted in over 26,000 patients and the mortality rate from hiatal hernia is very low – it’s 0.08%. To put it into context, the mortality rate from oesophagostomy or gastrectomy, which is a cancer operation, which I do in the UK, currently sits at 1.3%, so substantially higher than what we see with anterior reflux surgery. The 90-day reoperation rate is 3%.
The other thing I’m often asked with patients who have a very small para-oesophageal hernia, say a two-centimetre hiatal hernia, is what’s the evidence of having surgery versus having just medical therapy? In the UK we conducted one of the largest trials ever conducted, which was called the reflux trial, where we randomised patients who had reflux with very small hiatal hernia, say less than two centimetres, to either having surgery or having the best medical therapy. We showed in a randomised control trial that at five years, patients’ reflux control is better with having an operation compared to the best medical therapy. In patients who are fit to have an operation is one thing. And secondly, these are patients who have small hiatal hernias, just to clarify. So that’s great in a randomised control trial, but patients often asked me if I have a hiatal hernia repair, or if I have an anti-reflux operation, what’s the chance of me needing another operation? So I conducted a national cohort study a few years ago now, in 2020, with a median follow-up of six years, which showed that if you have an anti-reflux operation, your chance of needing another anti-reflux operation within those six years is around 9.4%.
Proton Pump Inhibitor (PPI) Use
It’s important for patients to be aware that it’s not a cure by any means for patients to get off their proton pump inhibitor. If a patient is trying to get off their proton pump inhibitor entirely – if they are on a very high dose, say, for example, they’re taking 40 milligrams of Omeprazole twice a day – it’s very unlikely at six years that that patient will be completely off their PPI.
We know that only 6 however won’t go on to the same dose of proton pump inhibitor, but they will go on to some proton pump inhibitor. So it may be that you started on 40 milligrams twice a day, and you may end up on 20 milligrams once a day, but it’s important for patients who want to come off their medical therapy completely for them to understand that 40% of patients at six years are still off their PPI after surgery.
Hiatus Hernia Surgery in More Detail
As I talked about, there were three main components to this operation. And the first I’m going to deal with is the diaphragm.
Commonly surgeons will talk to you about mesh versus no mesh – mesh is a prosthetic material and they can be permanent, semi-permanent, absorbable, and completely absorbable. They can be biologic or non-biologic. And really what it comes down to is whether or not that mesh is how well it’s incorporated into the body or not.
The second alternative to a mesh repair is just doing sutures – simply repairing the diaphragm with interrupted sutures or continuous sutures.
There’s been a massive debate among surgeons as to whether or not you should use mesh or not use mesh. The best-randomised control trial that I know was undertaken in Sweden and showed that if you look at the recurrence rate at three years between patients who had a mesh versus patients who just had sutures as the repair of the diaphragm, the recurrence rate sits at 13 per cent versus 10 per cent. It’s essentially equivalent. Whether or not you repair the diaphragm with mesh or with sutures makes no difference to that in the long term.
There are some newer types of mesh which are coming out, it’s a constantly evolving field with companies developing new types of mesh. My honest disclosure is that I use primarily sutures as my default. And if the hernia looks very large or the defect is enormous and I’m very worried about the tension in the repair, then I may use specific types of mesh in those situations.
It’s something that you should ask your surgeon because mesh is a foreign body. And it’s being placed very close to the oesophagus there is a risk that surgeons worry about, particularly with permanent mesh, that it can erode into the oesophagus.
A randomised control trial from Australia showed that suture-only repair basically is the same as an absorbable and non-absorbable mesh in terms of quality of life down the line.
So you’ve repaired your diaphragm now, you’ve pulled the stomach down, you mobilized the oesophagus, and you’ve repaired your diaphragm. The question then is, you’ve got your stomach sitting there, what do you do with it?
In a randomised control trial from Germany, they looked at patients where they either fixed the stomach and the abdomen – stitched it to the diaphragm or stitched it somewhere in the abdomen – or did they formally wrap the stomach around the oesophagus in what we call a fundoplication? They showed that in patients who did a fundoplication, the long-term risk of reflux was lower, and it didn’t affect any of the other quality of life metrics.
What I take away from this is that if a patient says to me, my dominant symptom is reflux, then yes, pull down the stomach, and the patient should have some form of anti-reflux operation, whether that be a total fundoplication or a partial fundoplication.
If the patient says my main dominant symptom is that I can’t eat, then I would say no. What I would do is pull the stomach down and fix the stomach to make sure that the stomach doesn’t go back up into the chest and I repair the diaphragm properly.
There are many different ways of doing what we call a sphincter augmentation, looking at this junction between the oesophagus and the stomach.
Perhaps the most common is operation A in the UK is where you wrap the fundus around the stomach and you stitch one side of the stomach to the other side of the stomach in what we call, it’s called a Nissen fundoplication named after the surgeon, but it’s essentially a 360 degree posterior wrap.
You’re encasing the entire oesophagus 360 degrees of the way around and you’re wrapping the stomach posteriorly around the oesophagus. There’s the posterior aspect and the anterior aspect is covered 360 degrees all the way around.
The second type is a toupee wrap, which is where you wrap the stomach around the oesophagus again, posteriorly, but you don’t cover the anterior part of the oesophagus. You stitch the stomach to the oesophagus on either side. You leave the anterior part of the oesophagus bare and that’s called a 270-degree posterior wrap or a toupee. Toupee was again named after the surgeon.
The third and the fourth are what we call anterior portions of partial wraps. This is a dual fundoplication and essentially, it’s an anterior type of wrap, either, either a 90-degree or less than or more than 90-degree type of wrap.
I undertook a consensus guideline with the European Association of Endoscopic Surgery and, international consensus guideline with surgeons from North America as well as Australia. Based upon the current evidence available a posterior partial fundoplication or an anterior 90-degree fundoplication probably has the best outcome for patients with reflux in this context. It has good reflux control, but also it reduces the other symptoms associated with fundoplication, which are difficulty with swallowing. As you can imagine with a 360 wrap, you’re encasing the oesophagus in 360 degrees all of the way around. It’s very controlled, and provides very, very good acid control. However, you are potentially running the risk that the patient won’t be able to swallow afterwards – dysphagia potentially.
Reviewing all of the evidence showed that there was a higher rate of dysphagia and difficulty with gas bloating afterwards. The randomised control trial shows that the rate of dysphagia seen with a full 360-degree fundoplication is higher than that seen with a partial wrap.
So a total versus a partial rate of dysphagia appears to be higher. And the reflux control is actually equivalent between the two. So based upon the evidence, currently randomised evidence, we would suggest partial wrap is probably better for patients with this pathology.
Surgeons change their practice over time. When I trained we only did 360 degree Nissan wraps. Then over time, when I started my consultant practice I started thinking about the operation more, talking to more patients about their history and following them up after surgery, talking to other surgeons.
I take a really good patient history and if the patient’s main symptom is not reflux, but it’s difficulty with swallowing, as I said, I pull the stomach down. I do an anterior wrap, so a gentle wrap over the top, just to fix the stomach in place. I fix the stomach in multiple places and do a really good repair of the diaphragm, primarily with sutures. If the defect in the diaphragm is very large or the muscle is very weak, then I may use some form of mesh, but this is rare for me, I’ve only ever used it once. It’s important to talk to your surgeon so you know what’s going into your body.
Patients have to understand that when they talk to their surgeon, they may be talking with 20 years of experience in performing an operation, and perhaps the best thing is to be operated on by a surgeon who does an operation very well.
I think patient selection is absolutely key for para-oesophageal hernia – especially identifying what the dominant symptom of the patient is and what you’re trying to achieve with an operation. Investigations are key to really be able to identify which patients or which aspects of the symptoms are correlated with objective evidence and therefore what you’re going to target.
Counselling of patients is also very important because they need to understand what you’re going to, what symptoms you’re going to help with and what symptoms you aren’t going to help with.
Clinical Trials are Helping to Deliver Better Patient Outcomes
I’m director of a surgical trials unit and I am an upper GI surgeon. We are running two large scale international randomised control trials now from Oxford.
I am running a trial at the moment called GOLF, which is randomising patients between the LINX and fundoplication in patients with less than five centimetre height or hernia. And I’m also running a trial in patients with very poor motility, randomising them between best proton pump inhibitor and reflux stop, which is another device as well.
We are videoing every operation we do so we can identify steps that may have led to a better outcome for the patient. We can train surgeons to become better surgeons or tailor their operations in a more meaningful fashion.
Questions and Answers from Event Attendees
QUESTION: With a small hernia, is there an alternative to taking PPIs, and is it possible to reverse the hernia without surgery?
ANSWER: with a very small hernia, the answer is no. It’s an anatomical defect. It won’t reverse, but what it will do is it may just stay the same size. It may be one of these things whereby it stays with you forever. And if it’s minimally symptomatic, i.e. if you don’t have many symptoms, and say you’re on low dose proton pump inhibitor, I think it’s very reasonable to stick with that. If you want to try to get off your medical therapy at that stage, then yes, an anti-reflux operation is a very reasonable thing to consider. But outside of that, no. There are new techniques like endoscopic fundoplication, whereby you go down with an endoscope, flexible endoscope, like when you have an upper GI endoscopy for cancer, and you can do it from inside. But I would say that there’s only a handful of centres, maybe two in the UK, who are currently performing this in sufficient numbers to be considered acceptable in my opinion.
QUESTION: If those patients, the 40% who didn’t go back onto a PPI after surgery, do they have any common features, age, weight, size of hernia?
ANSWER: They tended to be in the 50 to 70 age group. Although, you know, that might be also an issue around follow up, because for patients over 70, they may just drop out of regularly seeing their GP is one thing to bear in mind. The second thing is a BMI is a big factor, without a doubt. if your BMI is more than 35, your chance of failure from any surgical intervention is much higher.
QUESTION: What causes the hernia in the first place?
ANSWER: No one honestly knows. There are some things like increased abdominal pressure associated with obesity is one of one of the risk factors. Other risk factors can be, if you’ve had a hernia in your groin, for example, some people do have, people talk about different types of collagen or different types of, fibrous tissue in your muscle. It is said that if you have a hernia in one area of your body, you are more likely to develop a hernia in another area of your body. There is limited scientific evidence to support that, but there is a study currently ongoing in Europe where they’re taking biopsies of the diaphragm and comparing it to muscle biopsies elsewhere in the body to look at different types of collagen, which I think is exciting or interesting in many ways to look at why patients may develop hernias.
QUESTION: How is it possible for reflux/acid without pain to come back out through nose, eyes and back of throat?
ANSWER: It can, absolutely. Reflux is a funny thing, isn’t it? Because it sits there. And what you can have is reflux going up. Patients commonly talk about when they lie flat, it comes up through their nose or commonly an acid taste at the back of their throat. The eyes are, I think, very unusual, but the nose is commonly affected. And I see a lot of patients in my clinic who have problems with their throat – what we call acid brush at the back of the throat. They’ve seen an ENT physician and they’ve seen multiple people and they end up then coming to see me. I scope them and see oesophagitis, inflammation of the oesophagus and diagnose them as having severe reflux.
QUESTION: What causes chronic throat clearing associated with reflux?
ANSWER: A couple of things. One is that you can have true gastroesophageal reflux irritating the back of the throat. It’s either acid coming up at the back of the throat or could be what we call laryngopharyngeal reflux as well, which is reflux right at the back of your throat. When you have this, as I showed with the type 3 hiatal hernia, you can have obstruction or partial obstruction to food and all the secretions from your oesophagus go down into your stomach. And you can have intra-oesophageal reflux. There are three main ways that you get this, but it’s irritation at the back of the throat. Most commonly from acid refluxing backup.
QUESTION: If you have Barrett’s oesophagus, should you have surgery?
ANSWER: I think it’s something we don’t honestly know. What I would say is that if you do have Barrett’s oesophagus, you are obviously it’s a potentially premalignant condition that may lead to oesophageal cancer down the line if untreated. So patients often go into regular surveillance. The honest truth is we don’t know. Did the only national cohort study, which looked at this in the UK, and we looked at whether or not if patients had symptomatic reflux and if they had an anti-reflux operation, did it reduce the risk of cancer? And the answer was yes, but you needed to treat 50,000 patients to see it. I think the chance with anti-reflux surgery is very low. But what I would say is, is James Gossage from St. Thomas’s through my trials unit again is running a trial for patients with Barrett’s oesophagus called LINACRE and that trial is offering patients anti-reflux operation with the links who have Barrett’s oesophagus. We hope to evaluate in that cohort of patients, whether or not a LINX procedure reduces or potentially causes regression of Barrett’s down the line, which I think is very exciting.
QUESTION: Please summarise what LINX is, just in case there are some people that don’t know?
ANSWER: The LINX is a metallic device. It’s a series of metallic beads around a magnet, which sits at the lower part of the oesophagus. In many ways it’s similar to the Nissan 360-degree wrap. The operation is much more simple, so you don’t have to do much mobilisation of the stomach at all. And it potentially takes away the side effects that some patients have with anti-reflux surgery, including gas bloating, inability to belch and so on. The trial that we’re running at the moment is comparing the LINX with fundoplication.
QUESTION: Would you say this is an area where there’s been considerable improvement and advances or is it still slow progress?
ANSWER: I think it’s slow progress. I think it’s an area whereby probably in the last five years people have started to start to really look at it in a lot of detail. And that’s including myself. Because most of us became very interested in cancer surgery we focused upon that. But now we’re starting to see a lot of patients in our clinic with reflux type symptoms and para-para-oesophageal hernia So that’s why it’s become an area of interest. In our trials unit, we’ve just taken over the National Hiatal Surgical Registry, the National Benign Surgical Registry, and every patient undergoing anti-reflux surgery or para-oesophageal hernia from June this year will be recorded in a registry, and they’ll be offered the opportunity to record their quality of life every six months for the next five years. We will be able to look at counselling patients who are coming up for surgery to say what their quality of life looks like in five years time in the UK.
QUESTION: Can the stomach reset itself to stop producing so much acid to cause reflux if food (and water) is not consumed for several days?
ANSWER: No. What I would say is that people do talk about using different types of diet to reduce the amount of acid or to modify your diet. And that can help in some ways. If you have a large hiatal hernia, though, it’s an anatomical issue basically either the either the junction between the stomach and the gullet is sitting too high or the stomach is sitting in the chest. Either way, that junction is not in the right position. So therefore, you have a pressure differential between your stomach, part of your stomach in your tummy and part of your stomach in your chest. And that’s causing reflux.
QUESTION: I experienced periodic significant chest pain, which was my only symptom prior to an endoscopy, which revealed Barrett’s and hiatus hernia. I’m still unclear what caused it, but it’s not recurred since PPI’s. Was it likely to be hernia related?
ANSWER: It could have been hernia related. It’s very hard when you talk about reflux is a quite a nebulous term. When I talk about taking a very careful history, what I mean by that is asking patients, are they experiencing symptoms of acid? Do they feel like a bitter taste maybe at the back of their throat? Have they noticed a change in the taste of food and things and these kind of things? Chest like severe, sharp chest pain is can be related to hiatus hernia, sometimes in an emergency setting. or in a in a short term setting if it’s very large in many ways. But most commonly with patients with Barrett’s, they experiencing reflux, they’re not experiencing pain as such, but they can experience what we call oesophageal spasm. If you have Barrett’s, it’s it can cause sort of what we call scarring on the oesophagus and maybe doesn’t contract in a normal fashion. And patients then experience this kind of spasm type pain as their as their oesophagus tries to contract against a part of the oesophagus, which isn’t really working very well.
QUESTION: I was misdiagnosed with Barrett’s, have a five-centimetre sliding hernia, terrible reflux, waiting nearly a year for review in Norfolk, suffer with regurgitation and feeling full.
ANSWER: Well, it sounds like you’re having a bit of time of it. I’m very sorry, in all honesty unfortunately the NHS is very stretched, as many of you obviously know, at the current time. The waiting lists for anti-reflux surgery in some areas of the country are extremely large, and people are waiting a long time. Resources are very stretched at the moment. However, what I would say, to caveat all of that, is that people are trying to reduce their waiting lists by doing initiatives on the weekends as well. In Oxford, we are prioritising patients with reflux and these type of symptoms for clinical trials, which helps us to get through the waiting list, and many of the centres participating in trials are prioritising it as an area of surgery for them.
QUESTION: is it safe to take low dose PPIs long term?
ANSWER: In all honesty, I would say low dose. I think the epidemiological data is out there. When you read papers, they say PPI linked to osteoporosis or PPI linked to dementia or PPI linked to cardiovascular disease. They’ve looked at a study in typically, you know, over 500,000 patients to come up with a change in risk of less than 5% to see that. With a very low dose PPI it is a safe, in my opinion, and this is my opinion, it’s a very safe medical therapy to take. However, if you are concerned about it ask your GP to go and see a surgeon and have a discussion with them. Surgery isn’t perfect, by any means, we take away the reflux in many ways, but we do leave you with potentially other symptoms, as we’ve talked about, such as gas bloating, inability to belch, sometimes some difficulty swallowing. It’s a trade-off. And it’s important to have that conversation. What I would encourage people to do, and I hope if you take nothing away from this, one of the things you do take away is if you are suffering with severe reflux, by all means, ask your GP to send you up to see a surgeon because it’s available and it’s a treatment that we can offer.
QUESTION: What’s the usual recovery time post surgery?
ANSWER: My patients typically have keyhole surgery, the recovery is pretty quick, two weeks. Realistically, you’re on a usually on a different type of diet, so softer type of food, and then you advance your diet sort of after that. Some procedures that like the LINX, for example, the recovery time is believed to be shorter. Again, that will be hopefully proved or disproved within my trial. What I would say, for disclosure, this is a national NIHR funded trial for LINX versus fundoplication. It’s been viewed by the government as an important trial of interest.
QUESTION: 10 years post Nissen surgery, would you know why a hernia has now reoccurred together with significant reflux?
ANSWER: As I alluded to, at six years, around 10% of patients will have a reoperation. What I would say is if you’ve made it to 10 years, that’s not a terrible outcome from surgery in many ways, it’s very rarely a permanent solution. It does come back sometimes. If you do have symptoms after that, revisional surgeries is complicated and challenging. But by all means, you should seek surgical intervention if you’re having symptoms. Myself and colleagues here in Oxford do a lot of revisional surgery and I think most surgeons would be willing to consider it. And it’s something that should be considered if you have a recurrent hernia and recurrent symptoms, definitely.
QUESTION: Are there a number of centres of excellence?
ANSWER: No, that’s the honest truth. At the moment we don’t have that in the UK. What we have are centralised oesophageal and gastric cancer to centres of excellence. There are, I think, 26 in England. But anti-reflux surgery and para-oesophageal hernia has never been centralised. What does happen, though, is that in an emergency setting, if a patient presents with an obstructed para-oesophageal hernia, that means where the hernia is stuck, and the patient can’t eat anything, or they are very unwell, and we’re worried about blood supply to the stomach, then that patient will be transferred to a cancer centre, because the stomach may need to be removed in that context. And that’s an emergency.
In Summary…..
As a surgeon it’s really important to understand patients, to really understand what symptoms they have. And for patients to speak to their surgeons about what the operation is trying to achieve. I commonly see patients and they present with sometimes a whole host of symptoms, diarrhoea for example. And I say whilst I can fix hiatus hernia, it’s not going to help with the diarrhoea at all. So just to be very clear, you understand what this operation is trying to achieve and what it’s not going to achieve.
About Sheraz Markar
Heartburn Cancer UK Trustee Sheraz Markar is a practicing oesophageal gastric surgeon, undertaking hiatus hernia surgery and also cancer surgery as well as part of his practice.
Sheraz believes mentors are really important in surgery, and as part of this Expert Speakers talk he explained that he has had three great mentors in his career:
- Sheraz’s first mentor was American surgeon was Don Lowe, and he taught Sheraz about para-oesophageal hernia He undertook a lot of para-oesophageal hernias in Seattle when Sheraz worked for him as a fellow.
- The second was Nick Maynard, Sheraz’s long-term mentor and now his colleague in Oxford. Nick is very focused on the symptoms that patients have, and is looking at revisional surgery for para-oesophageal hernia or hiatal hernia.
- And then finally George Hanna, Sheraz’s academic mentor. George taught Sheraz about cancer surgery and how we can develop robust quality of life tools for patients.
