Correction of Hiatal Hernia?

[Elith]

In 2000, I had a nissan fundoplication to correct my GERD problem. At that time, I understood that my hiatal hernia would be corrected. After the surgery, I had pain on eating or drinking, esp cold water, that "radiated" to my left shoulder. I had severe pain on the lower left side of my chest, above my stomach. I was told the pain on eating would subside and go away. Well, though it is not as intense, the pain never went away and now it has become chronic and increasing in a different way. I went to the surgeon at least twice post-op and he seemed annoyed with me, and really didn't answer my questions.   I went to the gastroenterologist and he did a post op endoscopy and told me he saw a lump in my stomach. (A stomach biopsy was done & was negative.) The report said: "The Pentax EG-2901 endoscope was introduced through the mouth...to the second portion of the duodenum...A hiatal hernia was found small with initially wide open LES, no esphageal inflammation. Bile reflux was found with mild gatritis." My questions are: (1) aren't GERD surgeries supposed to correct a hiatal hernia? (2) if not a hiatal hernia, pushing into my stomach, what other possibilities could it be and would this be the source of my chronic pain on the left side, now painful to touch, (3) now I get nauseated on small portions of any type of food, (4) can a wrap be re-wrapped? (5) would bile reflux make me chronically gassy? (6) two or more hospitals that I can go to in the SF Bay Area for an opinion? Thanks

[Kevin Pho, MD]

Hello - thanks for asking your question.

Please note my insight into the surgery specific questions will be limited since I am not a surgeon.

The Nissen flundoplication by itself does not necessarily correct the hiatal hernia.  The correction of the hiatal hernia may involve the some or all of the following components: reduction of the herniated stomach into the abdomen, herniotomy (excision of the hernia sac), herniorraphy (closure of the hiatal defect) an antireflux procedure, gastropexy (attachment of the stomach subdiaphragmatically to prevent reherniation).  There is also the possibility of the hernia recurring after surgical correction.

Without examining you, it would be difficult to say what the left sided pain is.  Of course, there could be complications from the surgery.  You may also want to inquire about a CT scan and blood tests to evaluate any pancreatic cause of the discomfort.

Another test to consider would be a gastric emptying scan evaluating for gastroparesis.  Nausea with small portions of food could be suggestive of gastroparesis.

It is possible for a fundiplication wrap to be redone.  Bile reflux can certainly cause a bloating, gassy feeling.  If medical therapy is not controlling your symptoms, then further surgical evaluation should be considered (they Roux-Y procedure as surgeon below has mentioned).

As for SF gastroenterologists, here is the American Board of Internal Medicine website where you can search for a nearby gastroenterologist for a second opinion:
http://www.abim.org/dp/apps/physdir1.htm

Followup with your personal physician is essential.

This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.

Thanks,
Kevin, M.D.

[tessa0825]

Im very concerned as to the answer you get...A wrap IS supposed to strengthen the LES and repair the hernia...How could a wrap even have been done if it is still WIDE OPEN?.....Hope you get some good advise.....Tessa

[surgeon]

when you posted this question you stated that the wrap was intact. The presense of residual hiatal hernia, per se, is not really significant. In this posting you also added the info that there was bile reflux with gastritis. That implies the bile is refluxing from the duodenum into the stomach, and not from the stomach into the esophagus. That would not have been treated or caused by the nissen procedure. Bile gastritis could cause nausea, gassiness, even tenderness, and would be treated with certain medications, and in some cases by surgery to re-route the attachment of the intestine to the stomach (a Roux-Y procedure). Each or your posts has information not in the other. It seems the wrap is intact, there's no longer esophageal reflux, but there is also bile reflux into the stomach. If that is a correct synthesis of your two different posts, I'd say again that the hiatal hernia is a non-issue: it's only significant if related to esophageal reflux, and other than what your ENT said, it seems there is no longer esophageal reflux. So your gastroenterologist needs to address your bile reflux. Yes, a wrap can be re-done. It doesn't seem necessary in your case, if I correctly put your info together. If you need another surgical opinion, you might try to see Dr Larry Way at UCSF.

[Elith]

Thank you doctors for your responses.  They were very helpful and
particularly made me understand that the hiatal hernia (small though it is) may not be my problem.  I also do not think I have a reflux problem.  Since your responses, I have started to use a band, which I wrap around my lower chest area, above my stomach, and this band eliminates my pain on the left side (midway above my stomach).  Some times the pain comes back after I take the band off and I just put the band back on.  This pain started after the surgery but now that I have control over it; I guess every thing is okay.  Thanks again.

[roger353]

A related discussion, Hiatal hernia correction surgery (Non invasive) was started.