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If you're contemplating surgery for your hiatal hernia, or you've already had one and are unhappy with the results, I think you'll find this information very enlightening.
First let's review the size of the normal esophagus and how much the opening expands with a small to medium hiatal hernia. The end of your esophagus is just under 1 inch (0.98). Where the stomach joins with the esophagus the diameter increases 4/10 to 8/10 of an inch. Thus, a small hiatal hernia has widened the opening from just under 1 inch to 1.3 to 1.7 inches. I think it's a good perspective to have because I've met many patients who assume there's a gaping hole in their diaphragm.
Your body has an anti-reflux barrier designed to prevent reflux from occurring. There are 3 components to this barrier, making it very obvious that your body considers it to be very important to prevent reflux.
The 3 parts are:
1. LES - lower esophageal sphincter - a valve in your lower esophagus to prevent reflux
2. Crural diaphragm - a ring of muscle also acting as a sphincter or valve that's located at the opening of your diaphragm where you esophagus passes through that acts to also prevent reflux.
3. Lastly there's the phrenoesophageal ligament - which acts as a sling, holding the esophagus to the diaphragm on the underside, again designed to prevent reflux.
I did a little research into how the anti-reflux barrier can bounce back from having stress put upon it. I did this because clinically with our patients we definitely see return of normal function, despite a supposed lack of evidence that these structures can return to normal on their own.
What I discovered is that there is some evidence to support that LES tone can partially improve with a small sliding hiatal hernia (95% of them are sliding). Additionally there is symptom improvement seen as relates to the crural diaphragm, with partial reversal seen on imaging.
This is exciting and supports what we see with our patients - Symptoms improve, function is restored.
Surgeries:
Nissen fundoplication - failure rate is 15 to 30% over 5 to 10 years
TIF - failure rate of 25 to 40% due to symptom recurrence.
Now the important question: WHY?
These are the factors that came up.
1. improper repair - meaning the surgeon didn't perform well
2. obesity - abdominal fat creates increased pressure upon the stomach and diaphragm.
3. increased intra-abdominal pressure - this is one of the biggest components leading to hiatal hernia and its cause varies and typically is multi-factorial. But to resolve it is a natural treatment regimen, once we identify the root cause(s).
4. silent reflux or LPR - missing LPR means that the reflux is primarily due to bile and pepsin, not stomach acid, so success of surgery will be poor.
5. gastroparesis - the contents of the stomach move too slowly and that creates increased pressure, forcing the stomach upwards.
6. esophageal dysfunction - this is primarily motility issues, with swallowing and movement into the stomach lagging.
How what can you do about it!
It is interesting to note that the six points mentioned above do tend to have a common root cause and it is what we evaluate our patients for her at Root Cause.
We look for the presence of the following and treat what is present.
1. Loss of vagus nerve tone
2 Posture abnormalities - spinal, diaphragm and core muscles
3. Nutritional deficiencies - particularly magnesium zinc, and vitamin B12, but not exclusively
3. Inflammation - this is a big area but can be evaluated for in blood, stool and symptomatically
4. Poor diet - a diet of "real" food is mandatory
5. Liver and gallbladder/bile flow - this needs to be normalized
6. Hypothyroid - if present needs to be add