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Medical Intel

Jul 31, 2018

A paraesophageal hernia can have symptoms as simple as acid reflux or feeling bloated after a small meal—or no signs at all. Dr. John Lazar, Director of Thoracic Robotics, discusses how we diagnose and treat paraesophageal hernias.



Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: Thanks for joining us today. We’re speaking with Dr. John Lazar, Director of Thoracic Robotics at MedStar Washington Hospital Center. Today we’re discussing benign esophageal diseases, a group of non-cancerous disorders in the esophagus, which is the tube that connects the throat to the stomach. Dr. Lazar, what are some of the benign esophageal diseases you see most often in your patient population?

Dr. Lazar: I would say that the most common benign disease that we see is something called the paraesophageal hernia. And what that is, is that over time, the diaphragm weakens and the stomach starts to track up into the chest. Um, and it can be quite uncomfortable at certain points which is generally when people start seeing us.

Host: What are some of the common symptoms of paraesophageal hernias?

Dr. Lazar: So, the most common one is reflux, meaning that you have this taste of acid coming up into your mouth or sometimes it causes you to cough. Other ones are after eating a small meal you feel very bloated. Sometimes it even causes you to actually have to vomit in order to feel better. This is something that happens gradually over time, so a lot of times, people don’t realize they even have these problems until someone points it out to them. Other issues with the esophagus which are less common is something called acalasia, which is the inability for the lower part of the esophagus that is connected to the stomach to open up all the way. So, food actually sits there at the end of the esophagus and usually you have to wash it down with a glass of water or unfortunately, even then, sometimes things come back up.

Host: So, they sound like pretty similar symptoms to other disorders. How common are these esophageal diseases?

Dr. Lazar: So, I would say that achalasia is probably very small, in the single digits, if you took the population as a whole. Or I would say that paraesophageal hernias are probably around 10 to 15 percent of the population. And most of the time they’re asymptomatic, meaning no one has any symptoms and they’re only...only found incidentally, meaning you went in for a chest x-ray or something else was bothering you and they did a CT scan and they ended up finding some of these things. I think when you’ve had long standing gastroesophageal reflux, it’s time to talk to your doctor about maybe even getting screened when a...with a EGD by a gastroenterologist, just to make sure that there’s no permanent damage done to the esophagus. I think if you’re in the category of, “Oh, you know, this happens every year, once a year,” you’re probably OK, but if it’s happening more and more often, then you really should talk to your doctor about getting screened.

Host: Are there certain groups of people who are more at risk, say men or women?

Dr. Lazar: So, generally people who have increased abdominal pressure, so that would be people who are overweight, uh, sometimes women who’ve had multiple babies, and over time, the diaphragm weakens. It’’s kind of hard to predict who will or who will not have it.

Host: In terms of treatment, what are some of the most common first-line treatments for these disorders?

Dr. Lazar: Sure. So, basically the only treatment is for the symptoms, unless you fix the problem. So, a lot of times people will take antacids, over-the-counter or prescribed by a gastroenterologist or a primary care physician. But if you want definitive therapy from it, surgery’s the only cure.

Host: Is there an issue with people taking antacids and things like that long-term as opposed to having surgery?

Dr. Lazar: Yeah, so there’s a growing debate as to whether a certain type of drug called proton pump inhibitors, or PPIs, also has long-term damage to other organs and that’s an area in which people are looking into but it’s become very popular in the news and so a lot of patients have been talking to their doctors about whether or not surgery’s right for them.

Host: Could you explain what a PPI is for individuals who might not know?

Dr. Lazar: So, a proton pump inhibitor works on suppressing the acid on a molecular signaling level and so therefore people have less symptoms from reflux because the pills tell the body to make less acid.

Host: When a person does need surgery, what are some of the more common procedures that are done?

Dr. Lazar: So, if we’re talking about a paraesophageal hernia, generally paraesophageal hernia repair involves pre-operative testing with an esophagram, which is drinking of contrast, and then they get x-rays that shows how the contrast goes down. The other common test is a CT scan of the chest, which is about a ten-second test. And then the other test can be something called manometry, which tests how well the esophagus squeezes food down the length of the esophagus.

Host: So they’ve run through all of these tests...and then, once they go in for treatment, what...are you doing open surgery with these folks, if it’s necessary...minimally invasive? What does that look like?

Dr. Lazar: So, almost all surgeons are doing minimally invasive paraesophageal hernia repairs. In the old days we would generally go through the left chest, which was a very painful procedure. Now we’re doing it minimally invasively through the abdomen where there’s less nerve endings and, uh, they’re able to go home much sooner. We do it robotically. Patients are brought to the operating room. They’re put to sleep. They’ll have five ports about the width of my index finger. And then we will use the robot, which is completely controlled by the surgeon, to then bring down the stomach back into the abdomen, take down all the scar tissue that was holding it in there, and then close the opening that’s in the diaphragm that...where the stomach was going in.

Host: Could you talk a little bit about the recovery from that type of procedure?

Dr. Lazar: Sure. So, the great advantage of robotic surgery or any kind of minimally invasive surgery for paraesophageal hernia, is that generally people go home anywhere from one to three days afterwards, uh, depending on the surgeon’s preference. So, generally they have less pain, they’re able to eat and drink much quicker, and so there’s really no reason to keep them in the hospital. Uh, they still take about seven to ten days to really get back on their feet once they’re home.

Host: What is the risk of not seeking treatment for long-term symptoms?

Dr. Lazar: So, I think that there’s a group of people who are very scared of surgery, and rightly so, who have paraesophageal hernias. Unfortunately sometimes the stomach can twist along the esophagus and cut off the blood supply, and therefore, it becomes a surgical emergency to reduce the stomach and get it back down and there’s a risk of the stomach becoming what we call ischemic, or there’s no blood supply to it. Uh, and that...that can be life or death in some cases. In the past we had talked about only treating symptomatic paraesophageal hernias, but there’s growing evidence because of this that maybe we should start taking care of these patients earlier when the hernias are smaller and they’re actually in better health.

Host: What are some of the emerging technologies or procedures that you’re using at MedStar Washington Hospital Center?

Dr. Lazar: So, I would say that the biggest technology that’s really catching on both nationally here and that we brought to the Washington Hospital Center robotic technology. And, in most senses, this is robotic assisted technology, so the surgeon still remains completely in control of what’s going on. The robot is there just to enhance visualization, enhance their ability to operate within a confined space, and to basically make it a smoother operation for the surgeon.

Host: Have you had any patients in the past who have had severe hernias who you were able to help with this type of surgery?

Dr. Lazar: Sure. So, I think, in a lot of senses, because of the enhanced visualization, we’ve been able to do a better operation than we would open in the abdomen, and in some cases, just as good as we would have done through the chest but with much smaller incisions and therefore better recovery because we’re able to take down all the scar tissue that basically keeps it up there. We’re able to reduce, you know, the stomach back in to the abdomen or in to the belly area and then close these large defects. Because we have wristed instruments, we’re able to then suture in a much better way or close the defects in the diaphragm and then make sure that the patients reestablish the normal anatomy.

Host: So, doing so, in reestablishing that anatomy, is there a follow-up procedure that these patients will have to have?

Dr. Lazar: No. Generally, once the surgery is performed, and then they’re able to get out of the hospital in a couple days, uh, we follow them along, at least a couple weeks, and we’ll see them back yearly just to make sure that everything’s OK. But generally speaking, uh, there’s no other procedure that’s usually required afterwards.

Host: Why is MedStar Washington Hospital Center the best place to go for treatment of hernias and other benign esophageal diseases?

Dr. Lazar: Well, we have a team of specialists in thoracic surgery who are very dedicated to understanding esophageal disease. We’ve all been specially trained in the esophagus. A lot of people get training in a lot of different things. Our passion is, uh, esophageal disease, whether it’s cancerous or non-cancerous. And, so therefore, I think that we have a lot of experience and knowledge in identifying esophageal disease and, technically speaking, we’ve dedicated our lives perfecting it.

Host: Thanks for joining us today.

Dr. Lazar: Thank you.

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