Q:My doctor has recommended keyhole surgery for my hiatus hernia. What is the success rate? Are there any way to avoid the operation. I've tried drugs and can't tolerate them. M L, Hollywood, Florida..........
A:Besides drugs, surgery is often offered as a good second option. With rolling hernia, when the possibility of trapping the stomach is a possibility, doctors always recommend surgery (Scand J Thorac Cardiovasc Surg, 1995; 29: 201-6).
As with many other standard procedures, the latest variety is keyhole surgery. Behind the generally good statistics (the reported 85 per cent success rate) a more complicated picture emerges. In one American study of 12 elderly patients undergoing laparoscopic repair of hernias, one patient was hemorrhaging so much blood that he required a postoperative celiotomy (incision through the abdominal wall to control bleeding). In the short term, gastroesophageal reflux disease was still present in five patients, or 42 per cent. Many of the other operations were not without incident. The two major complications included esophageal perforation and bleeding, and minor complications included atrial fibrillation and recurrence. The study concluded that reflux levels were high in those where fundoplication wasn't performed. This procedure entails folding of the fundus (or dome on the top of the stomach) around the lower esophagus (J Laparoendosc Surg, 1996; 6: 311-7).
In a recent American study of 30 patients, complications occurred in eight patients, or more than a quarter. Reflux developed in three of seven patients who didn't undergo fundoplication; three patients had reduced air volume in the left lung. One patient had difficulty swallowing and another, a major deep venous thrombosis with pulmonary embolism (Ann Surg, 1997; 225: 31-8).
Regular surgery also doesn't carry a far better track record. In one study at no less an august institution than the Mayo Clinic in Minnesota, of 49 patients who had open surgery over a eight year period, one patient died and complications occurred in 18 (or more than a third) (J Thorac Cardiovasc Surg, 1996; 112: 1340-4).
Long term studies of people born with this problem show that except in severe cases, surgery and drugs aren't necessary. In one study of 118 patients over 20 who'd been diagnosed as having a hiatal hernia in childhood, 94 didn't require surgery for their condition, even though a little more than half still had hernia and nearly the same number experienced monthly, mostly moderate heartburn. Also, of the 24 patients who underwent surgery as children, 18 still experienced heartburn every month, indicating that surgery basically made no difference. Furthermore, if children had been treated carefully when young, they tended to use far fewer antacids as adults (Gut, 1995; 35: 809-12).
Many alternative practitioners find that for all but the more severe cases, many of the problems of hiatus hernia can be controlled with diet and lifestyle changes. According to naturopath David Potterton and his excellent All about Hiatus Hernia and its Treatment without Drugs (Foulsham, The Publishing House, Bennetts Close, Cippenham, Berkshire, SL1 5AP) the diet should be rich in foods high in fibre. Avoid refined carbohydrates, overeating and red meat, which is hard to digest. Peel foods with tough skins and avoid pips. Also avoid those foods which commonly produce flatulence beans, peas, the cruciferous vegetables like cabbage and onions and fried or rich fatty foods. Choose wholewheat bread and cereals over hard fibres like oats. He also recommends, for those with a juicer, a fresh daily wineglassful two or three times a day of equal parts of apples, carrots and beetroot. Alcohol and caffeine should be avoided, as should drinking with meals or drinking liquids that are either very hot or very cold.
Another vital aspect is regulating your stomach acid. A number of naturopaths swear by digestive enzyme formulas which will help regulate the stomach digestive enzymes and avoid overproduction of stomach acid. An American product called Chirozyme T5-T9 Stm) is specifically formulated for hiatal hernia, ulcers and gastritis, with other herbs and vitamins which soothe and heal the digestive tract. You can order this from Lita Lee, PO Box 516, Lowell, Oregon 97452. Tel: (541) 937-1123.
In the UK, other good enzyme products include Biocare's Polyzyme Forte, and pancreatic enzyme products by Solgar and NutriWest, all available at the NutriCentre or other large healthfood stores. (These products should not be taken without the guidance of an experienced practitioner)
Finally, a good chiropractor or osteopath can often work on structural problems which often accompany this condition (such as vertebral subluxations between the fifth and ninth thoracic vertebrae).
Herbalists often swear by golden seal, slippery elm bark and marshmallow and liquorice (Potterton, Hiatus Hernia).
Meadowsweet (spiraea ulmaria) is a "herbal bicarbonate of soda" which treats overacidity and heartburn. David Potterton's book is overflowing with other excellent suggestions which offer a solid alternative to chronic antacid use.