Pre-operative evaluation

A hiatal hernia forms when part or all of the stomach extends into the chest cavity by sliding through the opening in the diaphragm the esophagus passes through. It can be freely sliding up and down which is more common, or fixed above the diaphragm which cause more symptoms. Surgical repair is generally reserved for those hernias that are fixed. It is crucial for the gastroenterologist to be able to recognize the different types of hernias n order to know which patients will benefit from surgical repair. The surgeon in turn will bring the stomach back down below the diaphragm and tighten the opening so it does not slide back up. Often times an intra-operative endoscopy is performed to assist the surgeon and make sure there are no problems.

When the lower esophageal sphincter pressures are very low, or after a hiatal hernia repair, a fundoplication wrap is usually performed. This involves the surgeon wrapping the upper stomach around the lower esophagus in order to create a tighter sphincter. Proper pre-operative endoscopic evaluation is needed, and often intra-operative endoscopy is used to assess the tightness of the wrap. In addition, esophageal manometry and pH studies may be needed before surgery  to help the surgeon decide which type of wrap is safest..

Gastric sleeve surgery for weight loss involves surgically removing 2/3s of the stomach leaving a tubular stomach with much less reservoir for food. Upper endoscopy beforehand is important to rule out diseases like ulcer, erosive gastritis and H.Pylori which could adversely affect the surgical outcome. In addition, if the patient has significant reflux or regurgitation symptoms without a hiatal hernia, esophageal manometry is important since reflux can worsen after this procedure.