INFORMATION ABOUT THE DIAPHRAGM
Here you will find easy-to-understand answers to the most frequently asked questions.
WHAT IS SPECIAL ABOUT THE DIAPHRAGM?
You can imagine the diaphragm as a thin but very stable dome that arches between the chest and abdomen. This flexible structure made of muscles and tendons is our most important breathing muscle.
But it also fulfils another vital task: it ensures that the abdominal organs remain in the abdomen even under the greatest strain and do not slide into the chest cavity. This means that the natural order and function are always maintained. A natural weak point is where our esophagus passes through the diaphragm muscles and reaches the stomach. This small muscle slit is called the "hiatus". If the delicate muscles separate there, we speak of a "hiatal hernia". The stomach can slide into the chest cavity through this tear and even become trapped there. The esophagus also shifts, with the result that the complex interaction of the organs is disrupted and the closure system to the esophagus fails. Acid reflux occurs.
WHAT ARE THE CONSEQUENCES OF A HIATAL HERNIA?
When the diaphragm breaks, the organs lose their support. The stomach pushes into the chest and the esophagus becomes detached from its anchorage. This displacement of organs deep in the body can result in a wide variety of problems. The most common
the closing mechanism between the esophagus and the stomach suffers. Sharp acids and digestive enzymes from the stomach rise up and "reflux" occurs, which in Latin means nothing other than "flowing back".
The resulting inflammation of the mucous membrane in the esophagus is classified in medicine into different degrees and can possibly transform into tumors in the most severe forms (Barrett's ulcers).
But the stomach can also become stuck in the diaphragm itself. This causes pain in the chest and upper abdomen. It is not uncommon for the heart to react and beat violently and irregularly. The symptoms only subside when the tissue is freed.
WHAT SYMPTOMS ARE TYPICAL?
The symptoms caused by a defective diaphragm are extremely diverse. They essentially affect four major areas: esophagus, mouth and throat, heart and breathing.
Heartburn and rising pain behind the breastbone are typical warning signs. Wine, coffee, fruit juices and even sweets are no longer well tolerated without acid-blocking medication. Frequent belching and a bloated stomach are a daily burden for patients. Many patients are not allowed to eat anything late in the evening and have to sleep with their upper body raised, otherwise acids can enter the esophagus unnoticed during sleep. If this reaches the windpipe, patients wake up in the middle of the night with sudden coughing fits and the feeling of suffocation. In the morning, patients complain of an unusually bad taste in their mouth, bad breath and mucus.
The gases that rise overnight can cause irritation of the upper respiratory tract and throat, resulting in hoarseness, clearing of the throat and a lump in the throat. Repeated inflammation of the paranasal sinuses and a "stuffy nose" lead patients to see an ENT doctor.
Independent of reflux, tissue can also become trapped in the diaphragmatic slit. This results in symptoms such as rapid heartbeat and the feeling of not being able to breathe properly.
All these changes are difficult to diagnose and despite extensive diagnostics, the correct cause is often not found.
WHAT SURGERY PROCEDURES ARE THERE?
Fundoplication
The creation of a fundoplication is the oldest and most widely performed surgery. It was developed in the last century and is based on the concept that if the lower oesophageal sphincter is weak, it must be tightened.
To achieve this, the upper part of the stomach, known as the "fundus", is detached from its natural attachments to the spleen and diaphragm, folded in (fold = "plica" in Latin), and then wrapped around the oesophagus. This creates the "fundoplication", the most well-known "anti-reflux operation", literally a "folding of the fundus".
There are now numerous variations of this fundoplication. To narrow the oesophagus, most surgeons pass the detached fundus behind the oesophagus, known as a "posterior fundoplication", and then wrap it either completely (360° according to Nissen) or almost completely (270° according to Toupet) around the oesophagus, forming a gastric wrap. Finally, the wrap is stitched to the diaphragm and oesophagus. Some surgeons still pull the stomach over the front of the oesophagus, known as "anterior fundoplication". The outcomes are considerably poorer, but the operation is technically simpler and quicker.
All these operations are generally named after the type of wrapping or stitching technique used, due to the wide range of variations: procedures named after Nissen, Rosetti, Toupet, Hill, Thal, Belsey, Dor, Bicorn, and many others.
Important: One of the main issues with any wrapping surgery is that belching becomes very difficult. Patients suffer from trapped air in the stomach, which cannot escape, leading to bloating. Vomiting also becomes difficult or even impossible in most cases. For affected patients, this can be one of the most distressing experiences. Unfortunately, long-term results show that many patients eventually need to resume taking PPIs (proton pump inhibitors).
These are the main reasons why many treating physicians, despite the significant distress caused by the condition, strictly advise against such surgeries and instead recommend continued medical treatment.
l.oe.h.d.e.procedure
This modern therapeutic approach was actually developed by me over 15 years ago. In medical terminology, it is called "laparoscopic oesophago-hiatal deltamesh enhancement", which is a laparoscopic reinforcement of the oesophago-hiatal unit using the specially designed DeltaMesh. Interestingly, the abbreviation is the l.oe.h.d.e.-procedure. Knowledge of this procedure is available exclusively at our centre worldwide. But how did this method come to be?
This is quite a fascinating story, one I would be happy to tell you in more detail at another time. To summarise briefly: our scientific research has shown that there is actually no weakened lower oesophageal sphincter, but rather a fascinating, three-dimensional interlocking mechanism of organs that protects us from reflux. This system is held together by the diaphragm. When the diaphragm fails, the system breaks down, along with its function.
This means that the oesophagus itself is not the issue, but rather the broken diaphragm. So the question arose for us: is it truly sensible to surgically detach parts of the healthy stomach and wrap them around the healthy oesophagus just because the diaphragm has failed?
We believe the answer is no! Nature had wrapping in mind.
For this reason, our motto is: reconstruction, not strangulation! First, the exact natural functional alignment of the oesophagus and stomach in three-dimensional space is restored. Second, the broken diaphragm is rebuilt precisely so that it can once again ensure the smooth interaction of all the organs.
To ensure the long-term stability of the diaphragm, we developed a specially patented mesh structure designed specifically for the hiatus. This differs fundamentally from all other mesh implants used: the spatial architecture of the diaphragm, the specific tissue properties of the hiatal muscles, and the principle of neutralising pressure and tensile forces were all taken into account during its design. The delicate muscle fibres in the diaphragm quickly bond with the often only a few centimetres wide implant, forming a highly stable, three-layered muscle complex that can withstand all stresses of daily life, high-performance sports, and even pregnancy.
Since 2005, every patient has been treated exclusively using the "l.oe.h.d.e. method". With over 2000 operations performed now, we can confidently say that this is the right path forward.
WHAT OTHER TREATMENTS ARE THERE?
Stretta® and Enteryx® procedures
These procedures also aim to narrow the esophagus, only this time from the inside. During a gastroscopy, the wall of the lower esophagus is damaged by hot radio frequency waves (Stretta®) or plastic polymers, previously also radioactive substances, are injected directly into the muscles (Enteryx®).
This results in severe inflammation, scarring and shrinkage, which can lead to a narrowing of the esophagus. On the other hand, the sensitive nerve endings in the esophagus are destroyed. The acid rising is no longer felt.
TIF® (Transoral incisionless fundoplication)
A fundoplication is attempted here, but only endoscopically. In this case, complex and technically very special instruments are inserted through the mouth under general anesthesia and the stomach wall is pierced and knotted from the inside in order to create some kind of constricting folds of tissue. Important structures, the vagus nerve, blood vessels, etc. cannot be seen in this way.
EndoStim®
Wires are surgically attached to the esophagus in order to stimulate the muscles of the so-called "esophageal sphincter" with small electric shocks. The stimulation device itself is implanted in the abdominal wall. According to the manufacturer, batteries must be replaced after 7-10 years.
Angelchik prosthesis
In order to avoid the complex surgical exposure of the upper stomach during fundoplication, the esophagus is wrapped and constricted with an air-filled silicone ring.
Linx®
In this procedure, a chain of magnets is placed around the esophagus instead of a silicone ring. The magnets attract each other and close the esophagus. One thing to note is that MRI diagnostics are limited due to the magnets implanted in the body.
WHAT DOES BARRETT'S ESOPHAGUS MEAN?
The formation of Barrett cells in the esophagus is occasionally described in patients with reflux disease. This has the following background:
If the many substances from the stomach such as enzymes, acids, bacteria, food residues, etc. keep flowing back into the esophagus, the delicate cells of the esophagus will eventually no longer be able to bear this strain.
Now they try to transform themselves into stomach cells, because stomach cells are naturally much better able to withstand such stress. But such a transformation cannot really succeed, of course, because an esophageal cell always remains an esophageal cell. Nevertheless, cells that have changed appearance and have characteristics of stomach cells suddenly appear in the esophagus: the so-called Barrett cells
(see blog in the menu. Barrett-information will be there).
In the early stages, these Barrett cells are not dangerous and carry only a very small risk of degeneration. Nevertheless, the progression should be monitored endoscopically every 2-3 years. If the changes become more severe, it is strongly recommended that these cell areas be removed and destroyed endoscopically.
Important: It is currently assumed that Barrett's cells do not heal. The saying goes: once Barrett's, always Barrett's. Even high doses of PPI cannot change this. A fundoplication even has a negative effect because the Barrett's cells are covered by the folding of the stomach during this operation and can no longer be checked endoscopically.
A fascinating glimmer of hope for these patients is shown by the studies after the operation using the “l.oe.h.d.e."- procedure:
On the one hand, the area with the Barrett cells can always(!) be completely viewed endoscopically. On the other hand, we surprisingly find that many patients can actually heal completely after the operation and Barrett cells can no longer be detected in repeated tissue samples!
WHAT DOES THE "ANGLE OF HIS" HAVE TO DO WITH REFLUX?
Wilhelm His, a highly respected professor of anatomy and physiology at the time, also gave his newly born son the name "Wilhelm" in 1863. Nomen est omen (in English: "the name says it all") and he too became a famous doctor and made important discoveries, particularly about the cardiac conduction system.
Wilhelm His also noticed that the esophagus does not actually open into the top of the stomach, but rather a little lower on the right side of the stomach. This inevitably creates a small angle between the esophagus and the stomach wall: the famous Angle of His.
Since in a diaphragmatic hernia the stomach slides up along with the esophagus that joins it, this Angle of His at the junction also changes, of course. Back in the 19th century it was postulated that this angle was crucial for reflux control, since it was always altered in these patients.
But further research, including that of Allison and his colleagues, soon showed what we know today: the diaphragm is the decisive factor! Everything else, including the angle, is a consequence and not a cause. This is why the guidelines for reflux surgery consider the artificial creation of a new Angle of His to be "not sensible". By the way: When the normal anatomy is restored, the Angle of His automatically returns to what it was before.