Dr. Glenn Ihde, MD, is with Matagorda Medical Group in Texas. Dr. Ihde has the distinction of having performed the most TIF procedures ever, 640 and counting! These are a combination of both straight transoral incisionless fundoplication (TIF) procedures, concomitant hiatal hernia repairs, and he’s revised a fair number of laparoscopic Nissens that have failed in the past. In this webinar, broken down into short highlighted segments below, Dr. Ihde discusses the relationship between hiatal hernias and reflux, zeroing in the importance of accurately measuring the hiatal hernia for physicians to make a more informed decision regarding a hiatal hernia repair. He also explains why he embraced the TIF procedure, over the older Nissen fundoplication: reducing many of the serious side-effects for his patients.
Webinar Highlights
Webinar Series: Relationship of hiatal hernia to reflux. Glenn Ihde, MD, Houston, TX
Dr. Glenn Ihde, MD, recaps how throughout the history of surgery, going back to the mid-twentieth century, a hole in the diaphragm was repaired and then it was noted that there was a relationship between hiatal hernia and reflux. However, after repairing the hole, nearly 50 percent of patients still experienced reflux, so this wasn’t the entire answer. Although Dr. Nissen is certainly famous for his work, it was Dr. Ron Belsey who showed through his research that the other 50 percent of reflux had to do with fundoplication. Dr. Ihde explains that in the history of reflux surgery, hiatal hernia played a significant role in the failure of reflux surgery, having to do with displacement of the wrap and movement of wrap through a hiatal hernia, or just the hiatal hernia itself. Following a conference in 2010, Dr. Ihde started doing hiatal hernia repairs in patients where laxity could be demonstrated. In patients with a Hill 3 junction, he started doing a hiatal hernia repair laproscopically followed by a transoral incisionless fundoplication, or TIF, cocomitantly.
Webinar Series: Accurate measurement of hiatal hernia. Glenn Ihde, MD, Houston, TX
In this portion of the webinar, Dr. Ihde explains that the medical community started to change the way it viewed hiatal hernias. In other words, it would define a Hill grade 2 as a laxity because that was the nomenclature that was being used at the time. Then a Hill grade 3 required a hiatal hernia repair. There really wasn’t any other criteria, other than the three-centimeter greatest transverse diameter. They looked at how they measured this dimension with the aim of improving the accuracy of defining who needed a hiatal hernia repair and who didn’t. The whole lesson here was that the hiatal hernia, based on the largest or the greatest transverse diameter, mattered more than the axial displacement.
Webinar Series: Study on accuracy of hiatal hernia measurement. Glenn Ihde, MD, Houston, TX
Dr. Ihde elaborates on how he and a group of physicians were getting together to discuss the issue of how they were using the Hill grade and whether using an endoscope to measure was accurate. The group decided to investigate, using a video-taped procedure for about 50 patients and blinding the raters as to whether it was an IV sedation or general anesthesia. What they found was that 43 per cent of the time, the Hill grade assignment appeared larger when they did it under IV sedation. In other words, this seemed to more fully distend the stomach into the hiatal defects where it was measurable. Some of the time they did find that the cases were larger under general anesthesia than under IV sedation, but the more accurate number (43 percent of the cases) was the larger measurement taken under IV sedation.
They decided at that point that all their assessments would be done under IV sedation to provide a more accurate sense of the actual size of the hernia.
They then looked at whether everyone agreed on what was the appropriate Hill grade criteria. What they realized was that one person’s Hill criteria was, let’s say Hill 3, the next person might call that a Hill 2 or they might call it a Hill 4. There’s no rhyme nor reason as to which one they would pick. Furthermore, the hernia might be considered a Hill 2 when viewed endoscopically, whereas laparoscopically it might be a larger Hill 3. Dr. Ihde was considering the failure rate, around 20 per cent, and summed up the situation regarding the measurement of the hiatal hernia with the following closing remarks in this video segment: “Well, if half the time we’re making the wrong judgment on hiatal repair, then that would account for 50 per cent of our failures.”
Webinar Series: Best practices for accurate hiatal hernia measurement. Glenn Ihde, MD, Houston, TX
Reflecting on recent studies regarding the positive efficacy of both TIF and the Esophyx® device and his vast years of experience, having successfully completed 640 TIF procedure with no injuries, Dr. Ihde sums up his best practices for the crucial element of accurately measuring the hiatal hernia. He emphasizes that physicians should do their own endoscopy under IV sedation, taking time to fully insufflate the stomach. If the patient is venting insufflation spontaneously, a little cricoid pressure can be applied to fully inflate the stomach. If regurgitation is a symptom, the bias should be towards a hiatal hernia repair. If a retroflexed tip of the scope can enter the hiatus, and is assessed to 3cm GTD or greater, a hiatal hernia repair can be expected. The Hill grade should be assessed and compared with what is revealed in a transoral incisionless fundoplication or laparoscopic surgery, to get a better sense of its accuracy. The endoscopy, especially if there is regurgitation, should be biased toward a hiatal repair. If there is a recurrence, the bias should be placed toward the hiatal repair, rather than the fundoplication, as studies have shown. Finally, Dr. Ihde reflects on how almost every situation of recurrence is associated with a lifting event: “I think the lesson is that the abdominal cavity is a pressurized system when you’re lifting or pushing or pulling or straining, and it’s going to fail at its weak points. The weak point is the various strenuous spots, and certainly the hiatus is one of them.”
Webinar Series: Why I quit doing laparoscopic Nissens. Glenn Ihde, MD, Houston, TX
Dr. Ihde reflects on why he quit doing laparoscopic Nissens, even as a fully trained advanced laparoscopic surgeon coming out of residency in 1998, which was also “the year that Nissens took a nosedive.” Physicians stopped referring Nissens due to all the side effects, “such as the dysplasia, the gassiness, what we call the Nissen bloating syndrome,” remarks Dr. Ihde. He was attracted to TIF by an initial paper showing that none of this was happening with a transoral incisionless fundoplication; in fact, in the registry, there was a negative correlation with these symptoms using TIF. Around the same time, medicines came out that controlled the symptoms of reflux and TIF could be completed without the side effects of a Nissen. He concludes that although a Nissen is very effective, it has serious side-effects which are too much for the public to tolerate.
Dr. Glenn Idhe Webinar on Hiatal Hernia for GERD Treatment
View the full webinar below, to see each of the highlighted segments, in their context, from Dr. Glenn Ihde, MD, a leading authority on the transoral incisionless fundoplication procedure with over 2 decades’ experience doing hundreds TIF of procedures. Dr. Ihde also takes some very interesting and relevant questions from various general surgeons, gastroenterologists and other informed members in the webinar audience, ranging from his post-op routine, the importance of doing a manometry and why Dr. Ihde prefers to do his own endoscopy.
