Events

Louise

Good evening, everyone. Thank you for joining us. We'll just give it another moment or two to allow everyone to get settled.

Once again, good evening, and a very warm welcome to our webinar on heartburn and acid reflux testing and treatment. My name is Louise, and I'm hosting this session.

I'm delighted to be joined by our expert speaker, Mr Ahmed Hamouda, consultant upper GI surgeon.

Tonight's session will begin with a presentation from Mr Hamouda, followed by a live Q&A session.

If you have any questions, please feel free to submit them using the Q&A icon at the bottom of your screen.

You're welcome to ask anonymously or include your name.

Just a quick note that this session is being recorded, so any names shared may be visible in the recording.

To help us get through as many questions as possible, please do keep them brief.

If you're interested in booking a consultation, we'll share all the relevant contact details at the end of the session.

Now over to you, Mr Hamouda.

Mr Ahmed Hamouda

Thank you very much, Louise. Thank you to all those attending. Today, I'd like to talk to you about heartburn and, more specifically, about reflux testing and how we go on to treating this condition.

So a little bit about me. I graduated in 1992 from Cairo, and I completed my training here in London. I then did two fellowships, one to do with the bile ducts and gallstones.

and another to do with weight loss surgery. I hold a professorship of general surgery at the university.

So, we're going to try and cover as much as possible regarding heartburn and reflux, and these are the topics we're going to be talking about in succession. I'll try and be as brief as possible so that you get a chance at the end of it to ask as many questions as you can, and hopefully I'll be finishing in about 30 minutes.

So, a bit of history about reflux disease. The symptoms were first described back in 1925, when a link was made between heartburn symptoms and the relationship to hiatus hernias.

Which is a structural anatomical deficiency where the stomach is being pushed up above the diaphragm into the chest.

Further on, 1934, a gastroenterologist found that reflux was mostly attributed to the presence of acid in the stomach, and that was flushing up into the palate.

So, GORD, or GERD, depending on whether you start the oesophagus with an O or an E, is a chronic condition, and it's a condition where the acid that's normally in the stomach will find its way through the leaky valve at the lower end of the gullet.

And push up into the gullet, causing these symptoms of discomfort.

Now, it's really important to mention that the valve normally is present at the lower end of the gullet here, as a result of the folds of mucosa, the lining, and the thickness of the stomach here.

the acute angle, what we call the angle of hiss, and some of the ligaments that surround this area. That is what structurally gives the valve its strength.

So, it's a common condition, reflux, and heartburn. At least 10-20% of people have suffered with some type of reflux at some point in their life. Some of the symptoms can occur almost on a daily basis.

The two main symptoms that we talk about are this feeling of burning behind the chest plate, especially after a meal or after some food types that can give you this type of presentation.

And the other real important symptom is regurgitation, where there's a sensation that fluid is flushing up into the gullet and into the back of the mouth, sometimes when you're lying flat, and you get this sort of effect where you just feel that there's too much fluid coming up and it's called regurgitation.

We know that gastro-oesophageal reflux disease is linked to certain lifestyle patterns and habits, smoking being one of them, and stress, for example.

Being overweight certainly doesn't help, as it increases the abdominal pressure, therefore pushing stomach contents up into the gullet.

Pregnancy is a natural event, obviously, where people get reflux with it. Eating a large meal very late at night, where you just go and lie flat in bed, and therefore gravity will push everything back up into the palate again, or certain beverages, such as alcohol or coffee.

There are certain medications that can also cause it to worsen, and specifically, non-steroidal anti-inflammatory drugs, so things like aspirin, diclofenac, and ibuprofen – those drugs – can increase the stomach acid and cause problems.

So, the symptoms that are very typical are the two that we mentioned, heartburn and regurgitation. Less typically, you will have a feeling of food sticking behind the chest plate.

Chest pain, very similar to pain that people get with perhaps maybe, you know, a lung infection or if you've had, sort of, a minor heart attack. Water brash. 'Globus sensations' means that you feel that there's something at the very top of your throat which is stuck.

nausea, and interestingly enough, reflux and heartburn can cause erosion to the back of the teeth, so dental issues. And if the fluid spills over into the lung, then you get a lot of coughing, spluttering at nighttime, particularly with wheezing and hoarseness of voice.

Diagnosis is quite simple, because usually when you present with these symptoms in a clinic, it's quite obvious to the doctor, the specialist who's there, that you suffer with gastro-oesophageal reflux.

And the response to antacids, because you probably will have been given antacids by your doctor to treat these symptoms, so a response to proton pump inhibitors, such as omeprazole, lansoprazole, and esomeprazole, is really important because

If those medications aren't actually giving you a relief from your symptoms, then there might be other reasons why you're getting your symptoms, not necessarily reflux.

Further evaluation is required if there is alarm features or risk factors for Barrett's. Now, Barrett's is a condition where the lower end of the gullet, as a result of the acid that's coming up into it on a regular basis is protecting itself by adopting the lining of the stomach.

So the lining of the stomach creeps up onto the lower end of the gullet, and that is called Barrett's. Why is it important? Because in a very small percentage of people who have Barrett's, they can then go on to develop something a bit more serious.

So, if you've been diagnosed with Barrett's, you probably will be on something called a surveillance programme.

Where you've been asked to come into the hospital every two to three years to have a check endoscopy and some biopsies and check to make sure that those Barrett cells are not changing into something a bit more serious.

And of course, these are the alarm features for diseases that are a bit more sinister. So on your left-hand side, gastrectomy malignancy, if you have new onset of indigestion after 60 years, or there's evidence that there's been bleeding, leading to anaemia.

Unexplained weight loss or tightness just behind the chest plate where food is sticking on a regular basis.

Or if it's painful to swallow with persistent vomiting. And of course, if there's a family history of similar sort of issues, then those alarm features, alarm symptoms that we look at to investigate a bit further.

On the right-hand side, you've got the alarm features of Barrett's, which I just described earlier, and that's the duration of reflux from 5 to 10 years, age 50 or older and male with, hiatus hernias, obesity or, smoking, and, if the reflux is happening at nighttime.

So how do we evaluate? Well, if you have reflux and you've been on medication for a few years, but you're finding that your reflux is still

quite significant, and you need increasing doses of medication, or in addition to your tablets, you need to take some Gaviscon and Renny on a regular basis, or you're worried about the side effects, then you should really come and see a specialist like myself, where I do a series of tests. The most important is an upper GI endoscopy or a camera test.

And basically, this will show whether you have a hiatus hernia.

Whether there is oesophagitis, which is inflammation of the lower end of the gullet.

And whether that's led to erosions or an ulcer. And of course, if there's Barrett's in addition, then biopsies from Barrett's are really important. As I mentioned earlier, if you've been diagnosed with Barrett's, you probably need to have a surveillance endoscopy every two to three years with further biopsies.

So, if that's the case, then endoscopy is the first line of investigation.

The second line of investigation that I think is really important, because a lot of people who come and see me in clinic, they say, 'Well, we've got these symptoms,' and the symptoms are very suggestive, or they could be atypical symptoms that I've mentioned in my previous slide.

And the only way, really, to clinch the diagnosis, apart from doing endoscopy, is to do something called a pH test an ambulatory pH monitoring.

And that is done with a Bravo capsule. And basically, what it is it's a little probe that sits in the gullet 2 inches above where the stomach is, and it measures how much acid comes up into the gullet over a period of time.

This can be combined with something called an oesophageal manometry, which basically measures the pressure exerted by the gullet as it squeezes food down into the stomach.

And it's a technical procedure which gives us a bit more information.

Additionally barium and CT. Barium is where you are asked to drink some dye down, and an x-ray is done to look at the shape of the lower end of the gullet and perhaps tip your head down with the barium and see if it refluxes back up into the gullet.

And a CT scan gives us a lot of information about all the structures surrounding the gut and the stomach, which is really important, because if you're planning an operation, if you're planning an intervention, you want to know if there's anything around it which is causing

More of a problem, or contributing to it, or could perhaps stop you from doing the operation.

So, a bit more to, you know, we want to talk a bit more about the Bravo reflux testing system, which is something that we've introduced here at Benenden for the last two years, and it's a really innovative technique, which is essential for people.

Who are suffering with reflux but also want to have management in the form of an intervention, an operational procedure.

It's a quick procedure. It's done, the same, very same as a camera. So, initially, I give you sedation and throat spray, pop down with the camera, check everything's fine, and then do some measurements, and pop down with the probe, which you can see here, that little piece of plastic and metal.

And then attach it to the side wall of the gullet 2 inches above the junction with the stomach.

It's then released; this whole mechanism is released, and the probe is left in place for up to 4 days.

Over that period of time, you have a recorder, which is worn on the waist or the chest, and the probe will send wireless signals to the recorder

regarding how much acid is coming up and what times during the day it is doing so. So this is just a diagrammatic representation of the system. This is the probe being inserted into the gullet.

It's suctioned onto the lining of the gullet, and a pin goes through the lining of the gullet to hold it in place. It's transmitting wireless signals here, and after approximately 4 days, the pin and the bit of lining will then slough off and fall away, and it then goes through the back passage. You don't need to have it removed.

Essentially, what then happens is the recorder gets sent back to us again in the hospital, and we I get this trace, which you can see in front of you here.

And this line here is the line where the acid in the gullet, if it drops below that line, there's too much acid in the gullet. So essentially, everything above the line, all these traces above the line, are more or less in keeping with normal.

When it drops down to below the line and sustains it, and this is a four-day recording, by the way, so you will find that there are significant episodes of reflux here.

During the four days. Quite significant episodes of reflux lasting for a period of time. We use very specific software to analyse all this, and it gives us a score; it gives me a score. I can then sit down in clinic with you, go through the test, and say, Well, actually, you have a problem.

And this problem can only be resolved by doing one of two things.

And I'll obviously come to that in a second.

This is just the endoscope, showing you a picture of a hernia in the hiatus internally. So, this is the scope passing through the lower end of the gullet here and into the stomach. It's then, if you imagine it, continuing up here and just popping back and looking onto itself.

It's looking at this pit, and this pit is where the stomach has been pushed up.

above the diaphragm. So this is the size of the head frame. You can see another one here, which is slightly larger, and that's the size of the frame. Normally, you would not see this pit. You would just see the stomach lining coming up to the scope here, and there wouldn't be a pit surrounding the scope.

Now, this is a bit technical, but we separate hiatus hernias into types.

If you think, if you look at this white, marker here, this is where the junction is between the stomach and the gullet.

If the white marker is pushed up above the diaphragm, we call it a sliding hiatus failure.

If the white marker stays where it's supposed to be, but a bit of stomach pushes up next to it, it's called a rolling heart swing.

And if both things happen, where the white marker is pushed up, but also you get a patch of stomach above the diaphragm, it's a mixed heist.

The only reason I discussed this with you is because if you have a rolling hiatus hernia, which is very rare, the most common hiatus hernia is sliding, but if you do have a rolling hiatus hernia, it's an indication to have surgery straight away, because unfortunately, this patch of stomach it's known to cause problems such as a twist or obstruction, or possibly even strangulation, where the blood supply is cut off to that bit of stomach.

So, gourd, reflux, acid coming up into the gullet. Can this cause problems? Yes, it can. The first issue I alluded to previously was oesophagitis, which is inflammation.

It can cause inflammation of the lower end of the collet and the lining.

As a result of too much inflammation, you can get a persistent narrowing, and that's called a stricture.

As a result of the inflammation being there for many, many years.

We can get Barrett's, which I described previously. It's creeping up of the stomach lining onto the lower end of the palate.

In a very small percentage of people who have Barrett's, it can go on to A form of cancer.

And of course, it can cause, if the acid is coming up into the back end of the gullet and spilling over into the lungs or the larynx, it can cause injury to the larynx or a pneumonia infection of the chest as a result of aspiration.

The four grades of oesophagitis, inflammation, grades A to D. The first grade you can see here, there are one or two streaks that are quite

shallow in length. And then grade B is when you get 3 or more streaks, and they're increasing in length.

With Grade C, you get an area circumference, so a quarter of the circumference is now inflamed. It's not just a single streak.

And in grade D, the whole of the circumference has become inflamed, and it's moving on to become a stricture.

These are the three complications of, reflux, and this is what we see when we go in with a camera.

So, I go in with a camera, and I can see this sort of, what I would call a slightly reddish appearance of the normal lining of the gullet. And here, I can see that there's a different colour. We use narrowband.

light to look at this in greater detail, but this segment is Barrett's, and what's happened is the lining of the stomach lower down here has started creeping up onto the gullet to protect it.

This is a growth, and this is when it has created a cancer.

This here is a stricture, so it's benign, but what's happened is, as a result of the inflammation, you may remember.

On the last slide, where we had grade D oesophagitis, it was all very inflamed, and if the whole circumference is involved, then it leads to a stricture.

What can we do with reflux? How can we treat? Well, the first thing that everybody will speak to you about when you have reflux is lifestyle and dietary change.

You need to identify the foodstuffs and the drinks that cause you reflux and stop using them. Stop taking them; stop eating them if you can.

Sometimes very difficult to do, because there'll be people who have reflux with almost anything that they eat.

The second thing is lifestyle measures. So, you've got to stop smoking; you've got to lose weight.

If you're sleeping at night, you should really raise the pillow and definitely have dinner very early in the evening. So, have your dinners at 5 and go to bed at maybe 9 or 10 to try and prevent or try and get all the food that's in your stomach to have moved on into the bowel so that it doesn't cause much of a problem anymore.

And then the next stage is, once you've tried the lifestyle and diet changes, and they haven't really worked, you will go on to medication.

And, of course, the medication that's very common is coating medication, so things that you take to line the side walls of the gullet, things like Gaviscon and Reni. But if that doesn't work, then you go on to a group of medicines called antacids.

And those are H2 receptor blockers, or proton pump inhibitors. H2 receptor blockers are an older

category of medication, which we used to use prior to the proton pump inhibitors. An example is famotidine, for example.

The proton pump inhibitors are the gold standard. You'll get things like omeprazole, lansoprazole, esomeprazole, and pantoprazole; those are the ones where, basically, essentially, they control the acid in the stomach and decrease the amount of acid production by up to 95%. It's called acid suppression.

Now, acid suppression is great, and it's been in use for years; we've used the medication for years. More recently now, we're becoming aware of the side effects of acid suppression.

And you may have heard in the news, or you may have read the articles, where the use of PPIs has been linked to dementia, for example. It was in the news about a week ago, and the research had suggested that there was almost a 30% chance of developing

You know, some form of dementia this is all caused by the fact that acid in the stomach is essential.

It is really quite useful for two things. It breaks down food substances that we are required to absorb and use in our body, and second, it protects against infections.

Especially infections of the gut. So, as a result of suppressing the acid in the stomach, you can get these infections in the gut.

And these deficiencies of essential nutrients that are required in the body because the acid isn't there to break them down anymore to allow the body to absorb them.

As a result of a deficiency of iron, magnesium, calcium, and B12, you then get the side effects that are, for example a minor heart attack or a stroke.

things like dementia. We talk about chronic kidney disease, and people who have CKD should really not be on proton pump inhibitors. Osteoporosis. So, we now realise that proton pump inhibitors and antacids generally are not a good thing the long term.

And then, of course, you can try this, probably. It should have proceeded this slide; it should have come before the slide on the medication, but you need to try dietary changes. So, try and avoid things that are going to cause you to trigger your symptoms, like fried food, chilli powder, and pepper.

fatty meats, for example. And of course, citrus fruits. Some people react to chocolate, peppermint, and fizzy drink.

And whatever you react to, you should really keep a diary of and try and avoid in the future.

And then you've got the good foods, where people say to you, 'Well, actually, you know, have a banana if you've got some reflux,' or 'Try oatmeal, brown rice, or carrots,' for example or watermelon, lettuce. And then milk has been known to try and, again, decrease the amount of reflux and coat the lower end of the gullet. So, all these things are lifestyle changes and dietary changes that you can try before you have the medication.

And then we move on. So we've had three things now, three categories, which are one, lifestyle and dietary change; two, medication to treat your reflux; and we talked about side effects, obviously.

Now, if you are, refractory, so in other words, your symptoms are not being treated by the medication. If you need increasing doses of the medication, if it's difficult for you to take the medication because you forget, for example, or if you've decided that the medication is not a good thing for you because you're worried about the side effects, then your third option

Is considering surgery and surgery to treat this condition was described very early on when it was first performed in 1955 by Rudolf Nissen.

Essentially, he theorised that if the stomach were to be wrapped around the lower end of the gullet, it would recreate this valve mechanism that has been lost over the years, that I described to you earlier, and that was causing the reflux to occur.

So basically, he described this operation. Where?

With keyhole surgery, what we do now is I go in, and if there's a hernia, I free it up, I dissect it, make sure that it's free from all the attachments, and then bring it back down into the abdominal cavity, where it belongs.

I then put stitches into the diaphragm to make it snug around the gullet, and the last bit here would be to take the floppy bit of the stomach, go behind the gullet, and then back onto itself and stitch it with non-absorbable sutures, which do not dissolve. So sutures that stay there for life.

The whole purpose is to create this wrap around the lower end of the gullet.

So, as described, it's two parts. Well, actually, it's three parts, because we've done the hiatus hernia, so we've brought that down. The second part is to put sutures into the oesophageal hiatus in the diaphragm to stitch it and make it snug around the gullet. And the third part is to take the floppy bit; we call it the gastric fundus.

Behind the gullet, and wrap it back onto itself, put stitches in that do not absorb.

So what does this actually do?

Well, if you look at the x-ray here, and if you look at a diagram that has been superimposed on the x-ray, where the wrap is, every time you have something to eat, for example, your stomach contracts because it's trying to push food down.

What it does is also wrap contracts around the lower end of the gullet because the whole of the stomach is trying to squeeze. So that bit that we use to do a wrap is also squeezing the lower end of the gullet, therefore increasing the pressure in that area.

And therefore, preventing the acid that sits below the wrap from going up into the collet above the wrap.

It is quite an effective procedure, and we know that at 10 years, almost 90% of patients who have had a wrap still free of significant reflux. Now, if you've had this operation and you get some mild reflux symptoms.

Then that is a much better option than having the reflux for such a long period of time.

Which will cause damage to the end of your palate. So if you've had this operation 2 or 3 years down the line, if you get an episode of reflux once a month, and you treat that with Gaviscon, then that in itself is a marked improvement.

So even though, you know, it isn't 100%, even if it's a very mild reflux that you get on occasion, then that's a better option than having the significant amount of reflux from before.

Every operation has its risks.

So, if you are actually creating a high-pressure zone at the lower end of the gullet.

You're preventing the asset from going up, but at the same time.

You are probably going to make it difficult, more difficult for chunks of food to go down through it.

So this word, dysphagia, means food sticking above the wrap.

And what's normal after this operation is that you would have one week of liquids, followed by one week of soft, sloppy food, and then you go on to solids, but you eat little enough of them, and you chew your food very well.

And this effect you need to get used to, so that in 3 or 6 months, you are now, you know, used to that wrap; you're eating a little wrap, and often you tune your food well, and you don't get any stuck episodes.

It also means that you burp less.

It's more windy down the bottom end, and you're a bit more bloated in the stomach area.

In the long term, the wrap can move back up into the chest again, especially if you're heavy lifting, going to a gym, doing squats with weights, or lifting heavy slabs or pieces of furniture. You might end up with a wrap migration, but

So please be careful, which can lead to a recurrence of these symptoms. And if the vagus nerve, which sits very close to where the gullet is, is bruised, then you can have altered bowel habits, mostly in the form of loose stones.

There are other treatments, apart from the fund duplication that I described.

But they are treatments that still need quite a bit of research involved. They need to have long-term results so that people can look at them and then compare them to the quantification. And one of them

is a mechanism where radiofrequency is used to thicken the lower end of the oesophageal muscle. The other is a mechanism, a device like this one, which is used to stitch

the side wall of the stomach onto the gullet and therefore recreate what we call the angle of hiss, you may recall from earlier in the presentation. So create a bit of an angle there that can almost act like a valve.

So, in summary, GORD, GERD, and reflux are common GI complaints. It can lead to long-standing issues, such as inflammation and strictures.

or parrot's oesophagus, which in a very small percentage can change something else.

Essentially, if you have this condition.

You can treat it with lifestyle and dietary modification, or you can go on to medications, but please be careful, because there is a cost to the medication. There's also, more importantly, side effects for the long-term use of medication, which we discussed.

And you may not be compliant; you may not want to take a tablet every single day of your life, maybe once or twice a day.

Surgery, at the end of the day, can be effective for controlling the symptoms.

In 90% of the cases, it lasts for a very long period of time, more than 10 years.

And it can improve your quality of life. Once you've had the surgery, you stop taking the tablets the day after your surgery.

Thank you very much for listening to my presentation, and I'm going to go back to Louise.

Louise

Thank you.

Let's move on to our Q&A session now. We're really pleased to have so many of you with us today, and whilst we might not be able to get through every question, we'll do our best as we can.

On this slide, you can find information on arranging treatment.

First question: Is there any proven connection between acid reflux and heart conditions, such as gastrocardiac syndrome?

Mr Ahmed Hamouda

Well, if you go back to the slides that I was talking about earlier.

The symptoms are very similar.

So, chest pain.

And that's why you need to differentiate between chest pain caused by reflux or chest pain caused by cardiac issues.

And normally that's something that your GP, or if you go into hospital, they will be very good with, because they'll run some cardiac tests, they'll check the heart and make sure that everything's alright, and then it will be more or less likely that it's reflux, in which case you'd be sent to someone like myself, where I do an endoscopy and confirm the diagnosis.

Also, in terms of the side effects of the medications, you may recall on that slide, I said that there was a chance of an increased risk of heart conditions or myocardial infarction as a result of long-term use of medications.

Louise

Thank you.

What options and tests are available for the use of lansoprazole for 3 months that allow, sorry, for 3 months that allows the diarrhoea to develop?

How do you test?

Mr Ahmed Hamouda

So, so, so my understanding is that somebody's been using lansoprazole, and they've developed diarrhoea.

And they want to know what tests are available.

Mr Ahmed Hamouda

Well, the first thing would be, first of all, to go back to your GP and to come off the Lansoprazole and see if that actually helps, because if it's the Lansoprazole, as soon as you stop it, then we will know that it's not; you know, your symptoms will improve, and you no longer

If you've stopped the lansoprazole and you still have symptoms, then your GP will most likely refer you for a colonoscopy and some tests on your bowel to check and take some biopsies.

But that's what it would be.

Need some investigation use.

Louise

Samuel says they've had a sliding hiatus hernia, for which they've been taking pantoprazole. They've been taking this for about 4 months. When they're lying in bed, they still get a reflux, and they're continuously clearing their throat.

They've had an endoscopy and a barium swallow. What does the best option proceed to manage this?

Mr Ahmed Hamouda

Well, we'd need to know what the endoscopy and the barium solo have shown, so I'm hopeful that we've got some information from it.

Remember I said about the endoscopy, we need to know if you've got oesophagitis, an ulcer, or a hiatus hernia. If that's the case, then please come and see someone like me to chat about options. It is likely that surgery might be on the cards for you.

Where you can have an operation to fix this and come off your medication.

Louise

Thank you.

Are there any non-surgical interventions, such as exercises, that have been proven to work in improving the LES?

Mr Ahmed Hamouda

I'm aware of people who've used certain

What you call 'gadgets' to strengthen the lower end of the oesophagus. Things that you put in your mouth create a vacuum, for example. I'm aware of them, but I don't know that they have any long-term effects.

That are sustainable.

So, apart from what I've mentioned today, which is lifestyle, dietary modification, medications, and surgery.

I don't know that anything else works as well.

Louise

Can breathlessness be a symptom of GORD on its own, or would you need to see other symptoms as well?

Mr Ahmed Hamouda

So, breathlessness can be a symptom of a large hiatus hernia.

If you've got a large hiatus hernia, and remember I said something about hiatus hernias, but I didn't actually explain that some of the hiatus hernias can be quite large, where a large portion of the stomach is up in the chest, compressing the lung.

And you can have almost half to three-quarters of the stomach up in the chest.

If you've got a really massive eye surgery. So that in itself can be a cause for breathlessness.

The other cause for breathlessness that I can think about is that if your reflux is causing aspiration, where it's spilling over into the lung, it's silent, so in other words, you don't get the chest pain with it, but you cough and splutter at night, and you develop aspiration pneumonia, you can be breathless as a result of that, obviously, as well.

Louise

Thank you.

Tony's asking, will a Grade A hiatus hernia repair itself with a change of lifestyle, such as anti-reflux modifications?

Mr Ahmed Hamouda

Very good question. Hernias do not repair themselves. So, very much like a hernia anywhere else in the body, it's a tear. Once you've got the tear, it's not going to fix and heal on its own, unfortunately.

So, it can remain stable, the same size, for a long period of time, or it can increase in size over a period of time, in which case it will become bigger.

But there is no incidence where hiatus hernia has repaired itself.

Louise

Thank you. Do you use the reflux stop operation?

This person understands, and it's a silicone device implanted near the stomach wall.

Mr Ahmed Hamouda

Yes, so a reflux stop is an operation that's, again.

new to the market, and I try to allude to this in my presentation.

You're comparing everything against the fundoplication, which is the gold standard. You've got a Lynx procedure, which is the magnetic ring around the low end of the gullet. You've got the strata.

Which I said was the radiofrequency ablation. And then you've got the transoral incisionless fund duplication. More recently, the reflux stop, which is basically a silicon bulb.

That's inserted under keyhole surgery into the lower end of,

not into, but just across the lower end of the gullet, with a bit of the stomach stitched on top of it to create this angle of hiss to give you an angle at the lower end of the gullet. So, again, very similar to the transoral incisionless fundoplication.

We don't do it at the Benenden, and it is still one of those things that needs at least 10 years of results for us to be able to recommend it on a regular basis.

Louise

Thank you.

When Paul moves his upper body, his chest has a muscular ache, which he assumes is the inflamed oesophagus. Is that normal?

Mr Ahmed Hamouda

Again, very difficult to tell without doing some tests and investigations, so you probably need to come in and have an endoscopy to check.

If your gullet is absolutely fine on the endoscopy and there's no evidence of oesophagitis, then it probably isn't.

Anything to do with reflux, and it could be something else.

Louise

How long is it considered to be acceptable and safe to take omeprazole?

Mr Ahmed Hamouda

Very good question. Again, we don't know. We know that long-term use, and again, it's a very vague term. When I say long-term, is it 2 years, 5 or 10?

I don't know, to be honest with you. People who have any of the conditions I described in my previous slide with the side effects should probably stay clear of it, if possible.

And if you have taken it for a long period of time and there's been no issue with it, then perhaps maybe continue.

I would have a chat with your GP.

Louise

This person has Barrett's, and they take a PPI, which doesn't seem to be working. What should they do?

Mr Ahmed Hamouda

Well, you've got Barrett's. How do you know that the PPI is not working? The only way to tell would be another repeat endoscopy, where the length of the Barrett segment is increasing, or biopsies reveal that there's been some change in the Barrett segment. Essentially, you're doing the right thing, because

With Barrett's, you want to prevent any more acid from causing an increase in your Barrett's segment or severity. So, you either need to continue taking the medication or consider an intervention, such as an operation.

Louise

This lady was born, bringing up her mother's milk. By the age of 13, after endoscopies, it was put down as a sliding hiatus hernia. They still do bring up food but cope with it. Can they tick over like this?

Mr Ahmed Hamouda

Well, you mentioned that you were diagnosed with a sliding hiatal hernia. Do we know what was done with it? Has it just been left? And of course if it has been left

We need to know what's happened to it. Is it increased in size? And if it has, then perhaps maybe it would be a good idea to have a conversation about how to treat it.

If it has been dealt with, then it seems to be that you should now be bettering yourself, but if you aren't, then again, you might just need some investigations and tests to figure out what's going on.

Louise

Would weight loss medication, i.e., injections, be advisable when suffering with GERD?

Mr Ahmed Hamouda

Good question. Weight loss injections are very common and very popular these days, and what they do is two things. They decrease the craving appetite by working on the satiety centre in the brain. They also delay gastric emptying.

So, they are actually keeping food in the stomach for longer than it needs to be. As a result, I have seen patients who have had and developed reflux symptoms with them.

And yes, I think it is possibly one of the side effects of having those medications. So you can either stop them which I don't think you want to.

But, if not, then perhaps, maybe come in and have some tests to try and figure out if there's anything else we can help.

Louise

Thank you.

I can actually answer the next question. This person has a significant hiatus hernia with one-third of their stomach in their chest. They were told that Benenden could not do the operation, as it's so significant, and they would need to go into ICU after the operation. And Benenden does not have that facility, is that true? And that is indeed true. We do not have that facility, do we?

Mr Ahmed Hamouda

We don't, unfortunately. So, Benenden, we've got no high dependency or intensive care unit.

And we are very happy to treat people, you know, on a day surgery or one-night stay basis, but when we think it's unsafe for us to do something and do an intervention, we always are very upfront and very honest about it.

Louise

Yeah, sorry about that. Are there specific exercises that can be undertaken to strengthen the stomach gullet muscles.

Mr Ahmed Hamouda

Exercise is generally a really very good thing, but when you've got a hiatus hernia, and when there's been an incidence where the stomach has been pushed up into the chest above the diaphragm, then please avoid any exercises that increase your abdominal pressure.

So, I would give you an example of maybe squatting with weights. That in itself can cause an exacerbation of the problem. But if you're doing general aerobic fitness exercises, you should be absolutely fine, and it's recommended.

Louise

Thank you.

This person's just written about their mum. She's 74, suffered for nearly 8 years, and had Gaviscon and omeprazole. She feels mucus draining from her head and is suffering so bad, up all night trying to eliminate it. Is she too old for the surgery, and what else can she try?

Mr Ahmed Hamouda

We are not ageist at all. We always look at people depending on their physical and physiological reserve.

So, you could have somebody who's 80 or 90 who's very fit and healthy, because they've looked after themselves really well, and you could have somebody who's 40 who's suffering with quite a lot of medical problems, where we wouldn't be able to do the surgery safely at Benenden.

So, you know, I would recommend that you come in and have a chat, and let's look at the whole situation.

Louise

Thank you.

Let's use one other acronym heavy. This person started on a PPI due to an SSRI.

They still use the SSRI but become so used to the PPI they can no longer go without the PPI. What protection can they use instead of PPI?

May need to explain that for everyone else.

Mr Ahmed Hamouda

Yeah, so they've been using a medication, which is an SSRI, and basically that is a medication that required the GP, obviously, to give them antacid medication to try and prevent any ulceration to the stomach, etc., or any side effects from the medication.

But as I understand it, they've now stopped the SSSRI, so there is no requirement for the PPI at all, and I wonder whether it would be a good idea to chat to your GP to wean you off the acid medication and see where you are. If there are no symptoms and you're weaning off gradually.

Then by all means, I think you should come off of it. I don't see any reason for you to continue to take it long-term.

If, however, you do develop symptoms, then you've always had reflux that was obviously masked by your PPI that you thought you were taking for something else. So, I would suggest seeing the GP and weaning off your PPI.

Louise

What is 2 cm hiatal hernia.

A sliding hiatus is not mentioned, they say.

Mr Ahmed Hamouda

Yes, so very common, 2 cm sliding hiatus hernias are very common. The vast majority of hiatal hernias are sliding anyway; we said that previously. I don't think it's a rolling. Basically, if you think back to my slide, there was a white dot where the junction between the stomach and the oesophagus was.

That white dot has been pushed above the diaphragm by 2 centimetres, and we measure the length on endoscopy.

So, in essence, what you've got now is 2cm of stomach above the diaphragm, and that's the length of the segment of the stomach.

Louise

Is a chronic mucus cough in the daytime, which they've had for 6 years, likely to be caused by reflux? This person's 60; they've had reflux since the age of 7. They've had tests, pH tests, etc., all normal, but the cough cannot be controlled without a steroid inhaler.

Reflux improved after diet change, but constant cough is concerning. Respiratory specialists think it's about an overproduction of mucus, but tablets for this are not working.

Mr Ahmed Hamouda

Yes, I mean, you've covered it quite well, in that you've actually said that you had the pH test which didn't show any reflux. And you may recall from my presentation, I said that that was the gold standard. If the pH test shows that there's no acid coming up into your gut, then this isn't a reflux issue as such.

Your respiratory physician has obviously looked at things and thought that the overproduction of mucus was the reason why you were getting the front cough.

I would suggest that this sounds more respiratory than it does reflux.

Louise

Thank you.

This person has been taking omeprazole for a year now for gastritis that was diagnosed via a gastroscopy, which they had because of a non-specific anaemia. They like to come off the PPI because of their history of anaemia.

And so how can they reduce the daily dose of 20 milligrams to every other day and see if they can do that and see how they get on? So every other day, 20 milligrams.

Mr Ahmed Hamouda

Absolutely. So, I mentioned previously weaning off, and what you should do with PPIs is you should wean them off gradually. So, if you're on 40, you need to go to 20 for maybe 2 or 3 days before you start taking it on alternate days. So, do 20 alternate days for about maybe a week.

And then try once every 3 days for another week, and then twice a week before you

Take it off the week after. So, over a period of 4 weeks, you should wean off very gradually.

Louise

This person is on 2 lots of 20 per day, and they also have 2 lots of Famotidine

But they also have episodes of vomiting acid for days at a time.

Is this the best option to manage the vomiting, and could it be something else?

Mr Ahmed Hamouda

Yes, it could be something else. I think you are on quite excessive doses of acid medication, and I would really want you to have an endoscopy and perhaps some further tests to try and figure out what's going on.

Because either you're taking the medication that's not really helping in any way, in which case you shouldn't be taking such large doses, or there is such a big hysteria and a big acid problem that the medication isn't touching it, in which case, I think perhaps an operation would be required. So, yes, I think that this is an indication for further testing.

Louise

Yeah, they do have a hiatus hernia. I guess it's just, what size is it? Yeah, so I missed that part.

This person has had a GI endoscopy and a CT barium scan on the NHS, and no problems were found. They're taking

Pantoprazole, I think I've said that one, and the reflux seems to have settled, but now they're getting a feeling of something in their throat which is uncomfortable, which I think is a symptom you mentioned. Do you know why this is?

Mr Ahmed Hamouda

Globus symptoms, we talked about it as being one of the atypical symptoms of reflux, and you've done really well in that you've had two good tests, CT, and endoscopy.

But I think what's missing is the pH test, so you perhaps need

a Bravo pH test to figure out how much acid is coming up, and then we can be in a better situation

More informed to see whether anything else could help.

Whether it's an increase in medication or consideration for surgery, that could possibly be the way forward.

Louise

Joan suffers from reflux, and she takes lansoprazole.

She also takes Palindromic for osteoporosis and has been told she'll have to stay on this lansoprazole because of it. She's worried about the long-term effects that it will cause her.

Mr Ahmed Hamouda

We talked about the long-term effects, of course. Palindromic acid is one of those things that needs protection, needs stomach protection, so I think that's why she's on the PPI.

It's a different one. So,

it's a chat with the GP, really, to see whether

They think that the long-term side effects of PPIs are so great.

You need to come off it and then try something else or maybe try a different medication.

You know, apart from antidromic acid.

But there are no, you know, quick and easy answers for these situations sometimes, but

As long as you're armed with the information, you can make a risk-benefit decision on what you should do.

So, whether it's stopping one medication or the other, it's really about risks and benefits, and I think that discussion should be with the GP.

Louise

Thank you. Glenn asks if natural supplements, such as Focal Assist.

Even assist, sorry, focal assist or even cure GERD. It's claimed on lots of websites and social media sites, apparently.

Mr Ahmed Hamouda

Yes, as I said to you previously, there's a lot out there, and a lot of people have got these devices that they suggest are helpful. My experience has been that people use them for a period of time, but their symptoms persist.

Or they come back in 2 or 3 years' time, and, you know, they need to have one of the

the gold standards, gold standard treatments for this condition. So, by all means, if you feel something is helping you, then use it with lifestyle and diet medication. But don't persist. If after a year or two you still feel that there's an issue, then please come in and be tested and look at other options.

Louise

Lauren asks, what's the difference between your investigation to test pH and the NHS investigation option of having a monitor for 24 hours?

Mr Ahmed Hamouda

Yeah, so when you have it done on the NHS, they do something called a wired pH test, so basically they put the probe down, but it's not wireless. It's attached to a very fine wire that sticks out through the nose. It then gets railroaded behind the ear and attaches itself to the recorder.

They should still be able to test you for a period of anywhere between 3 and 4 days, rather than just 24 hours, because the longer the test, the more information it gives. So you'll just be carrying the recorder as well as this tube that runs out of your nose for a period of, you know, anywhere between 3 and 4 days.

The Bravo test is exactly the same, but it's wireless. So it sends wireless signals, and it doesn't need to be taken out at the end. It just drops out on an end.

Louise

Is excessive mucus a symptom of silent reflux, and what could be done when Gaviscon and antacids have not worked?

Mr Ahmed Hamouda

The first part of the question is a simple yes. The second part of the question is what I was alluding to before: come in and have tests.

If the tests reveal that you do have an acid reflux problem and if it's quite significant, we can chat about surgery.

Louise

Okay.

Would a raised electronic bed help stop reflux at night?

Mr Ahmed Hamouda

Very similar to using 2 or 3 pillows to prop up the back of the bed. If you've got an electronic bed, even better, that's absolutely fine.

The issue is trying to use gravity.

at night time to prevent the acid from flushing up into the collet. So, as long as your head is higher than your waist area, then you're achieving that result.

Louise

Someone's asking about famotidine?

Mr Ahmed Hamouda

Committed D, yes.

Louise

So, I don't think we've covered off this one yet. Can you take it? How long can you take it for, and when?

Mr Ahmed Hamouda

So, going back to my slide, talking about medication.

I mentioned antacids. I said that there were H2 receptor blockers and proton pump inhibitors. H2 receptor blockers are the original medication that was used many, many years ago to treat acid. Famotidine is one of those medications.

It tends to reduce acid production by a significant amount, but not as much as proton pump inhibitors. So, when proton pump inhibitors came onto the market, they were considered the gold standard.

Medical management of reflux disease.

And that's why the majority of people that I know, GPs, etc., prescribe PPIs. But certainly, if famotidine is working for you, and it's decreasing the acid in your stomach, it's giving you the

You know, the symptom control that you need.

Then by all means, carry on taking.

Louise

I'm just going to go. We have several more questions, but I'm afraid we haven't got time for them all. The last one is, could you email us a copy of the slides? I think this going through those slides again will help people. And yes, you will get a copy of the presentation.

So, if we haven't covered your question, you have provided your name, and we will follow up with an email.

If you could just go on to the final slide, please.

As a thank you for attending, we're pleased to offer 50% off the value of your consultation.

A call back from your dedicated former patient advisor.

An email with a recording of this session, treatment information, and royalty reward points, which will have the slides. Updates on future events and health news.

And we'd really appreciate it if you could take a moment to complete the short survey at the end of this session, as it helps us to improve and tailor future webinars to your needs.

If you'd like to speak to someone to book a consultation, our private patient team is available until 8.30 this evening.

And they're available 8am to 6pm, Monday to Friday.

You'll find the contact number on your screen.

We also have upcoming webinars on a range of topics, including hip and knee pain, tummy tuck surgery, diabetes, and neurology and many more. You can sign up to these on our website.

So finally, thank you from us all here at Benenden Hospital for joining us today, and we hope to hear from you soon. So take care, and goodbye.

Mr Ahmed Hamouda

Thank you.

Phil Orrell

Okay. Thank you for joining us this evening. A very warm welcome to our webinar from Benenden Hospital this evening. My name is Phil. I'll be your host for this session, and I’m joined by our expert speaker, Mr Simon Bailey, Consultant General Surgeon here at Benenden who will be discussing hernia repair treatment.

For those of you who haven't joined one of these webinars before the format is as follows.

Mr Bailey's presentation will last around 25 minutes, and this will be followed by a Q and A session, where there's an opportunity for you to submit your questions, and you can do so by clicking the Q and A icon at the bottom of your screen.

So you can submit your questions, either during the presentation or following the presentation, and you can give your name when you submit your question, or you can do so anonymously. But at this point we should let you know that if you do give your name, we are recording this session for archiving.

If you'd like to book. Following this, we'll provide you with contact details at the end of the session. So without further delay, I will hand over to our expert, Mr Simon Bailey.

Mr Simon Bailey

Thank you, Phil, very much indeed. And good evening, everyone. Thank you. Firstly to Phil and Oliver and the team at Benenden for organizing the technicalities of this evening, and for preparing all of the slides, and thank you to everybody who is joining us. I see at present there are 43 on what I hope for you is a beautiful sunny evening, so Phil says, I’ll talk for 25 minutes on hernias. I could talk all day, but I’ll try and keep it as short and pithy as possible for you.

And give you as much opportunity to ask whatever questions you may have. So Phil, could I have the next slide.

So I won't bore you with too much detail. Suffice it to say I’ve been a Consultant general, colorectal and keyhole laparoscopic Surgeon for the last 20 years in the South East of England, in Kent.

I practice at Benenden Hospital and should you require any more information about me. It's freely available on my website, so I won't bore you with the intricacies of that. I'll move along to the main meat of the evening. If I could have the next slide, please.

So essentially, hernias and hernia repair is a very common condition, and I’ll endeavor to give you an overview on what is quite a complex scenario and talk through the commoner types of hernias which most people will see at some point. Potentially.

We'll talk briefly about the causes, but most importantly, about the symptoms and the way in which it's diagnosed and then we'll talk about what is involved during the consultation period and potential assessment.

But most importantly, and I’m sure what everybody is waiting to talk about this evening is really, what are the options for treatment? What are the latest developments in the options for treatment and what are the outcomes and results?

And finally, Phil will show you a patient case study, and then we'll leave plenty of opportunity for you to ask any questions that you may have.

So, Phil, next slide if I may please.

Essentially, what is a hernia? And what types of hernia. Can there be? Well, essentially, a hernia is a defect in the muscle wall, usually of the abdominal wall, but can occur internally which allows the content of the abdomen, usually either a piece of fatty tissue called the omentum, or the bowel, to protrude through it, giving a lump

On the screen that you can see in front of you are the commonest types of hernias

Epigastric, which is usually just above the belly button just below the rib cage in the midline umbilical hernia, which is around the belly button itself and a femoral hernia which can occur in the groin, but deep in the groin.

What is indicated there the inguinal ligament. The commonest type of hernia, however, by far, is an inguinal hernia, and predominantly more men than women suffer from it, but it's becoming increasingly common in women.

So if you move on to the next slide, Phil. Why are hernias potential issue?

Well, to firstly and most importantly, reassure everybody? What you can see on the screen at the present moment, with regard to incarceration and or strangulation, is actually a very rare event and not something that we see terribly often, I’m delighted to say.

Incarceration occurs when a bit of the bowel protrudes through the hernia, as you can see on the left hand side of the screen and gets caught within the hernia.

These types of hernias make it difficult to push the content back in again, and can be quite tender, particularly after exercise.

On the right hand side you can see that the bowel has changed colour, and that's because this is a strangulated hernia where the blood supply to that affected piece of bowel is compromised, causing it initially to become devolved blood, and eventually, if left long enough to burst.

Now to reassure you. The risk of that happening is actually vanishingly small. If I fix 400 hernias a year, I fix two or three in anger, either on the left or the right hand side of the screen. But obviously prevention is by far better than cure. Hence the reason that we're keen to get at these things earlier rather than later.

Next slide, please, if I may.

So, as I said a moment ago, what is a hernia? Well, as you can see from the diagram. It is where a part of the intestine or fat the omentum pokes through a weakness the commonest weaknesses around the belly button, as I’ve said before or within the groin itself.

If that window where the muscle is weakened, suddenly contracts, then the bowel can get caught resulting in incarceration. But I hasten to add that scenario is very unlikely, and so, too, is compromise to the blood supply, which would cause strangulation.

As is quoted here about two to three in every 100 presentations of hernias strangulate in the first year. But if the hernia is there more chronically for many years, the risk of strangulation and incarceration gradually diminishes.

Thank you. Next slide, please.

So, what are the consequences of not treating a hernia well, essentially, initially, the main consequence is, the hernia may get larger and as they increase in size they may cause more and more discomfiture.

Reducing mobility and reducing the ability of someone to perform the tasks that they would want to do.

If left for longer, then gut symptoms can occur. For example, if the transit through the gut is slowed down, some patients present with constipation.

Groin hernias are particularly closely related to the bladder, and some patients find that they get symptoms of urgency and frequency to pass urine which can be quite debilitating, particularly at night.

Obviously, as I’ve already alluded to. If it becomes incarcerated or strangulated, then pain may pursue and in the worst case, scenario, abdominal distension, nausea, and vomiting. But this presentation is very rare.

Essentially the critical thing is that if a hernia is sore and it's reducing your ability to do the normal things that you would want to do.

That's the time to start considering having it corrected next one, please, sir.

So what are the commonest causes of hernia. Well, the vast majority are caused by sudden changes in the pressure of the abdominal cavity and sudden tension applied because of that on the anterior abdominal wall muscle.

We've seen an awful lot of hernias recently following the covid pandemic where patients are presented with very bad and chronic coughs, and that actually is generally the commonest cause.

It can be as innocuous an injury as stretching up for a high shelf to a sudden sneeze or cough.

But as we get older, so our gut gets slower, and constipation can certainly affect hernia formation. Long periods of sitting and straining, I’m afraid, are not good for us

At this time of year. People leaping out into the garden, having not done a great deal of exercise, or lifting, is also a common reason, and of course, people who go to the gym or perform exercises which they're not used to can promulgate a hernia formation.

It is common to find a family history of hernias, particularly on the male side of the of the of the family.

And with hernias, such as incisional hernias, where previous operations have occurred. Then it is possible for the repair, after the primary operation, to fail, and for hernias to occur.

We have here on the slide connective tissue disorders and other health conditions. These actually are generally very rare causes. The vast majority are created by sudden changes in abdominal pressure. As alluded to a moment ago.

Next slide, please. Thank you.

So what are the symptoms? Well, the first and primary symptom is that patients often just notice the bulge itself. They may be showering one day and actually see that one side looks slightly larger than the other.

Some patients find that they develop tenderness in and around the area as a first presenting symptom, and that can be associated with or without a lump. It doesn't necessarily mean that you'll be able to feel the lump yourself. It may be that pain and discomfiture, particularly in the groin, is the first symptom.

The bulge can often be increased in size by increasing abdominal pressure. For example, when coughing or lifting something heavy, but when you lie down flat and gently massage it, the bulge may go back in again.

If a little bit of small bowel is caught within that bulge, then it may be associated with a squelch, which is not an uncommon finding.

Some patients purely and simply get pain on exercise, and think that they've got a problem with their hip or their knee, or so forth, and often present to orthopaedic Surgeons, when, in fact, they have very small hernias that they can't feel the sensation of burning that's alluded to in the 3rd paragraph is uncommon.

Very occasionally there are some complex nerves that run particularly in the groin, and if they are pressed upon by a small lump, it can cause a sensation of warm water being poured over the inside of the groin or pain into the testicle or the vagina. But again, that's generally uncommon

Finally, swelling of the scrotum or sensation of heaviness in the scrotum is usually associated with a long standing and very large chronic hernia, and has usually been predated by the symptoms that I’ve discussed previously.

Next slide, please.

So I think that's a critical thing to say. Everybody who presents with a hernia does so in a different manner for the thousands of people I’ve seen with hernias. I've seen and heard thousands of different stories, so you might have the swelling. It might be a soft, squidgy lump in the groin that you can push back with that aforementioned squelch sign.

Sometimes the hernias appear, and you lie down or sit down and they've gone.

Pain is not always a symptom, and some people have completely asymptomatic. Large hernias and other people have very small, impalpable hernias, which cause a great deal of discomfiture.

And occasionally you might pop to see your GP. Or family doctor for some completely other reason, and they'll say, oh, have you noticed that you've got a hernia there.

Again, that's nothing to worry about, and it may be that you've actually had the hernia for some considerable period of time. But if there is a diagnostic concern, or there is an issue then, simply organizing a scan is very straightforward and very easy to do, and your GP. Would be able to do that for you.

Next slide, please, Phil.

So how is a hernia diagnosed? 90% of the diagnosis is made by simply listening to what the patient has to tell you.

You know, if there is a change in your body, and you know, if you've noticed something different when you come to the outpatient clinic, having taken a history, and listened to the story.

It's absolutely essential that the Surgeon you go to see physically examines the area properly.

This should be done in both the lying and standing position, and the examining Surgeon should make certain that they ask you to cough, sneeze, or move in the way that produces your symptom profile.

If there is a diagnostic issue with it, and it's not immediately obvious, clinically.

Number of ways in which we can investigate a hernia more accurately. This can either be done with a dynamic ultrasound scan. Again, in the lying and standing position, and again, by applying abdominal pressure which can allow us to actually visualize the defect in real time.

In very, very rare circumstances. Where there remains an issue, then these days with modern three t. MRI scanners, which we have at Benenden. It is possible to MRI the affected area, and actually, during the acquisition of the pictures, get the patient to cough, so that this demonstrates whether or not. There is, in fact, a hernia.

99.9% of the time. However, the diagnosis is simply made by the patient and by physical examination.

Next slide, please, Phil.

So what are the treatment options? The first and most important thing to say is that and I say this very regularly. If you ever meet a Surgeon who tells you have to have an operation, if it's not lifesaving, run away from them.

Essentially, the critical question that one has to answer is, how much does this affect the quality of your day to day life?

If the answer to that question is not greatly and simple. Occasional over-the-counter medication, such as paracetamol or ibuprofen, is able to control your symptom, and you haven't had any worrying issues from it regards incarceration or strangulation, then a period of watchful waiting and observation is perfectly fair enough.

However, I’m here this evening, obviously, to talk about surgery. So with the next slide we will discuss that.

So there are a myriad of different ways of correcting hernias, and it really depends upon the anatomical location.

The Surgeon's abilities, and the patient's preference, the latter being the most important.

Essentially hernia repair can be divided into open or laparoscopic keyhole repairs and then the question one has to ask is, whether mesh or no mesh is required in order to do so.

The commonest method of hernia repair worldwide is open hernia repair, and for the hernia that's indicated on this particular slide. It would be an inguinal hernia. The commonest technique that's used again in the UK and worldwide is the Lichtenstein meshed inguinal hernia. Repair.

This essentially involves a small incision in the groin. Eight to 10 centimeters is a little bit larger than normal and then the anatomy is exposed initially.

The hernia and its content are reduced back into the abdominal cavity.

The musculature is then reopposed in an anatomical fashion, using stitches which either dissolve over a period of time, or remain in place, dependent on the Surgeon's preference and the anatomy itself.

Then a piece of mesh is placed which essentially covers the defect and reinforces the repair to minimize the risk of recurrence.

These type of operations can be done both under general anaesthetic, where you're completely asleep.

Local anaesthetic, where just the area of worry. The area of surgery is infiltrated or numbed. Using local anaesthetic.

This technique is generally reserved for those patients who are not fit for any other form of anaesthetic and then the halfway house is a spinal anaesthetic, where a local anaesthetic is injected into the back that numbs the legs, and the groin for approximately three to four hours.

Allowing time for surgery and recovery. But you are awake when this occurs.

Open. Hernia repair is generally applied for the femoral, inguinal, umbilical, epigastric hernias, and the larger incisional hernias.

Thanks, Phil. Next slide, please.

As I said. The decision when the Surgeon offers surgery is whether or not it can be done by keyhole.

Keyhole surgical interventions are generally reserved for groin hernias, particularly inguinal hernias, but certain types of incisional hernias, and other rarer abdominal hernias, such as the Spigelian hernia, are also corrected by the keyhole technique.

The operative Surgeon generally makes smaller incisions, usually approximately three of them with cuts which are about a centimeter to two apart.

One of the ports which is placed will have a camera to allow visualization of the area, and also for carbon dioxide to be blown in, which opens up the space to allow the operation to occur.

Two further ports essentially hold the instruments that are then used to firstly reduce the hernia and put it back where it's supposed to be, and then put in a piece of mesh which acts rather like the repair of a hull of a boat, where the mesh is held in position by the pressure of the abdominal cavity.

Some Surgeons tack them in place, although this is not being used as frequently any longer as glue is much more commonly used, meaning that there's no foreign material. After a period of time when the glue is reabsorbed.

Keyhole surgery is generally reserved for smaller hernias, or those hernias which occur simultaneously on both sides, we call that bilateral hernia repair

The recovery from both keyhole surgical interventions and open interventions is generally the same, and if one looks at quality of life, studies at 30 days, those who've had keyhole operations, and those who have open operations score. Very similarly, although initially, recovery in the first week after keyhole surgery is slightly quicker.

Final thing, I will say, is that keyhole operations, laparoscopic hernia repairs are always done under a general anaesthetic. So you are completely asleep.

Next slide, please.

So what would one expect after an operation. Well, the vast majority of hernia repairs are performed as day surgical interventions come into the hospital early in the morning, when you will be seen and admitted by the admitting nursing staff on the ward.

You will then see the Anaesthetist and the Consultant to discuss both the anaesthetic and any further questions that you may have

The Surgeon themselves, and your consent form would need then to be countersigned.

Following the surgery, providing you are comfortable and confident, and have passed urine. Then it is safe for you to go home after being reviewed by the Anaesthetist, the Surgeon, and the nursing staff, looking after you.

Generally speaking, in the first one to five days. The first week following surgery, most people are able to walk around their house, generally get outside and walk very short distances. Most people simply require simple pain, relief, such as paracetamol and ibuprofen regularly, but stronger painkillers are dispensed on discharge from the hospital just in case more is required.

Stitches usually dissolve under the skin, and there is waterproof dressing applied over the top of their wounds. So patients are able to shower, but not bath.

Generally speaking, after a week of taking it reasonably, easily. It's then possible to gradually build your exercise tolerance essentially dependent on how comfortable and confident you feel.

It is critical, however, that picking up anything over five kilos is avoided, at least until the three week mark.

So, for example, I generally say to people, a small bag of shopping is fine and picking a light toddler up, provided you use good manual handling technique is okay.

But anything heavier than that should be avoided, as the repair is still fairly immature at this point, and it is the commonest time when rupture and issues can occur.

As far as driving is concerned. Generally speaking, two or 10 days to two weeks is required more for an insurer than anything else. But most people are back driving within a couple of weeks.

And within three weeks most people are off pain relief and is back to at least 75% of normal activity.

Generally speaking, hernia repairs are fully sound at six weeks.

And at this point the vast majority of patients are able to go back to their normal day to day activities and normal exercise regimes.

The one caveat that I do put in that is that professional sports, people, or people who play higher level of sport generally take a little longer to recover back to their normal functional capacity. But that's not most of us

Next slide, please, Phil.

So I’d now like to show you all the team at Benenden would like to show you a short synopsis of a gentleman called terry king

And his successful hernia. Repair over to you, Phil.

Terry King

I was experiencing some pain and discomfort in lower stomach area.

I quickly had appointments to see, make sure that the diagnosis was correct, which he confirmed.

And he set out the procedures. How it would roll out for me.

And the operation was carried out in August.

Having only received diagnosis in in early summer. So that was marvelous.

The nursing care was first class and a little back, being like it, like being in a hotel, being our holiday.

Your every need was pampered to, and you're made very comfortable and at home.

I think, after about a month I was back playing golf

And not feeling any ill effects.

Yes, the highlight of my experience at Benenden Hospital was the seamlessly smooth transition from operating theatre to my private room.

Where I enjoyed a light snack, and in the knowledge that everything had gone fine, and I had the rest of my life to look forward to unhindered by having waiting list issues hanging over me.

Mr Simon Bailey

Thank you for all for that.

I'm conscious of the time. It's nearing half past seven. So I was wondering, do you want to throw the floor open to the questions. Phil?

Phil Orrell

Yes, of course. Thank you for that informative presentation, Mr Bailey. Lots of useful information to digest there.

So we can take some questions from the attendees

First of which is, a person asking, can a hernia with a bulge cause lower back ache?

Mr Simon Bailey

So the answer to that question is, it's uncommon to do so.

If a hernia is causing a change in the way in which someone is their posture, and so forth. It can certainly affect the lower back

Nerves that run through the inguinal canal generally are peripheral nerves, i.e. They don't come from the lumbar back region, and common nerve pain or aches are within the testicle, the groin, or down the front of the leg.

So I think that unlikely is the honest answer to that question.

Phil Orrell

Okay, thank you.

The next person asks, you mentioned that it is bad to leave a hernia. Does that apply to all types of hernia. Would a very minor one ever go away on its own?

Mr Simon Bailey

So the answer to the question is, if a hernia is present, it won't go of its own accord. You can't exercise to get rid of it. However, go back to my original premise. If you ever meet a Surgeon who says to you, you've got to have an operation run away from them. Essentially, if it's asymptomatic, and it's not preventing.

Any normal day-to-day activity. And it's small and long standing, particularly if it's in the upper part of the abdominal cavity, the likelihood of it progressing and causing a problem is actually quite small. So I would strongly counsel a patient in that circumstance that a watchful waiting policy is the one to go for.

Phil Orrell

Okay, thank you.

This attendee asks if I had an open hernia repair under local anaesthetic. Would I need to stay overnight? I'm very anxious of general anaesthetic and hospital stays.

Mr Simon Bailey

No, not in the slightest day case operation without any issue whatsoever.

The local anaesthetic, as I said, could either be instilled around the groin itself, which we do very uncommonly these days in less than 5% of patients.

But a spinal anaesthetic which wears off after two or 3â h is extremely safe, extremely effective, and would not necessitate an inpatient stay.

Phil Orrell

Thank you, Mr Bailey.

The next attendee, Mr Tarleton says, I developed an incisional hernia after keyhole surgery on my bowel. I've since experienced constipation and discomfort. Is this dangerous?

Mr Simon Bailey

Okay. Well, I’m very sorry to hear that you've developed an incisional hernia.

Constipation is a very common condition. The worrying symptoms to watch out, for from hernias are, if the constipation becomes very severe, associated with a lack of passing flatus, abdominal distension, nausea, and vomiting, which is an indication of incarceration and impending problem, and should be checked quickly.

The good news is that if the incisional hernia is larger in size, the potential for this occurring is actually very small.

But if the gentleman is experiencing symptoms from it, then it would most definitely be sensible for him to have that checked sooner rather than later.

Phil Orrell

Great. Thank you.

This person asks, I have a hiatus hernia. How would you treat this?

Mr Simon Bailey

Right now a hiatus hernia is a completely different kettle of fish, essentially hiatus hernias are incredibly common conditions. About 95% of us have them. To a greater or lesser extent, they cause symptoms of gastroesophageal reflux, heartburn, discomfiture under the breastbone, burning sensation on swallowing and so forth.

Most hiatus hernias are treated by lifestyle, modification.

Avoidance of precipitants, such as spicy food, alcohol, cigarette, smoking, tobacco, chewing and simple anti-acid medications.

If these factors don't work, then investigation of the hiatus hernia is important, and that's done by a camera test to look down through the gullet and into the stomach to assess the size and type of the hernia.

And it's also then possible to determine how much acidity is generated, for what sort of frequency and what sort of height, and this is done with either something called ph. And manometry studies, or a bravo capsule

Repair of the hiatus hernia. There are a multiplicity of different types. And that's actually a very specialist circumstance which I can do. But we don't do at Benenden.

Phil Orrell

Okay, thank you.

This next attendee says, would a mesh-free repair for an indirect bilateral inguinal hernia be advisable?

Mr Simon Bailey

Yes Well, so the answer to that question is, it is always patient choice.

The should ice and Bassini repair were the original way that we performed hernias, hernia, surgery for inguinal or groin hernias. Prior to the invention of mesh.

The difficulty is that younger Surgeons have not been trained in the original ways of doing it, and therefore don't know how to do it.

I do. Do. Should ice and Bassini repairs, and generally approximately 10% of patients who come to see me opt for that technique. It's a very good technique. The recurrence rates are slightly higher. Long term with a mesh repair. The recurrence rate is stated at 1% at 10 years.

With an anatomical repair. The recurrence rate is approximately one to 2% annum.

But, generally speaking, if you get five years out from surgery, the risk of it coming back again is 0.

So they are very good operations. They work extremely well, and they're certainly available to do.

Phil Orrell

This next attendee, Annabelle asks for an umbilical hernia is the recurrence rate 30%, as advised by an NHS Consultant?

Mr Simon Bailey

No. So very straightforward.

The recurrence rate for an umbilical hernia should be less than two to 5% over a five year period. So I’m not entirely sure where that figure was obtained from.

Phil Orrell

This attendee asks, is having a cough during the first week after surgery going to be a problem?

Mr Simon Bailey

Well, the answer to that question is, yes, it will be quite sore, and you'll need to put your hand over the area afterwards and take your pain relief regularly.

Obviously significant and profound coughs generally would preclude doing a hernia repair until that cough is treated or investigated and treated. But you know, the occasional cough and sneeze is not an issue at all.

Phil Orrell

Okay, thank you.

This attendee asks, I have a, apologies, if I’m if I’m pronouncing this incorrectly, Spigelian?

Mr Simon Bailey

Spigelian.

Phil Orrell

Spigelian hernia.

And I’m going to have a laparoscopic surgery at Benenden soon. Can I be driven back to London after the op?

Mr Simon Bailey

Yes.

Make sure you take plenty of pain, relief, drive slowly and avoid emergency stops, but shouldn't be an issue at all to drive back to London.

Phil Orrell

Okay, bear with me.

So the next attendee asks, how common is it to have very infrequent episodes of protrusion every three months or so?

Mr Simon Bailey

That's difficult to say. I mean most people. If they have a hernia, it's present on a regular basis, or it's usually just there.

So to have an episode every three months would be very unusual.

Phil Orrell

Alright, this is quite detailed this one.

I have a shunt which drains into my bowel. I'm also scheduled to have an umbilical repair. Soon is it advisable to go ahead with this? As I’m worried, it may impact on the shunt into the bowel.

My Consultant is aware.

Mr Simon Bailey

Right, shunts lots of different types of shunts. My thought might be that this is a ventriculoperitoneal.

Shunt which drains something called a hydrocephalus. This is really very esoteric that will drain into the abdominal cavity, not into the bowel, and it's usually tunneled under the skin and sits in the pelvis.

The answer to your question is, if you're having an umbilical hernia repair, it's unlikely that they'd go anywhere near it, and I’m sure the operative Consultant will have done the appropriate imaging to know where the course of that drain is before embarking on surgery.

If they haven't, I would certainly ask them to do so.

Phil Orrell

Okay, thank you.

This next attendee. Russell asks, I had a bilateral hernia repair five years ago, and one side has reoccurred.

How difficult is it to have the repair carried out again? And what are the risks second time around.

Mr Simon Bailey

Yeah. Good question.

So yes, it is certainly possible to have it repaired. It does slightly increase the complexity of the surgery, but not massively. It would need an open repair because the anatomy following a keyhole. Surgery is too distorted to get back into the same area to see the anatomy.

The risks, as far as risks of surgery are concerned. Well, the risks of any operation. Things like infection, bleeding, pain, delayed wound, healing, and bruising are the risks of all surgery. The main risk of redo operations in a man is damage to the testicular vessels, causing the testicle to either atrophy or shrink.

Or, in the worst case scenario. If one is unable to expose the anatomy properly, then removal of the testicle is required.

The risk of damage to the testicle is of the order of one in five to 8,000, and the risk of having to remove a testicle is approximately one in 10 to 15,000, so I can say that in 30 years of fixing a hernia I’ve never had to remove anybody's testicle.

But it is a recognized complication, and therefore the patient should be well aware of that.

Phil Orrell

Thank you.

The next person asks with keyhole surgery for a bilateral inguinal hernia. Do you perform TAP or TEP?

Mr Simon Bailey

Okay. So the question being asked is, the TAP is a Trans Abdominal Preperitoneal repair

TEP is a Total Extra Peritonea repair.

That's quite fine print. I perform a TEP, because I believe you can view the anatomy more accurately, and the mesh is not placed inside the abdominal cavity, so the chance of it migrating and causing issue is smaller.

Phil Orrell

Thank you.

The next person asks, does the body tolerate a mesh hernia repair well?

Mr Simon Bailey

Absolutely.

There are about 10 million per annum done worldwide with extraordinarily good and well documented outcomes, and the mesh itself is an inert entity.

It is recognized by both the FDA in the United States and the national institute of clinical health excellence here in the UK. So yes, we wouldn't be using it if it weren’t tolerated. Well.

Phil Orrell

Thank you.

The next question is, I had an incisional hernia about six months. About six months. Post-op had hernia repair, a sutured a small and not keen on mesh.

Now have another small bulge nearby, uncomfortable sitting for long, but I’m not sure what to do. What do you advise?

Mr Simon Bailey

So, that needs a clinical assessment via the general practitioner in the first instance, and if there is any concern or quandary on the diagnosis, then imaging initially, with ultrasound scan, would be the sensible thing to do that ought to be assessed.

Phil Orrell

This person asks, would a mesh-free repair for a bilateral inguinal hernia on a very active 65 year old, that weight trains and exercises a lot be advisable?

Mr Simon Bailey

So the answer to that question. If one weight trains and exercises, there is an increased potential for recurrence, and therefore yes, it is feasible, but one would potentially need to change the exercise regimen which may well be the promulgating factor in the first instance.

In that circumstance I have operated on international powerlifters in the past, and every time have used mesh in that circumstance.

Phil Orrell

Thank you.

The next person asks how, soon after heart surgery, aortic root replacement, would you be able to perform a hernia repair?

Mr Simon Bailey

So with aortic root replacement, it is likely that the patient would need to be taking an antiplatelet blood thinning agent. They would want that in situ for at least six months I would suggest that after that sort of surgery one a would need a higher level of anaesthetic, input and secondarily, I would leave it at least six months.

Preferably a year following the primary index heart operation.

Phil Orrell

Thank you.

Another fairly detailed question here from attendee, Chris.

I had an operation for an inguinal hernia eight years ago, following a recent ultrasound. I now have two small, two small inguinal hernias, left and right. Will there be a problem operating on the same place again, when a mesh was put in eight years ago, and would both sides be done at the same time?

A recent physical exam showed there was no protrusion, so no need for an operation. Right now. My question is more about the future. As I anticipate a need at some point.

Mr Simon Bailey

Okay. So again, I would only recommend surgery if it were symptomatic and affecting quality of life.

Essentially, it's possible to do one or both sides at the same time.

Is there a problem operating in the same place? No, not really scarring can distort the anatomy slightly, but any good and competent hernia Surgeon should be able to negotiate their way around that without too much aggravation.

Phil Orrell

This person asks, why is laparoscopic, inguinal hernia repair recovery time, less than an open repair? I think they're saying.

Mr Simon Bailey

Because the well, that's a good question.

So as I go back to my original fact, the quality of life studies of 30 days really that there is no difference between the two. If you look at patient activity, pain levels, and satisfaction with outcome.

Keyhole surgery generally is done through slightly smaller incisions, which generally tend not to be quite as painful in the first two to five days. But analgesia demand at a week is essentially the same in both groups, and most people don't require any surgery, so the benefits of laparoscopic surgery with regard to pain relief are

Generally in the first week, but negligible thereafter

Phil Orrell

Okay. This lady asks. I have a Spigelian.

Mr Simon Bailey

Yeah, Spigelian. Almost.

Phil Orrell

Spigelian hernia, and I’ve been given conflicting advice. My private Consultant recommends open surgery.

But the NHS Consultant advises laparoscopic surgery and removal of my gallbladder at the same time.

The waiting time for NHS is lengthy, whereas the private Consultant can do the surgery next week. I'm concerned whether I’m having the optimal treatment.

I have Parkinson’s and arthritis.

Mr Simon Bailey

Okay, so that's an extremely difficult question, I’m afraid to answer without seeing the patient properly taking a full history, full physical examination, understanding what medications and investigations have been done, and so forth.

I am certain that both Consultants will have their reasons and rationales for doing that, and that, I’m afraid, is something that the patient would need to discuss directly with their both private and NHS Consultants, but I would strongly recommend them to them that

The time factor really shouldn't be an issue. What should be the most important thing is doing it in the right and sensible manner.

It's unusual to remove gallbladders at the same time as doing hernia, surgery.

Phil Orrell

Thank you.

Somebody asks, I have a supra umbilical hernia, and I also have gallstones and kidney stones. Would that complicate my hernia operation?

Mr Simon Bailey

No. As long as you're dealing with the as long as you're dealing with the inguinal hernia now the kidney stones well, they're a subsidiary issue, they can be very painful and unpleasant, but if they're if they're not causing any issue, leave them be, and the same thing with the gallstones.

Phil Orrell

Okay, thank you. Straightforward.

If I’m on blood pressure tablets, five milligrams, would surgery be okay?

Mr Simon Bailey

Absolutely no problem in the slightest.

The A small dose of antihypertensive agent is extraordinarily common in the in the population, and the Anaesthetist and the pre-admission team would give advice on that without any problem whatsoever.

Phil Orrell

And this person asks, is the mesh cut to size?

Mr Simon Bailey

Yes, absolutely. Each piece of mesh is individually tailored for the size and anatomy of the patient, in order to cover the area appropriately, but not to put excessive tissue material in.

Phil Orrell

Thank you.

And I think you answered this with your penultimate slide, Mr Bailey, but it might be worth reiterating. This person asks, is there any limit on the weight within normal lifting capability that can be lifted after hernia repair?

Mr Simon Bailey

So I tell everybody not to lift anything over five kilos for the first three weeks and 10 kilos for the first six weeks, and thereafter, generally, people can lift whatever they want in reason, using good manual handling technique.

By the eight week point most hernia repairs are 100% sound. But obviously one needs to always be careful and not overload the repair.

Nothing is a hundred percent guaranteed.

Phil Orrell

The final question here is, with a mesh free repair on an inguinal indirect hernia. Are you able to operate on any size, hernia, or does it have to be small? One to 2 cm?

Mr Simon Bailey

No, it can operate on any size hernia, but obviously with a very large hernia. The tissue is generally very much more attenuated and thinned, and therefore the success long term of repairing it with just an anatomical repair.

Is lower. It's very difficult to quantify that, unfortunately, as numbers are small, but certainly the larger they are, the less long-term success there is with an anatomical repair alone.

Phil Orrell

Okay, I think we are at a point where we've answered all your questions.

So, I will move on to the final slide.

As it says on the screen there, following this session. We are offering a call back from your dedicated patient advisor.

You will also receive the recording of the session, some treatment information, pricing, and some reward points for our loyalty scheme via email.

And obviously, as it says, there on the screen. You can access hernia treatment via self-pay through your Benenden health membership, private, your private medical insurer or the NHS.

And obviously you can select your specific contact preferences, and then we can keep you updated on upcoming news and offers and events.

And following this session, you'll receive a survey, and we'll be very grateful if you could complete that, because it helps to inform and shape our future events.

If you would like to discuss your consultation, our Private Patients team are here.

The lines are open tonight until 8.30pm or weekdays, 8am to 6pm. If you wanted to speak to the Private Patient team, and the contact number is on your screen there.

Next month we have a variety of webinar events on knee, surgery, tummy, tuck, surgery, and shoulder pain treatment. So you can sign up to any of those and find more information on our website.

All that remains for me to say is. Thank you very much on behalf of Mr Bailey and the team here at Benenden hospital. Thank you for tuning in, and we hope to hear from you very soon.

Thank you, and goodbye.

Mr Simon Bailey

Thank you very much.