Hiatal Hernia – from Diagnosis to Treatment

Podcast Transcript

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Siva Raja, MD, PhD:
Hi, I am Dr. Siva Raja. I'm one of the thoracic surgeons at the Cleveland Clinic main campus, and I'm also the Director of Esophageal Surgery for the Center for Esophageal Diseases. With me I have Dr. Monisha Sudarshan.

Monisha Sudarshan, MD:
I'm one of the thoracic surgeons at Cleveland Clinic main campus as well and the Director of Esophageal Research.

Siva Raja, MD, PhD:
At the Cleveland Clinic, we deal with the entire spectrum of diseases that affect the esophagus. As we, hopefully, as a series, we would like to talk about the various different esophageal problems. Today, we're going to dedicate the podcast to talking about hiatal hernias. It's a condition that we commonly encounter and it's commonly encountered in the community. So today we're going to have a conversation about hiatal hernias and what it means and how to take care of them. So Dr. Sudarshan, would you be able to tell us briefly, what is a hiatal hernia so that people can understand what that disease actually entails?

Monisha Sudarshan, MD:
A hiatal hernia is when part of your stomach can bulge through a muscle that is dividing your chest and your abdomen called the diaphragm. That muscle can bulge at the point where your food pipe, your esophagus, connects with your stomach. We do see this. It's quite a common occurrence, and most often it happens in patients that are older and overweight. Perhaps smokers.

Siva Raja, MD, PhD:
Do you think they were born with this or did this just happen along the way?

Monisha Sudarshan, MD:
Well, there are different types of hiatal hernias. Some people are born with certain types of hiatal hernias, but most people acquire them through their lifetime.

Siva Raja, MD, PhD:
Okay. Okay. So how does one know if they have a hiatal hernia? Is there some sign or some symptom, or is there some problems that they have that tells them that perhaps they have a hiatal hernia?

Monisha Sudarshan, MD:
There are a variety of symptoms with hiatal hernia. Some patients, most commonly, some patients will experience reflux. So that's heartburn, or they might feel refluxes, a bitter feeling in their stomach, in their throat. Some patients will experience regurgitation, so food comes up, especially when they bend down or when they sleep. Some patients may have nausea or discomfort pain in their chest, discomfort pain in their belly. They could experience bloating or belching. So quite a diverse array of symptoms that are associated with hiatal hernias.

Siva Raja, MD, PhD:
Okay. It does sound like some of these symptoms can happen on a daily basis, either from a once-in-a-while occurrence, or sounds like it could be a hiatal hernia. All right. So if you think you have a hiatal hernia, what do you think the next step is for our patients? How do they go about figuring out if they have a hiatal hernia? Who should they see?

Monisha Sudarshan, MD:
There are a variety of tests that we can do to diagnose a hiatal hernia. For example, we have a barium swallow where the patient swallows a dye, and we take a variety of x-rays. It gives us a good view of the anatomy of the esophagus and the stomach and can tell us if there's a hiatal hernia present, what kind and how big it is.

Monisha Sudarshan, MD:
We also have endoscopy, which is when we put a long, flexible tube with a camera at the end down the food pipe or esophagus. We can have a look inside the esophagus, inside the stomach, and this too can tell us whether there's a hiatal hernia present and what else is going on there. There's also CT or a CAT scan that can give us the anatomy in the chest, not only of the esophagus in the stomach, but all the organs there, but at the same time, it can tell us if a hiatal hernia's present, the size, et cetera.

Siva Raja, MD, PhD:
So Dr. Sudarshan, it sounds like the hiatal hernias can cause quite a bit of problems for patients. Is it dangerous? Is it something that if you get a diagnosis, you need to seek medical attention immediately?

Monisha Sudarshan, MD:
Well, it depends. If there's a hiatal hernia and this patient is experiencing a lot of symptoms, such as nausea, vomiting, pain that is not going away, there is a possibility that hiatal hernias because the stomach is in the chest can twist and cause problems. That is on one spectrum. Then on the other spectrum, you have very small hiatal hernias that may not give any problems or the patient may not even know about it. So yes, it can be dangerous if it's at the severe side of the spectrum.

Siva Raja, MD, PhD:
If they were told they have a hiatal hernia, should they seek medical attention immediately? Or is it something that they can go talk to their doctor about the next time they see them? What do you think?

Monisha Sudarshan, MD:
Most generally, patients can talk to their doctor the next time they see them unless they're having severe symptoms, such as nausea, vomiting, pain that's not going away, they cannot eat or drink. So they're having those kinds of symptoms, they should see their doctor sooner than later.

Siva Raja, MD, PhD:
It sounds like they can be small, medium, large. It sounds like they can be any size. Is there certain things that you think are more associated with the small ones that are not very dangerous perhaps, and then things that are maybe associated with things that are larger that may cause these things that require you to seek immediate medical attention? Could you walk us through that a little bit?

Monisha Sudarshan, MD:
Yeah. So patients can have small hiatal hernias, and they may have no symptoms. These don't necessarily need to have any surgical treatment. They may have small hiatal hernias and have a little bit of symptoms that are very well-controlled with medication. So they may have reflux and with medication they're doing okay, and it's a very small hiatal hernia. Once again, these can be observed. Then you have the patients with very large hiatal hernias. Even if they don't have symptoms and they have a very large hiatal hernia, these we recommend do fixing because there's a chance that the stomach can get twisted or get a volvulus, which is the medical term. If the stomach gets twisted, this can cause more problems. For large hiatal hernias, whether they have symptoms or no symptoms, we do generally recommend seeking help and fixing it.

Siva Raja, MD, PhD:
So if you saw somebody who had a large hernia but was doing okay, what would your thoughts be? That's something that I see in my practice a lot is that I see patients come to see me for these hernias and they're quite large, but they seem like they're doing okay. At which point they're here to talk to us about should it be repaired or not. How do you approach somebody who has these large hernias but seem to be doing okay? They still have symptoms, but doing okay. What would you tell of them?

Monisha Sudarshan, MD:
I mean, so we would have a discussion about what the hernia surgery actually involves and then the risks of observing the hernia. The risks include, if it's a large hernia, as they continue to age, it most often just continues to become larger. The most severe symptom associated with that is the risk of the stomach twisting while it's just being observed. If that happens, they might need emergent surgery, which is always more complex and unwanted. So in these cases, we have a discussion about why, even though they might not have big symptoms if it's a very large hernia. We do recommend fixing it early so they don't get into trouble later on with a gastric volvulus or the twisting of the stomach.

Siva Raja, MD, PhD:
It sounds like we're on the same page when it comes to large hernias. I do tell people exactly that is that no, a couple of things. You could watch it. It's not that everybody with large hernias are going to have problems. But I think that when you do have a problem, it sometimes tends to be a very, very big problem. Based on where you are, where you live and what kind of resources are available, sometimes it's not possible to have it fixed emergently where you are and have to go to a local hospital and then get transferred to a larger hospital where that kind of expertise is there. Sometimes it's best to just prevent these problems before they end up causing you these things. So the large ones, I think we're on the same page.

Siva Raja, MD, PhD:
I think we're on the same page on the small ones too. They can cause some problems, and mostly it seems like the problems that my patients tell me about is heartburn. It sounds like these large hernias are problematic, but these small ones just seem to be a bit of a nuisance causing heartburn. So what are your thoughts, and maybe I'll share my thoughts afterwards, on people who come to you to you with heartburn, but are taking medicines and the medicines seem to be working okay? But they want to know if they should have an operation to come off the medicine. What are your thoughts?

Monisha Sudarshan, MD:
We do offer operations for patients with small hernias. If they're taking medications and having side effects from the medications or if they're taking medications and they're not well-controlled. If patients have small hernias and they're taking medications and are very well-controlled, generally we would recommend watching this and waiting for surgery.

Siva Raja, MD, PhD:
I guess we're also on the same page on this one. There are a lot of things you can do to decrease your reflux. There's some weight loss. If people are overweight, they can lose weight obviously. If you have a diet that is very high in foods that have acid in them, you can cut out things like tomatoes, oranges, lemonades, things that have a lot of acid and you can cut them out. Those things, all help decrease your acid reflux as well. I know there are some society guidelines that recommend that you should fix hernias even when the medical therapy is working. But our concern has always been that any time you do something, especially for something that's like this that's not cancer, you've got to make sure that this works for somebody long term. The natural history of some of these hiatal hernia operations is that they can loosen a little bit with time and then they can have some heartburn come back.

Siva Raja, MD, PhD:
If you're trying to get somebody off the med and give them an operation to get off the medicine, and then maybe five, six, 10 years down the line that they've got to go back on the medicine, it sounds like you haven't done what you hope to do. But clearly for people for whom it's not working this seems like the logical next step.

Monisha Sudarshan, MD:
What are your thoughts on medications and recent studies?

Siva Raja, MD, PhD:
So the recent studies I guess you're talking about are the ones that have come out over the last three or four years that suggest some correlation between maybe higher rates of kidney problems, some Alzheimer’s and things of that nature. At the moment, we're not 100% sure exactly what to do with those studies. These studies have raised some very important and valid questions, but I don't know if we have the answers yet. Obviously, these studies tell us that there may be a problem with these medications when you take them, especially at higher doses for long periods of time. Exactly how much and how long we don't know yet. So if anyone can get away without taking them, obviously that's the way to go, meaning that there are other classes of medicines. If you can't take these medicines called proton pump inhibitors, which you may know them as Prilosec or Nexium or Protonix. If you can take things like Pepcid and still have good control, that's obviously the better approach given that we're still trying to figure out what goes on.

Siva Raja, MD, PhD:
But in the absence of that medicine ... So the Pepcid and things like that, or Tums working for you, this is the only class of medicine that's sort of left for us. I think that there are consequences to leaving reflux unchecked, such as scarring on your food pipe and things like that that make it difficult for you to swallow later, or even making your quality of life bad from just up in the middle of the night with the burning chest pain and things like that. So I think that even though there may be some issues long term at the moment, we don't seem to have anything better.

Siva Raja, MD, PhD:
These operations do have some side effects. I tell my patients when I offer them operations, that especially when they are doing well on medicines, that you're asking for an operation that has some side effects. They're not complications, they're side effects. I mostly talk to them about the idea that you can't belch as often, or you can't vomit and that makes them a little bit gassy. They can be a little bit bloated. It has some side effects. If you're going to take on that risk of that side effects, then you've got to make sure that the medicine also has some side effects. Otherwise, if you feel very good on medicine, then the operation may get you off the medicine, at least in the short term, but you're left with these other side effects.

Siva Raja, MD, PhD:
What are your thoughts? What do you tell your patients about the side effects that they could experience if you fix the hernia? We'll talk about exactly how we fix it in a bit. But in general, what are your thoughts on the side effects after these operations?

Monisha Sudarshan, MD:
So similar to what you are saying, we do talk that, and especially initially there might be more side effects from the surgery and as they start healing, the side effects will decrease. So one of them initially can be a little bit of difficulty swallowing. That's because when we do this surgery, and we'll cover this in another video, we wrap the stomach. Sometimes when you do the surgery, there's inflammation initially, and this can cause some difficulty swallowing. Most often, this does tend to get better with time. There can be some bloating and belching, especially when large meals or carbonated beverages are eaten after the surgery. So we do recommend staying away from things like carbonated beverages, because it might make the bloating worse.

Siva Raja, MD, PhD:
Thinking about medication for heartburn and symptoms of that nature, it seems like when medicine works, I think that most people would agree that medications are safe enough to take at the moment. Obviously, we're going to keep studying that question and hopefully we'll have an answer in the next few years as to how safe they are long term, but for now they work. They work well, and they appear to be safe enough.

Siva Raja, MD, PhD:
On the flip side, when medicines don't work for you, I think that surgery is a reasonable option when the hernias are small and obviously when the hernias are large or they're in the middle, where they're not too small, not too large, but are having symptoms, surgery seems to be the appropriate answer to patients. How do we make that decision when the symptom is bad enough? What are your thoughts on how to decide between medicine and surgery when the answer isn't so obvious? Meaning that people aren't having significant pain when they eat with very large hernias or when it's obvious that they have horrible heartburn where the medicines aren't touching it. So we have a lot of people in the middle where it works somewhat. When do you decide and how do you decide whether they should stay on the medical therapy or they should get surgery? What are your thoughts?

Monisha Sudarshan, MD:
These are always tough decisions and always taken in conjunction with the patient, their symptoms, their lifestyle. We do have a swallowing center with a lot of gastroenterologists, expert endoscopists and together we can evaluate the patient, do tests, such as endoscopy that we talked about before, talk about medication, changing medications. If these are truly not working, then together make the correct decision to go forward with surgery.

Siva Raja, MD, PhD:
No, I think that is a great approach. The philosophy here is that no one person is smarter than all of us. So I think getting more opinions is always going to be is better because medication is one thing, but also from a surgery standpoint surgery has, they permanently change your anatomy. Before embarking on any operation, however small or however large, I think you should get all the opinions and all the information before you do it because afterwards it doesn't help you as much.

Siva Raja, MD, PhD:
When on medical therapy, I think that people who are on medical therapy usually need it for a long period of time. So I think it's important for patients to be monitored when they're on these medications though, they need to be monitored for the kidney function. They need to be monitored with some laboratory tests to make sure that things are going okay. Also, they should be monitored to make sure that it's still working.

Siva Raja, MD, PhD:
I think that for most patients, since they see their family doctor, family care physician, a lot more often than they see a surgeon or a gastroenterologist, it's probably a reasonable point to start. But for patients for whom they have either severe heartburn or are technically very complicated, I think that having a gastroenterologist who specializes in this follow them or on occasion in patients who've had surgery, that we would follow them ourselves and take care of the acid medication. So I think that the moral of the story there is that someone should keep an eye on you as opposed to taking these medications for year and year out, even though some of these medications are over the counter now. A lot of them don't need a prescription, but that doesn't mean that they shouldn't be monitored.

Siva Raja, MD, PhD:
In our prior discussion. We've talked a lot about what a hiatal hernia is and also what treatments there are, medical therapy, and we briefly touched on surgery as one of the options. But we generally talked about what it means to have it, who should probably think about being on medical therapy versus surgical therapy. So once we've decided as a group with the gastroenterology input, with the patient's input and the surgeon's input, that surgery might be the way to go. How do you approach these hernias? Is it a simple operation? Is it a complicated operation? What are your thoughts, Dr. Sudarshan?

Monisha Sudarshan, MD:
Once we have made the decision to proceed with surgery, we work with our Swallowing Center to get a few more studies that help us guide our intraoperative decision making. So one of them is called a manometry study. Here's where a catheter is inserted in the esophagus, and it tells us how well the esophagus is contracting and how well it moves. It can change what we do in the surgery. There's another test called a gastric emptying study and here where we look at how well the food leaves the stomach. Once again, depending on whether it's normal or abnormal, we can take care of those things during surgery. We can also get a pH study, which measures the pH or acid in the esophagus, once again guiding us for our surgical management. Before we take any patient to surgery, we make sure that their heart and lungs are in good function to tolerate the general anesthesia, and they're in good shape to recover from the surgery.

Siva Raja, MD, PhD:
Is it a big surgery? What do you think?

Monisha Sudarshan, MD:
Well, most of our surgeries we approach minimally invasive. So these can be done laparoscopically or robotically, and both have very small incisions in the abdomen, and we're able to work with long instruments and able to do the surgery just with that. So that has less pain and faster recovery for patients. There are however, some times where we're not able to do that safely. These can happen if patients have had a lot of previous surgeries in their belly or have had a previous hernia repair already that has not worked. In these cases, sometimes we do have to make a bigger incision in the belly called a laparotomy, or rarely we have to go in the chest and fix these hernias that way. Those are a bit more bigger than the laparoscopic surgery.

Siva Raja, MD, PhD:
Okay. So it seems like if the problem is bad enough. I think that those surgeries are not that big. They are bigger than the laparoscopic surgery. I think people generally still do pretty well with that. So you've got to make sure that the problem that they hear is significant enough that if you were to do a bigger operation, that you've got to make sure it's worth it.

Monisha Sudarshan, MD:
Yes.

Siva Raja, MD, PhD:
So if you're doing a laparoscopic surgery, I think that in terms of going into what the details, the nitty gritty of the surgery, I think that it's best probably described as a video. I'm sure that we can put a video for that.

Monisha Sudarshan, MD:
Yes.

Siva Raja, MD, PhD:
However, the question that's probably going to come up and it comes up a lot in my clinic, I'm sure yours too, is that people want to know about mesh. What are your thoughts on mesh? Why would you use it? Or when would you use it? Or if you would use it?

Monisha Sudarshan, MD:
So mesh is a synthetic material that's in a flat form that sometimes patients might hear is used in these kinds of surgeries. I personally never use mesh if possible. We can do other methods to avoid the mesh, and I try to do that because I would like to avoid the complications associated with mesh. That can be infection or erosion into some of the structures that we are working with. What about you?

Siva Raja, MD, PhD:
We're on the same page on that one. I think that the one side, I don't use is the mesh, especially the plastic meshes, the artificial meshes, because they've been associated with a lot of problems. The second and more important or equally important problem is that the meshes have never been shown that it in some ways makes the operation last longer or helps the patient as opposed to not having a mesh. So in something that doesn't work, but has a problem, it seems like a no-brainer not to use it. It's not to say that I haven't come across in my career rare situations where just using stitches to fix the hernia was enough. There have been a handful of situations where some form of mesh or some form of material that was needed to plug the holes or whatever that is needed.

Siva Raja, MD, PhD:
In all of those situations, I can safely say that I've only used biological mesh. So biological mesh is a version of the mesh where it is something that gets absorbed by your body. It's something that is not retained at all long term, and it becomes your own tissue and it's not associated with infections or any of those other problems that people have had with those meshes.

Siva Raja, MD, PhD:
So in the belly is always been my practice not to use that, especially in repair of hiatal hernias is not to use these meshes. So I think we're on the same page when it comes to a mesh. I think that's what I tell my patients when they ask is that the goal is not to use a mesh.

Siva Raja, MD, PhD:
So what are your thoughts on operations for the repair of hiatal hernias in people who already had operations for hiatal hernias? Is it harder? Is it the same? Do people do as well? What are your thoughts?

Monisha Sudarshan, MD:
Yeah. So there are some patients who have had previous hernia repairs and who perhaps after years or even earlier can have their symptoms come back. These are more complex to diagnose and to manage. First and foremost is we do several tests to understand what the problem is because there can be a wide variety of problems that can be causing their symptoms. So once we actually identify what is going on, then we can talk about what kind of surgery to do to fix that to get them better. 100% these surgeries are always more complex than the first surgery because you have scar tissue from the first surgery or in case they've had their initial surgeon use a mesh that causes more scar tissue. These are more complex surgeries.

Monisha Sudarshan, MD:
We try to do these minimally invasive, but they more often need a bigger incision, which is a laparotomy to fix them. Generally, the recovery is more prolonged or they're longer in the hospital and it takes them longer at home to recover from these. But overall, when we identify the problem correctly and you pick the right patient and the right surgery, they do get relief from the second surgery.

Siva Raja, MD, PhD:
Great. I couldn't agree more on the re-do operation. I always tell folks that the bar is a little higher on the second operation because of the operation a little harder to do and also the operation taking a little bit longer to recover from. So making sure that their symptoms weren't an operation again. So the re-do operations are tricky for a couple of reasons. One is that a lot of times you weren't the person doing the first operation. So we don't quite know exactly what was done the first operation. But I think that these operations tend to fail in one of several different ways, and so identifying which way in which it failed allows you to then redo the operation in a way that you could address how it failed the first time. Trying to do the same operation over and over again and expecting a different result is sort of like the definition of insanity.

Siva Raja, MD, PhD:
I think you've got to put the pieces together and try to figure out how can you make this better and how did it fail last time and try to do better. That's the goal of most surgeons, and we try to do that here as well. All right.

Siva Raja, MD, PhD:
Along the lines of surgeries for reflux, I think the one question that always comes up in my clinic is what about all these new technologies that are coming out now? Specifically they're talking about the LINX device, which a magnetic band that is placed around esophagus, or another endoscopic hiatal hernia repair with a flap called TIF, which is transoral, which means through the mouth, incisionless fundoplication because it's done entirely through your food pipe. So far, at least my take on this, and I'll let Dr. Sudarshan speak for herself as well, is that these are very interesting technologies that are coming out.

Siva Raja, MD, PhD:
I think that they hold a lot of promise. But in my mind, I don't think that the burden of proof that they work and they work long term and they work without problems has been met. Patients who have hiatal hernias and people who have reflux are patients who don't have some catastrophic medical problem that's going to be the end of them in a year or two or three. People live a very, very long time. So anything you do should also work for a very, very long time. If it doesn't, you need to know in a predictable, in a reliable way that you could fix it again. Those are the elements that I don't know have been demonstrated in those technologies is that, do they work long enough? Do they work well enough? And any problems they cause could they be fit easy enough? Because the standard operations that we talked about with the wrap and et cetera, have been around for many, many decades and they've been shown to be safe to do, they've been safe to redo. What are your thoughts?

Monisha Sudarshan, MD:
Yeah, I think we're on the same page. It's great to see so much innovation happening around this problem. However, there's just not enough data out there to show that these work long term, and these are patients suffering from these different kind of symptoms. We want something that works longer term and if it has problems, it's a fixable problem. Sometimes these technologies can have problems that are really tough to fix. I think we need more data, we need more longer term data, before these can be routinely used for hiatal hernia.

Siva Raja, MD, PhD:
Sure. I mean, I would be happy to do those operations in the setting of a clinical trial or something of that nature but where we're studying them very closely. Patients have also been educated about the things that we know, things we don't know and the things that we know that we don't know.

Monisha Sudarshan, MD:
The recovery from this operation can be quite rapid. So patients can stay anywhere from as short as one day to a few days in the hospital. We generally start slow in terms of what we can offer them to drink or eat. So they start off with some liquids. We make sure everything is going down easily after the surgery. We might do a test depending on what was done during the surgery, and then we can slowly progress to soft foods. So these are mushy foods that are easy to get down, easy to swallow, keep up the nutrition. Most of our patients stay on that for a few weeks. Once everything has settled down, everything has started to heal, then we slowly guide them through returning to a normal diet. There's extensive education about nutrition. Not only just how to maintain a healthy nutrition, but how are some of the few foods to avoid such as carbonated beverages that can make things worse after such a surgery.

Siva Raja, MD, PhD:
Yeah. I think our nutritionists are very good at working with people with reflux. I think that people underestimate the effectiveness of appropriately controlling your diet. What we put into this body makes a difference in how much reflux that you have. I think they're very, very knowledgeable, and they're a great resource for helping our patients on that one. How do you follow them long term? The old adage used to be that, "If you don't look, you never find." How do you follow patients to see if they're doing okay or if their hernia's back or any of those things? What is your personal protocol, if you will, on how to follow folks?

Monisha Sudarshan, MD:
So in my clinic, we follow them with a face-to-face interview or a phone interview to see what their symptoms are doing. But also within the first year and subsequent years, we are doing some imaging, such as a barium swallow, to make sure they're doing okay in terms of the anatomy, and if they're having symptoms to see how that shows up on an imaging. We can also do pH studies to see how their reflux has been, especially if they had reflux before. I think these are important to follow because even if they're doing fine clinically, if there's any issue that comes years down the line, we're able to identify it early and see how it progresses. So we'll have objective things to look at longer term.

Siva Raja, MD, PhD:
Yeah. I think I do the same. I have people come and see me at least, see myself or somebody in my clinic at least once a year just to make sure they're doing okay for a while. Obviously, if you're doing okay for a few years, then maybe once every few years, but I think that we try to keep tabs on people lifelong, as opposed to saying, "Call me when you've got a problem." Because a lot of times you can identify a problem and try to fix it sooner. That's one. Two, I think that one of the things that happens is that sometimes these hernias come back to a little bit, a small amount, but just because the hernia is back a little bit doesn't mean they need another operation.

Siva Raja, MD, PhD:
We operate on people who don't feel well for the most part. So if you're feeling well and just because an x-ray shows you have a little bit of a hernia doesn't mean another operation. I think that knowing what's going on with you will allow us to provide you with the right information so that you can make the decision that is needed, how you're going to watch your weight or what you're going to eat or things like that. And also to keep an eye on these hernias. Once we know you have a small one, sometimes if they get bigger, sometimes they don't. You only know that by keeping an eye on it. But I think that one of the hallmarks of what we do is to follow people in one way, shape or form long term.

Siva Raja, MD, PhD:
I think that the virtual visits that have become a lot more popular in the last year for obvious reasons has actually helped us follow more patients because people come from far away and this allows us to keep in touch with them and see how they're doing. We also work with the local gastroenterologists, local family care doctors to get whatever test that might be needed so that we can look at those things.

Siva Raja, MD, PhD:
One of the things that we're doing that's very unique here that a lot of places aren't doing is that we're actually trying to figure out how to identify these problems just by asking people questions about how they're feeling. So you're doing a lot of work with these questionnaires on people with esophageal problems. Could you briefly talk to us? I know a lot of this stuff, the data is super secret yet, but could you just talk a little bit about what you're doing so that patients can get a sense of what's down the line in terms of that?

Monisha Sudarshan, MD:
Yeah. So we're trying to develop a questionnaire that patients can quickly fill up while they're waiting for their appointment. So it's not a burden for them, but at the same time can give us objective information on what they're experiencing and more importantly, how it affects their life. Because patients may have one symptom, but it really doesn't affect their life overall in any significant way. Or they may have some symptom that is actually not that bad when they're talking about it, but to them, it's affecting their life a lot. So that tells us that's something that we need to pay attention to and fix. So we're developing this questionnaire that we can give patients to routinely. This helps us not just diagnose the problem initially, but also follow them before and after surgery. After surgery, if they're having more issues or things that pop up years later after the surgery, we're able to track it in an objective way with a score and able to do it more systematically than just asking them about it and documenting it in a note.

Siva Raja, MD, PhD:
Sounds like there's a lot of work there that you're doing and a lot of work to be done. It sounds like it's something that can also down the road is something that the patients can sort of fill out and send it to you and then you can sort of keep track of people that way as much as anything else. All right. Well, so this is this been an interesting discussion about hiatal hernias. Hopefully you guys found it as helpful as we have. Until next time.

Monisha Sudarshan, MD:
Thank you.

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