PD DR. MED. ECKHARD LÖHDE
HOW IS THE DIAPHRAGM STRUCTURED?
Some additional details about the diaphragm: The diaphragm is an active but very sensitive muscle-tendon sheet that extends dome-shaped from the back to the front rib arches.
However, it is not, as mentioned, our "most important" respiratory muscle; rather, it facilitates the power of breathing. Yet, with its relatively fine musculature, it can modulate the airflow. This allows us to manipulate the larynx like an instrument, enabling us to speak and sing melodically and with varying volumes.
At the same time, it ensures the vital order in our body. Every organ in the upper abdomen is anchored to the diaphragm, thus being assigned its anatomically precise position. This prevents essential organs like the heart, lungs, and liver from being jumbled during vigorous movement, as we sometimes see with loops of the intestine. Additionally, it separates the thoracic cavity from the abdominal cavity, as both breathing and circulation rely on the alternation of positive and negative pressure.
This clear anatomical structure is not accidental but has a significant meaning: Our organs never function alone; they are interconnected like gears in a clockwork, contributing to the overall mechanism! They all work as a team. This is also true for the esophagus, as its integration with the left ventricle is crucial, for example, for preventing reflux.
The diaphragm's function in maintaining order plays a key role in many diseases.
WHY DOES IT ALWAYS RUPTURE HERE?
The primary weak point in the system of the core engine is the hiatus. This is not surprising, as the diaphragm, which is otherwise largely closed, must provide an opening for the esophagus at this point. Once a hole is present, there is always the risk that it will enlarge.
Several risk factors converge in this area: The crura muscles are located in the abdomen and are only covered by a thin layer rather than a strong fascia. Behind the muscles is a cavity in the thorax, meaning the muscles lack a posterior support. The muscle orientation corresponds to that of the back muscles, but the forces acting during thoracic breathing are directed bilaterally to the sides rather than axially. This causes the two intertwined muscles to be pulled apart. While they serve as stabilizing muscles, they also transition into the moving diaphragm area with significant tensile and stretching forces. The consequence is that, under certain conditions, these muscles may separate, and the previously small hole in the diaphragm enlarges.
As a result, the esophagus, followed by the stomach, loses its assigned position in the core engine system. The "gears" shift. This can have various consequences. Most commonly, there is a gradual failure of the sensitive closure function. The esophagus slides out of the pressure zone of the heart. The constantly upward-pushing aggressive acids from the stomach, as well as aerosols and stomach gases, can no longer be held back by the impulse from the left ventricle. This leads to the condition known as gastroesophageal reflux disease (GERD).
WHAT SYMPTOMS ARE TYPICAL?
In cases of reflux, heartburn and rising pain behind the breastbone are typical warning signs. Wine, coffee, fruit juices, and even desserts can only be tolerated with acid-blocking medications.
Many patients are advised not to eat late at night and must sleep with an elevated upper body. If reflux reaches the trachea, patients may suddenly wake up in the middle of the night with coughing fits. In the morning, they often complain of a bad taste in their mouth, halitosis, and mucus buildup.
Increased susceptibility to infections, frequent antibiotic use, and chronic bronchitis, along with asthma-like attacks, can affect some patients for years. The rising gases can cause irritation of the upper respiratory tract, chronic coughing, mucus production, hoarseness, or repeated inflammation of the sinuses or vocal cords.
Regardless of reflux, there can also be an acute or chronic entrapment of tissue in the diaphragm opening. Patients report a feeling of pressure in the upper abdomen, nausea, and pain radiating to the back.
Symptoms may include palpitations, chest pain, and even shortness of breath. Patients feel they cannot take deep breaths because the diaphragm is blocked. Increased blood pressure is not uncommon and may require medication.
Extensive heart diagnostics show that the heart is healthy. It is, but as the central organ responsible for our core engine, it reacts to any changes in the system.
WHAT DOES BARRETT'S ESOPHAGUS MEAN?
You will read a lot about the topic of Barrett from me: it is simply too important!
As a result of reflux, so-called Barrett cells can develop. These are cells of the esophagus that transform into stomach cells because the surrounding environment now resembles the stomach more than a normal esophagus. Such transformations are not without danger and cancer cells can develop over several stages.
Read more blogs on this topic: www.reflux-loehde.de
Once cells have changed, it is generally accepted that they can never heal again. Such cell changes cannot be reversed by high doses of acid blockers, as PPIs can only reduce the acidity, but the unchecked reflux of all gastric juice, including bile acids, continues. Barrett's cells can even develop during ongoing PPI therapy.
Nevertheless, Barrett's patients should take the medication in normal doses in this situation in order to provide some relief or mucous membranes. It is still unclear why patients with relatively minor symptoms develop Barrett's, while others do not, despite significant burns.
What I can answer for you, however, is that after the l.oe.h.d.e.-operation and restoration of the natural closure, we observe that, particularly smaller and early discovered Barrett changes, heal completely. All the others actually show no further progression!
WHAT OTHER SURGERY PROCEDURES ARE THERE?
The fundamental principle of all conventional surgical procedures is: The esophagus can no longer close properly. Therefore, it must be narrowed in some way.
Fundoplication
In this procedure, the upper portion of the stomach is cut from its natural attachment to the diaphragm and spleen and then wrapped around the esophagus like a scarf and sewn in place. This is intended to constrict the esophagus from the outside. When the stomach is completely wrapped around 360 degrees, it is called a Nissen fundoplication; if wrapped 270 degrees, it is referred to as a Toupet fundoplication. There are also variations depending on the surgeon; for instance, the Bicorn procedure is a "mini fundoplication."
Linx
In the Linx procedure, a metal magnetic chain is wrapped around the esophagus instead of the stomach. The magnets click together, compressing the organ. When eating and drinking, one must swallow against the magnets. It is important to note that the strong magnetic field can attract the Linx chain during MRI examinations, potentially leading to complications. The chain may need to be surgically removed beforehand.
Endoscopic Therapy
Various attempts have been made to narrow the esophagus endoscopically. Tissue-damaging substances and even radioactive elements have been injected deep into the esophageal wall (Enteryx procedure, Stretta procedure). This destroyed the sensitive wall of the esophagus. The resulting deep scars, creating hourglass-like constrictions in the esophagus, were intended to achieve narrowing and heal the patient. There have also been elaborate attempts to suture a narrowing fold into the esophagus endoscopically. Many of these procedures have fortunately been abandoned due to poor results and severe damage. However, patients still report their implementation in humans.
Very Important!
Procedures are repeatedly "offered" that seemingly promise something new. In reality, they are traditional surgical forms of fundoplication that have been slightly varied and mixed with additional applications, such as the insertion of titanium meshes, etc. It is crucial to carefully scrutinize the surgical approach.
The hiatus region is incredibly sensitive. Do not rush into any intervention!
WHAT OTHER TREATMENTS ARE THERE?
Medications
Medications are a crucial factor in the treatment of gastroesophageal reflux disease (GERD). Compared to the suffering in the past, they are a blessing for patients today. Most of the medications, known as PPIs (proton pump inhibitors), block the production of harsh hydrochloric acid in the stomach. This often alleviates symptoms and can even make them disappear. PPIs rank among the top 10 most sold medications worldwide.
These medications must be taken for life and in increasingly higher doses. This is because the underlying cause, namely the displacement of organs, cannot be cured with them. If the medications are discontinued or reduced, symptoms return immediately.
While there may now be less or no acid due to medication use, the closure remains defective, allowing stomach contents to continue flowing into the esophagus. Nothing has changed in that regard. Besides acid, the stomach contains bile acids, pepsins, enzymes, bacteria, food remnants, etc., which cannot be blocked. The result: Many patients will never be completely symptom-free, and the esophagus can still be damaged despite the medications.
It should be noted that the use of these medications is generally approved only for a period of about three weeks. However, they are often taken for years. Aside from the numerous side effects of the medications, there is no longer any acid available for the stomach's natural protective barrier, digestion, intestinal bacteria, etc. For example, vitamin B12 can no longer be absorbed from food, and further side effects on calcium metabolism and liver function over the years should also be considered.
WILL MY HEALTH INSURANCE COVER THE COSTS OF THE SURGERY?
Good news
The entire hospital costs for an operation are now covered by all public and private health insurance companies for Germans. Foreign patients are kindly requested to inquire about the costs via email to my office.