What is the treatment approach for aerophagia after hiatal hernia repair?

Treatment of Aerophagia After Hiatal Hernia Repair

Behavioral techniques that reduce swallowing rate are the most effective treatment for aerophagia after hiatal hernia repair. 1

Understanding Aerophagia After Hiatal Hernia Repair

Aerophagia (excessive air swallowing) can occur following hiatal hernia repair and may manifest as:

• Belching and regurgitation 1, 2
• Bloating and abdominal discomfort 2
• Potential worsening of existing gastrointestinal symptoms 2

First-Line Treatment: Behavioral Techniques

Diaphragmatic Breathing Techniques

• Open-mouth, diaphragmatic breathing significantly reduces belching frequency 2
• Strengthens the anti-reflux barrier and reduces aerophagia symptoms 3
• Can reduce swallowing rate, which has been associated with symptomatic improvement 1

Swallowing Modification

• Conscious reduction of swallowing frequency is effective in managing aerophagia 1
• Minimized swallowing techniques have shown sustained results at 18-month follow-up 2

Lifestyle Modifications

• Elevating the head of the bed (15-20 cm) to reduce nocturnal reflux and associated aerophagia 3
• Avoiding large meals within 3 hours before bedtime 3
• Weight reduction in patients with obesity to decrease intra-abdominal pressure 3
• Patient education on mechanisms of GERD and aerophagia to improve treatment adherence 3

Pharmacological Management

• Optimize PPI therapy with proper timing (30-60 minutes before meals) 3
• Consider dose escalation or switching to another PPI if response is inadequate 3
• Alginate-based antacids for breakthrough symptoms 3
• Baclofen may be effective for predominant belching symptoms, though limited by side effects 3

Advanced Interventions

• In cases with persistent symptoms despite behavioral and medical therapy, consider:
  • Upper endoscopy to evaluate mucosal integrity 3
  • High-resolution manometry to evaluate esophageal function 3
  • 24-hour pH-impedance monitoring to determine the mechanism of persistent symptoms 3

Surgical Considerations

• For persistent severe symptoms, surgical revision may be necessary, but carries significant risk:
  • 37% complication rate in re-operative hiatal hernia surgery 4
  • Risk of dysphagia as a complication of hiatal hernia repair (16.3% in one series) 5
  • Laparoscopic, open laparotomy, or transthoracic approaches may be considered based on individual factors 4

Pitfalls and Caveats

• Ensure proper diagnosis of aerophagia versus other post-operative complications
• Behavioral techniques require patient commitment and practice for effectiveness 1, 2
• Initial symptomatic improvement with behavioral techniques may be short-lived without reinforcement 1
• Surgical revision carries significant risks and should be considered only after failure of conservative measures 4

Monitoring and Follow-up

• Regular assessment of symptom improvement 3
• Reinforcement of behavioral techniques if symptoms recur 1
• Consider cognitive-behavioral therapy for patients with esophageal hypersensitivity component 3