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Originally published February 25, 2025
Last updated February 25, 2025
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Gastroesophageal reflux disease’s (GERD) main causes are a faulty lower esophageal sphincter and/or a hiatal hernia. While physicians often assume the lower esophageal sphincter is to blame, research now shows hiatal hernias cause a higher percentage of GERD.
“Over time, we’ve realized that hiatal hernias account for about 70% of reflux,” says John C. Lipham, MD, a gastrointestinal surgeon with the USC Digestive Health Institute, part of Keck Medicine of USC.
Surgery may be performed if a hiatal hernia is causing chronic reflux. Unfortunately, even after surgical repair, hiatal hernias often recur.
Is there a better way to treat GERD, one that prevents hiatal hernias from returning? This is what Lipham and Keck Medicine researchers are studying in a clinical trial.
A hiatal hernia develops when there is a weaknesses in the diaphragm muscle separating the thoracic and abdominal cavities. This muscle can weaken so that the upper portion of the stomach ends up pushing up and eventually through a small opening in the diaphragm (the hiatus).
Patients, especially those with a large hiatal hernia, may experience acid reflux symptoms as acid and bile flow back into the esophagus. Symptoms include heartburn, regurgitation, chest or abdominal pain, and dysphagia.
If a hiatal hernia is causing chronic GERD, treating it is important because ongoing GERD can eventually cause Barrett’s esophagus, which leads to an increased risk of esophageal cancer.
Surgery can repair a hiatal hernia. “Traditionally, we suture the hole in the diaphragm closed and place mesh over the repair,” Lipham says.
Unfortunately, 30%-50% of hiatal hernias redevelop even after surgical repair. “When surgeries fail, it’s usually due to recurrence of the hiatal hernia,” Lipham says. “In fact, 85%-95% of the time when someone develops recurrent reflux again after surgery it’s because of recurrence of the hernia.”
The mesh placed over a repaired hernia does not stop the hernia from redeveloping. “The mesh has never been shown to decrease recurrence rates,” Lipham says. “Despite this, people keep trying different types of mesh — biologic mesh, synthetic mesh, porcine mesh, you name it — to see if it will somehow result in a lower recurrence rate. Unfortunately, it hasn’t.”
Lipham and Keck Medicine researchers are focusing their research on how to prevent hiatal hernias from returning.
In a prospective, randomized controlled clinical trial, they are studying whether platelet-rich plasma can improve wound healing and resolve hernias long-term. The use of platelet-rich plasma isn’t new; it’s already a treatment in orthopedics and dermatology.
In their study taking place at Keck Medicine, Lipham and his colleagues will treat participants’ hiatal hernias. One group will receive a standard mesh repair, while a second group will receive mesh treated with platelet-rich plasma.
“Research shows that the reason people develop a hiatal hernia is because they have a collagen deficiency in the connective tissue of that area,” Lipham explains. “That deficiency allows the hole in the diaphragm to stretch out, which leads to hernias forming. But even if we sew the hole closed, the fact remains that we’re sewing deficient tissue back together. And because of the deficiency, it doesn’t heal as tightly or as well as it should. Applying the platelet-rich plasma will increase collagen deposition. This will encourage connective tissue to grow to help keep the area together, lowering the chance of a hernia recurring.”
Lipham says this is the first prospective randomized controlled trial to test platelet-rich plasma in hiatal hernia repair.
Lipham hopes this research gets the medical community thinking about a new approach to treating hiatal hernias: stimulating better wound healing to prevent recurrence.
He also believes more physicians will come to realize the outsized role hiatal hernias play in GERD. “Until now, everyone’s put their research money on better ways to fix the lower esophageal sphincter. But at the end of the day, they all fail because of the recurrence of the hiatal hernia,” he says. “To this day, I think there are many who don’t even realize that hiatal hernias are part of the disease, and they definitely don’t realize how much of the disease hernias are responsible for.”
As more providers come to understand that hernias are responsible for 70% of GERD, more funding will be spent on research targeting hernia repair and recurrence.
“So maybe platelet-rich plasma won’t be 100% of the answer, but I think it will stimulate others to look at other ways to improve wound healing to prevent recurrence of the hernia,” Lipham concludes.
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