The diaphragm is an active but very sensitive muscle-tendon plate that expands in the shape of a dome from the back to the anterior costal arches. However, as is often claimed, it is not our “most important” respiratory muscle, but rather it conveys the power of breathing. Instead, it is able to modulate respiratory flow with its rather fine muscles. This allows us to blow on the larynx with great variation and to speak and sing like an instrument, melodically and at different volumes.

At the same time, it ensures the very important order in our body. Each organ in the upper abdomen is fixed to the diaphragm and is therefore assigned its exact anatomically position. As a result, vital organs such as the heart, lungs and liver in particular cannot swirl and possibly get tangled up even during the most intense movement, as we all know when it comes to intestinal slings. In addition, it separates the chest area from the abdomen, because breathing and circulation depend on the alternation of negative and positive pressure.

This clear anatomical structure is not random, but has a special meaning: Our organs never work alone, but are connected like cogs in a clock to make their contribution to the overall work! They all work as a team. This also applies to the esophagus. This is because their embedding in interaction with the left heart chamber is crucial, e.g. for secure closure against reflux.

This regulatory function of the diaphragm has a decisive key function in many diseases.

The primary weak point in the core engine system is the hiatus. This is not surprising because the otherwise largely tightly closed diaphragm must provide a passage for the esophagus right here. And once there is a hole, there is always the risk that it will widen.

However, there are a number of risk factors in this area: The crura muscles lie in the abdomen and are therefore only covered with a thin coating and not with a strong fascia. There is a cavity in the chest behind the muscles so that the muscles have no back support. The course of the muscles corresponds to that of the back muscles, but the forces involved are bilateral, i.e. oriented towards the sides, and not axially, especially during thoracic respiration. This is how the two interwoven muscles are pulled away from each other. Although they serve as support muscles, they pass into the moving diaphragm area with the corresponding high tensile and stretching forces. The result: Under certain conditions, these muscles fall apart and the formerly small hole in the diaphragm grows ever larger. As a result, the esophagus followed by the stomach loses its assigned position in the core engine system. The “gears” slip.

This can have many consequences. The most common is now a gradual failure of the sensitive shutter function. The esophagus slides out of the pressure zone of the heart. The aggressive acids of the stomach, as well as aerosols and gastric gases, which constantly push upwards, can no longer be held back by the impulse from the left ventricle.

Reflux disease develops.

Heartburn and increasing pain behind the sternum are typical alarm signs of reflux. Wine, coffee, fruit juices and even sweets are often only tolerated with acid-blocking drugs. Many patients are no longer allowed to eat late in the evening and have to sleep with a raised upper body. If the reflux still reaches the trachea, patients are startled with sudden coughing attacks in the middle of the night.

In the morning, patients complain of bad taste in the mouth, bad breath, and mucus. Susceptibility to infections ranging from frequent doses of antibiotics to chronic bronchitis and asthma-like attacks accompany some patients for years. The rising gases can cause upper respiratory tract irritation, chronic cough, mucus formation, hoarseness or repeated inflammation of the sinuses or vocal cords.

Regardless of reflux, acute or chronic constriction of tissue in the diaphragmatic slit can also occur. A feeling of pressure in the upper abdomen, nausea and pain radiating to the back are reported. There are symptoms such as palpitations, chest pain and even shortness of breath. Patients feel that they can no longer breathe deeply because the diaphragm is blocked.

It is not uncommon for there to be elevated blood pressure, which is treated with medication. Extensive diagnosis of the heart shows that the heart is healthy. That's what it is, but as the central organ of our core engine, it reacts to every change in the system.

You will read a lot about Barrett from me: It is simply too important! As a result of reflux, so-called Barrett cells can develop. These are cells in the esophagus that convert into stomach cells because the surrounding environment is now more like the stomach than a normal esophagus.

Such transformations are dangerous and cancer cells can develop over several stages. After successful Löhde operation and restoring the natural closure system, we were able to observe that minor Barrett changes in particular can actually heal. These results are particularly important for research!

The basic principle of all conventional surgical procedures is:
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‍The esophagus is obviously no longer able to close properly. So you have to narrow the esophagus in some way.

‍​Fundoplication
The installation of a fundoplication is the oldest and most widespread operation. It was developed in the last century and is based on the concept: When the occlusive muscle gives way, you have to tighten it!
For this purpose, the uppermost part of the stomach, the so-called “fundus”, is separated from its natural attachment to the spleen and diaphragm, folded in (fold = plica in Latin) and then wrapped around the esophagus. This is how fundoplication occurs, a “fundus fold” as the most well-known anti-reflux operation.
There are now a number of variations of this fundoplication: In order to constrict the esophagus, most surgeons pull through the severed fundus behind the esophagus as a “posterior fundoplication” and then completely (360° after nits) or almost completely (270° after toupee) with this gastric cuff. Finally, the cuff is sewn to the diaphragm and esophagus. Some still pull the stomach forward across the esophagus as an “anterior fundoplication.” The results are significantly worse, but the operation is technically easier and faster.
All of these operations are therefore generally referred to by proper names based on the type of wrapping or suturing technique: Nissen, Rosetti, Toupee, Hill, Thal, Belsey, Dor, etc. This is the Bicorn process ZFunLikatio”.

​​Linx
‍In the Linx process, instead of the stomach, a metal magnetic chain is now wrapped around the esophagus. The magnets click together and the organ is squeezed shut. When eating and drinking, you have to swallow against the magnets. It should be noted that the strong magnetic field during MRI scans can attract the Linx chain and lead to a risk. The chain may have to be surgically removed beforehand.

Important information about wrapping operations: The main problems of any wrapping operation include making belching very difficult. Patients suffer from the large amount of air that floats up the stomach but cannot escape. Vomiting is also mostly severe or even impossible. For affected patients, this is one of the worst experiences. Unfortunately, long-term results show that many patients will soon have to take PPIs again. These are the main reasons why, despite the considerable suffering, many treating doctors strictly advise their patients against such an operation and are more likely to recommend further drug therapy.
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​​​endoscopic therapy
‍Various attempts have been made to narrow the esophagus endoscopically. For example, tissue-damaging substances and even radioactive elements were injected deep into the wall of the esophagus (Enteryx procedure, Stretta process). The sensitive wall of the esophagus was destroyed as a result. The resulting deep scars with hourglass-like constrictions in the esophagus should now narrow and heal the patient. Attempts were also made to sew 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 that they have been carried out in humans.

‍Very important!
‍Processes are “offered” time and again that seem to promise something new. In fact, however, these are traditional forms of fundoplication, which vary somewhat and are mixed with additional applications, such as the inlay of titanium nets, etc.

Here, it is important to check the surgical procedure very carefully. The hiatus region is incredibly sensitive. Don't rush an operation!

Medication is a very decisive factor in the treatment of reflux disease. Compared to the suffering of the past, they are a blessing for patients today. Most preparations, the so-called PPIs (proton pump inhibitors), block the production of hot hydrochloric acid in the stomach. As a result, the symptoms are often improved and can even disappear completely. PPIs are among the top 10 best-selling drugs worldwide.

These drugs must, of course, be taken throughout life and in ever increasing doses. Because the actual cause, namely the displacement of the organs, cannot be cured with it. If the medication is stopped or reduced, the symptoms return immediately.

As a result of taking medication, there is now less or no more acid, but the occlusion remains defective and stomach contents can continue to flow into the esophagus. That hasn't changed, of course. It's just that it often doesn't burn as hard anymore. In addition to acid, the stomach contains bile acids, pepsins, enzymes, bacteria, food residues, etc. which cannot be blocked. The result: Many patients are never completely symptom-free and the esophagus can be damaged despite the medication.

In principle, it must be considered that the manufacturer only approves the use of PPIs for a period of approximately 4 weeks! Yet they are even taken for years. Apart from the side effects of the drugs, there is now no more acid available for the natural protective mantle of the stomach, digestion, intestinal bacteria, etc. For example, vitamin B12 can no longer be absorbed from food and it is important to consider other side effects of the drugs on the calcium balance and the liver over the years. Nevertheless, it has been shown that these drugs are surprisingly well tolerated by the body.

That's good news!

‍In the meantime, they are clinic costs covered by all most health insurance companies during an operation. Foreign patients should contact the Löhde secretariat team.

At Medical coaching Unfortunately, health insurance companies in Germany are not yet taking over this special form of individual care, as medical coaching goes far beyond standardized services. Comprehensive, intensive 1:1 support, which is tailored exactly to your needs, has not yet been covered by health insurance companies. We understand that this may be an additional burden and hope that this will change in the future.
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The Löhde process requires in-depth knowledge, such as Core engine works and where the real organ positions are. These are, of course, the prerequisites for a successful reconstruction of the diaphragm.

Such training with final certification requires the implementation of many operations under direct supervision. This does not even include training in recurrent operations and how to deal with complications. Such a training course is complex and barely implemented while working, especially by experienced surgeons, who have to be in the operating room every day.

“Everyone” will certainly never master the Löhde process. But there are undoubtedly very good and talented surgeons who would be eligible for this procedure. However, the certification process is not yet complete. This is because it is important to impart knowledge of 3-dimensional organ functions, anatomically exact diaphragm reconstruction and DeltaMesh implantation directly at the operating table, not only theoretically but also in practice.

This is how things are progressing slowly — but always for the benefit of the patients.

Unfortunately, health insurance companies in Germany do not yet provide this special form of individual care, as medical coaching goes far beyond standardized services. Comprehensive, intensive 1:1 support, which is tailored exactly to your needs, has not yet been covered by health insurance companies. We understand that this may be an additional burden and hope that this will change in the future.

Yes, medical coaching is an essential first step to enable an operation using the Löhde method. Not every patient is suitable for this method. Our more than 30 years of experience show time and again that alleged reflux patients actually suffer from other causes that should be treated differently. Unfortunately, misdiagnoses are common, and medical coaching serves to rule them out and make a precise diagnosis. This creates the best basis for successful treatment tailored to your needs.