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Reflux Surgery

Gastroesophageal Reflux Disease (also known as GERD) is caused by your stomach acid ascending up your esophagus and occasionally into your throat or lungs.

This is caused by an incompetent muscle sphincter located at the junction of the stomach and esophagus. It is called the lower esophageal sphincter (LES). When your LES does not contract properly, stomach contents can escape from your stomach upwards. Certain foods and medications can worsen this problem. Anything that increases your stomach acid, such as smoking, alcohol, and caffeine can worsen your symptoms.

The most common symptoms of this disorder are heartburn and regurgitation of stomach contents up into your throat. These symptoms are worsened with lying down or bending over. If the acid gets into your lungs or has continued contact with your vocal cords, one can also develop a chronic cough or hoarseness.

Certain lifestyle changes may relieve some of the symptoms of GERD. Raising the head of the bed on blocks so as to create an incline allows gravity to prevent regurgitation. Decreasing the amount of food one eats before bedtime may also be effective. In overweight patients, weight loss is also helpful. Medications directed at reducing the amount of acid the stomach produces are the mainstay of medical management. For those patients whom medicine no longer controls symptoms, surgery is an excellent option.

Unchecked heartburn may be creating permanent damage to your esophagus. Inflammation (or esophagitis) is usually the first step with long-term acid exposure. This may cause patients to experience substernal chest pain and/or pressure, and burning sensation in your chest or throat. As this progress, ulcers may develop in the esophageal lining. Ulcers may cause pain, bleeding, and difficulty swallowing. Eventually, with chronic irritation, a stricture or narrowing of the esophagus may occur secondary to scarring. This will cause a significant problem with swallowing called dysphasia. Prolonged acid exposure may also cause a change in the type of cells that line the esophagus. This is called Barrett's Esophagus. Once this develops, there is an increase in the risk of developing esophageal cancer.

GERD is often associated with a hiatal hernia. The esophagus hiatus (opening) is made up of the diaphragmatic muscles. If this opening enlarges, the stomach may herniate up into the chest cavity. You can have a hiatal hernia without having GERD.

In patients with symptomatic GERD, an evaluation usually begins with a gastroenterologist. To confirm the diagnosis, an upper GI (specialized x-ray exam) or an upper gastrointestinal endoscopy (looking into the esophagus and stomach with a small camera and scope) can be done. The endoscopy allows the gastroenterologist the ability to directly view your esophagus and biopsy any unusual areas. If the diagnosis is confirmed and a patient is doing well on medical therapy, then no further workup is usually warranted.

In those patients whose symptoms continue despite medical treatment, or who are refluxing stomach contents into their lungs, surgical intervention is warranted. More sophisticated testing is needed prior to surgical therapy. Esophageal manometrics are important prior to surgery. This test evaluates the muscular tone of the esophagus and LES. Some patients may have an associated motility disorder of the esophagus, which may alter the type of surgery recommended. A ph monitoring test is also extremely important. This test evaluates how much acid exposure a patient has had in their esophagus over a period of time.

Surgery to control the symptoms creates a high-pressure zone in the area of the incompetent LES by wrapping a portion of the stomach around the esophagus. This surgery is extremely successful when performed for the right reasons and on the right patients. Now in 2004, it is done with small incisions (each about 1 cm) and the laparoscope. There are usually 5 small incisions in all. Occasionally, because of previous abdominal surgery, a patient may not be a candidate for laparoscopic surgery and the procedure will be converted to an open surgical approach for patient safety. It is imperative when choosing a surgeon that one makes sure he or she has extensive experience with this particular laparoscopic procedure.

Most patients can be discharged the following day. After surgery, patients may experience various side effects that usually resolve after 2-3 months. It is very important after this surgery that patients begin to eat slowly and chew carefully. There may be some dietary restrictions over the first few weeks. No carbonated beverages or meat products. More common side effects such as early satiety (getting filled up quickly), increase in flatulence (gas) and dysphasia (difficulty swallowing) account for the majority of postoperative symptoms. These will resolve over the ensuing months.

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Frequently Asked Questions

As long as I take my medication for heartburn I don't get the acid burning, however, when I lie down, I still notice regurgitation of stomach contents into my throat and mouth. Can anything be done for this?
Your acid symptoms are well controlled with the medication because they prevent the stomach from producing acid. However, you need to reconstitute a high-pressure zone at the esophagogastric junction to prevent regurgitation. Your lower esophageal sphincter is incompetent. This can be corrected with surgery.
For the past few years I've had difficulty swallowing. My doctors have told me I have achalasia. Is there anything that can be done surgically?
Absolutely. Achalasia implies there is a very hypertonic area at the esophagogastric junction as well as no peristaltic activity (contractions) of the esophagus. The procedure of choice for most patients is a laparoscopic Heller esophagogastric myotomy. This cuts one of the muscle layers of the esophagus and enables complete relaxation of the hypertonic area. Because of this, an anti-reflux procedure also done with the myotomy should be done to prevent heartburn. There are often non-surgical procedures as well as Botox injection and preventative dilations, but these options tend to be transient.
My doctor says I have Barrett's Esophagus on endoscopy. Will medication cause regression of my Barrett's?
Most likely, medication will not cause regression, but can keep the disease in check. Surgery with a fundoplication has been shown to cause regression with very little morbidity.
My heartburn medication is no longer effective. Are there any other more permanent solutions?
For those patients resistent to medical management, laparoscopic fundoplication provides a safe, effective, and long lasting treatment for patients with severe gastroesophageal reflux. An overnight stay is all that is usually required, and most patients return to their normal activities within 1-2 weeks.
What side effects might I experience after surgery for severe GERD?
Most patients have some dysphagia (difficulty swallowing) following surgery, which is self-limiting. After surgery, it is very important you eat slowly and chew carefully. Other common side effects include diarrhea, flatulence (excessive "gas") and early satiety (feeling full quickly). These symptoms will also resolve with time. Most patients are eating whatever they prefer within a 3-6 week period of time.

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