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GERD Surgery

Gastric reflux, also called gastroesophageal reflux disease (GERD), is a condition where the stomach’s contents (food or liquid) rise from the stomach into the esophagus, a tube that carries food from the mouth to the stomach. Food mixed with the stomach’s digestive acids can irritate and damage the esophagus.

Causes

Normally, the stomach’s contents are retained in the stomach with the help of the lower esophageal sphincter (LES), a muscle that contracts and relaxes to maintain the one-way movement of food. However, gastric reflux occurs when the LES weakens. The exact cause of this is not known, however, certain factors including obesity, smoking, pregnancy and possibly alcohol, may contribute to GORD. Common foods such as spicy foods, onions, chocolates, caffeine- containing drinks, mint flavorings, tomato-based foods, citrus fruits and certain medications can worsen gastric reflux.

Impact

Living with gastric reflux is inconvenient as symptoms can severely interfere with your life. You may have to follow certain dietary restrictions and reflux occurring in the night can hinder a good night’s sleep, thereby affecting alertness and productivity the next day.

Anatomy

Food travels from the mouth through the esophagus, a long, narrow tube that opens into the stomach. This food pipe is lined by muscles that expand and contract to push food down the tube, a process called peristalsis. The stomach secretes acid and other digestive enzymes for the digestion of food and stores food before it enters the intestine.

A band of muscles called the lower esophageal sphincter (LES) are present at the junction of the esophagus and the stomach. This acts as a valve, preventing the reflux of acid and chyme (food mixed with acid and digestive enzymes) from the stomach into the food pipe.

Symptoms

Heartburn is usually the main symptom of GERD, characterized by a burning-type pain in the lower part of the mid-chest, behind the breast bone. Other symptoms include a bitter or sour taste in the mouth, trouble swallowing, nausea, dry cough or wheezing, regurgitation of food (bringing food back up into the mouth), hoarseness or change in voice and chest pain.

Diagnosis

Your doctor may order some of the following tests to diagnose gastric reflux:

  • Endoscopy: allows the doctor to examine the inside of your esophagus, stomach and portions of the intestine with an instrument called an endoscope, a thin flexible lighted tube
  • Barium X-rays: involves swallowing a barium preparation, which can be detected through X-rays
  • Twenty-four-hour pH monitoring: involves inserting a tube through your nose into the esophagus and positioning it above the LES. The tip of the tube contains a sensor which can measure the pH of the acid content refluxed into the esophagus. The tube will be left in place for 24 hours.
  • pH capsule: allows measuring acid exposure in the esophagus. A small wireless capsule is introduced into the esophagus by a tube through the nose or mouth. The tube is removed after the capsule is attached to the lining of the esophagus. The pH sensor transmits signals to a computer which collects the data about the acid exposure over the next 24 hours. The capsule eventually falls off the esophagus lining and is safely passed in the stool.
  • Impedance study: requires two probes; one is placed in the stomach and the other just above the stomach. The dual sensor helps to detect both acidic and alkaline reflux.

Treatments

Treatment aims at reducing reflux, relieving symptoms and preventing damage to the esophagus. Some of the treatment options include:

  • Antacids: over-the-counter medicines that provide temporary relief to heartburn and indigestion by neutralizing acid in the stomach
  • Other medications: reduce the production of acid in the stomach
  • Endoluminal gastroplication or endoscopic fundoplication technique: minimally-invasive method that requires the use of an endoscope with a sewing device attached to the end, known as an EndoCinch device. This instrument places stitches in the stomach below the LES to create a plate which helps reduce the pressure against the LES and strengthen the muscle.
  • Nissen’s fundoplication: is a surgical procedure in which the upper part of the stomach is wrapped around the end of your esophagus and esophageal sphincter, where it is sutured into place. This surgery strengthens the sphincter and helps prevent stomach acid and food from flowing back into the esophagus.

Prognosis

The outcome of treatment varies from person to person. Some may experience mild recurring symptoms, while for others, treatment can be very successful. Most people respond well to lifestyle changes and medications. However, a relapse is very common after cessation of medications, so the condition does require monitoring.

When medications fail to resolve symptoms, surgery is recommended. The success rate of surgery is approximately 92%.

Untreated

If left untreated, chronic GERD can cause serious complications such as inflammation of the esophagus, esophageal ulcers, narrowing of the esophagus, chronic cough and reflux of liquid into the lungs (pulmonary aspiration). Some people develop Barrett’s esophagus, a condition characterized by changes in the esophageal lining, which can lead to esophageal cancer.

Surgical Treatment

If conservative treatment options fail to resolve your GORD, your doctor may recommend a surgical procedure called Nissen Fundoplication. Nissen Fundoplication surgery reinforces the lower esophageal sphincter’s ability to close and helps to prevent gastro-esophageal reflux from occurring. This surgery can be performed laparoscopically through tiny incisions in the abdomen or through an open approach, which requires a large abdominal incision.

Nissen Fundoplication Procedure

Nissen Fundoplication is performed on an outpatient basis under general anesthesia. Steps involved in Nissen Fundoplication procedure include:

  • Your surgeon makes a small incision in the upper abdomen and inserts a tube called a trocar through which the laparoscope is introduced into the abdomen. A laparoscope is a long, narrow telescope with a light source and video camera at the end. The scope is passed through a tiny incision into the abdomen where images from the camera are projected onto a large monitor for the surgeon to view. Laparoscopes have channels inside the scope enabling your surgeon to pass gas in and out to expand the viewing area or to insert tiny surgical instruments for treatment purposes.
  • Additional small incisions may be made for other surgical instruments.
  • With the images from the laparoscope as a guide, your surgeon wraps the upper part of the stomach, the fundus, around the lower esophagus to create a valve, suturing it in place.
  • The hole in the diaphragm through which the esophagus passes is then tightened with sutures.
  • The laparoscope and other instruments are removed, and the gas released.
  • The tiny incisions are closed and covered with small bandages.

Postoperative information

After the surgery, you should keep the area clean and dry, and not shower or bathe during this time. The incisions usually heal in about 5 days. You may feel soreness around the incision areas. If the abdomen was distended with gas, you may experience discomfort in the abdomen, chest or shoulder area for a couple of days while the excess gas is being absorbed. Contact your doctor immediately if you have a fever, chills, increased pain, bleeding or fluid leakage from the incisions, chest pain, and shortness of breath, leg pain or dizziness.

Benefits of this approach

Laparoscopy is much less traumatic to the muscles and soft tissues than the traditional method of surgically opening the abdomen with long incisions (open techniques). It is also associated with a shorter hospital stay, less post-operative pain and faster recovery.

Preparation

Before the procedure, you may be instructed to be on a liquid diet for two days. Your surgeon will prescribe a solution for you the day before surgery to cleanse your bowel.

Outcome

Surgery is found to be beneficial in approximately 92% of patients. However, as with any surgery, Nissen Fundoplication may involve certain risks and complications which include infection, injury to blood vessels, stomach or esophagus, swallowing difficulties, gas embolism (gas bubbles in the bloodstream) and the need for a laparotomy (performed through a larger abdominal incision). Sometimes, the new valve weakens or loosens months or years after the surgery, causing symptoms again. If symptoms are severe, the surgery may need to be repeated.

Postop stages of recovery and care plan

Your surgeon may give you a prescription pain medicine or recommend non-steroidal anti-inflammatory drugs (NSAIDs) for the first few days to keep you comfortable. Your surgeon may instruct you about your diet and activity restrictions. Care should be taken with your wound. You are advised not to lift heavy objects for 8 to 12 weeks.

Down-time, lifestyle or off- work duration

Shortly after surgery, you can gradually resume your daily activities. You are encouraged to start walking as early as possible to reduce the risks of blood clots and pneumonia. You will be able to get back to work in 2 to 3 weeks.