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Understanding GERD and Surgical Treatment Options

What is Gastroesophageal Reflux Disease (GERD)?

GERD, commonly known as heartburn, is a medical condition where stomach acid frequently flows back into the esophagus, leading to discomfort and potential damage to the esophageal lining. This reflux can cause symptoms like a burning sensation in the chest, acid regurgitation, and chronic cough.

This condition is quite prevalent, with many adults in the United States experiencing heartburn or GERD at least monthly.

The sensation of heartburn is often described as a sharp, burning feeling located under the neck or between the ribs. It may also manifest in the chest, throat, or neck. Additional symptoms include regurgitation of food or liquid into the throat or mouth, difficulty swallowing, frequent coughing, or wheezing.

Food passes from the mouth to the stomach via the esophagus. At the lower end of the esophagus is a small muscle ring known as the lower esophageal sphincter (LES). This sphincter opens to allow food entry into the stomach and then shuts to prevent stomach contents, which are highly acidic, from reversing into the esophagus.

In cases of GERD, the LES malfunctions, failing to close properly and allowing acid to reflux, causing irritation and inflammation in the lower esophagus. Prolonged exposure to these stomach acids can lead to damage. Continuous acid contact can even alter the cells lining the lower esophagus, a condition known as "Barrett's esophagus." This condition escalates the risk of developing cancer in the esophagus.

What are the Causes of GERD?

Overfilled Stomach: Consuming large meals can increase the likelihood of reflux.
Diet Choices: Eating foods that are high in fat or spice can contribute to GERD.
Certain Medications: Some medicines can relax the LES or otherwise increase the risk of reflux.
Weak LES (Lower Esophageal Sphincter): A naturally weak LES, the muscle responsible for closing off the esophagus, can lead to GERD, as it may not function effectively to prevent stomach acids from flowing back into the esophagus.
Lifestyle Factors: Smoking or alcohol consumption can exacerbate GERD.
Tight Clothing: Wearing clothes that exert pressure on the abdomen, such as tight belts or waistbands, can provoke GERD symptoms.
Physical Activity: Engaging in intense exercise, especially soon after eating, can trigger reflux.
Body Position Changes: Activities like bending over or lying down shortly after eating can cause stomach contents to flow back into the esophagus.

Additionally, a condition known as a hiatal hernia can occur, where the upper part of the stomach protrudes into the chest cavity, which can also cause GERD. Notably, when surgery is performed to address GERD, it often also corrects a concurrent hiatal hernia, if present.

Options for Managing and Treating GERD:

The treatment of GERD (Gastroesophageal Reflux Disease) typically involves a combination of lifestyle modifications, dietary adjustments, medication, and potentially surgery. These treatments are often explored sequentially:

Lifestyle Changes:

- Dietary Adjustments: Reduce or eliminate consumption of foods that trigger GERD, such as spicy or fatty foods.
- Use of Over-the-Counter Antacids: These can neutralize stomach acid and are available at drugstores or grocery stores.
- Weight Management: Losing excess weight can reduce the pressure on the stomach and LES, thus decreasing reflux.
- Reducing Harmful Habits: Cutting back on or quitting smoking and alcohol consumption can alleviate GERD symptoms.
- Posture After Eating: Avoid lying down immediately after meals. Sitting or standing helps prevent reflux.
- Elevating the Bed Head: For those experiencing nighttime symptoms, raising the head of the bed can help gravity keep stomach contents from refluxing.

Medications:

If lifestyle modifications do not sufficiently alleviate GERD symptoms, medication may be necessary. The two main categories of medications for GERD are over-the-counter remedies and prescription drugs:

Over-the-Counter Antacids:

- - Function: These medications work by neutralizing stomach acid, thereby making the stomach contents less irritating to the esophagus.
- - Accessibility: Antacids are readily available and can be purchased without a prescription at most stores.
- - Usage: They are typically used for immediate relief of mild symptoms.

2. Prescription Medications:

- - Effectiveness: Prescription drugs for GERD are generally more potent than over-the-counter options. They can be more effective in healing an irritated esophagus and providing symptom relief.
- - Types: These may include proton pump inhibitors (PPIs) and H2 blockers, which reduce acid production more significantly than antacids. Other medications may enhance the function of the LES or expedite stomach emptying.
- - Consultation: It's important to discuss with your primary care doctor to identify the most suitable medication for your condition. Your surgeon, if involved, can also provide guidance, especially if surgery is being considered as an option.

Each type of medication has its own benefits and potential side effects, so it is crucial to have a thorough discussion with your healthcare provider about the best treatment approach for your specific case of GERD. Remember that medication can be a key component of a comprehensive treatment plan, which might also include ongoing lifestyle and dietary changes.

Surgery:

Surgery is considered for GERD when lifestyle changes and medications are insufficient, or if long-term medication use is not desired. Surgical interventions are highly effective in treating GERD, with the most common procedure being fundoplication.

Fundoplication Surgery

This surgery has been performed since the late 1950s. Initially, it was done through an open incision in the abdomen. Since the 1990s, fundoplication is more commonly performed laparoscopically, involving multiple small incisions. This minimally invasive method is now the standard care approach.

- Procedure:

- - Hiatal Hernia Repair: If present, a hiatal hernia is repaired first.
- - Wrapping the Stomach: The upper part of the stomach is then wrapped around the lower end of the esophagus. This action strengthens the LES (lower esophageal sphincter), making it more effective at preventing acid reflux. It's akin to reinforcing a tube with extra material or tape.
- Techniques:
- - Laparoscopic Fundoplication: Involves small incisions (5mm-10mm) and the use of special instruments.
- - Open Surgery: In certain cases where the laparoscopic approach is deemed unsafe, the surgery may be performed through a single, larger incision in the upper abdomen.

What are the Benefits of Undergoing Laparoscopic Surgery?

Opting for laparoscopic surgery typically offers several key advantages:

Reduced Postoperative Discomfort: Patients often experience lower levels of pain following the surgery.
Shortened Hospital Stay: The duration of hospitalization post-surgery is usually less.
Quicker Resumption of Daily Activities: Patients can often return to their regular routines, including work, more rapidly.
Minimal Scarring: Although multiple scars are present, they are considerably smaller.

Determining if Laparoscopic Surgery for GERD is Suitable for You

Consult with your primary care physician or a gastroenterologist to assess if laparoscopic surgery for GERD is a viable option.

In the event that GERD surgery seems a probable option, undergo a comprehensive evaluation by a skilled surgeon in this field. This assessment might involve an endoscopy, a barium swallow X-ray, or other tests to examine the effectiveness of your esophagus in processing food. Discuss with your healthcare provider or a gastroenterologist to identify an appropriate surgeon for this evaluation. If you have any questions feel free to contact us.

Preparing for Laparoscopic GERD Surgery: What to Anticipate

Before undergoing laparoscopic surgery for GERD, there are several preparatory steps and considerations:

Comprehensive Physical Examination: A full physical check-up is necessary to ensure you're fit for surgery. Your overall health status will be assessed.
Additional Diagnostic Tests: Depending on your age and health condition, extra tests like an EKG (to evaluate heart health) might be required.
Consultation with Your Surgeon: The surgeon performing the operation will discuss the potential risks and benefits with you. You will need to sign a consent form acknowledging your understanding and agreement to proceed with the surgery.
Pre-Surgery Instructions: Your surgeon's office will provide specific guidelines on what to do and what to avoid before the surgery. These instructions can vary, but typically include:
- - Hygiene: Showering the night before or the morning of the surgery, possibly using an antibiotic soap as directed by your surgeon.
- - Medication Adjustments: You may be advised to temporarily discontinue certain medications, like blood thinners, supplements, or drugs affecting your immune system or blood pressure. Ensure you discuss these changes with your surgeon.
- - Fasting: Avoid eating or drinking after midnight on the night before your surgery. If necessary, take approved medications with a small sip of water on the morning of the surgery.
- - Quitting Smoking: Stop smoking 4 to 6 weeks prior to the surgery to lower the risk of postoperative infections.
Post-Surgery Arrangements:
- - Transportation: Arrange for someone to drive you home after the surgery.
- - Home Assistance: You may require some help at home following the procedure. Discuss with your healthcare provider the level of assistance you'll need.

It is essential to follow these preoperative instructions carefully to ensure a safe and successful surgery and recovery. If you have any doubts or questions, it's important to address these with your healthcare team well in advance of the surgery date.

What to Expect on Surgery Day:

IV: You will be given a small needle and IV tube in a vein (typically in the arm) by a nurse or medical team member for medication administration during surgery.

Anesthesia: Administration of general anesthesia will be issued to ensure unconsciousness and a pain-free experience during the operation, which can extend over several hours.

After surgery, you will be transferred to the recovery room immediately until full consciousness is regained. The anticipated hospital stay is at least one night, with the possibility of a longer stay if necessary.

How is Laparoscopic GERD Surgery Performed?

Once you are under anesthesia, your surgeon creates multiple small incisions in your abdominal area, each measuring between one-quarter to one-half inch. Subsequently, the surgical team inserts small tubes into these incisions and passes tiny instruments through them. Among these instruments, there is a miniature video camera, or "scope," which projects the surgical area onto a TV screen in the operating room, providing your surgeon with a clear view.

To enhance visibility and instrument maneuverability, carbon dioxide gas is introduced into your abdomen during the procedure. This gas inflates the abdominal cavity, aiding the surgeon in performing the surgery with improved precision.

What is Next if Laparoscopic GERD Surgery is Not Possible?

In some cases, laparoscopic GERD surgery may not be feasible, and your surgeon may opt for open surgery, involving a single large incision. Several reasons for the need to switch to open surgery include:

Previous Abdominal Surgery: If you have undergone prior abdominal surgeries, resulting in extensive scar tissue formation, it can hinder the laparoscopic approach.
Intraoperative Bleeding: If bleeding complications arise during the procedure, your surgeon may choose open surgery for better control.
Complex Repairs: In cases where the stomach or esophagus requires intricate repairs that cannot be accomplished laparoscopically, open surgery may be the preferred method.
Limited Visibility: Sometimes, the laparoscope may not provide adequate visibility inside your body, prompting the need for open surgery.
Excessive Body Weight: If you are significantly overweight, laparoscopic surgery may pose challenges, leading to the preference for open surgery.

It is important to note that the decision to switch to open surgery is not a complication, but rather a safety measure taken by your surgeon. They will assess the situation during the laparoscopy and make the best judgment to ensure your safety and the success of the procedure.

Post-Surgery Expectations and Guidelines

Pain Levels:

Post laparoscopic GERD surgery, any discomfort typically remains mild, but you may require prescription pain medication for a brief period.

Activity Levels:

You can resume light activities at home immediately following the surgery, including walking and using stairs. However, it's advisable to avoid heavy lifting and strenuous tasks, such as lifting weights exceeding 10 lbs or engaging in activities that require significant exertion.

Return to Normal Activities:

Expect to return to your regular activities in approximately 4 weeks. Your surgeon will provide specific guidance on when you can engage in various activities.

Diet and Medications:

In most cases, you will not need antacids or GERD medications after the surgery. There may be a temporary need for a liquid diet (no solid food) post-surgery. Consult your surgeon for details regarding any special dietary requirements.

Post-Surgery Doctor Visit:

It is recommended to schedule a follow-up appointment with your surgeon within 2-4 weeks after the operation to monitor your recovery and address any concerns.

What Side Effects Can Occur?

Studies indicate that this surgery is highly effective in curing GERD, and most individuals experience significant improvement in their condition. However, a small percentage of patients may not experience relief or may have their reflux symptoms return months or even years later. In such cases, a second surgery may be considered if necessary.

Short-term side effects can include temporary difficulty in swallowing, which typically resolves within 1 to 3 months after the operation. Your surgeon may recommend a special diet during the initial weeks following surgery.

Long-lasting side effects are rare, but they may include challenges with belching or vomiting, as well as occasional stomach bloating. In some instances, patients may require a procedure to stretch their esophagus later on. Additionally, a few patients may experience increased flatulence for a brief period following the surgery.

Complications

What are the Potential Complications?

While this operation is generally regarded as safe, it is essential to acknowledge that like any surgical procedure, complications can occur. These potential complications may encompass:

Bleeding: Internal or external bleeding post-surgery.
Infection: Within the abdominal cavity or in the bloodstream
Adverse Reaction to General Anesthesia
Injury to Adjacent Organs: Such as the small intestine, ureter, or bladder, which can occur during surgery.

Your surgeon will have a thorough discussion with you regarding these potential risks. They will also assist you in evaluating whether the benefits of undergoing this operation outweigh the risks when compared to alternative treatments for your GERD.

When to Reach Out to Your Doctor:

Make sure to contact your physician or surgeon if you experience any of these symptoms post-surgery:

Rectal Bleeding: Any bleeding from the rectum.
Increasing Abdominal Swelling: Unusual or excessive swelling in the abdomen.
Chills: Could indicate infection.
Persistent Fever: A temperature exceeding 101 degrees F (39 C) that persists despite non-prescription medications.
Unmanaged Pain: Pain that your current medications do not alleviate.
Persistent Nausea or Vomiting: Ongoing issues that prevent you from eating or drinking.
Respiratory Issues: Persistent cough or shortness of breath, which could suggest complications like a pulmonary embolism.
Purulent Drainage: Pus or blood from any incision, indicating a possible infection.
Worsening Redness around Incisions: Increased redness or size of redness around incisions.

It is essential to maintain open communication with your healthcare provider and to promptly report any concerns or symptoms following your surgery. Prompt attention to these symptoms can prevent complications from escalating and ensure a smoother recovery.
If you have any other inquiries or concerns about your recovery, do not hesitate to contact your doctor's office for guidance and clarification.

Important Note: The above information is not a substitute for a thorough discussion with your surgeon regarding the necessity of an upper gastrointestinal surgery.

If you have inquiries about the appropriateness of an upper gastrointestinal surgery for your situation, alternative options, billing, insurance coverage, or your surgeon's qualifications and expertise, please feel free to contact us.

Should you have any questions pertaining to the surgical procedure or post-operative care, it is advisable to engage in discussions with your surgeon either prior to or following the operation.