Gastroesophageal reflux disease (GERD) is a condition in which stomach acid refluxes (or surges upward) from the stomach into the esophagus (food swallowing tube). The acid reflux can cause many symptoms, including heartburn, chest pain, bad taste in the back of the mouth or aspiration of the acid into the lungs causing cough, wheezing or hoarseness. With long-standing reflux, the acid may cause ulcers of the esophagus, narrowing of the esophagus due to scar tissue, causing difficulty swallowing, or a change in the lining of the esophagus to one that is predisposed to cancer. GERD is a very common condition, affecting more than 40 percent of adults in the United States. For most individuals, simple antacid therapy can take care of GERD. However, in a small group of patients, the symptoms may not respond to therapy or may require very potent, expensive medicines. It is in this group of patients that an operation to correct GERD may be indicated.
Normally, a valve-like muscle, or sphincter, located at the junction of the esophagus with the stomach, opens during swallowing but then closes tightly to prevent acid from refluxing into the esophagus. In some individuals, the valve has adequate strength but relaxes at the wrong times, but in most individuals with GERD the sphincter is not strong enough to prevent reflux. In still others, the muscles of the upper esophagus are weak and not coordinated during swallowing, and this may cause similar symptoms as those with GERD.
Prior to consideration of an operation, medical therapy is initiated to control the disease. If this fails, appropriate diagnostic tests are done to establish the cause of the symptoms, to assess for complications and to see whether it is likely that an operation may be of benefit. These tests usually include an upper G.I. endoscopy (placing a lighted scope through the mouth into the esophagus and stomach), an esophageal pH study (to document whether acid refluxes into the esophagus) and esophageal manometry (a test of the strength of the muscles of the esophagus). Sometimes, a barium swallow (upper G.I. X-ray) or other tests may be used in the evaluation.
In patients who have complications of GERD, such as ulcers, a change in the lining of the esophagus, or stricture (narrowing), and if continuous therapy with potent antacids is necessary and unwanted, an operation may be indicated. The most commonly used anti-reflux operation is the Nissen fundoplication. This operation has been performed using standard open techniques with a large incision for the last 30 or 40 years and was shown to result in excellent long-term postoperative results. However, many patients elected not to undergo the operation due to the resulting discomfort and disability.
Over the last few years, surgeons have developed the technique of the Nissen fundoplication using laparoscopic instruments and five or six very small (5 to 10 millimeter) incisions instead of the one large one. In this operation, the upper part of the stomach on the left side (the fundus) is freed from the surrounding tissue, wrapped around the downstream part of the esophagus and sewn to itself to create a buttressing collar around the sphincter valve. While performing the fundoplication wrap, a large rubber dilator is positioned in the esophagus to prevent making the wrap too tight. However, due to swelling at the site of the sutures, there may be mild narrowing of the esophagus early postoperatively, leading to some difficulty in swallowing.
Many complications can occur during the operation, including injury to the spleen, stomach, esophagus, liver or surrounding organs, which may require blood transfusion or a change to the open operation. Each of these complications is rare but potentially serious. Postoperatively, some patients feel bloated and may have a change in their bowel habits. Others have trouble belching or vomiting. However, most patients have complete relief of the reflux symptoms without the need to take any antacid medications. Rather than being hospitalized for 7 to10 days postoperatively, as was the case with the open operation, most patients are discharged within the first three days and may return to work within a week to ten days. As the laparoscopic Nissen fundoplication has only been performed for a few years, it is impossible to state what the long-term results will be, but as every effort is made to duplicate what was done with the open operation, we anticipate excellent long-term results.
Surgeons performing reflux operations
Mark Watson, M.D
Homero Rivas
Robert Rege, M.D.
Daniel Scott, M.D.
