Minimally Invasive and Gastrointestinal Surgery

Gastroesophageal reflux disease, also known as GERD, is a condition in which stomach contents move upwards into the esophagus (reflux). More than 19 million American adults suffer from GERD, and nearly 1 in 10 experiences symptoms from GERD every day. Common symptoms include:

• Heartburn (burning discomfort behind the breastbone)
• Regurgitation (food and liquid coming back up)
• Frequent belching
• Difficulty swallowing

In many patients, GERD may also lead to conditions such as:

• Asthma
• Coughing
• Hoarseness
• Throat clearing

GERD is usually treated with medications and life style modifications for mild or moderate cases. ‘Life-style modifications’ includes things like:

• No eating late at night
• Avoid laying down flat after a meal
• Sleep with the head of the bed elevated
• If a patient is overweight, losing weight may help with GERD symptoms
• Avoid thinks like alcohol, carbonated beverages, and spicy foods.

More severe GERD (inadequately controlled with lifestyle modifications and medications) may require surgery.

Symptoms from mild GERD can often be successfully treated with medications designed to decrease the amount of acid produced in the stomach. Commonly prescribed medications include H2-blockers (such as ranitidine) and proton pump inhibitors (such as omeprazole). Unfortunately, these medications don’t work for everybody. Other patients may find that GERD medications may work for a while, but over time become less effective at controlling symptoms. Proton Pump Inhibitor medications are the most potent acid-inhibitors and the most commonly prescribed GERD medications. Unfortunately, numerous studies have shown that long-term use of these medications can lead to decreased bone density and an increased risk for fractures of the wrist, hip, and spine.

In GERD, stomach contents in addition to acid reflux upwards from the stomach and into the esophagus. These stomach contents include digestive enzymes that may be especially damaging to the larynx (voice box) and lungs (airway) in patients with symptoms such as hoarseness, cough, and asthma related to GERD. Unfortunately, medications for GERD are only good for decreasing the acid content of the stomach contents that ultimately reflux into the esophagus – these medications don’t actually stop the reflux from occurring. This is one reason why GERD medications don’t work for some patients.

When medical treatment for GERD fails, an antireflux procedure may be an option. Procedures designed to treat GERD include:

• Endoscopic, incisionless procedures such as the Transoral Incisionless Fundoplication (Esophyx or TIF)
• Laparoscopic antireflux surgery such as Nissen fundoplication
• Newer devices such as the LINX® magnetic system

One of the keys to getting a good result following an antireflux procedure is a proper preoperative evaluation. In order to determine if a patient is a candidate for GERD surgery, one or more of the diagnostic tests described below may be required.

• Upper endoscopy – in this procedure a thin, flexible fiberoptic scope is gently guided down the esophagus and into the stomach. During this procedure, patients are sedated. Upper endoscopy is necessary to examine the esophagus for signs of acid damage (esophagitis) or for pre-cancerous changes that can happen in certain patients with long-standing GERD (Barrett’s esophagus). The doctor may perform a biopsy or take some pictures during the procedure. All patients need to have an endoscopy before considering GERD surgery.
• 24-hour esophageal impedance testing/pH study – this test involves the placement of a very thin, soft tube through the nose and into the esophagus. The tip of the tube is placed just above the top of the stomach at the end of the esophagus. This test measures the amount of acid (and non-acid in the case of impedance) reflux experienced by a patient during the course of a day’s time.
• Esophageal manometry – this test involves the placement of a soft, thin tube through the nose and into the esophagus. Patients are asked to swallow and the motility of the esophagus (squeeze pressure and pattern) is measured.
• Other tests – there are several other tests that may be helpful in determining the correct diagnosis and evaluating patients for a possible surgical procedure aimed to cure their GERD. Not all of these tests are necessary for every patient. A gastroenterologist often directs the pre-operative evaluation. A gastroenterologist is a physician who specializes in the medical (non-surgical) treatment of disorders of the gastrointestinal tract. Sometimes, surgeons direct the preoperative evaluation or request additional testing in certain patients.

Any time an internal body part pushes into an area where it doesn't belong, it's called a hernia. The hiatus is an opening in the diaphragm - the muscular wall separating the chest cavity from the abdomen. Normally, the esophagus goes through the hiatus and attaches to the stomach. In a hiatal hernia, the stomach bulges up into the chest through that opening. There are two main types of hiatal hernias: sliding and paraesophageal (next to the esophagus).

In a sliding hiatal hernia, the stomach and the section of the esophagus that joins the stomach slide up into the chest through the hiatus. This is the more common type of hernia. These sliding hiatal hernias are a risk factor for GERD. When a patient with GERD requires surgery, if a hiatal hernia is present, it is repaired at the time of the antireflux surgical procedure.

Barrett’s esophagus is a condition in which the cells of the lower esophagus become damaged, usually from repeated exposure to stomach acid. A diagnosis of Barrett's esophagus can be concerning because it increases the risk of developing esophageal cancer. The risk is small, and monitoring of Barrett's esophagus focuses on periodic endoscopic exams to find precancerous cells. If precancerous cells are discovered, they can be treated to prevent esophageal cancer. Patients who develop esophageal cancer may require an esophageal resection.