Incisionless Fundoplication
Incisionless Fundoplication for the Treatment of GERD
What is it?
Gastro-esophageal reflux disease (GERD) is a very common condition in which stomach contents reflux into the lower esophagus causing a variety of symptoms. This condition, which creates the sensation of heartburn, is one of the most common esophageal ailments Americans face today. When left untreated, GERD may increase the risk of developing cancer of the esophagus.
What causes it?
The cause of GERD is typically multifactorial and involves factors that affect the ability of the lower esophageal sphincter muscle to prevent stomach contents from refluxing into the esophagus. These factors include abnormal positioning of the sphincter (such as in the case of hiatal hernia), consumption of certain foods that affect its ability to contract (alcohol, caffeine, peppermint, etc.), and a variety of other factors.
What are the Symptoms?
The most common symptoms of GERD are referred to as typical symptoms. These include heartburn, abdominal or chest pain, belching or bloating, and difficulty swallowing. Atypical symptoms result from the effects of reflux on the respiratory system, and include chronic cough, pneumonia, wheezing, and hoarseness of the voice.
How is it Diagnosed?
The work-up for GERD typically begins with an upper endoscopy, in which the lining of the esophagus can be evaluated and biopsied to determine if any pre-malignant changes have occurred (Barrett’s esophagus). A hiatal hernia may also be detected during this procedure. Hiatal hernias and other structural variations may be further evaluated by an upper GI barium swallow exam, which will allow the esophagus and stomach to be visualized on an x-ray. The function of the esophageal muscles should also be evaluated by a manometry test which measures the pressures in the esophagus during swallowing.
The diagnosis and severity of GERD is finally confirmed with a 24-hour pH test. This is accomplished either by placing a small tube into the esophagus which protrudes from the nose or an implantable device that eventually passes out through the GI tract. Information regarding acid exposure to the lower esophagus is recorded and may be analyzed to generate a score (DeMeester score) that describes the severity of GERD.
Evaluation for Treatment
Patients with GERD need a full evaluation of their esophageal anatomy and function prior to consultation for surgical treatment. Pre-operative tests include upper endoscopy (EGD) and video barium swallow. Patients may also require an esophageal manometry test with a 24 hour acid evaluation. The basic evaluation can be performed by your gastroenterologist or our specialists can recommend and perform the required tests. Some tests may need to be repeated. To schedule an appointment call 614-293-3230.
Incisionless Fundoplication Treatment Option
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GERD is initially managed medically using H2 blockers or proton pump inhibitors, as well as lifestyle modifications. In the event of failure of medical management or premalignant damage to the esophagus (Barrett’s esophagus) detected on endoscopy, surgical management is recommended.
Surgical management involves tightening the opening in the diaphragm through which the esophagus enters the abdomen from the chest and then wrapping part of the stomach partially or completely around the lower esophagus. This is technically known as a fundoplication. If a hiatal hernia is present it is repaired in conjunction with this fundoplication. Traditionally this surgery was performed through an incision in the abdomen. Today however, specialists at The Ohio State Medical Center are offering a new treatment called Endoluminal Tissue Fusion. It is performed using the EsophyX device that is passed into the stomach through the mouth with the guidance of an endoscope, or small flexible camera. Once the device is passed through the mouth and into the stomach, small plastic fasteners that fold the upper stomach unto itself and recreate the lower esophageal sphincter (LES), are placed by the surgeon. Recreation of the LES stops the stomach acid from backing up into the esophagus, thus providing relief from the sensation of heartburn. This approach does not require any skin incisions and is therefore associated with fewer complications, less pain, and a faster recovery when compared to other surgical options. While the procedure often requires an overnight hospital stay, the recovery is rapid and the procedure provides prompt improvement in symptoms.
Complications, although rare, include bleeding and infection. It is uncommon to require a blood transfusion for this operation. Post-operatively rare problems may occur, mainly involving difficulty with swallowing or the fundoplication slipping into the chest.
In an otherwise healthy person, little is required to prepare for surgery. Depending on your age, gender, and health problems, some routine blood tests, an EKG and a chest x-ray may or may not be needed. Your surgeon or family doctor will order these tests as needed. You will be asked to refrain from eating 8 hours before surgery. Be sure to let your doctor know what medications you are taking, as some will need to be stopped before surgery. In general, all blood thinners need to be stopped for several days. These include aspirin, Ibuprofen or Motrin, Coumadin and Plavix.
This operation is generally performed with general anesthesia. An IV line will be placed in your arm for fluids and you will be brought into the operation room. The anesthesiologist and nurses will use monitors to check your heart rate and breathing during the procedure. These may include EKG leads, a blood pressure cuff, an oxygen mask and sleeves on your legs to prevent clots from forming.
Once you are asleep, the operating room team will work together to perform your operation. When your operation is complete, you will be awakened from anesthesia in the operating room but you may not remember this. After a few hours in the recovery room you will be transferred to the surgical ward. It is common to feel groggy and nauseated soon after surgery and medication is available to help with these discomforts. At the Ohio State University Medical Center most patients following incisionless fundoplication remain in the hospital overnight following the surgery. You will gradually be allowed to increase your intake by mouth, first liquids only followed by soft then regular solid food. Once your surgeon feels your recovery has been appropriate, meaning you are able to eat and drink adequate quantities and you pain is adequately controlled with pills, you will be discharged to home.
Heavy lifting of greater than 10 lbs or any strenuous physical activity should be avoided until your follow-up appointment. Driving should be avoided particularly while taking narcotic pain medication. Symptoms that should prompt an immediate call to your surgeon include severe pain, fever of > 101 F, inability to swallow, vomiting, or shortness of breath.
This information is not intended to replace a visit with your physician. If you have further questions, please call 614-293-3230.