Gastro-esophageal reflux disease (GERD) is a very common condition in which stomach contents reflux into the lower esophagus causing a variety of symptoms. When left untreated, GERD may increase the risk of developing cancer of the esophagus.
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.
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.
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.
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. Over the past decade the laparoscopic approach has gained favor as the preferred technique. This is a minimally invasive approach that involves specialized video equipment and instruments that allow a surgeon to perform the fundoplication through several tiny incisions, most of which are less than a half-centimeter in size. The concept of the surgery remains the same as the open approach. The advantages of this method include a shorter hospitalization, less pain, fewer and smaller scars, and a shorter recovery.
Laparoscopic fundoplication is a safe and effective treatment for GERD. However, in the presence of adhesions or variations in anatomy, this method becomes dangerous and your surgeon may need to make the prudent decision to continue by making the traditional incision to safely complete the operation. This should not be seen as a failure, but as a wise decision by your surgeon to prevent dangerous complications.
Other complications, although rare, include bleeding and infection. It is uncommon to require a blood transfusion for this operation. There is a risk of injury to the esophagus, liver, stomach, bowel, and spleen. 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 remain in the hospital for 2-3 days 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.
You may experience pain at the incision sites and in the chest, as well as mild difficulties swallowing. You will be provided with a prescription for narcotic pain medicine. You should take a stool softener in conjunction with this pain medicine in order to prevent constipation. 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 the your surgeon include severe pain, fever of > 101 F, inability to swallow, vomiting, redness or drainage at the incision sites, 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.