The Division of Thoracic Surgery

Gastroesophageal Reflux Disease

Intro

Gastroesophgeal reflux disease (GERD) is a common problem. Nearly 44% of Americans experience recurrent heartburn and 18% of these individuals use some type of nonprescription medication for their problem. GERD results from a failure of the antireflux barrier provided by the lower esophageal sphincter, the diaphragmatic crura, and phrenoesophgeal ligament. Normally, following a swallow, the lower esophgeal sphincter (LES) relaxes and allows food to pass into the stomach. It then immediately closes to prevent reflux; however, in some patient, the LES stays relaxed. This allows contents of the stomach, which are often acidic, to reflux back into the esophagus and damage the lining. Symptoms of chronic heartburn result, however, not all pateints with GERD have heartburn symptoms. Respiratory disease and muscosal changes such as Barrett's esophagitis are often indicative of chronic reflux disease.

Diagnosis

Diagnosis of GERD are dependent on one of the following studies

  1. presence of documented esophgeal injury ( esopphagitis) on edonscopy
  2. Excessive acid reflux during 24 hr intraesophgeal pH monitoring

Management

Lifestyle

Some patients are born with a weak lower esophgeal spincter. However, lifestyle does contribute to symtpoms. Fatty foods, spicy foods, certain medications, right clothing, smoking, drinking alcohol, vigrous exercise, and body habitus affects reflux symptoms. In many cases, changing diet, losing weight, reducing or eliminating smoking, alcohol, caffeine, or altering sleeping and eating patterns can help lessen symptoms.

Medical therapy

Esophagitis will heal in approximately 90% of cases with intensive medical therapy which included proton pump inhibitors. However, approximtely 80% of patients have recurrent symptoms within one year of drug withdrawal. Hence, pateints often need lifelong medication. Furthermore, while medication addresses acid related reflux, the esophagus may continue to be damaged secondary to alakine reflux.

Surigcal Therapy

Patients with continued symptoms depite medical therapy or patients who do not want to take chronic antacid medication should consider surgery. Surgery addresses the mechanical nature of the condition and is curative in 85-93%of patients. Longitudinal studies report good to excellent long term results in 80-93% if surgically treated patients. Surgery should be considered for patients who have

  1. failed medical management
  2. opt for surgery despite successful medical mangement due to lifestyle considerations
  3. have complications of GERD (Barrett's esophagus; grade III or IV esophagitis)
  4. have medical complications attributable to a large hiatal hernia (bleeding, dysphagia)
  5. have atypical symptoms (asthma, hoarseness, cough, chest pain, aspiration) and documented reflux

Pre-operative studies

Before considering surgery for GERD, the following studies are recommended

  1. Esophagogastroduodenoscopy
  2. Esophageal Manometry
  3. 24 hr pH intraesophgeal pH monitoring
  4. Barium swallow

Patients undergoing reoperative srugery will likely also attain a gastric motility study.

Laparoscopic Nissen Fundoplication

Laparoscopic repair of GERD involves utilizing small ¼ to ½ inch incisions to enter the abdominal cavity. Approximately 5 incisions are made and a small video scope is inserted into the abdomen. The cavity is insufflated with CO2 gas. Tissues around the esophgeal hiatus are dissected and small arteries that run between the spleen and stomach are divided. The most common procedure is the Nisen fundoplication which involves wrapping part of the stomach around the distal esophagus in a 360 degree fashion. This is suture together and the esophgeal hiatus is tightened with sutures. Patients with decreased esophageal motility may get a loose wrap or a partial wrap (Toupet fundoplication). The choice and success of the procedure depends on the training and expertise of the surgeon.

The primary goal of surgery is to re-establish the antireflux barrier with causing a wrap that is too tight and results in devere dysphagia. Occasionally, the esophgus may need to be lngthened to allow for a longitubdinal, tension free funcoplication that rests in the abdomen. Factors which may preclude laparscopic surgery and convert to "open" surgery include obesity, history of prior surgery, or leeding.

What to do before surgery

  1. Review potential risks and benefits with your surgeon
  2. Lose weight
  3. Have a pre-operative eval with anesthesiologists including blood work, xrays, ekg
  4. Shower the night before surgery
  5. After midnight the night before surgery, do not eat or drink anything except for medication with a sip of water.
  6. Your surgeon may request that you clean your colon and drink clear liquid for a day or so before surgery
  7. Certain drugs such as blood thinner should be disconinuted after consultation with your doctor
  8. Diet medication or St. John's Wort should not be used for 2 weeks prior to surgery
  9. Quit smoking
  10. Arrange for help at home

What to expect the day of surgery

  1. Arrive at the hospital on time
  2. A small needle/catheter will be placed into your vein
  3. You will be under general anesthesia for the surgery. Your family can wait in the familty waiting room
  4. Following the operation, you will be sent to the recovery room until you are fully awake

What to expect after surgery

  1. You will have serveral small band-aids covering yoru incision which can be removed 48 hrs after surgery
  2. Light activity is encouraged at home but no strenuous activity for 6-8 weeks.
  3. Post-op pain is mild and generall is address with tylenol or advil
  4. You will be on a modifed diet as outlined below

What are the effects after surgery

  1. Most patients are symptom free or have significant improvement of their GERD symptoms
  2. Some patients have tempory difficulty swaloowing immediately after surgery. This usually resolvs one to three months after surgery
  3. Occasionally, pateints may require an outpatient procedure to stretch the esophagus ( endoscopic dilation )
  4. The ability to belch and/or vomit may be limited. Few pateints report some stomach bloating

What are the possible complications

  1. adverse reaction to general anesthesia
  2. bleeding
  3. injury to esophagus, spleen, stoch, or internal organs
  4. infection of wound, abdomen, or blood

When to call your doctor

  1. Fever over 101 degrees F
  2. Bleeding
  3. Increasing abdominal pain or swelling
  4. Perisstent nausea or vomiting
  5. Chillls
  6. Perissitent cough or shortness of breath
  7. Redness around your incisions that is getting worse or bigger
  8. Unable to eat or drink

Email Comments about this website may be directed to: kzahner@partners.org

NOTICE: This email is not for medically related issues. Comments or concerns regarding patient-related care should be directed to the Thoracic Surgery Clinic at 617-732-6824.

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Division of Thoracic Surgery
Brigham and Women's Hospital
75 Francis Street
Boston, MA 02115

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