Gastroesophageal Reflux disease (GERD)

GERD is burning sensation in the chest or upper abdomen that happens frequently after eating, lying down and exercise.  This happens as a result of disrupted valve mechanism between the esophagus and the stomach leading to reflux of stomach acid in the esophagus. Continuous reflux of acid in the lower esophagus leads to erosion and inflammation of the lower esophagus. This leads to burning sensation in the lower chest and if severe, leads to reflux in the back of the throat.  More than two episodes of heart burn within a week is considered abnormal and requires treatment.  There is an association of increased prevalence of GERD in the population leading to increased incidence of esophageal cancer.

Hiatal hernia is a defect in the diaphragm/muscle membrane between the chest and the abdomen. With increasing age and weakness of the diaphragm, the defect gradually increases in size leading to herniation or moving up of the stomach in the lower chest. This leads to disruption of the protective mechanism leading to abnormal reflux of acid in the lower esophagus

 

Depending on the severity of GERD, patient may have following symptoms,

Heartburn: burning sensation in the lower part of chest

Waterbrash: regurgitation of excessive mucus or acid from the esophagus leading to bitter taste in the back of the throat.

Cough: Acid reflux in the upper esophagus leads to inflammation of the vocal cords leading to constant coughing

Recurrent pneumonia or Asthma: this is due to silent aspiration of the refluxed acid contents into the airways.

GERD is known to be caused due to

  • Disruption of Lower Esophageal Sphincter valve mechanism
  • Hiatal hernias
  • Abnormal esophageal motility
  • Delayed gastric emptying of the stomach
  • Smoking
  • Obesity
  • Pregnancy

Some of the test required in the diagnosis of GERD includes the following

EGD: A gastroscope is introduced in the esophagus and stomach. Any inflammation of the esophagus, stomach is noted and biopsy of any abnormal tissue can also be taken.

Bravo pH study: Acid measuring chip is placed in the lower esophagus which monitors the reflux of acid in the lower esophagus. This chip transmits the recording to a recording device for 48 hours. You will turn in the recording device to your gastroenterologist who will determine the abnormal results. The results are reported as DeMeester score. A Score of <14 is considered normal. The acid chip in the esophagus falls off on its own after a couple of days.

You are required to stop taking any antacid medications 5 days prior and 2 days after the Bravo pH probe is placed.

Upper Gastrointestinal Study with bagel and marshmallow 15 degree head down evaluates esophageal motility. This helps to determine whether a 360 degree wrap or 270 degree warp is required. If the esophagus is found to have dysmotility, 360 degree Nissen wrap will lead to dysphagia.

 

Some patients, but not all, experience one or more of the listed symptoms below after the operation:

  1. Shoulder pain last from 1-3 days after surgery. The pain is related to CO2insufflation necessary for laparoscopic operations. The nerves located in the area of the lower esophagus also supply the shoulder leading to a referred pain.
  2. Difficulty swallowing solid food for 1-5 days. This is due to some swelling in the lower esophagus which eventually resolves. During this time we will recommend you to have liquid diet. After 2 weeks, you will advance your diet slowly to a regular diet.
  3. Nausea and/or vomiting may occur after surgery for 1-2 days. This is usually related to general anesthesia administered during the operation.
  4. Early satiety for 5-7 days. This may be due to some of the stomach used to construct the wrap (fundoplication).
  5. Passing more gas. As a natural mechanism to help symptoms of GERD, our brain involuntarily learns to swallows air. Once the valve is created, the only way the air can move is downwards leading to increased flatus. Once this behavior is unlearned by the brain, passage of more gas will reduce.
  6. Increase frequency of bowel movements for 2-3 weeks.
  7. Incisional pain.
  8. Epigastric discomfort. This correlates to the location of the operation. As the healing continues, this discomfort will get better.

Some of the initial remedies which are recommended to help with the symptoms of GERD include the following.

Smoking cessation

Weight loss to Body Mass Index of less than 26

Proton pump inhibitors: omeprazole (Prilosec, Zegerid), lansoprazole (Prevacid), pantoprazole (Protonix), rabeprazole (Aciphex), and esomeprazole (Nexium) decrease acid production and are available by prescription. However GERD is a mechanical problem and not a chemical problem.

Though the acid production is reduced, the bile and other gastric content continue to reflux in the esophagus causing the ongoing damage.

Though medical management is considered the mainstay of treatment, depending on the severity of your GERD, treatment may involve lifestyle changes, weight loss, or surgery.

When lifestyle changes fail to help with GERD or GERD become refractory of medication, Surgery is preferred options as lifelong GERD can potentially lead to increased esophageal Cancer. Nissen fundoplication (360 degrees) is the standard surgical procedure to treat GERD. If there is poor esophageal motility a Toupet fundoplication (270 degree) is undertaken.

              

A Single Site Laparoscopy fundoplication is procedure where the upper part of the stomach (fundus) is wrapped or plicate around the lower part of the esophagus recreating the valve mechanism.

We avoid placement of any prosthetic mesh material. If hiatal hernia is present, this is fixed at the same time.

Essentially all our procedures are done through single site Laparoscopy. This means, the entire operation is performed through a small 1 cm incision in the umbilicus. This can be compared to conventional laparoscopy where 4-5 incisions are made on the abdominal wall. The advantage here is better cosmetic scar and less pain. The only scar is hidden in the umbilicus which itself is a natural scar.

 

GERD

GERD is burning sensation in the chest or upper abdomen that happens frequently after eating, lying down and exercise.  This happens as a result of disrupted valve mechanism between the esophagus and the stomach leading to reflux of stomach acid in the esophagus. Continuous reflux of acid in the lower esophagus leads to erosion and inflammation of the lower esophagus. This leads to burning sensation in the lower chest and if severe, leads to reflux in the back of the throat.  More than two episodes of heart burn within a week is considered abnormal and requires treatment.  There is an association of increased prevalence of GERD in the population leading to increased incidence of esophageal cancer.

Hiatal hernia is a defect in the diaphragm/muscle membrane between the chest and the abdomen. With increasing age and weakness of the diaphragm, the defect gradually increases in size leading to herniation or moving up of the stomach in the lower chest. This leads to disruption of the protective mechanism leading to abnormal reflux of acid in the lower esophagus

 

Symptoms

Depending on the severity of GERD, patient may have following symptoms,

Heartburn: burning sensation in the lower part of chest

Waterbrash: regurgitation of excessive mucus or acid from the esophagus leading to bitter taste in the back of the throat.

Cough: Acid reflux in the upper esophagus leads to inflammation of the vocal cords leading to constant coughing

Recurrent pneumonia or Asthma: this is due to silent aspiration of the refluxed acid contents into the airways.

GERD is known to be caused due to

  • Disruption of Lower Esophageal Sphincter valve mechanism
  • Hiatal hernias
  • Abnormal esophageal motility
  • Delayed gastric emptying of the stomach
  • Smoking
  • Obesity
  • Pregnancy

Diagnosis

Some of the test required in the diagnosis of GERD includes the following

EGD: A gastroscope is introduced in the esophagus and stomach. Any inflammation of the esophagus, stomach is noted and biopsy of any abnormal tissue can also be taken.

Bravo pH study: Acid measuring chip is placed in the lower esophagus which monitors the reflux of acid in the lower esophagus. This chip transmits the recording to a recording device for 48 hours. You will turn in the recording device to your gastroenterologist who will determine the abnormal results. The results are reported as DeMeester score. A Score of <14 is considered normal. The acid chip in the esophagus falls off on its own after a couple of days.

You are required to stop taking any antacid medications 5 days prior and 2 days after the Bravo pH probe is placed.

Upper Gastrointestinal Study with bagel and marshmallow 15 degree head down evaluates esophageal motility. This helps to determine whether a 360 degree wrap or 270 degree warp is required. If the esophagus is found to have dysmotility, 360 degree Nissen wrap will lead to dysphagia.

 

What to expect

Some patients, but not all, experience one or more of the listed symptoms below after the operation:

  1. Shoulder pain last from 1-3 days after surgery. The pain is related to CO2insufflation necessary for laparoscopic operations. The nerves located in the area of the lower esophagus also supply the shoulder leading to a referred pain.
  2. Difficulty swallowing solid food for 1-5 days. This is due to some swelling in the lower esophagus which eventually resolves. During this time we will recommend you to have liquid diet. After 2 weeks, you will advance your diet slowly to a regular diet.
  3. Nausea and/or vomiting may occur after surgery for 1-2 days. This is usually related to general anesthesia administered during the operation.
  4. Early satiety for 5-7 days. This may be due to some of the stomach used to construct the wrap (fundoplication).
  5. Passing more gas. As a natural mechanism to help symptoms of GERD, our brain involuntarily learns to swallows air. Once the valve is created, the only way the air can move is downwards leading to increased flatus. Once this behavior is unlearned by the brain, passage of more gas will reduce.
  6. Increase frequency of bowel movements for 2-3 weeks.
  7. Incisional pain.
  8. Epigastric discomfort. This correlates to the location of the operation. As the healing continues, this discomfort will get better.

Treatment

Some of the initial remedies which are recommended to help with the symptoms of GERD include the following.

Smoking cessation

Weight loss to Body Mass Index of less than 26

Proton pump inhibitors: omeprazole (Prilosec, Zegerid), lansoprazole (Prevacid), pantoprazole (Protonix), rabeprazole (Aciphex), and esomeprazole (Nexium) decrease acid production and are available by prescription. However GERD is a mechanical problem and not a chemical problem.

Though the acid production is reduced, the bile and other gastric content continue to reflux in the esophagus causing the ongoing damage.

Though medical management is considered the mainstay of treatment, depending on the severity of your GERD, treatment may involve lifestyle changes, weight loss, or surgery.

When lifestyle changes fail to help with GERD or GERD become refractory of medication, Surgery is preferred options as lifelong GERD can potentially lead to increased esophageal Cancer. Nissen fundoplication (360 degrees) is the standard surgical procedure to treat GERD. If there is poor esophageal motility a Toupet fundoplication (270 degree) is undertaken.

              

A Single Site Laparoscopy fundoplication is procedure where the upper part of the stomach (fundus) is wrapped or plicate around the lower part of the esophagus recreating the valve mechanism.

We avoid placement of any prosthetic mesh material. If hiatal hernia is present, this is fixed at the same time.

Essentially all our procedures are done through single site Laparoscopy. This means, the entire operation is performed through a small 1 cm incision in the umbilicus. This can be compared to conventional laparoscopy where 4-5 incisions are made on the abdominal wall. The advantage here is better cosmetic scar and less pain. The only scar is hidden in the umbilicus which itself is a natural scar.