Gastroesophageal Reflux Disease (GERD)

Gastroesophageal Reflux Disease (GERD) is an extremely common condition in which acid from the stomach refluxes up into the esophagus creating symptoms of indigestion. Classically, these symptoms are described as a burning or pain in the chest. It often occurs with eating or drinking, and is worse when a person bends over or lies down. Some people report being awakened at night by bitter tasting fluid refluxing into their throats causing burning and coughing. Other symptoms may include dysphagia (difficulty swallowing) and frequent belching. The long term effects of significant GERD may include scaring and stricturing of the esophagus producing difficulty swallowing, damage to the teeth from repeated exposure to acid, and aspiration of acid leading to bronchitis or pneumonia. Prolonged injury to the esophageal lining by the acid may also produce cellular changes (Barrett’s Esophagitis) which may increase a person’s risk of developing esophageal cancer.

The initial treatment of GERD is with the use of antacid medications, such as histamine blockers (Pepcid, etc.) or proton pump inhibitors (Nexium, etc..), changing the type of foods eaten, the timing of meals, avoiding tobacco and alcohol, and elevating the head of the bed. Many people have adequate relief of their symptoms with these interventions. There are some people, however, which require actual surgical correction of the reflux problem. These individuals are generally those who do not obtain adequate relief of their symptoms with conservative treatment. They may have also developed complications of their disease, such as recurrent stricturing of the esophagus, Barrett’s esophagitis, or ulcerations, recurrent pneumonia or bronchitis. Operation is also offered to individuals who do not want to take antacids the rest of their lives.

The workup for a person with significant GERD will almost always include upper endoscopy, to evaluate the anatomy and the degree of injury to the esophagus, and to rule out diseases of the stomach which may also be present. Additional tests may be ordered, such as a barium upper GI study, a manometry study (to evaluate the motility of the esophagus), and a pH study (to document the presence of acid reflux and correlate it with the person’s symptoms). The surgical treatment of GERD is based on the understanding that it is a dysfunction of anatomy. The lowest segment of the esophagus is known as the lower esophageal sphincter. Increased pressure in this segment prevents frequent and prolonged acid reflux events into the esophagus. When this ‘valve’ does not perform it’s function adequately, a person experiences the symptoms of reflux. Often the dysfunction of the sphincter is due the presence of a hiatal hernia. A hiatal hernia is the protrusion of the upper most part of the stomach and the lower esophageal shincter into the chest through the diaphragm (the wall of muscle which separates the chest cavity from the abdominal cavity).

The surgical correction of GERD is designed to pull the stomach and the sphincter back down into their proper anatomic positions, repairing the defect in the diaphragm, and recreating the pressure valve in the esophagus to prevent reflux. The operation, called a Laparoscopic Nissen Fundoplication, is carried out using minimally invasive techniques of very small incisions and specialized instruments and cameras. The procedure generally requires 45 to 90 minutes to complete. Most patients spend one night in the hospital and are discharged the next morning. After surgery, a patient can expect to experience some mild dysphagia and bloating. These symptoms usually persist 7 to 14 days, and resolve as the post-operative internal swelling resolves. Nevertheless, it is recommended that for 7 to 14 days after surgery, the patient limit his/her diet to very soft, easy to swallow foods. These expectations will be discussed at length by your surgeon. Laparoscopic Nissen Fundoplication is very effective at controlling GERD, frequently allowing the patient to cease taking antacid medications altogether.

All content copyright 2010, Alan F. Jacks, MD, PA