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Click Here For An Animation Of A Nissen Fundoplication
What is GERD?
Gastro-Esophageal Reflux Disease is the result of acid from the stomach backing up into the esophagus. The esophagus is the long tube that connects the mouth to the stomach. The tissues of the esophagus are not designed to handle the harsh acid of the stomach. A muscular valve called the Lower Esophageal Sphincter (LES) is designed to keep acid from backing into the esophagus. This valve is located in the gastro-esophageal junction or entry of the stomach. When the LES valve fails, patients develop symptoms of heartburn, pain, indigestion, and an occasional acid or metallic taste in the mouth. Patients may wake up with a severe cough or even suffer from aspiration of stomach contents into the lungs. Patients may also develop symptoms of asthma.
Over time, significant injury to the esophagus can
occur from GERD. This
includes inflammation, ulceration, stricture, premalignant changes known
as Barrett Esophagus, and even cancer.
The initial treatment for GERD includes medications that decrease the stomach’s production of acid, elevating the head of the patient’s bed, eliminating meals close to bedtime, avoiding foods like chocolate, caffeine, and alcohol, and stopping smoking. When these measures fail or become unacceptable, surgery becomes the best answer.
What is a Hiatal Hernia?
A Hiatal Hernia
is often present in patients with GERD.
A Hiatal Hernia occurs when the upper part of the stomach slides through
an opening in the diaphragm, and up into the chest. This opening is called
the “hiatus”. This commonly allows the lower esophageal sphincter muscle
(LES) to fail in the low pressure environment of the chest, which then
results in GERD or reflux.
What is a Paraesophageal Hernia?
In Paraesophageal Hernias, the gastro-esophageal junction (entry to the stomach) remains where it belongs in the abdomen. Other parts of the stomach are twisted and squeezed up into the chest beside the esophagus where they do not belong. Patients with this problem usually do not have symptoms of reflux or GERD. With this type of hernia, complications can occur such as incarceration or even strangulation. Incarceration is common, and occurs when the stomach is stuck and is being squeezed by its tight position. This results in severe chest pain, difficulty swallowing, indigestion, nausea and vomiting. Strangulation is a surgical emergency, and occurs when the blood supply to the stomach is so twisted that it is cut off. This can lead to death of the stomach, and can be life threatening.
The Surgical Treatment of GERD, Hiatal Hernias, and Paraesophageal Hernias
The
surgery for these problems is largely the same. The surgery is aimed at both creating a functional valve
between the esophagus and stomach, and repairing the Hiatal hernia or
Paraesophageal hernia with a
biologic mesh. Endoscopy and
motility testing done prior to surgery will help determine the type of
surgery that will work best. The
most common procedure is called a Nissen Fundoplication.
This surgery involves wrapping a portion of the stomach around the
esophagus to create a new valve. These
procedures are now performed through the laparoscope, although
occasionally an open surgery is required.
The
laparoscopic surgery typically requires 5 incisions, each less than half
an inch long. The patient’s
abdomen is distended with carbon dioxide gas.
The surgeon then inserts a special called the laparoscope
which allows him to see inside the body.
The other incisions in the abdomen are for specialized instruments
to perform the surgery.
Most
patients are able to go home the day after surgery, or as soon as they are
able to eat adequately. The
vast majority of patients are permanently cured of their GERD with few or
no problems.
Your
Diet Following Surgery
It can be difficult to swallow following GERD surgery. A good
solution is to eat several (6 - 8) small meals daily and chew thoroughly
(15 to 20 times) A full liquid diet is
recommended for the first 2 weeks after surgery.
Liquids or foods that are passed through a blender are usually well
tolerated. Soups, custards,
pudding, ice cream, apple sauce, oatmeal, pureed vegetables, and similar
foods work well for most people. Some foods that tend to
cause problems and should be avoided in the first few weeks are bread,
pasta, rice and carbonated beverages.
If you swallow something that sticks in your throat, remember to relax, drink plenty of fluids, and wait, it will eventually pass.
A Nissen Fundoplication showing the sutures that create the wrap
The
Risks of Surgery
All surgery has risks,
including the risks of bleeding, infection, and anesthesia . Unique to the surgery for GERD are the risks of injury to the
stomach, the esophagus, the liver, the spleen and other abdominal organs.
After surgery it is possible
for the stomach to “slip” and have GERD return.
As with any laparoscopic procedure, problems can develop during
surgery that require the operation be converted to an open procedure.
In reality, the success rate is very high, and complications are
uncommon.
After
Surgery
Most patients are able to stop all of their GERD medications and restrictions after surgery, although please discuss this with your surgeon first. It can be difficult for many patients to eat in their usual manner following surgery. Large bites will simply not pass into the stomach as easily as before.
It is important to learn how to eat slowly after this procedure.
Small bites of food should be chewed 15 to 20 times before
swallowing.
It is common for patients to
lose some weight following GERD surgery. Occasionally a patient will lose
as much as 10 to 20 pounds in the first few weeks after their procedure.
A good solution is to eat several (6-8) small meals daily, until
your weight and condition has stabilized.
Center for Minimally Invasive Surgery
(253) 572-7120
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