Acid reflux or “heartburn” occurs when stomach contents leak back, or reflux, into the esophagus. Refluxed stomach acid creates a burning sensation in the chest or throat called heartburn or indigestion. Occasionally, people describe reflux as a burning sensation in the back of the mouth.
Heartburn that occurs more than twice a week may be considered gastro-esophageal reflux disease (GERD). Some people have GERD without heartburn. In other words, it is a “silent’’ reflux. Others experience pain in the chest, hoarseness in the morning, or trouble swallowing.
What Causes Acid Reflux?
The esophagus is the muscular tube that carries food from the mouth to the stomach. At the end of the esophagus there is a valve called the lower esophageal sphincter (LES). The function of the lower esophageal sphincter (LES) is to keep stomach contents from refluxing back into the esophagus. Reflux that happens from time to time is normal and usually does not cause any symptoms. Chronic reflux, however, can cause ulcers , an erosion of the lining of the esophagus, a stricture, or severe inflammation.
Reflux is a mechanical problem. It is caused by the sphincter (LES) being dysfunctional, sometimes, a hiatal hernia preventing the sphincter from working properly. Foods, chemicals and certain medications can weaken the function of the sphincter (LES) Examples include:
- Certain Medications
- Anticholinergic drugs ( urinary tract disorder medications)
- Asthma Medications
- Calcium Channel Blockers (High Blood Pressure)
- Diazepam (anxiety disorders and seizure medication)
- Nitrates (Angina)
- Opioid Analgesics ( Prescription pain medications)
- Some Antidepressants
Other conditions can lead to higher pressures in the abdominal cavity which can overwhelm the sphincter LES causing it to become ‘weakened’ and incompetent. Examples include the following:
- Chronic cough or straining
- Bending over
- Over eating or eating late in the evening
When the sphincter (LES) is displaced by a hiatal hernia, patients often experience reflux. A hiatal hernia allows the sphincter (LES) to slide up into the chest (diaphragm) which weakens the sphincter causing reflux.
Over time chronic acid reflux can lead to changes in the cells that line the esophagus. This is known as Barrett’s Esophagus. Patients can also develp pre-cancerous changes (dysplasia) as a result of chronic reflux. Once a patient develops these findings, careful and close follow-up is mandatory with an annual upper endoscopy to rule out the development of cancer.
In most cases reflux can be managed with simple strategies. If you are experiencing reflux you should visit with your doctor for diagnosis and treatment. Pain in the chest can also signify serious conditions such as heart disease so a professional medical consultation is required to distinguish heartburn from something more significant.
Once diagnosed properly, reflux can be managed with several strategies including lifestyle changes and medical therapy
- Avoid causative agents (STOP SMOKING and ALCOHOL CONSUMPTION)
- Weight loss
- Avoid over eating and late night meals
- Elevate the head of the bed a few inches
- Antacids (tums, pepto-bismol)
- H2 blockers (zantac, pepcid)
- Proton pump inhibitors (prilosec, prevacid, zegerid, nexium)
- Your physician may order additional testing including: x-ray (upper gi series), endoscopy, manometry. pH (BRAVO) testing
Surgical treatment of acid reflux
Most GERD symptoms will respond to lifestyle changes and medical management. People who do not respond to conservative management should consider surgery. Over time the cost of the medicines can be significant and some patients will elect to have surgery to correct the condition. Studies have shown that results are better if the surgery is done before the patients GERD becomes severe (maximum medical therapy). Any patient who has developed Barrett’s esophagus or pre-cancerous changes (dysplasia) in the lower esophagus should strongly consider anti-reflux surgery. There are recent studies that report the regression of these findings in some patients who undergo the operation. Patients with Barrett’s esophagus or dysplastic changes who undergo the surgery should continue to have close follow-up including endoscopy on a regular scheduled basis until the condition resolves.
Nissen Fundoplication is the standard surgical treatment for GERD. In this operation, the upper part of the stomach is wrapped around the lower end of the esophagus and the hiatal hernia is repaired.
Advantages to Laparoscopic surgery
- Less Pain
- Shorter Hospital stay
- Faster return to work
- Improved cosmetic result
Can everyone have laparoscopic surgery?
BMI surgeons perform this procedure laparoscopically in most cases. In the event your condition makes you a poor candidate for laparoscopic surgery, your surgeon will discuss other options during your office visit. In some cases, patients are good candidates for anti-reflux surgery however their body mass index may be greater than 35. In these cases, many patients are offered weight loss surgery instead – particularly the Roux Y Gastric bypass.
The pre-operative period
The risks and benefits of the procedure will be reviewed during your r clinic appointment. As with any surgical procedure, you will be required to have some routine pre-surgical labs and tests performed. These include, blood work, x-rays, and an EKG. In the event that additional tests are required, your BMI surgeon will explain and order these on a case-by-case basis.
On the day before surgery you should have only a clear liquid diet and nothing to eat or drink after midnight with the exception of some medications. . You should shower the day before or the morning of your operation.
Medications such as aspirin, coumadin, or other blood-thinnig agents should be stopped at least 7 days prior to surgery. Vitamin E, diet medications and St’ John’s wort should also be stopped at least 7 days prior to surgery. Your surgeon will be happy to discuss any specific questions or concerns you may have. BMI surgeons encourage all patients to stop smoking and begin an exercise program prior to any surgical procedure.
After surgery, you will spend 1 – 2 nights in the hospital. You will be encouraged to ambulate as soon as possible and will be encouraged to utilize the incentive spirometer after surgery. (Pain is controlled With liquid narcotics. There is very little pain after surgery.)
Most patients have complete resolution or a significant improvement of their symptoms. In fact, most people will wake up from surgery and notice a difference right away!!
After the operation and for the next few weeks, patients consume what is referred to as a “post-nissen diet.” This is composed mainly of slippery food for example scrambled eggs, cottage cheese, and/or yogurts. In the first 4-6 weeks after surgery there can be swelling at the wrap which narrows the opening to the stomach. Some patients will swell more than others and at times can have difficulty swallowing. Liquids and post nissen diet provides nutrition that will pass smoothly through the opening. If solid food is taken too soon after surgery, it can irritate the lining of the wrap and aggravate the swelling thus prolonging the transition to a regular diet. At BMI of Texas we will have you visit with a dietician in the office who will help you with your dietary issues.
A laparoscopic Nissen Fundoplication is a very safe operation and has a less than 1% mortality. Potential acute complications are rare but can include bleeding, infection, damage to the stomach, esophagus, the vagus nerve, the spleen, or other internal organs. Other less common risks are hernia, wound problems, need for open surgery or re-operation.
Some patients will experience mild abdominal bloating after surgery.
After a fundoplication there is some swelling at the junction between the stomach and esophagus which inhibits some patients from burping as they did before to expel the swallowed air. The air is then passed into the intestines and consequently patients may experience some bloating. The good news is that once the swelling subsides most patients can burp normally.
You should call your BMI surgeon if you experience:
- persistent fever over 101 degrees
- persistent nausea or vomiting
- worsening abdominal pain- uncontrolled by medication
- increasing abdominal swelling
- chest pain
- shortness of breath
- redness around or pus coming from incisions
- inability to tolerate liquids
What are the restrictions, after this surgery?
There are no real significant restrictions after surgery. We ask that you avoid any extreme heavy lifting or straining for several weeks. Activities of daily living such as walking or lifting groceries are not a problem. People are allowed to shower the day after surgery.