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Gastroesophageal Reflux Disease (GERD)

What is gastroesophageal reflux disease (GERD)?

Gastroesophageal reflux is common. Most Americans experience it occasionally. It occurs when the lower gastroesophageal sphincter (LES) opens spontaneously, too frequently, for excessive periods of time, or does not close properly allowing stomach contents to rise up (or reflux) back into the esophagus. Gastroesophageal reflux is often called "acid reflux" or "heart burn" because digestive juices—primarily acids—rise up with the food back into the esophagus. Gastroesophageal reflux is common and does not necessarily mean one has a "problem" like gastroesophageal reflux disease (GERD). Other GERD signs and symptoms include chest pain, coughing, asthma, and hoarseness, among many symptoms. When acid reflux occurs, food or fluid may be tasted in the back of the mouth or many times people describe a bitter taste in their mouth. In summary, people with GERD experience, among many symptoms:

  • Frequent heartburn / acid indigestion—burning-type pain in the lower part of the mid-chest and in the mid-abdomen
  • Dry cough
  • Asthma symptoms
  • Difficulty swallowing

The lower esophageal sphincter (LES) is a ring of muscles at the bottom of the esophagus that acts like a valve between the esophagus and stomach. The LES is responsible for preventing the "back flow" (or reflux) of stomach contents back into the esophagus while allowing food to pass into the stomach with eating.

Persistent reflux that occurs more than twice a week, leads to symptoms, or damages the esophagus, is considered GERD, and it can eventually lead to more serious health problems, including cancer. People of all ages can have GERD.

Causes

The cause of GERD is complex and has many factors that contribute to the disease. The factors that may contribute to GERD are:

  • Loss of LES function
  • Hiatal hernias
  • Esophageal dysmotility
  • Delayed gastric emptying of the stomach

A hiatal hernia occurs when the upper part of the stomach and the LES move above the diaphragm, the muscle wall that separates the abdomen and its contents, like the stomach, from the chest. Normally, the diaphragm helps the LES keep acid from rising up into the esophagus. When a hiatal hernia is present, acid reflux can occur more easily. In addition, a hiatal hernia can mask the symptoms of GERD. A hiatal hernia can occur in people of any age and is most often a normal finding in otherwise healthy people over age 50.

Other factors that may contribute to GERD include:

  • obesity
  • pregnancy
  • smoking

Common foods that can worsen reflux symptoms include:

  • citrus fruits
  • chocolate
  • drinks with caffeine or alcohol
  • fatty and fried foods
  • garlic and onions
  • spicy foods
  • tomato-based foods, like spaghetti sauce, salsa, chili, and pizza

Medical and Endoscopic Treatment

Over-the-counter antacids or medications that stop acid production (H2 blockers) or help the muscles that empty your stomach may be recommended. Antacids work to neutralize the acid in the stomach, H2 blockers and Proton Pump Inhibitors (PPI) decrease acid production. Long-term use of H2 blockers and PPIs can be harmful, as they can accelerate osteoporosis and have potent carcinogenic (i.e., cancer causing) effects.

Reflux medications:

  • Antacids, such as Alka-Seltzer, Maalox, Mylanta, Rolaids, and Riopan neutralize acid
  • Foaming agents, such as Gaviscon, work by covering your stomach contents with foam to prevent reflux.
  • H2 blockers: famotidine (Pepcid AC) and ranitidine (Zantac 75) decrease acid production.
  • Proton pump inhibitors: omeprazole (Prilosec, Zegerid), lansoprazole (Prevacid), pantoprazole (Protonix), rabeprazole (Aciphex), and esomeprazole (Nexium) decrease acid production and are available by prescription.
  • Prokinetics: help strengthen the LES and make the stomach empty faster. This group includes bethanechol (Urecholine) and metoclopramide (Reglan). These are generally ineffective and seldom used.

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.

Lifestyle Changes

  • If you smoke, stop.
  • Avoid foods and beverages that worsen symptoms.
  • Lose weight if needed, to a Body Mass Index of 26kg/m2 or less.

Tests to Evaluate GERD

  • Upper Gastrointestinal Study with bagel and marshmallow 15 degree head down evaluates esophageal motility. The body has innate capacity to push a food bolus down into the stomach, however this can be disrupted. Patients that are surgical candidates need to have this study completed ot better evaluate the type of operation that needs to be undertaken.
  • Upper endoscopy (EGD provides excellent visualization of the esophagus and may be performed in a hospital or a doctor's office. The doctor may spray your throat to "numb it" and then, after lightly sedating you, will slide a thin, flexible plastic tube with a light and lens on the end called an endoscope down your throat. Acting as a tiny camera, the endoscope allows the doctor to see the surface of the esophagus and stomach and search for abnormalities.
  • pH monitoring examination involves the doctor placing a tiny device in the esophagus that will stay there for 48 hours. While you go about your normal activities, the device measures when and how much acid comes up into your esophagus. This is often called a Bravo pH study.
  • Barium swallow radiograph uses x-rays to help spot abnormalities such as a hiatal hernia and other structural or anatomical problems of the esophagus. With this test, you drink a solution and then x-rays are taken. The test will not detect mild irritation, although strictures—narrowing of the esophagus—and ulcers can be observed. We are able to undertake this in our office.

Definitive Treatment

Surgery is the preferred option when medicine and lifestyle changes do not help to manage GERD symptoms. Nissen fundoplication is the standard surgical procedure to treat GERD. Nissen fundoplication is the minimally invasive (i.e., the least invasive) definitive therapy for GERD. During the fundoplication, the upper part of the stomach, known as the fundus, is wrapped around the LES to strengthen the sphincter. This, along with the repair of a hiatal hernia, prevents the flow of acid from the stomach into the esophagus, and strengthens the valve between the esophagus and stomach. If there is poor esophageal motility a Toupet fundoplication is undertaken.

Approach: Laparo-Endoscopic Single Site (LESS) surgery:

LESS anti-reflux operations involve the same surgical plan, in general, as conventional laparoscopic surgery, but with only one incision at the umbilicus (i.e., belly-button). When the operation is over, there is only one scar, and it is hidden in the umbilicus (i.e., the belly button). Thereby, there is no scar, as the new scar is hidden in the "old scar" of the umbilicus. LESS surgery promises improved cosmesis, quick recovery, reduced pain, and shorter length of hospital stay. Most of all, after LESS fundoplication, there is "no scar".

Dr. Rosemurgy and Dr. Ross have treated thousands of patients with GERD. Dr. Rosemurgy and Dr. Ross are believed to have one of the world's largest experiences in treating GERD with fundoplication and are also believed to have one of the world's largest databases of patients treated for GERD. Together, Dr. Rosemurgy and Dr. Ross have completed over seven hundred fifty LESS fundoplications.

Dr. Rosemurgy and Dr. Ross are known leaders in performing minimally invasive procedures for a wide array of diseases. Patients who come to them will benefit from their expertise and experience. They pioneered the LESS surgery approach for GERD. Both Dr. Ross and Dr. Rosemurgy have presented and written on this approach and on GERD extensively and widely. They have presented about LESS fundoplications at many national and international surgery meetings.

LESS fundoplication relieves or dramatically lessens symptoms of GERD with cosmetically superior outcomes relative to conventional laparoscopy, with no apparent scar. LESS fundoplication is encouraged for symptomatic GERD and is efficacious even after failures of lifestyle changes or medications.

Approach: Transoral Incisionless Fundoplication

For some patients, it is possible to correct GERD through an endoscopic approach. The name of this approach is called a Transoral Incisionless fundoplication. This means that the intervention is undertaken through the mouth, without any incision anywhere. While not everyone is eligible for this form of therapy, it emphasizes that care is individualized for each person.

Anti-reflux surgery addresses the physical causes which create GERD by repairing any hernia and defects in the diaphragm as well as strengthening the barrier between the stomach and the esophagus.

What to expect after anti-acid reflux operation: Some patients, but not all, experience one or more of the listed symptoms below:

  1. Shoulder pain last from 1-3 days after surgery. The pain is related to CO2 insufflation necessary for laparoscopic operations. The CO2 irritates the diaphragm which in turn sends referred pain to the shoulders. The shoulders are not injured. The more active you are after surgery (i.e. walking and staying out of bed) the quicker the pain is going to resolve.
  2. Difficulty swallowing solid food for 1-5 days. After surgery you may experience swelling at the end of your esophagus and beginning of your stomach, where the wrap (fundoplication) was constructed. This swelling is normal! We will instruct you to be on a thick liquid diet (i.e. milk base liquids: yogurt etc.) for the first 2 weeks. 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. You will feel full with half or less amount of food you usually consume. This occurs because we use part of your stomach to construct the wrap (fundoplication). However, the stomach will stretch if you continue to gradually increase the amount of food consumed.
  5. Passing more gas. Patients who suffer from acid reflux learn, over time, that swallowing air (aerophagia) relieves some of the heartburn symptoms by pushing the acid into the stomach. Once a normal valve is constructed, the brain will have to unlearn that behavior which takes several months after surgery. Consequently, you will notice that you are passing more gas from below after surgery.
  6. Increase diarrhea for 1-2 weeks. Some patients complain about diarrhea after surgery, which is also explained by aerophagia.
  7. Discomfort at the belly button for 1-7 days. We use the belly button to access the surgical site with very small instruments and a scope. Some level of discomfort is normal. If, however, you notice the belly button to have redness, hot to the touch, discharge, increased pain, and/or fever, please call my office or come to our emergency room.
  8. Discomfort below the sternum for 1-7 days. This is the location of the actual operation inside your abdomen. It is normal to feel discomfort for several days.

Dr. Sharona Ross and Dr. Alexander Rosemurgy

If you suffer from gastroesophageal reflux disease (GERD), we invite you to learn more about anti-reflux surgery. Patients located in the greater Tampa Bay area or anywhere in the state of Florida, we urge you to contact our office to schedule a consultation with Dr. Ross or Dr. Rosemurgy. We can inform you about an effective surgical treatment for GERD which has become the standard surgical method which results in a remarkable relief of symptoms in 95 percent of those patients who receive it.

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Sharona Ross, M.D. - Tampa Laparoscopic Surgeon
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