• Surgery
• Heartburn and Gastroesophageal Reflux Disease (GERD)

Heartburn and Gastroesophageal Reflux Disease (GERD)

What is Heartburn?

Heartburn is a common medical condition and it can have a profoundly negative impact on a patient’s quality of life if it is not controlled. Heartburn originates in the esophagus which is a long muscular tube that moves food from the mouth to the stomach. The esophagus has several structures that prevent backflow (or reflux) of stomach contents into the esophagus. The most important of these structures is a circular band of muscle at the opening of the stomach known as the lower esophageal sphincter. Prevention of reflux is important because the stomach contents are acidic and can damage the soft lining of the esophagus.

Heartburn is a term used to describe pain and burning in the chest due to irritation of the esophagus from acid reflux. Some mild reflux occurs normally, usually after meals, and for most people causes no symptoms. However, when acid reflux is more severe and causes damage or symptoms healthcare providers refer to it as “Gastroesophageal Reflux Disease” (GERD). Acid reflux occurs when the pressure in the stomach overcomes the lower esophageal sphincters ability to prevent backflow of acid into the esophagus. There are three basic underlying mechanisms for GERD:

1. Increased pressure in the stomach:
   1. Eating a large meal
   2. Lying on your back after eating
   3. Being overweight (abdominal obesity)
   4. Other mass in the abdomen (eg. pregnancy)
   5. Bending over or straining to lift heavy objects
2. Decreased strength of the lower esophageal sphincter:
   1. Weak sphincter muscles
   2. Certain medications
   3. Smoking
   4. Drinking alcohol or coffee
   5. Other medical conditions
3. Increased stomach acid/irritants
   1. Eating spicy foods
   2. Genetic and medical disorders

Common symptoms that may be associated with esophageal reflux are summarized in Table 1.

Table 1: Common symptoms associated with acid reflux into the esophagus

Esophageal Symptoms	Other Symptoms
Heartburn (pain and burning in the mid chest)	Chronic cough
Regurgitation of food or acid into the mouth	Hoarseness and throat clearing
Difficulty or painful swallowing	Asthma
Chest pain without burning
Nausea
Nighttime waking with chest pain/discomfort

Advanced Acid Reflux Disease

Prolonged exposure of stomach acid in the esophagus can cause chronic inflammation, damage to the esophagus wall (ulcers), and sometimes, transformation of the lining of the esophagus. Esophagus transformation occurs when chronic acid exposure causes normal cells to become glandular cells which resemble the lining of the stomach and intestines. This process is called intestinal metaplasia which occurs in the lower part of the esophagus and is referred to as “Barrett’s Esophagus”. Metaplasia is a risk factor for developing cancer of the esophagus because it involves changes in cell structure which can result in cancer.

Chronic inflammation, ulcers, and Barrett’s Esophagus typically result in severe acid reflux and swallowing symptoms. Table 2 below summarizes symptoms suggestive of more advanced GERD. However, significant damage can occur in the esophagus without these symptoms.

Table 2: Advanced symptoms of acid reflux with esophagus injury

Increased pain with swallowing

Difficulty swallowing solids or liquids

Vomiting or coughing up blood

Extreme chest pain and/or heart burn

Indications for Surgical Treatment of Acid Reflux

There are two goals for treating acid reflux.

1. Relieve symptoms and provide patient comfort
2. Prevent chronic damage to the esophagus

Treatments for acid reflux can be categorized as conservative lifestyle changes, oral medical therapies and surgery. If you are being referred by your physician to see a surgeon, it generally means that lifestyle modification and medical management has failed to adequately control your symptoms.

The surgical procedure to reduce acid reflux from the stomach into the esophagus is called Fundoplication. The most common indications for Fundoplication are listed below:

1. Persistent reflux symptoms despite lifestyle modification and treatment with medications to reduce stomach acid.
2. Severe inflammation of the esophagus and/or Barrett’s Esophagus
3. Presence of a narrowing of the esophagus (stricture)
4. Poor control of other symptoms due to reflux such as:
   1. Asthma
   2. Hoarseness
   3. Aspiration into lungs
   4. Chronic cough
   5. Dental erosion

Methods of Surgical Treatment for
Gastroesophageal Reflux

Surgical management of esophageal reflux involves wrapping part of the stomach around the esophagus and stitching it in place to re-enforce the lower esophageal sphincter. By wrapping some of the excess stomach tissue around the esophagus, a tighter sphincter is created that helps to prevent acid reflux.

There are a variety of surgical methods and approaches all of which utilize this basic principle. The most common method is referred to as “Nissen Fundoplication” which is best conducted laproscopically. Laproscopic surgery uses small incisions in the abdomen through which small tools and a camera are placed. Laproscopic techniques minimize tissue trauma in surgery and provide faster healing times. Additional details of the procedure most appropriate to your case can be discussed with your surgeon.

 

Post-Surgery Management – What to Expect

Most patients have a positive response to fundoplication including decreased reflux symptoms and increased quality of life. Most patients are cured of their reflux symptoms after surgery, but some patients (about 10-20%) require ongoing medical therapy to suppress acid production. Patients should be prepared to experience additional side effects of surgery as listed below, most of which improve with time.

• Difficulty Swallowing – Patients often require a modified diet based largely on fluids for a short time following surgery. This usually resolves with time and the patient can return to a normal diet.
• Gas/Bloating – Due to increased tone of the lower esophageal sphincter some patients have difficulty belching after surgery with an uncomfortable feeling of gas in the stomach. This usually resolves with time.
• Revision of Surgery – Due to surgical complications, failure of treatment or persistent difficulty swallowing about 5% of patients will require a revisional surgery.