Get Your Foregut Surgery Questions Answered
What is GERD?
GERD is a medical acronym for Gastroesophageal Reflux Disease. GERD is also commonly referred to as "heartburn" or "reflux". GERD is when gastric and intestinal contents flow backward up into the esophagus. This causes a burning sensation in the lower chest (heartburn). Patients can also have hoarse voice, bronchitis, aspiration pneumonia, chronic cough, night cough, asthma worsening, sensation of something in the throat, food getting stuck, sinus and dental issues. Some patients will describe gastric contents (or vomit) in the throat when they bend down to pick something up or seeing gastric contents on their pillow in the morning. These issues are related to irritating acid and bile in the throat, windpipe, sinuses and teeth. The esophageal lining is designed for exposure to neutral pH liquids such as saliva and mucous. With GERD, the esophageal lining is exposed to gastric acid and bile which causes irritation and chronic inflammation. This can ultimately lead to esophageal cancer if left untreated for a prolonged period.
What is a hiatal hernia?
A hiatal hernia is an abnormally large opening in the diaphragm muscle (hernia) at the hiatus. This allows the stomach to herniate up into the chest. This allows acid and bile to reflux into the esophagus. The hiatus is the only opening in the diaphragm and is where the esophagus transits from the thoracic cavity to the abdominal cavity. The diaphragm, a large domed muscle for breathing, separates the thoracic (chest) cavity from the abdominal cavity (belly). The word hiatus means "gap". The esophagus squeezes swallowed food from the mouth into the stomach. The normal size of the hiatus is about the size of a quarter (25 cent coin), just large enough for the esophagus. GERD patients commonly have a hiatus the size of a lemon or bigger. Some patients have significant reflux with a normal sized hiatus.
Does everyone with a hiatal hernia have GERD?
No. Some patients have a hiatal hernia seen on x-ray or on EGD (stomach scope) but they have no reflux symptoms.
Can you get GERD without a hiatal hernia?
Yes. Some patients have significant GERD without a hiatal hernia.
What causes GERD?
Most patients with significant GERD have a hiatal hernia but you can still have significant GERD without a hiatal hernia. The body has many ways to keep acid and bile out of the esophagus. We have a lower esophageal sphincter (LES), which is a group of muscle fibers that act like a valve in the lower esophagus. When the hiatus is intact, it helps to keep the stomach and a portion of the esophagus in the abdominal cavity. Normal esophageal motility is a coordinated muscular contraction that squeezes food down from the mouth into the stomach. When part of the lower esophagus is in the abdominal cavity, this also serves as a valve to keep acid and bile from getting into the esophagus. Think of the stomach like a cake decorator's icing bag. When you squeeze the bag (stomach), icing shoots out the tip (esophagus). As upright mammals, we frequently increase the intra-abdominal pressure each time we strain, cough, laugh, lift or bend over. This squeezes on the stomach like an icing bag which causes acid and bile to shoot up the esophagus like icing out of the tip. Imagine, however, if someone also squeezed the tip of the icing bag, this would prevent icing from shooting out of the tip. An intra-abdominal portion of the lower esophagus works in this way, like someone squeezing on the tip of the icing bag. No icing, no acid. A hiatal hernia allows the esophagus and top of the stomach to herniate up into the thoracic cavity. This reduces our ability to keep irritating acid and bile out of the esophagus.
What is silent reflux?
Some patients with no reflux symptoms are discovered to have evidence of significant GERD during medical tests done for other symptoms. An example would be a patient found to have esophagitis on EGD (stomach scope) performed for another reason. Another example would be a patient having laryngoscopy (scope of the larynx) for hoarseness and is found to have chronic inflammation typical of chronic reflux.
Is it normal to have some reflux?
Yes. Some reflux is normal. If you eat a large spicy tomato sauce meal with two glasses of wine and then go straight to bed, you will likely experience some heartburn. This is normal.
What's a peptic stricture?
Longstanding reflux can chronically irritate the lower esophagus to the point that scar tissue builds causing a stricture (narrowing). Patients will typically complain of swallowing difficulty. EGD (stomach scope) will find the stricture and can dilate this at the same procedure.
What are PPI's?
PPI = Proton pump inhibitor. PPI's were a new class of drugs that dramatically decrease acid secretion in the stomach, much more than the medications that preceded them. These medications required a prescription when they were first approved by the FDA but many of them are now OTC (over the counter) medications that can be purchased without a prescription.
Can't I just take PPIs forever?
Shutting off acid secretion to such a great extent is not how our bodies normally function. As you might imagine, there are consequences to this. PPIs can cause vitamin and electrolyte deficiencies and increase the risk for certain infections. The known consequences are calcium and magnesium vitamin deficiencies from malabsorption, change in normal healthy bacteria in our intestines (the microbiome), multiple hyperplastic polyps in the stomach, hypergastrinemia, diarrhea and increased risk for clostridium difficile colitis and pneumonia. The associated calcium deficiency can affect bone health.
I take a PPI twice daily so why do I still have reflux?
PPI's don't stop reflux; they simply increase the pH of the GI (gastrointestinal) contents that are refluxing. PPI's reduce the impact of the acid that is refluxing but do not address the bile and other irritating GI secretions that are bathing the esophageal lining. The only thing that will stop the abnormal reflux is surgery.
What is Barrett's esophagitis?
Barrett's esophagitis is when the lining of the esophagus changes to combat the chronic irritation of acid and bile. Normally, the esophageal mucosa (lining) is squamous cells that can handle neutral pH substances like mucous and saliva. They are not designed to combat acid and bile. Gastric mucosa (stomach lining) consists of columnar cells which are designed to handle acid and bile. In patients with chronic GERD, the squamous cells lining the esophagus can change to columnar cells as a protective mechanism against acid and bile irritation. The medical term for this process is "metaplasia". The main problem with this is that the shift to new columnar cells can progress to esophageal cancer. If you are found to have Barrett's esophagus during EGD (stomach scope) biopsy, you will need to have repeated endoscopies done at some interval defined by your doctor. If Barrett's progresses to cancer, you want to diagnose this early. Barrett's esophagus gets its name from Norman Barrett, the surgeon who first described this condition. Norman Barrett was an Australian-born British thoracic surgeon.
What is dysplasia?
Dysplastic cells are abnormal cells that can progress to cancer. A known progression to esophageal cancer is when normal esophageal mucosa squamous cells evolve into columnar Barrett's esophagus, then dysplasia, then cancer cells. Dysplastic progression starts with Barrett's with no dysplasia, then low grade dysplasia, then high grade dysplasia then cancer. A patient with Barrett's esophagitis with low grade dysplasia needs to be monitored more closely than a patient with no dysplasia. Closer monitoring involves repeating EGD (stomach scope) at shorter intervals (3 - 6 months vs 12 months).
What does EGD stand for?
EGD = esophagogastroduodenoscopy. EGD is also commonly called "stomach scope". This term describes the organs that it examines: the esophagus (E), the stomach (G for gastric) and the duodenum (D). The duodenum is the first portion of the small intestine beyond the stomach.
How do you treat GERD?
The two main types of treatment for GERD are medical and surgical.
Medical (non-operative) treatment involves taking an acid-suppressing medication (PPI's etc) and diet and lifestyle modifications. Examples of lifestyle modifications include: don't eat before lying flat or bedtime, avoid large meals, avoid wearing tight-fitting garments, avoid foods known to cause reflux such as caffeine, chocolate, peppermint, spearmint, alcohol, spicy foods and avoid smoking. Gravity can help reduce reflux by elevating the head of your bed. Losing weight will help to reduce the higher intra-abdominal pressure associated with obesity.
Surgical treatment involves repairing the hiatal hernia and wrapping the upper stomach around the lower esophagus (Nissen fundoplication).
What is a Nissen fundoplication?
The most common surgical treatment for GERD refractory to medical management is a Nissen fundoplication. This is where the top part of the stomach (fundus) is wrapped completely (360-degrees) around the lower esophagus and stitched to itself (plication). The operation is done laparoscopically or robotically through 5 small incisions. Most patients go home the next day.
How do I know when I need surgery for GERD?
Many patients have adequate symptom control with diet and lifestyle modifications and taking acid-suppressing medications. If patients continue to have significant symptoms despite maximal medical therapy, then surgical repair should be considered. Some patients desire to stop taking PPIs due to the serious side effects but their symptoms are too severe off medications so they pursue surgical management in order to discontinue medications.
What's the relationship between obesity and GERD?
Obese patients have elevated intra-abdominal pressure. That pressure squeezes on the stomach forcing acid and bile up into the esophagus. Obese patients can have significant GERD without a hiatal hernia. Losing weight can reduce GERD symptoms.
What is a pH probe?
This study measures the number and severity of acid reflux episodes. This is a very objective way to determine if you have abnormal reflux or not and if so, how severe. There are different ways to do this such as passing a small catheter down your nose into your esophagus or having a BRAVO probe placed by EGD (stomach scope) onto the esophageal lining which sends data to an external device, while you record your symptoms to see if they match reflux epidoses. The BRAVO probe eventually falls away from the esophageal lining and is passed in the stool. There is also an impedance test that can measure non-acidic reflux as well.
What is an esophageal manometry test?
The esophagus (swallowing tube) has a simple task of getting swallowed food from your mouth to your stomach, but it is a very complex organ. Normal esophageal motility involves a coordinated contraction of esophageal muscle that squeezes the swallowed food in synchrony until the bolus reaches the stomach. Dysmotility is when this process is uncoordinated. Esophageal dysmotility can cause heartburn symptoms that are not related to acid or bile reflux. The manometry test can identify patients whose symptoms are related to esophageal dysmotility and not acid or bile exposure.
Why do I need manometry and pH probe before fixing my hiatal hernia?
Before any surgery, it is important to determine if the potential benefits from the operation outweigh the potential risks. One aspect of this is to make sure you have a condition that will benefit from an operation. Since there are many conditions that can mimic GERD, it is important to determine if your GERD symptoms are caused by acid and/or bile refluxing into your esophagus or from something else. If you have a really large hiatal hernia or a paraesophageal hernia which can lead to strangulation of the stomach then the pH probe may not be necessary, though manometry study is still useful since it determines the type of anti-reflux procedure best suited for each patient.
A Nissen fundoplication is highly successful at treating symptoms caused by acid and bile reflux into the esophagus. If a pH probe determines that you do not have acid or bile refluxing into your esophagus, a surgery that treats this is not likely to improve your symptoms.
Manometry is important for two reasons. It will determine if your symptoms may be caused by an esophageal dysmotility syndrome and it can also determine if your esophageal motility is strong enough to handle a wrap of the stomach around the lower esophagus. If you perform a full 360-degree Nissen wrap on an esophagus with dysmotility, weak esophageal muscle or uncoordinated muscular contraction, the patient may have severe swallowing difficulties after the procedure. It is important to determine before surgery if the esophagus is strong and coordinated enough to handle a stomach wrap.
What are the chances of developing Barrett's esophagitis?
10-20% of patients with chronic GERD will develop Barrett's esophagitis.
What are the risks of Nissen fundoplication?
Relief from acid and bile reflux after Nissen fundoplication is dramatic and immediate. Nissen patients are some of the happiest patients after surgery. The most common nuisance symptom after Nissen is difficulty swallowing. This is due to edema (swelling) of the esophagus, wrap and hiatal hernia repair making things tighter until the edema resolves. The degree of swallowing difficulty and the time for it to resolve varies widely from one patient to the next. The severity of this symptom depends on the individual patient's edema reaction to surgery and their inherent esophageal motility. Some patients will develop gas bloat syndrome. Before surgery, swallowed air or carbonation could be easily relieved with a belch. After surgery, this air now must work its way through the GI tract. This can cause symptoms of gas and bloating.
What is a partial wrap?
Some patients have weakened or uncoordinated muscle function of the esophagus. The pre-op motility study (manometry) demonstrates that the esophagus will not tolerate a complete 360-degree wrap. In these cases, surgeons may choose to perform a partial wrap. There are several different partial wraps such as Dor or Toupet that encircle the esophagus less than 360 degrees.
How long are you in the hospital after Nissen?
Most patients are discharged the same day or the next day. Large hiatal hernia or paraesophageal hernia repair patients are more likely to stay overnight or for a day or two after surgery.
What is the recovery?
There are no major lifting restrictions after laparoscopic or robotic surgery. Most patients are off pain medications within a few days and back to work within a week.