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Heartburn (GERD), Hiatal and Paraesophageal Hernias

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 can develop symptoms of asthma, and may even suffer from acid related dental problems.

 



Over time, significant injury to the esophagus can occur from GERD.  This includes inflammation, ulceration, stricture, premalignant changes known as Barrett's 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.

 

                                    A Nissen Fundoplication showing the sutures that create the wrap.
 

                                             

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 camera 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.

The latest innovation in GERD surgery is the use of the surgical robot. We are now able to offer Robotic Surgery for a variety of GERD problems. The robot can increase our precision, and new developments continue to improve the lives of our patients. The robot may be offered for selected patients and conditions. Please feel free to discuss this with your surgeon. 
 

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.  As soon as swelling from the surgery has resolved you will be able to return to a more normal diet.

Some patients find that eating after this surgery is far more difficult then others.  For those patients we recommend a much more gradual diet plan.  This alternative plan is found here Nissen Fundoplication Diet, in the Patient Education section.

 After GERD surgery you will need to change your eating habits.  You must chew food thoroughly, swallowing only small portions at a time.  It is also important to frequently drink fluids during meals, to wash food down into your stomach.

If you accidentally swallow a large bite that sticks in your throat, remember to relax, drink plenty of fluids, and wait, it should eventually pass.  If your symptoms do not improve over 1-2 hours, please seek medical attention.  Forcing a large bite of food could cause serious injury to the esophagus.



 

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.