Gastroesophageal Reflux (GERD)
Laparoscopic Nissen Fundoplication
Gastroesophageal reflux disease (GERD) occurs when the esophagus is exposed to prolonged periods of stomach acid. A defective lower esophageal sphincter is responsible for most cases of reflux. The lower esophageal sphincter (LES) is a high pressure zone near the junction of the stomach and esophagus. Normally, the LES acts like a valve closing after swallowing. The LES fails to close adequately in patients suffering with GERD, allowing the esophagus to be exposed to acid. Heartburn, esophagitis, esophageal stricture, and even cancer may result from GERD.
The symptoms associated with GERD are variable but generally include:
- Heartburn – 30-60 minutes after eating
- Regurgitation – worsened with lying flat
- Excessive belching
- Aspiration – stomach contents refluxed into the airway
- Asthma – chronic result of aspiration
- Chest pain – burning mid-chest pain
- Difficulty swallowing
- Pain with swallowing
Several studies are helpful to your doctor in making the diagnosis of GERD:
- Esophagram (Baruim Upper GI)
- Assess the function of the esophagus
- Identify structural abnormalities (esophageal stricture, achalasia)
- Reveal associated problems (aspiration, poor gastric emptying)
- Upper Endoscopy
- Identify damage caused by reflux (esophagitis, Barrett’s
- esophagus, malignancy)
- Biopsy esophagus for evaluation of malignancy
- Esophageal Manometry
- Assess the function of the LES
- Assess the wave-like motion (propulsive function) of the esophagus.
Laparoscopic Nissen fundoplication is a viable option after failure of lifestyle changes, sufficient attempts at medical management, or prolonged medical management. Lifestyle changes typically include:
- Weight loss
- Smoking cessation
- Reduced fatty food intake
- Reduced consumption of caffeinated and carbonated beverages
- Elevation of the head of the bed during sleeping
- No oral intake four to six hours prior to going to sleep
Medical management may include:
- Over-the-counter antacids/H2 blockers (stomach acid production blockers)
- Proton pump inhibitors (stomach acid production blockers)
- Stomach motility agents (quicker stomach emptying and increase LES pressure)
- Stomach lining coating agents (protects healing portions of the stomach)
- While the treatments listed above may resolve symptoms, patients will continue to have gastroesophageal reflux.
In the past, surgery was a last resort because of the prolonged recovery time and large, painful incision involved with the procedure. With the new minimally invasive approach, surgery is now a viable option after early attempts of modifications and medical management fail to adequately resolve symptoms.
The laparoscopic Nissen fundoplication is performed through five quarter-inch incisions through which a camera and four instruments are placed. A new lower esophageal valve is constructed by wrapping a two-centimeter portion of the stomach around the lower-most portion of the esophagus. This collar is then anchored to the tough fibers of the diaphragm (the respiratory muscle separating the chest from the abdomen). The procedure typically lasts from forty-five minutes to one and a half hours. Patients are started on clear liquids the next morning and are discharged in the afternoon. The open surgical technique involves an 8-10 inch upper abdominal incision with a hospital stay of 5-7 days.
Patients recover sooner after laparoscopic Nissen fundoplication. Return to activities can occur within 2-7 days, compared to 4-6 weeks with an open approach. Wound infections occur less frequently with the laparoscopic technique. Also, less pain has been reported with laparoscopy. Most importantly, greater than ninety percent of patients are symptom-free ten years after the procedure.