After food passes through the esophagus into the stomach, a muscular valve called the lower esophageal sphincter (LES) closes, preventing the movement of food or acid upward. Gastroesophageal reflux, or heartburn, occurs when the LES relaxes too frequently, allowing acid from the stomach to flow backward into the esophagus.
"Most people with chronic heartburn can be successfully treated with a combined plan of lifestyle modification -- including changes in diet, smoking cessation and the elimination of caffeine and alcohol -- and medication, usually proton pump inhibitors such as Prilosec® or Prevacid®," says Farhad Navab, M.D., chief of the Gastroenterology Division at Baystate. "The prevalence of this problem has, in fact, made proton pump inhibitors one of the most commonly prescribed medications in the United States."
"While the medications ease the discomfort caused by the influx of acid into the esophagus, they don’t cure the reflux action itself, which is a mechanical problem of the lower esophageal sphincter," says David Earle, M.D., chief of Minimally Invasive Surgery at Baystate Medical Center. "A long term answer is surgery, but traditional open surgery requires a lengthy hospital stay and a prolonged, uncomfortable recovery."
Surgeons at Baystate Medical Center and Mary Lane Hospital, however, now offer an attractive alternative: laparoscopic surgery for GERD, called Lap Nissen Fundoplication. Pioneered at Baystate by Albert Alexander, M.D., and Viriato Fiallo, M.D., both of Pioneer Valley Surgical Associates, the procedure reduces operating room time to two to three hours -- and inpatient recovery to two overnights in the hospital. And according to Dr. Earle, "The long term results are excellent. Studies of patients ten years after surgery found complete control of symptoms in 91% of the cases."
Complications of GERD
Beyond the intense discomfort associated with heartburn, GERD can cause, or lead to, more serious problems. According to David Pleet, M.D., a gastroenterologist at Springfield Medical Associates, "Advanced GERD patients may suffer esophagitis, a serious inflammation of the esophagus. In less than five percent of the patients with reflux, GERD can progress to complications such as scarring of the lower esophagus, pre-cancerous changes in the esophagus, asthma, a change in voice, and inflammation resulting in bleeding and pain."
One of the most carefully watched complications of GERD is Barrett’s metaplasia, a condition in which some of the esophagus cells are replaced with cells ordinarily found in the intestine. Unchecked, the metaplasia may become dysplasia, a condition in which the esophagus is lined with abnormal, precancerous cells.
Even when damage is not present, GERD patients may want an alternative to a lifetime of medication. As long as the reflux remains uncorrected, a patient with GERD must remain on agents which reduce acid secretions to relieve symptoms, a prospect that may mean decades of drug treatment.
Fixing the Problem
Rather than treating the symptoms, surgery can correct the reflux itself. It improves the natural barrier between the stomach and the esophagus.
The procedure involves wrapping a portion of the gastric fundus around the lower esophagus to strengthen the esophageal "valve" and inhibit the upward flow of stomach acids. Once completed, Dr. Earle says, the recovery generally requires only one or two inpatient days. There are complications associated with the operation, but they are few and usually minor. Usually people have some difficulty swallowing after the operation, but this is mild.
Laparoscopy," Dr. Pleet says, "makes the surgery more attractive, especially for younger patients who don’t want to take medications all their lives or for patients who have reached the maximum limits of their medication. It may also be the only alternative for patients who have simply failed to respond to medical management."
For a referral to a gastroenterologist or a surgeon specializing in GERS, or to receive a free packet of information, please call Baystate Health Link at 413-794-2255. Outside the area, call 1-800-377-HEALTH.
Frequently Asked Questions
How can a Laparoscopic Procedure Treat my Chronic Heartburn?
The laparoscopic procedure improves the natural barrier between the stomach and the esophagus. In this procedure, the surgeon wraps a part of the stomach known as the gastric fundus around the lower esophagus. This prevents the flow of acids from the stomach into the esophagus.
A laparoscopic surgical procedure is an alternative to traditional or what is known as "open" surgery, in which a large incision must be made to expose the area of the body to be operated on. Small incisions are made to accommodate small tubes. These create a passageway for special surgical instruments and a laparoscope.
A laparoscope is a fiber optic instrument that is inserted in the abdominal wall and is used to examine visually the interior of what is known as the peritoneal cavity. This device is used to transmit images from within the body to a video monitor, allowing the surgeon to see the operative area on the screen.
What About my Hospital Stay and Recovery Period?
Since the small incisions used in this type of procedure do not cut across large tissue areas, scarring tends to be significantly reduced. Patients who are appropriate candidates for a laparoscopic procedure usually stay in the hospital from four to five days, instead of the nine days required for traditional surgery.
In many cases recovery time can be as little as seven to thirteen days, compared with twenty eight days for traditional surgery.
How do I Know if a Laparoscopic Surgical Procedure is Right for Me?
Only your doctor can best determine whether you are a candidate for a videoscopic surgical procedure to treat gastroesophageal reflux. If he or she thinks you can benefit form the procedure, you will then be referred to a surgeon.