Meridian Surgery Center Join us on Facebook Meridian Surgery Center Home

End Your Heartburn with Laparoscopic Hill Repair

What is GERD?

Gastroesophageal reflux disease (GERD) is a term used to collectively describe the problems and symptoms that occur when acid from the stomach washes up into the esophagus (food tube which brings food from the mouth to the stomach). This can lead to inflammation and irritation of the lining of the esophagus as well as causing the typical symptoms that are generally associated with GERD or acid reflux.

What are the Symptoms of GERD?
GERD encompasses a wide range of symptoms that include:

  • Heartburn–Burning or tightness behind the breastbone or at the top of the belly.
  • Acid Regurgitation–Sour or bitter taste in the throat or mouth.
  • Water Brash–A hot sensation in the stomach followed by a large amount of watery liquid in the mouth.
  • Dysphagia–Difficulty swallowing or painful swallowing. The sensation of a lump in the throat or food getting “stuck” after swallowing.
  • Asthma, laryngitis and chronic cough are unusual symptoms that GERD can cause.

Symptoms typically occur after eating a meal and can be especially noticeable with a large meal or spicy foods. Antacids relieve some symptoms. Symptoms often are worse when lying flat, straining or sleeping.

What can worsen the symptoms of GERD?

  • Fatty foods, chocolate, coffee, peppermint as well as alcohol and use of tobacco products can cause or worsen symptoms.
  • Certain drugs such as Theophylline, Albuterol, and Calcium channel blockers can also cause symptoms of GERD.

Are any other problems or diseases associated with GERD?

  • Pregnancy can exacerbate the symptoms of GERD. The pressure of the fetus on the stomach can increase the amount of acid “splashing” up into the esophagus
  • Scleroderma and other diseases that cause high stomach acid production as well as connective tissue disorders are also frequently associated with GERD.
  • Obesity, which causes an increase in abdominal pressure, is also thought to contribute to and worsen acid reflux.

Anatomy

  • Esophagus–Tube that brings food from the mouth to the stomach.
  • Stomach–Stores food and produces acid to help kill germs in food. Breaks up food into small pieces to prepare it for the small intestine where digestion takes place.
  • Duodenum–Receives food from stomach. Enzymes from the pancreas and bile from the liver mix with the food to break it down into nutrients that the body can absorb.
  • Hiatus of Diaphragm–Where the esophagus passes through the diaphragm to connect with the stomach. Muscular fibers of the diaphragm wrap around the esophagus as it passes into the abdomen. When this area is too loose or lax, the stomach can “slip” or “slide” through up into the chest. This creates a pressure differential that allows stomach acid to freely wash up into the esophagus. This condition is known as a hiatal hernia.
  • Normal inner anatomy of esophagus and stomach–Normally, the lining of the esophagus and stomach are made of different types of cells. The cells that line the esophagus are not as resistant to acid as the cells that line the stomach. There is normally a sphincter muscle (a valve or “gate”) between the esophagus and stomach called the Lower Esophageal Sphincter (LES), which serves as a barrier and protects the esophagus from acid.

What actually causes GERD?
A complex interaction of many problems can cause reflux:

  • Esophageal Dysmotility–Weak or uncoordinated esophageal contractions (movement).
  • The cells that make up the lining of the esophagus impaired the resistance of the esophageal lining and are defective in their protection of the esophagus against acid. .
  • LES dysfunction–Poorly functioning sphincter muscle (gate between stomach and esophagus) that allows acid to wash up into the esophagus.
  • Delayed emptying of the stomach (gastroparesis)–Poor motor function of the stomach (not draining into the intestine) that allows acid to “pool” in the stomach, which backs up into the esophagus.
  • Hiatal hernia–Allows acid to wash up into the esophagus as a result of the pressure differences between the abdomen and chest.
  • Loose hiatus muscle fiber causes reflux even without a hiatal hernia.

What kind of problems does GERD cause in the esophagus?

  • Reflux esophagitis–Injury and inflammation of the inner lining of the esophagus from prolonged exposure to acid and digestive enzymes. This produces pain as well as occasional painful swallowing (known as odynophagia).
  • Reflux esophagitis can progress to complications:
    • Long-standing inflammation and scarring can progress to a mutation called Barrett's Esophagus, which is a pre-malignant condition. This is the replacement of the cells lining the esophagus with mutated cells more typical of the stomach or intestines (metaplasia) as a result of the long-term damage caused by GERD and acid. Occurs in approx 10 percent of patients with GERD.
    • Strictures is severe scarring and narrowing of the esophagus that can occur. .These can cause food to become “stuck” or can cause pain when swallowing.
  • One in 200 patients each year develops cancer of the esophagus, which is 50 times the normal risk of this cancer. Cancer of the esophagus represents one of the more serious complications of GERD. It is a precancerous condition associated with cancer of the esophagus. It is thought to be caused by ongoing injury, mutation and damage to the lining of the esophagus.

How many people suffer from GERD?
It is one of the most common conditions affecting the gastrointestinal system. Anywhere between 36 and 77 percent of people have symptoms of GERD (heartburn, regurgitation of acid, etc.), spread equally between men and women.

  • 7 percent have daily heartburn
  • 14 to 20 percent have weekly heartburn
  • 15 to 50 percent have monthly heartburn

Can children get GERD?
Yes. Children and even infants can have GERD, particularly those with neuro-developmental disorders (such as cerebral palsy). As much as 90 percent of children with these problems can have some degree of chronic GERD.

How do you get GERD?
GERD is a problem that has many inciting factors such as diet, smoking, obesity, alcohol, pregnancy, the presence of a hiatal hernia, as well as some other diseases affecting the gastrointestinal system. These all contribute to the onset and severity of GERD; however, no single factor has been identified as the “cause” of this disease.

How do I know if I have GERD?
You should ask your doctor to evaluate any frequent or recurrent symptoms. Most often the diagnosis of GERD is based on the presence of these symptoms and their improvement with antacid medications. In some instances–such as symptoms that are vague, unusual, or long standing–your doctor may decide to perform other tests to help in the diagnosis.

Diagnostic Tests:

  • Barium Swallow–This is a special x-ray exam of the stomach and esophagus. It requires that you drink a chalky substance that coats the lining of your stomach and esophagus in order to produce pictures. 
  • Upper Endoscopy–The scope and camera allow for clear and detailed viewing of the lining of the esophagus and stomach as well as the ability to take small biopsies to examine the cells if irregularities are noted.
  • 24-hour pH Monitoring–Registers the amount and frequency of acid in the esophagus and allows for a correlation with symptoms such as heartburn and pain. A probe is placed into the esophagus to record the acid level in both the esophagus and stomach for a full 24 hours. Impedance testing can monitor non-acid reflux. This is the most accurate method of detecting reflux and GERD.
  • 48-hour pH Monitoring–Newer systems now allow 48-hr monitoring of esophageal acid without the need for an uncomfortable and unsightly nasal probe. (Bravo test).
  • Esophageal Manometry–Measures the motor activity (movement) of the esophagus and the sphincter pressure via a probe placed into the esophagus. Usually used in patients who are considering surgery to treat their GERD.

When should I be treated for GERD?
GERD should be treated when the frequency and intensity of one's symptoms begins to have an effect on quality of life. Long-standing reflux may cause an increase risk of esophageal cancer (40 times), and therefore, people with chronic symptoms should probably be treated. Long-standing reflux also may lead to complications, such as strictures or bleeding. Therefore, those with frequent or recurring symptoms should be treated.

How is GERD treated?
Mild and infrequent symptoms – nonprescription therapy is often enough:

  • Avoid foods that induce reflux (coffee, fat, etc.)
  • Avoid eating close to bedtime and lying down after meals
  • Eliminate smoking
  • Reduce/eliminate alcohol
  • Elevate your head during sleep
  • Lose weight
  • Take over-the-counter antacids as needed (TUMS, Gacascon)

Treatment – For patients with severe or frequent symptoms of esophagitis:

  • Prescription therapy is almost always necessary in patients who have severe or frequent symptoms. It is important to see your doctor so that he/she can diagnose and treat you and this problem appropriately. Initially, drugs such as Zantac, Pepcid, Tagamet or Axid may be used to treat the symptoms of GERD. In addition to these drugs, lifestyle changes such as losing weight, eliminating smoking and alcohol and avoiding eating too close to bed time are also important to implement.
  • If over-the-counter remedies don't relieve your symptoms, then a proton pump inhibitor (PPI) such as Prilosec, Protonix, Nexium, Aciphex, or Prevacid will most likely be used.
  • Anyone taking over-the-counter antacid medication for more than two months should see his or her doctor.

What should I know about PPIs?
Proton pump inhibitors are a group of drugs that effectively block acid production in the stomach and relieve the symptoms of GERD. They are safe and generally well tolerated. Unfortunately, they are expensive and usually will require an increase in dosage the longer they are taken. And they are now shown to cause osteoporosis because of impaired calcium absorption. Individuals who, after maximizing medical (non-surgical) treatment for GERD, still experience the following problems should consider surgical treatment for reflux disease:

  • Incomplete relief of symptoms
  • Development of a stricture or esophageal narrowing
  • Barrett's Esophagus
  • Relapse of symptoms after discontinuing medical treatment (after at least eight weeks of medication)
  • Intolerable side effects from GERD medication

Do I have to take the medicines for life?
That depends on a number of variables, such as the frequency and severity of your reflux (GERD) symptoms, whether you have any complicating conditions (esophagitis, Barrett's), and whether you desire to take daily medications for the remainder of your life. For most patients with frequent or severe symptoms, discontinuing the use of antacid medications will cause the reflux symptoms and GERD to return.

What if my symptoms persist?
If symptoms persist while you are on medication, you need to see your doctor. He or she may recommend additional testing to confirm the diagnosis and exclude complications of GERD (such as stricture or Barrett's), or a more serious problem.

Do I have options other than taking long-term medications?
Surgery to improve or prevent GERD has shown excellent results. Patients with GERD that is not well controlled with medicine alone, complicated GERD (severe esophagitis, Barrett's or strictures), the presence of a hiatal hernia and patients who are young and face life-long medication use are considered good candidates for anti-reflux surgery. The surgery to fix GERD and reflux can be performed in three ways: Hill Repair, Nissen Fundoplication or Toupet repair.

What are my options other than medicines?
New endoluminal treatments (performed via a flexible scope through the mouth) exist for GERD. Procedures such as Stretta, EndoCinch, Enteryx and the Plicator are approved by the FDA and initially have shown encouraging results. Because they are new, the long-term results are unclear. At this time, the most clinically effective and proven treatment for severe or complicated GERD is surgery. Gastrointestinal surgeons have performed this surgery for more than 40 years. Recent innovative surgical techniques have allowed surgeons to perform this operation laparoscopically (use of very small incisions, special instruments, and a video camera).

What is Linx?
The LINX System is a new, FDA-approved device made of small, flexible band of magnets enclosed in titanium beads. The magnetic attraction between the beads helps keep a weak esophageal sphincter closed to prevent reflux. The LINX System is implanted around the weak sphincter just above the stomach in a minimally invasive procedure that typically takes less than one hour.

Linx - FDA approved for the treatment of GERD

LINX is the only available FDA-approved device for the treatment of GERD. In fact, an FDA advisory panel voted unanimously in favor of the LINX System’s safety, efficacy and clinical benefit. Learn more about this particular treatment for GERD >

What is Laparoscopic Hill Repair?
A Hill Repair restores normal anatomy through repairing the Hiatal Hernia and the weak anti-reflux valve (LES). The result is normal anatomy and normal function. Surgeons using the laparoscopic technique make five small incisions in order to perform the surgery. The Hill Repair has the longest published follow-up rate: 88 percent of patients have discontinued GERD medication and are satisfied 17 years after surgery. Most surgeons have no experience with the Hill Repair, but Dr. Wright has preformed more than 1,500 of these procedures.

What is a Laparoscopic Fundoplication?
A Laparoscopic fundoplication is a surgical procedure in which a portion of the stomach (the fundus) is wrapped around the lower esophagus in order to prevent reflux of gastric acid and fluid into the esophagus. The benefits of this surgical approach include a rapid recovery, minimal time in the hospital (usually less than 24 hours), and very little pain and scarring. Surgeons perform laparoscopic fundoplication by inserting very small instruments through four to five very small (less than ½-inch) incisions, including a telescopic camera that connects to a TV monitor. Most patients are able to leave the hospital the day after their surgery is performed.
Even though both the open and laparoscopic procedures make the same internal changes, the open approach to this operation requires a much longer incision than the laparoscopic approach. This translates to a longer hospital stay, more discomfort, and a longer recuperation period.
The two most commonly performed Fundoplications are:

  • The Nissen Fundoplication–A complete (360 degree) wrap of the stomach around the esophagus
  • The Toupet Fundoplication–An incomplete (270 degree) wrap of the stomach around the esophagus

Your surgeon will determine which option is best for you based on the results of your testing. Most patients will undergo the Hill Repair because it seems to have the best results over the long-term. The top part of the stomach is wrapped around the esophagus, which forms a “valve” between the stomach and esophagus. This valve prevents acid from refluxing up into the esophagus, thereby greatly improving or preventing symptoms of GERD. In addition, the esophageal hiatus is narrowed with stitches and any hiatal hernia is repaired. The operation usually takes less than the hours to perform in routine cases.

Do I have to go to the hospital?
Healthy patients can undergo outpatient laparoscopic anti-reflux surgery safely and at considerable cost savings. Meridian Surgery Center is a leader in this patient-friendly approach.

What can I expect from the surgery?
Laparoscopic anti-reflux surgery has been shown to provide positive results in more than 90 percent of properly selected patients with GERD. In addition, recent evidence has shown that the operation can resolve much or all of the damage to the esophagus from the stomach acid of long-standing reflux. Most patients no longer require medication or have reflux symptoms following surgery.

What about robotic surgery?
Dr. Wright performed the first robotic anti-reflux surgery in the state in 2010 and performs this in selected patients.

Are there any problems that can occur with surgery?
The Laparoscopic fundoplication is a very safe and effective surgery, but all surgery does have some risk. It will be important that you choose a surgeon who has good training and experience with this procedure. Make sure to ask your surgeon how many procedures that he or she has done and what his or her results have been. In the hands of an experienced surgeon, the overall risk of serious complications is less than two percent.

Potential Complications of Surgery

  • Injury to an abdominal organ or to the bowel, stomach, or esophagus
  • Bleeding
  • Failure to completely relieve reflux symptoms
  • Difficulty swallowing
  • Inability to vomit
  • Diarrhea
  • Distended, painful stomach
  • Injury to the nerve that controls movement of the stomach

What should I do if I am interested in surgery to treat my GERD?

You should ask your primary care doctor, gastroenterologist, or family doctor for a referral to a surgeon who is trained and familiar with laparoscopic anti-reflux surgery. You and your surgeon will be able to determine the best approach for the treatment of your symptoms as well as the prevention of future problems that can develop with long-standing GERD.

 

 

Meridian Surgery Center and Cascade Hernia Institute are conveniently located in the heart of Pierce County, just south of Seattle and east of Tacoma, in the city of Puyallup, Wash.