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Cartersville Surgical Associates, PC
970 Joe Frank Harris Parkway
Cartersville, GA 30120
Phone: 770.386.1261
Fax: 770.386.3873
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Gastroesophageal reflux disease is a very common disorder in American society, affecting more than ---million Americans. While most patients with GERD can be treated medically, some have incomplete relief of symptoms, or complications of GERD and are best served with surgical intervention.
The most common symptom of GERD is heartburn, however some patients may also develop difficulty swallowing (dysphagia) or pain with swallowing (odynophagia). Patients may also have persistent regurgitation, chest pain, chronic cough, or a host of other respiratory complications including asthma.
Treatment can include lifestyle changes, medical therapy or surgical therapy. Life style changes include weight loss, and dietary management, as well as avoidance of other inciting factors such as alcohol and nicotine. Patients with GERD are encouraged to eat smaller meals, avoid eating for 3-4 hours prior to lying down to go to sleep and are encouraged to avoid caffeine containing foods such as chocolate, caffeinated soft drinks, coffee and tea. Foods such as peppermint may also exacerbate GERD.
For patients who have incomplete control with lifestyle and dietary modification, medical therapy is indicated. There are two general classes of drugs that suppress acid production that are used in the treatment of GERD. H2 blockers such as Pepcid, Tagamet and Zantac were historically the mainstay of medical therapy for GERD. These medication are quite effective at suppressing acid production and work within 20 minutes of an oral dose. For patients who do not obtain adequate or long lasting relief with H2 blockers, another class of drug, proton pump inhibitors (PPI) may be prescribed. These medications are much more effective at suppressing acid production and are often only taken once a day. Unlike H2 blockers which work very quickly, it may take 24-48 hours for PPI's to reach peak plasma concentration. In todays medical environment, PPI's are often the first line drug used to treat GERD. For patients that do not obtain complete relief with daily PPI's, H2 blockers may be used in combination to provide breakthrough control of symptoms. Also, prokinetic agents such as Reglan may be used to alleviate symptoms. Though combined medical therapy was once a fairly common approach to the treatment of GERD, most patients that fail single drug therapy are considered for surgery. Certainly for young, low risk patients with inadequate control with PPI therapy, a surgical approach to the management of GERD is reasonable.
The surgical approach to GERD involves mobilizing the stomach and creating a wrap around the esophagus with the mobilized portion of the stomach. Though originally described as an open operation, minimally invasive techniques for fundoplication (Laparoscopic Nissen Fundoplication) were developed in the early 1990's. The surgery is performed through a series of 5 small incisions in the abdomen, and typically takes 1-1 ½ hours. The success rate for this operation is very good with nearly 99% of patients obtaining immediate relief of symptoms following surgery. This has also proven to be a durable operation with 92-93% of patients symptom free at 10 years. Clearly some patients will have recurrence of symptoms, many of these patients can be managed with medical therapy, or patients can have revisional surgery.
There are several new minimally invasive approaches to GERD, but most of these have proven to have lower success rates than the laparoscopic Nissen fundoplication. Data regarding short and long term success for these procedures (Stretta procedure and endoscopic placation) is being accrued at the present time. At present, we do not offer these approaches at Cartersville Surgical Associates.
Patients with GERD who are contemplating surgery need an endoscopic evaluation of the esophagus (EGD) and a manometric evaluation of the esophagus. Many patients will also have a radiographic evaluation of the esophagus (Upper GI). Though many patients may have a 24 hours pH probe in preparation for surgery to document reflux, patients with classic symptoms and endoscopic evidence of GERD do not need to have a 24 hour pH probe.
All patients will have a transient change in the way they eat after a laparoscopic Nissen Fundoplication. Immediately post operatively patients are allowed clear liquids including orange juice and other citrus containing liquids that prior to surgery may have significantly exacerbated their reflux, The morning following surgery, patients are allowed a soft diet. Patients are asked to remain on a very soft diet for the next week to ten days. Patients are encouraged to avoid bread or meat during this time. Patients are also encouraged to avoid carbonated beverages and to eat frequent small meals. Large meals in the first few weeks post op may lead to nausea, bloating and crampy pain. Most patients return to a normal diet within 3-4 weeks post op, though the early satiety may last for 6 months. As a consequence of the dietary changes associated with surgery, most patients lose 10-15 pounds after surgery.
Rarely, patients may have persistent difficulty swallowing (dysphagia) beyond the typical 3-4 weeks post op. These patients may benefit from endoscopic dilation of the esophagus at the level of the fundoplication. Only about 1-2% of patients experience perisistent dysphagia after this procedure. Additionally, patients may develop gas bloat after surgery. This may improve with avoidance of gas producing foods and carbonated beverages. Rarely, patients are unable to regurgitate or vomit after surgery. Patients with persistent dysphagia, gas bloat or inability to regurgitate may occasionally require revisional surgery.
Clearly, if patients are well controlled with medical therapy, and are satisfied with a medical approach to GERD, a medical approach is the most reasonable approach. However, for those patients not controlled with medicine, or not able to take the medicine because of expense, compliance or side effects, surgery is a viable option. Most patients are able to leave the hospital the day following surgery, and return to work within 7-10 days. Patients are encouraged to do no lifting greater than 30 pounds for 4-6 weeks post operatively.
The surgeons of Cartersville Surgical Associates have an extensive experience with Laparoscopic Nissen Fundoplication and will work closely with your primary care physician and other gastroenterologic specialists to make certain that you receive the optimal therapy for GERD.
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