Correction of Acid Reflux into the
Esophagus by Laparoscopy
To understand this procedure, it is helpful to know
some upper intestinal tract anatomy. It starts with the food tube or
esophagus. This organ moves food down to the stomach with sweeping muscle
contractions. At the lower end of the esophagus is a specialized muscle
called the lower esophageal sphincter (LES). The LES should remain tightly
contracted until food or liquid arrives from above.
The LES then relaxes, allowing the food and liquid to pass. Then it again
becomes tightly contracted. This action prevents stomach acid, bile salts,
and enzymes from flowing up into the esophagus, causing symptoms and tissue
damage.
Gastroesophageal Reflux Disease (GERD)
GERD occurs when excess stomach acid flows up into the esophagus because of
a weak LES.
Almost everyone experiences reflux and heartburn at one time or another,
often after a large meal. However, prolonged and frequent acid in the lower
esophagus can cause injury such as inflammation, ulceration, scar formation,
and stricture and, after a long period of time, even cancer. Some people
have severe symptoms with no tissue damage, while
others may have few symptoms and much tissue injury. Reflux inflammation or
esophagitis along with ulceration commonly occurs.
It is known that
GERD is aggravated by heavy meals, nicotine, fatty foods, obesity, and lying
flat in bed. Symptoms are reduced by making lifestyle changes that avoid
these culprits. Medications are also very effective in treating GERD. Still,
these treatments do not always work and, especially in younger patients
facing a lifetime of medication, surgery may become a treatment option.
Laparoscopy
Most females have
heard of laparoscopy, also known as "bellybutton" or "Band-Aid" surgery.
Gynecologists have long used this technique to tie the Fallopian tubes and
to inspect the female reproductive organs. Now this technique has been
expanded to include correction of severe reflux disease and esophagitis.
With new video technology, the laparoscope has become a miniature television
camera. Exquisite magnification is now possible, showing the abdominal
organs in great detail.
Laparoscopic Fundoplication
Fundoplication means folding or wrapping, and that is exactly what the surgeon does to the upper stomach in this procedure. The patient is first given a general anesthesia. Then the abdomen is inflated with carbon dioxide, a harmless gas, through a small incision at the naval. The laparoscope, a thin tube carrying the video-camera, is inserted. Four pinpoint incisions are then made in the upper abdomen through which needle-like instruments are inserted. These act as the hands of the surgeon, allowing him or her to dissect and suture. The upper part of the stomach is wrapped and sutured around both sides of the esophagus. This technique restores normal pressure to the LES and prevents acid from refluxing into the esophagus. The patient is usually started on clear liquids the first day after surgery and discharged later that day.
The five tiny incisions heal quickly leaving only slight blemishes.
Typically the patient returns to
next
normal activities within a week. A
soft diet is recommended for 1 to 2 weeks. Pain is very minimal, usually
requiring no medication after 1-2 days.
What Are the Benefits?
The main benefit is the elimination or improvement in
heartburn symptoms without the need for regular medication. The risk of a
subsequent stricture of the esophagus may be reduced as well. The surgery
requires no large, painful incision. There is a very short hospital stay and
very rapid recovery. The hospital expense is usually less in comparison to
the older open method and since the patient can return to work much quicker,
there are far less lost wages.
What Are the Complications?
There is always a very rare risk with general
anesthesia for any type of surgery. Internal bleeding or infection may also
occur. A common but usually short-term problem is called gas-bloat.
Since the LES muscle has been tightened, the patient
may be unable to belch, resulting in a feeling of bloating and discomfort.
Eating frequent small meals slowly and chewing thoroughly helps. In a few
instances, especially in heavy patients or where abdominal surgery has
been previously performed, the surgeon may be unable to do the laparoscopic
technique and must resort to the traditional but still effective open
surgery.
Are There Other Treatment Options?
The primary alternative to laparoscopic surgery is
medication to reduce stomach acid. The best of these drugs are called the
proton pump inhibitors. These drugs in adequate dosage can almost eliminate
stomach acid. Patients can take these drugs for prolonged periods of time,
and may make surgery unnecessary. It is usually only in those patients where
this treatment is ineffective, or when the patient does not wish to take
long term medication, that surgical repair is considered.
Who Can't Have the Procedure?
In some instances the surgeon will not recommend the
procedure. The following list is a general one and each case is individually
evaluated:
-
Poor normal muscle function in the main portion of the esophagus. This is also called dysmotility and is measured by a pressure recording technique in the esophagus.
-
Pregnancy
-
Esophageal cancer or a precancerous state of the esophagus as determined by endoscopy
The following conditions make this type of surgery more difficult and at times not possible:
-
Extreme obesity
-
Extensive previous surgery in the upper abdomen producing adhesions
-
A shortened esophagus as occasionally can occur with severe prolonged reflux disease
In each
situation, the surgeon will weigh the benefit for the patient against the
risks, always considering other medical problems and always making a
recommendation that is in the patient's best interest.
Summary
Acid reflux in
the esophagus, with inflammation and ulcerations, is a very common problem
experienced by nearly one in every three people. General measures such as
acid-reducing medicines, antacids, and diet modification can control most
cases. In severe cases, where medical measures such as medications fail,
laparoscopic fundoplication may be the best way to correct the problem and
prevent recurrence.
This material does not cover all information and is not intended as a
substitute for professional medical care.
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