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Laparoscopic Acid Reflux Surgery – Medical and Surgical Treatment Options

Acid reflux occurs when stomach acid flows backward into the esophagus. This causes heartburn and other symptoms. Chronic or severe acid reflux is known as gastroesophageal reflux disease (GERD).

Mild or moderate reflux symptoms can often be relieved with diet and lifestyle changes. Over-the-counter and prescription medications can also help with symptom relief. Medications used to treat GERD include:

antacids
H2 blockers
proton pump inhibitors (PPIs)
Unfortunately, some people aren’t helped by lifestyle changes or medications. Surgery may be an option for those people. Surgery focuses on repairing or replacing the valve at the bottom of the esophagus that normally keeps acid from moving backward from the stomach. This valve is called the lower esophageal sphincter (LES). A weak or damaged LES is what causes GERD.

Untreated GERD can develop into a condition called Barrett’s esophagus. This condition increases the risk of esophageal cancer. However, esophageal cancer is rare, even in people with Barrett’s.

Diagnosis/Preparation
The diagnosis of gastroesophageal reflux disease can be straightforward in cases where the patient has the classic symptoms of regurgitation, heartburn, and/or swallowing difficulties. Gastroesophageal reflux disease can be more difficult to diagnose when these classic symptoms are not present. Some of the less common symptoms associated with reflux disease include asthma, nausea, cough, hoarseness, and chest pain. Such symptoms as severe chest pain and weight loss may be an indication of disease more serious than gastroesophageal reflux disease.

The most accurate test for diagnosing gastroesophageal reflux disease is ambulatory pH monitoring. This is a test of the pH (a measurement of acids and bases) above the lower esophageal sphincter over a 24-hour period. Endoscopies can be used to diagnose such complications of gastroesophageal reflux disease, as esophagitis, Barrett’s esophagus, and esophageal cancer, but only about 50% of patients with gastroesophageal reflux disease have changes that are evident using this diagnostic tool. Some physicians prescribe omeprazole, a proton-pump inhibiting drug, to persons suspected of having gastroesophageal reflux disease to see if the person improves over a period of several weeks.

Medical and Surgical Treatment Options
GERD is generally treated in three progressive steps:
1. LIFE STYLE CHANGES
In many cases, changing diet and taking over-the-counter antacids can reduce how often and how harsh your symptoms are. Losing weight, reducing or eliminating smoking and alcohol consumption, and altering eating and sleeping patterns can also help.

2. DRUG THERAPY
If symptoms persist after these life style changes, drug therapy may be required. Antacids neutralize stomach acids and over-the-counter medications reduce the amount of stomach acid produced. Both may be effective in relieving symptoms. Prescription drugs may be more effective in healing irritation of the esophagus and relieving symptoms. This therapy needs to be discussed with your primary care provider and your surgeon.

3. SURGERY
Patients who do not respond well to lifestyle changes or medications or those who do not wish to continually require medications to control their symptoms, may consider undergoing a surgical procedure. Surgery is very effective in treating GERD. The most commonly performed operation for GERD is called a fundoplication (usually a Nissen fundoplication, named for the surgeon who first described this procedure in the late 1950’s). A fundoplication involves fixing your hiatal hernia, if present, and wrapping the top part of the stomach around the end of the esophagus to reinforce the lower esophageal sphincter, and this recreate the “one-way valve” that is meant to prevent acid reflux. This can be done using a single long incision on the upper abdomen, or more commonly by minimally invasive techniques using several small incisions, called laparoscopic surgery.

Aftercare
Patients should be able to participate in light physical activity at home in the days following discharge from the hospital. In the days and weeks following surgery, anti-reflux medication should not be necessary. Pain following this surgery is usually mild, but some patients may need pain medication. Some patients are instructed to limit food intake to a liquid diet in the days following surgery. Over a period of days, they are advised to gradually add solid foods to their diet. Patients should ask the surgeon about the post-operative diet. Such normal activities, as lifting, work, driving, showering, and sexual intercourse can usually be resumed within a short period of time. If pain is more than mild and pain medication is not effective, then the surgeon should be consulted in a follow-up appointment.

WHAT ARE THE ADVANTAGES OF THE LAPAROSCOPIC METHOD?
The advantage of the laparoscopic approach is that it usually provides:

reduced postoperative pain
shorter hospital stay
a faster return to work
improved cosmetic result

The patient should call the doctor if any of the following symptoms develop:

Drainage from the Incision Region
Swallowing Difficulties
Persistent Cough
Shortness of Breath
Chills
Persistent Fever
Bleeding
Significant Abdominal Pain or Swelling
Persistent Nausea or Vomiting
Risks or complications that have been associated with fundoplication include:

Heartburn Recurrence :
Swallowing difficulties caused by an overly tight wrap of the stomach on the esophagus
Failure of the wrap to stay in place so that the LES is no longer supported
Normal risks associated with major surgical procedures and the use of general anesthesia
Increased bloating and discomfort due to a decreased ability to expel excess gas
Complications, though rare, can occur during fundoplication. These complications can include injury to such surrounding tissues and organs, as the liver, esophagus, spleen, and stomach. One of the major drawbacks to fundoplication surgery, whether it is open or laparoscopic, is that the procedure is not reversible. In addition, some of the symptoms associated with complications are not always treatable. One study showed that about 10% to 20% of patients who receive fundoplication have a recurrence of gastroesophageal reflux disease symptoms or develop such other problems, as bloating, intestinal gas, vomiting, or swallowing problems following the surgery. In addition, some patients may develop altered bowel habits following the surgery.

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