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Lap surgery has became a preferred method of treatment for refractory G.E.R.D. Hiatus Hernia and Achalasia cardia. With the introduction of manometric and 24 hrs ph study, the indication for surgery and results of surgery are clearly defined and demonstrated.
The fundoplication can be tailored according to the Oesophageal motility and preexisting dysphagia symptoms.
We commonly perform floppy ( 360˚ ) Nissen fundoplication in majority of cases. Toupet or 270˚ partial wrap is performed in-patients with In effective Oesophageal Motility (I.E.M) to avoid postop dysphagia.
Surgery offers a long term relief and a improvement in the quality of life for suffering GERD patients and avoids life long medication. In Barrett’s oesophagus it offers definite benefit and controls symptoms. Reflux disease associated with Hiatus hernia can easily be done laparoscopically. Now even large hiatus hernia with half the stomach in the thorax can be repaired laparoscopically with minimal pain and quick recovery.
Achalasia cardia
Various options available are pneumatic dilatation, botulinom toxin injection and surgical cardiomyotomy. (Hellar ’s operation) and randomized trial and meta analysis it is proved beyond doubt that surgical myotomy offers the most permanent relief. Laparoscopically performed cardiomyotomy is preferred modality of treatment for obvious reasons. In complicated or recurrent cases this can even be done thoracoscopically. We usually combine it with anterior wrap to prevent gastroesophageal reflux due to disturbed lower esophageal sphincter mechanism.
FAQ :-_________
What do we understand by acid peptic disorder?
Literally speaking acid peptic pertains to:
- Acid : - Which is any substance which when dissolved in a solvent releases Hydrogen ions. In this particular case we are talking about hydrochloric acid which is produced in our stomach.
- Peptic :- That which promotes or helps in digestion. Collectively they constitute disorders of acid production in the stomach which result in digestive abnormalities.
What clinical diseases fall under this broad heading ?
Acid peptic disorder is a term which represents a common group of pathological (disease) conditions also known as peptic ulcer disease in which the inner lining (mucosa) of the stomach and duodenum ( common ) gets damaged or destroyed causing ulcers to appear (these are similar to wounds resulting from damage to our skin anywhere on our body).
What are the causes of Acid Peptic Disorder?
Acid peptic disorder result when damaging agents such as the stomach acid are able to overcome the defense mechanism of the mucosal lining of the stomach and duodenum ( part of intestine which continues distal to stomach). The two major factors responsible for causing peptic ulcers to develop are:
- Helicobacter pylori ( bacterial infection)
- Use / misuse / chronic use of pain killers
What are Other causes
- Smoking / Tobacco chewing
- Alcohol
- Prolonged use of steroids / many other medicines
- Tumors of acid secreting cells Chronic kidney / lung diseases
- Chronic liver diseases
- Diet - low fibre, caffeinated, decaffeinated drinks ( known to aggravate symptoms)
- Blood group 'O'
What are the signs and symptoms of patients suffering from APD?
Classically patients with Acid peptic disorder present with upper abdominal pain. The pain has a burning character and occurs either a few hours after a meal or between midnight and 3.00 a.m. However not all patients with these complaints may have a peptic ulcer and vice versa peptic ulcer may be present without any abdominal pain. Though no longer common a patient of Acid peptic disorder can present with a complication of peptic ulcer disease which include :
- Bleeding from the ulcer.
- Perforation at ulcer site i.e. a through and through hole develops in the wall of the intestine causing food and intestinal juices to enter the abdominal cavity.
- Penetration into surrounding organs. Such as liver, pancreas and large intestine.
- Narrowing of intestinal lumen at ulcer site causing obstruction to the normal passage of food forwards.
What are some of the other clinical entities, which can be confused with Acid peptic disorder?
A number of non ulcer diseases can also result in symptoms similar to those seen in patients of Acid peptic disease such as:
- Acid reflux into esophagus (Food pipe).
- Gallstones
- Chronic pancreatitis ( prolonged disease of pancreas)
- Pain originating due to heart conditions
- Disorders of intestines
Some of the less common and ominous conditions include:
- Cancer of the stomach
- Cancer of the pancreas
What are the investigations?
It is important to realize that due to lack of any precise sign or symptom of Acid peptic disorder, the patients history and examination are unreliable tools for establishing a diagnosis.
The diagnosis of this condition is mainly done by endoscopy and X-rays.
- Endoscopy consists of visual inspection of the esophagus (food pipe), stomach and duodenum through a flexible, fibre optic tube passed through the patients mouth into the gut. This has the added advantage of obtaining a piece of tissue from the ulcer and surrounding area for examination. This is done by passing instruments through a separate channel in the endoscope tube. Accurate documentation is also possible by recording the procedure on video and colour print outs.
- Radiography requires x-rays to be taken after the patient ingests a radio opaque contrast medium. It is a cheap and readily available investigation though accurate as compared to endoscopy.
What are the treatment modalities available?
Tremendous advances have been made in the management of peptic ulcer disease. Medicines are now available for:
Medical Therapy
- Neutralizing the stomach acid locally ( Antacids)
- Decreasing (or completely abolishing) acid production.
- Antibiotics for treating the local bacterial infection.
- Drugs which improve local defense barriers in the stomach.
Surgical Therapy
Currently in uncomplicated peptic ulcer disease surgical treatment is infrequently used. However it may be required in cases where complications due to peptic ulcer have occurred, the treatment comprises:
- Removing the acid producing area of the stomach by removing part of stomach.
- Dividing the nerve which stimulates acid production or combining it with creation of a separate passage for the bolus of food to by-pass the ulcer area.
- Simple closure of the ulcer area in case it has perforated.
- Tying the blood vessel supplying the ulcer (in case it is bleeding).
How long does it take for ulcer to heal after starting medication?
The healing rate may differ with different medication, however most ulcers will heal by four to six weeks though the medication my further continued to prevent recurrence.
Can a peptic ulcer recur?
Yes, peptic ulcers are known to recur even after adequate treatment. This recurrence differs slightly depending on site of ulcer 50 - 60% of ulcers in the stomach reappear after 1 -2 yrs. 70-80% of ulcers in the duodenum also reappear. However they may not cause any symptoms to the patient and are detected only on routine endoscopy done as a follow up.
When is it necessary for a tissue sample to be obtained from the ulcer site?
It is now quite a routine practice to take tissue sample for analysis if an ulcer is seen on endoscopy as it helps in determining presence of bacterial infection (with H. pylori) known to be one of the causes of peptic ulcer disease. Biopsy is also necessary in (stomach gastric ulcer) as they have a higher chance of becoming cancerous.
Is it necessary before starting medical therapy to get investigation done?
It has now been commonly accepted that young patients less than 40 yrs of age with short duration of symptoms may be given a course of medicines without confirming the presence of an ulcer. However if their complaints persist despite treatment then they must undergo the investigations. Elderly patients and those having a long duration of complaints must be investigated prior to starting any medication.
Who are more likely to get Acid Peptic Disorder?
In young patients an ulcer in the duodenum is seen more commonly. In elderly patients occurance of ulcers in the stomach and duodenum is similar. Males have a 3 -4 times greater chance of suffering from Acid peptic disorder as compared to females. This is also seen in persons who are anxious / tense or are involved in highly responsible and stressful situation (Pilots / surgeons etc.).
When is the surgical option considered in these patients?
Surgery is considered in case medical therapy fails to control disease progression or in case a complication due to peptic ulcer occurs such as perforation at ulcer site, bleeding from ulcer and obstruction.
What is the incidence of recurrence following surgery?
The ulcer is known to occur in 1 -15 % of patients even following surgery.
What is GERD ?
Normally after food passes through the esophagus (food pipe) into the stomach, a muscular valve called the lower esophageal sphincter (LES) closes, preventing the movement of food or acid upward.
Gastroesophageal reflux occurs when the LES is weakened or relaxes too frequently, allowing acid from the stomach to flow backward into the esophagus.
Some people may also suffer from a hiatus hernia, which is caused by an opening in the diaphragm, a flat muscle that separates the lungs from the abdomen. A hiatal hernia allows a portion of the stomach to protrude into the chest. This condition can then cause the LES to fail.
Why should GERD be treated?
Although most cases of gastroesophageal reflux are caused by a weakened valve, there might be other causes that should be assessed by your doctor. If left untreated, gastroesophageal reflux can cause: esophageal ulcers, esophageal bleeding, inflammation of the esophagus, chronic hoarseness, Barrett's esophagus, and narrowing of the esophagus (peptic stricture) that can cause difficulty in swallowing. It can also cause cancer if left untreated for a long time.
How do I know if I have GERD?
A physical examination and specific tests by your doctor can determine if you have GERD. This condition may however, produce the following symptoms:
- Painful burning in the upper chest or abdomen (heartburn)
- Indigestion
- Regurgitation of food in mouth on lying down
- Difficulty sleeping after eating
- Hoarseness
- Chronic Cough
- Sore Throat
- Asthma
- Difficulty Swallowing
Some or all of these symptoms may occur several times a day, particularly at night, and may become chronic.
How is GERD diagnosed?
- Symptomatology
- Upper GI endoscopy : Which will show refux and presence or absence of esophagitis.
- Barium swallow : It will show presence of reflux and associated hiatus hernia if present.
- 24 hour pH monitoring : Will document excessive presence of acid inside the esophagus
- Manometry : Will document oesophageal pressures.
Not all the tests are always required.
Treatment options
What Can I Do To Take Control Of My Heartburn?
Lifestyle Changes...
DO:
- Sleep with the head of the bed elevated 6 inches
- Have smaller, more frequent meals
- Choose low-fat foods
- Wear looser-fitting clothing and looser-fitting belts around the waist
AVOID:
- Eating large meals, especially before sleep
- Lying down for two to three hours after eating
- Eating chocolate or peppermints
- Smoking cigarettes
- Drinking alcohol
Medicines
Medicines will give relief to symptoms till the time you take them regularly. Few patients may also get long term relief but may recur again. Moreover, many medicines have side effects.
Surgical Correction
For patients with persistent symptoms requiring chronic medication, surgery is an option, which is also a curative mode of treatment. Surgery can repair the valve (LES) as well as repair the hiatus hernia if present.
Surgical Options
- Conventional open surgery
- Laparoscopic Surgery
AIM of both the above procedures is the same : i.e repair of LES and/ or hiatus herniams
How is Laparoscopic surgery for GERD different from open surgery.
Traditional open surgery for GERD requires a large 10-12 cm muscle cutting incision unlike laparoscopic surgery which requires four to five 5 mm tiny incision to perform the same procedure
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OPEN |
LAPAROSCOPIC |
Post operative pain |
Significant |
Minimal |
Hospital stay |
5-6 days |
1-2 days |
Symptom relief |
Good |
Good |
Cosmesis |
Poor |
Excellent |
How successful is the surgery
Worldwide experience has shown that over 90% of patients are symptom free after laparoscopic surgical procedure for gastroesophageal reflux disease. Most dramatic change that occurs is in the improvement in quality of life.
What can a patient expect following surgery
After laparoscopic surgery patients can expect mild pain in their abdomen at the site of small incisions, which usually disappears in 24 to 48 hours. They will also have a feeling of difficulty in swallowing due to a newly constructed sphincter which goes away by 4 weeks. Patients are put on liquid diet immediately after surgery and are discharged next morning on a soft diet.
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