Laparoscopic surgery has became a preferred method of treatment for refractory G.E.R.D (gastro esophageal reflux disease), 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 esophageal motility and pre-existing dysphagia symptoms.
We commonly perform floppy (360˚) Nissen’s fundoplication in majority of cases. Toupet or 270˚ partial wrap is performed in patients with ineffective esophageal Motility (I.E.M) to avoid postoperative dysphagia.
Surgery offers a long term relief and an improvement in the quality of life for GERD patients and avoids life long medications. In Barrett’s oesophagus, it offers definite benefits and controls symptoms. Reflux disease associated with Hiatus hernia can easily be done laparoscopically. Now even large hiatus hernias with half the stomach in the thorax can be repaired laparoscopically with minimal pain and quick recovery.
Various treatment options available are pneumatic dilatation, botulinom toxin injection and surgical cardiomyotomy (Hellar’s operation). Randomized trials and meta analyses have proved beyond doubt that surgical myotomy offers permanent relief. Laparoscopically performed cardiomyotomy is a preferred modality of treatment for obvious reasons. In complicated or recurrent cases this can even be done thoracoscopically. We usually combine it with the anterior wrap to prevent gastroesophageal reflux due to disturbed lower esophageal sphincter mechanism.
What do we understand by acid peptic disorder?
Literally speaking acid peptic pertains to:
- Acid: - 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.
Which clinical diseases are included in this 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 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 (APD)?
Acid peptic disorder result when damaging agents such as the stomach acids are able to overcome the defence mechanism of the mucosal lining of the stomach and duodenum (part of intestine which continues distal to the stomach). The two major factors responsible for peptic ulcers to develop are:
- Helicobacter pylori ( bacterial infection)
- Use / misuse / chronic use of pain killers
What are Other causes
- Smoking / Tobacco chewing
- Prolonged use of steroids / many other medicines
- Tumours 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 the esophagus (Food pipe).
- Chronic pancreatitis ( prolonged disease of pancreas)
- Pain due to heart conditions
- Disorders of the intestines
Some of the less common and ominous conditions include:
- Cancer of the stomach
- Cancer of the pancreas
What are the investigations of choice?
It is important to realize that due to lack of any precise sign or symptom of Acid peptic disorder, the patient’s 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 patient’s 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 not as accurate as endoscopy.
What are the treatment modalities available?
Remarkable advances have been made in the management of peptic ulcer disease. Medicines are now available for:
- Neutralizing the stomach acid locally ( Antacids)
- Decreasing (or completely abolishing) acid production.
- Antibiotics for treating the local bacterial infection.
- Drugs which improve the local defence barriers in the stomach.
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, in which case, the treatment comprises of:
- 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 medications; however most ulcers will heal by four to six weeks, though the medication may be 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 which is 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 samples for analysis if an ulcer is seen on endoscopy, as it helps in determining the presence of bacterial infection (with H. pylori) known to be one of the causes of peptic ulcer disease. Biopsy is also necessary in (stomach 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 whereas in the elderly, ulcers can occur in the stomach or duodenum. 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 recur in 1 -15 % of patients after 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 hiatus 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)
- Regurgitation of food in mouth on lying down
- Difficulty sleeping after eating
- Chronic Cough
- Sore Throat
- 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?
- Upper GI endoscopy: It will show reflux 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.
What Can I Do To Take Control Of My Heartburn?
- 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
- Eating large meals, especially before bedtime
- Lying down for two to three hours after eating
- Chocolate or peppermints
Medicines will give relief to symptoms till the time they are taken regularly. Few patients may also get long term relief but may recur again. Moreover, many medicines have side effects.
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.
- Conventional open surgery
- Laparoscopic Surgery
The aim of both the above procedures is the same i.e. repair of LES and/ or hiatus hernia
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 incisions to perform the same procedure.
Post operative pain
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. The most dramatic change that occurs is the improvement of the 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 eases off 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 the next morning on a soft diet.