The following hypothetical consultation about surgery for gastroesophageal reflux disease (GERD) is presented for purposes of general information. If you think you have a similar condition, please see your doctor to discuss your individual case and the exams and treatments that are best for you.
Heartburn, a burning sensation in the chest or throat, is caused by stomach acid irritating the tissues of the esophagus. Occasional heartburn is common. If it occurs many times each week, however, it may be considered gastroesophageal reflux disease (GERD). GERD can affect people of any age, and it can eventually lead to more serious health problems.
In some cases, GERD cannot be controlled with medication. People with GERD can be helped by a surgical procedure called a Nissen fundoplication. In our example, the patient is a 45-year-old man who has both GERD and a hiatal hernia. His primary care doctor has referred him to discuss surgery to treat both these problems.
Doctor: Hello. How are you?
Patient: I’m fine, thank you.
Doctor: How can I help you?
Patient: I have terrible heartburn, and my doctor sent me to you. I’ve had some tests already.
Doctor: I see from your chart that Dr. Smith has been treating you for reflux for some time now.
Patient: Yes, about two years.
Doctor: Please tell me about how all this started, and what kinds of symptoms you’ve been having.
Patient: Well, I’ve had heartburn for a long time. I’d get it occasionally and take antacids. Then one night I had terrible chest pain after I went to bed. My wife knew it was bad, because I didn’t complain. I just lay there thinking, "Am I having a heart attack?". But it felt like very bad heartburn, and I had eaten a large dinner with a lot of rich food. I got up and took antacids and it finally passed.
Doctor: Was that the only time you had the severe pain?
Patient: No, it happened again, and then my wife convinced me to go to the doctor.
Doctor: And what did the doctor diagnose at that visit?
Patient: The doctor thought it was GERD. She sent me for an endoscopic exam, which showed that my esophagus was inflamed. She also said I have a hiatal hernia. I’m not sure how the two are related, but I guess one makes the other one worse.
Doctor: That’s right, and we’ll talk more about that. Did your doctor order any other tests?
Patient: I had a test that measured acid exposure, and another that measures the pressures in my esophagus when I swallow.
Doctor: Yes, those are called pH and manometry testing.
Patient: No one ever told me the results of the manometry.
Doctor: Oh? OK. Let’s look over them together. They review the test results.
Doctor: Have you been taking any medication for heartburn?
Patient: Yes, I have taken antacids, H2 blockers and then a whole series of different proton pump inhibitors. The latest were Prilosec and then Aciphex.
Doctor: Have you had any trouble swallowing?
Doctor: Any hoarseness, sore throat?
Patient: I’ve been getting hoarse every now and then, particularly in the mornings. My wife pointed out that I clear my throat a lot.
Doctor: Any wheezing, coughing, shortness of breath?
Doctor: Do you have asthma?
Patient: No, no asthma.
Doctor: Do you smoke?
Patient: I did. The doctor told me it would help to quit. I had been thinking I should, anyway, and this gave me a reason, so I did.
Doctor: Good. And that was how long ago?
Patient: Eighteen months.
Doctor: Do you snore or have sleep apnea?
Patient: Why do you ask?
Doctor: Sleep apnea, is associated with GERD and so is some types of snoring. Both matter if we do surgery for your condition.
Patient: I don’t snore.
Doctor: Do you have any other health problems, for example weight loss or gain, bleeding from anywhere, … do you take pills for any other condition?
Patient: No. I’m in pretty good shape overall. I’ve got some extra weight, but I’m working on that now.
Doctor: All right. I’ll examine you now, and then we’ll talk about the surgical options.
Doctor examines the patient, noting that he is moderately overweight.
Doctor: I do see that you are moderately overweight, and you’ve mentioned that you’re working on that. Excess weight can contribute to the reflux problem, as you know.
Doctor: The endoscopy showed significant inflammation of your esophagus, and the manometry results indicate you’re your valve between the esophagus and stomach, called the “LES”, is weak. The pH testing shows that when you reflux acid, that’s when you hurt—there’s good correlation between acid exposure and symptoms. That helps predict a good outcome to surgery, if that’s what you chose. You also have a hiatal hernia.
Patient: Right. But I don’t understand why I have this, or what the hiatal hernia means.
Doctor: In many cases of GERD, such as yours, there can be more than one thing going on. As you may know, the diaphragm separates the chest from the abdomen. The stomach is usually in the abdomen, but, when it herniates into the chest, acid more easily gets pulled into the esophagus, causing heartburn.
Patient: It certainly is painful.
Doctor: Yes, because quite literally, the acid burns the lining of the esophagus.
Patient: So that weak valve is part of the problem and so is the hernia?
Doctor: Yes. People who have GERD may have a weakened LES, or they may have a hiatal hernia, or they may produce more acid than other people. They may have all of these problems. The proton pump inhibitor medication you’ve been taking reduces the amount of acid you produce.
Patient: So that there is less acid that can leak out.
Patient: Okay. What does the surgery involve?
Doctor: We do two things. We fix the hiatal hernia and we create a better valve in the lower part of the esophagus. To do this, we wrap the upper part of the stomach around the lower esophagus, and we effectively strengthen the LES mechanism.
The doctor draws picture of the operation on scratch paper.
Patient: Do you think the surgery could help me?
Doctor: I think that in your case such an operation could help reduce your reflux and relieve your symptoms.
Patient: Is it laparoscopic surgery?
Doctor: Yes, we do this laparoscopically in almost every situation.
Patient: Is that standard now, to do the surgery laparoscopically?
Patient: What are the advantages of doing it that way?
Doctor: There is generally less discomfort and quicker healing, because the incisions are much smaller than in open surgery. Even though the incisions are smaller, it’s the same operation.
Patient: And the scars are smaller?
Doctor: Yes. We will make four or five very small incisions in your abdomen, each one about half an inch long.
Patient: What is the success rate of the surgery?
Doctor: For laparoscopic fundoplication, the success rate is approximately 95 percent. Typically patients have good relief of their GERD symptoms for years after their operation.
Patient: So it is not a permanent solution?
Doctor: It depends on your individual case. Suppose you gain more weight, or have forceful vomiting soon after surgery. This may weaken the repair. Most have long-lasting relief of their heartburn, and only a small percentage of patients need occasional antacids or acid blockers.
Patient: What if I don’t have the surgery?
Doctor: If the lining of the esophagus is burned and inflamed over a long period of time, there can be changes in the cells, and those changes can become precancerous. That is a condition called Barrett’s esophagus. If this were to happen, you would need to come in periodically to get your esophagus checked for this. If you did not have the surgery, we could continue to try to control the reflux with medication. Weight loss will definitely help.
Patient: What are the side effects of taking the medication for a long time?
Doctor: Mainly that the symptoms are not well controlled; but there may be a problem with continuing reflux, even if it’s not acid. Some believe that reflux of non-acid stomach contents is more dangerous in the long term than acid reflux. It may be that bile reflux from the stomach is more closely associated with cancer than acid.
Patient: I understand. If I do have the surgery, will I need to stay in the hospital overnight?
Doctor: Yes. Most patients stay at least one night in the hospital.
Patient: How long does the operation take?
Doctor: It takes about two hours for me—of course, you’ll take more time to go to sleep, wake up, etc.
Patient: What are the risks?
Doctor: First, there are risks to the anesthesia. You will have general anesthesia and there is the chance that you will have a reaction to the anesthesia or that you will have trouble breathing.
Patient: Are there other risks?
Doctor: From the surgery itself, there is a risk of bleeding or infection, and the possibility of injury to the tissues around the stomach and esophagus We do everything we can to minimize these and other risks. If there is an infection, we will give you antibiotics to treat it.
Patient: And what complications could there be afterward?
Doctor: The surgery may not work over the long term, as we’ve discussed. And there is a very small possibility that the valve we create will fail, and we would need to do another surgery to correct it. Other complications that patients may experience after the surgery are difficulty swallowing, bloating, diarrhea, and the feeling that you are full after eating a small amount of food. These usually go away two or three months after the surgery. I like to emphasize that this operation produces new symptoms, meaning that you trade heartburn for other side effects. We use some of your stomach to make the new valve, so you won’t be able to eat as much early on. That can be a good thing, yes? Also, if you have fizzy drinks, swallow a lot of air, or do anything that makes you fill your stomach with gas, you won’t be able to burp out the air very easily. That’s a side effect of the operation. Most people say this type of thing: “I feel a lot better. It’s different. It’s not normal. But, it’s much better.”
Patient: How do I prepare for the surgery?
Doctor: We’ll instruct you not to eat or drink anything after midnight before the surgery. On the morning of the surgery, you can take your normal medicines with a small sip of water. You’ll come here to the hospital and we’ll do the procedure in the operating room, under general anesthesia. We'll you here overnight while you come out of the anesthesia, observing you and making sure that you are ready to go home the next day. Our nursing staff will give you more details.
Patient: How long does it take to recover from the surgery?
Doctor: You’ll probably leave the hospital in two or three days. You’ll need to stay on soft food for 3 weeks after this surgery, so as to not stress the repair. Plus, the swelling due to surgery around your stomach might make it hard to swallow solid foods, so, you’ll need to be on liquids and soft, mushy food for 3 weeks.
Patient: How soon will I be able to go back to work?
Doctor: It depends on your occupation. People have gone back to work as soon as the next day. In general, patients take between two and six weeks off work to recover.
Patient: Will there be any restrictions on me after the surgery?
Doctor: We tell patients not to do any heavy lifting for six weeks—that’s a general precaution.
Patient: What do you consider heavy lifting?
Doctor: Anything you cannot comfortably lift at arm’s length is too heavy, and of course anything that hurts is too heavy.
Patient: All right. Well, I think I want to have the surgery. It sounds like it could help.
Doctor: All right. I’d like to see you one more time before the operation to make sure we’ve both covered all our concerns. My assistant will schedule a tentative date for your operation, and I’d like to see you about three weeks before that date. Is there any chance you can lose some weight before this elective operation? This is not required nor an emergency. I'd like to do everything possible to make it safer and more reliable. (More discussion follows….)
Patient: Thank you.
For more information, visit UC San Diego Gastroenterology or read more about GERD.