The esophagus is a muscular tube that allows food to pass from the mouth to the stomach. When you eat or drink, the muscles at the top of the esophagus (Upper esophageal sphincter – UES) relax and allow food or liquid to be pushed through the rest of the esophagus through a process called peristalsis until it passes through the lower esophageal sphincter (LES) into the stomach. When any part of the esophagus malfunctions, it can greatly inhibit aperson’s ability to eat and drink and can cause moderate to severe discomfort. Gastroesophageal Reflux Disease (GERD)
Although occasional heartburn is common, especially after a heavy meal, more than 40 million Americans suffer from severe and persistent symptoms of gastroesophageal reflux disease or GERD. GERD is a painful and often serious disease in which the acid in our stomach flows back up into your esophagus and throat causing a burning feeling in the middle of your chest. This is due to a weakened lower esophageal sphincter (LES) which is a one way valve at the top of your stomach that usually prevents reflux into your stomach.
Symptoms include: Frequent heartburn and acid regurgitation Chest pain, especially when bending over or lying down Trouble swallowing comfortably Hoarseness, wheezing, Adult onset asthma Chronic coughing Sour or bitter taste in your mouth or throat Sleeping on multiple pillows at night Regurgitation of food or coughing that wakes you up in the middle of the night
If gastroesophageal reflux is left untreated for a long period of time, the sensitive tissue in the esophagus will become inflamed (esophagitis) and can cause pain. Extended exposure can lead to sores or ulcers in the esophagus which may lead to bleeding. You may also develop scar tissue which may lead to a stricture which will narrow the esophagus and make it difficult to swallow.
Chronic irritation can also lead to the growth of abnormal cells in the esophagus, called Barrett’s esophagus. This can be linked with an increased risk of cancer and requires close surveillance, discussion with your gastroenterologist and discussion about possible surgery.
Lifestyle changes and medications can significantly reduce the severity of GERD symptoms. Because smoking, caffeing, alcohol, chocolate, citrus and fatty foods can all trigger GERD, the first step is to avoid these agitators. Losing weight, eating smaller meals, eating more slowly and using pillows at night can all offer some relief.
Over the counter and prescription drugs such as Maalow, Mylanta, Tums, Tagamet, Pepcid, Zantac and Prilosec can all alleviate GERD symptoms. There are also prescription strength variants such as Prevacid, Protonix or Nexium which may be prescribed.
Patients choose to have surgery for many reasons. Patients who have regurgitation of food, hoarseness, asthma or findings of esophagitis, esophageal stricture and Barrett’s esophagus should consider surgical repair as these conditions will not improve with medication alone. Some young patients choose to have surgery because they do not want to be on medications for the rest of their life. This is also an acceptable reason.
Surgery for reflux disease involves a laparoscopic fundoplication. This is when the surgeon wraps the upper part of your stomach around the lower portion of the esophagus specifically around the lower esophageal sphincter (LES) which strengthens the sphincter, thus preventing any reflux of stomach contents into the esophagus. The surgery takes about one to two hours. Patients usually stay in the hospital overnight.
Achalasia is a rare esophageal condition that occurs when the lower esophageal sphincter is unable to relax because the nerves to it fail. This prevents food from passing into the stomach. Patients find it difficult to swallow food (dysphagia) and describe a “sticking” feeling in their throat and chest.
Achalasia can also cause food regurgitation because the food does not pass into the stomach. If the patient is asleep when this happens, it can cause choking or pneumonia if food enters the lungs.
Achalasia can be treated with dilation of the lower esophageal sphincter or by injecting Botox (botulinum toxin) into the esophagus to temporarily relax the sphincter. Both of these are only temporary solutions, and the only permanent solution is surgery.
During surgery, an esophagomyotomy (cutting of the esophageal muscle) is performed over the sphincter in order to completely release the sphincter allowing smooth passage of liquids and solids from the esophagus into the stomach.
The results of surgery are best if performed soon after the diagnosis is made because waiting will lead to permanent dysfunction of the esophagus which can not be repaired surgically. Repeated dilations and botox injections increase the chances of surgical complications.
Preparation for Surgery: You will either have a phone or in-person interview with the hospital anesthesia team to discuss your procedure, notify you of medications you should stop or take the day of surgery and let you know what time you should come in for your surgery. You will be asked to come in a couple hours earlier than your schedule surgery time. On the day of your surgery:
Most patients leave the hospital within one to two days after surgery. They are usually able to return to work in one to two weeks. After surgery, you will be kept on a soft diet in order that food does not get stuck secondary to swelling immediately after surgery. You will want to chew slowly and thoroughly and avoid carbonated beverages. Fully cooked pasta and vegetables are a good choice while heavy meats and raw vegetables are likely to cause problems. Once the swelling has dissipated within two to four weeks, you will be able to resume eating all foods without restrictions including those that used to cause reflux symptoms !
You will find that you can resume normal activities within a week or two after surgery.