LAPAROSCOPIC FUNDOPLICATION

Condition of Esophagus 

Gastroesophageal reflux diseaseoccurs when stomach acid frequently flows back into the tube connecting your mouth and stomach (esophagus). This backwash (acid reflux) can irritate the lining of your esophagus. Many people experience acid reflux from time to time.

Gastroesophageal is mild acid reflux that occurs at least twice a week, or moderate to severe acid reflux that occurs at least once a week. Most people can manage the discomfort of this problem with lifestyle changes and over-the-counter medications. But some people with Gastroesophageal may need stronger medications or surgery to ease symptoms.

Conditions that can increase your risk of Gastroesophageal reflux disease include:

  • Obesity
  • Bulging of the top of the stomach up into the diaphragm
  • Pregnancy
  • Eating large meals or eating late at night
  • Eating certain foods (triggers) such as fatty or fried food
  • Drinking certain beverages, such as alcohol or coffee
  • Taking certain medications, such as aspirin

Most common symptoms of this disease are:  burning sensation in your chest (heartburn), usually after eating, chest pain, difficulty swallowing, regurgitation of food or sour liquid, burping and others. Usually the symptoms appear an hour or two, after a meal and they get worst when you lay down. GERD is caused by frequent acid reflux. When you swallow, a circular band of muscle around the bottom of your esophagus (lower esophageal sphincter) relaxes to allow food and liquid to flow into your stomach. Then the sphincter closes again. If the sphincter relaxes abnormally or weakens, stomach acid can flow back up into your esophagus. This constant backwash of acid irritates the lining of your esophagus, often causing it to become inflamed.

Over time, chronic inflammation in your esophagus can cause: Narrowing of the esophagus (esophageal stricture), meaning damage to the lower esophagus from stomach acid causes scar tissue to form. The scar tissue narrows the food pathway, leading to problems with swallowing. Also, an open sore in the esophagus (esophageal ulcer). In this case the stomach acid can wear away tissue in the esophagus, causing an open sore to form. An esophageal ulcer can bleed, cause pain and make swallowing difficult. The most important complication of all (appears to 10-20% of all cases) is the precancerous changes to the esophagus (Barrett’s esophagus). Damage from acid can cause changes in the tissue lining the lower esophagus. These changes are associated with an increased risk of esophageal cancer. To confirm the diagnosis the doctor must do an upper endoscopy.The doctor inserts a thin, flexible tube equipped with a light and camera (endoscope) down your throat, to examine the inside of your esophagus and stomach. Test results can often be normal when reflux is present, but an endoscopy may detect inflammation of the esophagus (esophagitis) or other complications. An endoscopy can also be used to collect a sample of tissue (biopsy) to be tested for complications such as Barrett’s esophagus.

Treatment

Your doctor is likely to recommend that you first try lifestyle modifications and over-the-counter medications. The options include: Antacids that neutralize stomach acid and reduce acid production(such assucralfate), medications that block acid production and heal the esophagus. Also, prescription-strength proton pumps inhibitors (such asprazoles).

If you don’t experience relief within a few weeks, your doctor might recommend prescription medication or surgery.  The most common surgery that takes place in these cases is the Fundoplication, in which the surgeon wraps the top of your stomach around the lower esophageal sphincter, to tighten the muscle and prevent reflux. Fundoplication is usually done with a minimally invasive (laparoscopic) procedure. The wrapping of the top part of the stomach can be partial or complete. This method is successful to 85-93% of the patients that undergo surgery. Medication must be preferred to surgery to older patients or patients that have other major health issues. At least two recent clinical studies are arguing in favor of the surgical treatment. Using the Nissen laparoscopic method, the surgeon uses a laparoscope to put a ring of titanium beads around the outside of your lower esophagus. This strengthens the valve between the esophagus and stomach. Food and liquids can still pass through. The surgery lasts 2 to 3 hours; the patient can be mobile within the following 3 to 4 hours and be home after a day or two, without any post-surgical pain. In most cases, the patient can go back to with daily routine within a week, without any medication necessary or a diet program.

Indications for Surgery

When the diagnosis of reflux is objectively confirmed, surgical therapy should be considered in individuals who:

  • Have failed medical management (inadequate symptom control, severe regurgitation not controlled with acid suppression, or medication side effects)
  • Opt for surgery despite successful medical management (due to quality of life considerations, lifelong need for medication intake, expense of medications, etc.)
  • Have complications of GERD (e.g., Barrett’s esophagus, peptic stricture)
  • Have extra-esophageal manifestations (asthma, hoarseness, cough, chest pain, aspiration)
  • The coexistence of Barrett’s esophagus with gastroesophageal reflux symptoms is also considered by many a clear indication for GERD surgery.

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