Upper G.I. Surgery
Gastroesophageal Reflux Disease (GERD)
Three types of treatments exist for GERD. These include lifestyle modifications, medications, and surgery. In patients with severe symptoms life-style modifications have showed limited benefit.
A number of drugs are approved to treat GERD, and are among the most prescribed medication in Western countries.
- Proton pump inhibitors (such as omeprazole, esomeprazole, pantoprazole, lansoprazole, and rabeprazole) are the most effective in reducing gastric acid secretion. These drugs stop acid secretion at the source of acid production, i.e., the proton pump. The long term use of these medications may have adverse side effects.
- H2 receptor blockers (such as ranitidine, famotidine and cimetidine) can reduce gastric secretion of acid. These drugs are technically antihistamines. They relieve complaints in about 50% of all GERD patients.
- Sucralfate (Carafate) is also useful as an adjunct in helping to heal and prevent esophageal damage caused by GERD, however it must be taken several times daily and at least two (2) hours apart from meals and medications.
- Baclofen is an agonist of GABAB receptor. In addition to its skeletal muscle relaxant properties, it has also been shown to decrease transient lower esophageal sphincter relaxations at a dose of 10mg given four times daily.
A Biomechanical Malfunction
As complex as the reflux issue appears, the solution is relatively straightforward because reflux and its complications are actually caused by a biomechanical malfunction-a loose valve (LES) at the end of the esophagus. The pharynx, esophagus and stomach are basically mechanical organs. They don't absorb food or nutrients but rather are designed to function in the process of ingestion -taking in the food and preparing it for the small intestine, where absorption becomes the important function. Thus, the solution to the problem of reflux is to correct the mechanical problem (the loose valve) through surgery. Antireflux procedures such as Nissen fundoplication re-establish the barrier (valve) between the esophagus and stomach, and keep both gastric and duodenal juice out of the esophagus, abolishing the environment that places patients at risk for Barrett's metaplasia.
Minimally Invasive Surgical Approaches to Treat Reflux Disease
The Laparoscopic Nissen Fundoplication procedure is used to construct a new valve between the stomach and the esophagus. The stomach is pulled up and around the esophagus, then secured around the esophagus, and the valve is then placed into the abdomen below the diaphragm. In the past, an open surgical procedure was necessary to surgically stop gastroesophageal reflux in patients with severe disease. Today this can be done laparoscopically. Small ports are pushed through the belly wall (4 to 5 are used). One contains a video camera and shows the surgeon the inside of the abdomen. This allows the defective valve between the esophagus and stomach to be augmented without opening the abdomen. Much of the work in laparoscopic Nissen fundoplication was pioneered at USC. Designed to reconstruct the valve between the stomach and esophagus to eliminate gastroesophageal reflux, the surgery entails a complete 360-degree fundoplication where the upper stomach is folded around the lower esophagus. The procedure takes approximately 1-2 hours and patients can return home one or two days after the operation.
While some patients with severe reflux disease may benefit from the laparoscopic Nissen fundoplication, which is a 360 Degree valve, others with esophageal motility disorder may benefit from a partial valve, a 270 Degree Laparoscopic Toupet Fundoplication. For short esophageal length, a Collis gastroplasty (using part of the stomach to add length to the esophagus) and constructing a fundoplication over the added "neo-esophageal" segment represents the optimal approach.
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