Managing GERD: A Florida surgeon’s perspective

A graphic representation of laparoscopic Nissen fundoplication surgery, in which the top of the stomach (the fundus — hence the term fundoplication) is wrapped around the bottom of the esophagus.

While there’s no record of prehistoric man seeking a chalky substance to calm his stomach, heartburn goes as far back as Shakespeare, as Beatrice says of Don John in “Much Ado About Nothing:” “That man always looks so sour! Just looking at him gives me heartburn.”

We now know that heartburn, while uncomfortable at best, is a symptom of the much more serious condition of GERD (gastroesophageal reflux disease). Also known as acid reflux, the disorder was first described in 1925 by two physicians looking the relation between heartburn and hiatal hernias. It occurs when the stomach contents rise into the esophagus.

In addition to heartburn, symptoms include the taste of acid in the back of the mouth, bad breath, chest pain, vomiting, breathing problems and wearing away of the teeth. The major complication of GERD is the development of Barrett esophagus, a pre-cancerous lesion.

Dr. Matthew Tufts, a Port Charlotte-based general surgeon who specializes in bariatrics, anti-reflux surgery and other minimally invasive general surgery techniques, understands GERD from a personal and professional perspective.

“Gastric acid production in the stomach is normal, but refluxing the acid into the esophagus, which is the tube from your mouth to your stomach, can cause a lot of different problems, most commonly the sensation of “heartburn.” As the disease progresses it can lead to more ominous results, damaging the esophagus’ ability to squeeze and even cause irreversible damage to the lining of the esophagus.”

Dr. Tufts said about one in four people have some spectrum of the disease. Healthcare statisticians agree, while noting that the number may be higher, since many people with GERD symptoms don’t consult a healthcare provider. A 2014 systematic review estimated that some 30% of the U.S. population has GERD.

“It’s generally pretty mild,” said Dr. Tufts, “but about one in four people take something for heartburn at least once a week, something like Tums, Zantac, Protonix and the like. Because there’s a spectrum with acid reflux disease, some people are totally happy doing that.

“On the flip side, there are people with acid reflux that’s causing a cough, scratchy throat or even some breakthrough heartburn on medications that lead to sleep disturbances,” he said. “Those are the people that may be interested in surgical options.”

According to Dr. Tufts, laparoscopic Nissen fundoplication surgery may be an option for esophageal reflux not treated well by medications. Named for the Swiss surgeon who developed it, Nissen fundoplication is a procedure to reinforce the lower esophageal sphincter. In this procedure, the surgeon wraps the top of the stomach around the lower esophagus. This reinforces the lower esophageal sphincter, making it less likely that acid will back up in the esophagus.

“Wrapping the stomach in this manner creates a pressure valve that will prevent reflux of acid and food contents back into the esophagus,” Dr. Tufts said.

“The reflux surgery wasn’t very popular at first because they had to do it through a large and painful incision,” said Dr. Tufts, “but once the new technology of both robotic and laparoscopic techniques became widely available, it’s actually become a pretty popular operation.”

Dr. Tufts explained why: “Number one, people don’t like to take medications, which may be very expensive to take every day for 20 years. So, it’s been shown to be cost effective to have one surgery to treat that.

“Number two, there has been some studies recently that showed that the some antacid medications may be related to some complications down the road, including kidney disease, pneumonia and even dementia.”

The drugs in question are known as PPIs (proton pump inhibitors) and include Prilosec, Nexium and Prevacid. These drugs essentially shut down acid production in the stomach. (Other drugs such as Zantac and Tagamet are acid reducers, not inhibitors.)

“These were big studies looking at massive amounts of people, and they do show a correlation,” said Dr. Tufts, “but not necessarily that those medications are causing these complications.

“I still think they’re safe medications,” he added. “That’s why in my discussions with patients, I’ll recommend surgery only if their medications aren’t controlling their symptoms or they’re having actual hard signs that they’re not tolerating their medications.”

The surgery takes about an hour and a half, Dr. Tufts said. It’s done under general anesthesia laparoscopically with about five small incisions about the size of a pen

“You’re in the hospital about one day,” he said. “You’re on a strict diet for about four weeks where you let your esophagus kind of ease back into eating normal food. You’re on soft diet for about two weeks then you start to re-introduce normal foods. And the goal at the end of four weeks is that you can eat whatever you want, including the stuff that would give you heartburn in the past.”

For more information on GERD or for a physician referral, please contact Consult-A-Nurse at 941-624-4441 or visit FawcettHospital.com.

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