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This is a term to describe contents from the stomach splashing up into the esophagus. It is normal for humans to experience some reflux of gastric contents, but the frequency that exceeds a normal exposure diagnoses gastroesophageal reflux disease. Notice that the word "disease"  is in the phrase and is the "D" in the acronym GERD. There is a pathological level of gastroesophageal reflux earning a patient the diagnosis of the disease.

GERD is a common disorder that affects millions of Americans. Many of these patients are not happy or insufficiently treated with medications alone. In addition, there has been a lot of press about the potential negative side effects related to anti-reflux medications. Surgery is an effective option that relieves GERD symptoms and prevents patients from needing these medications. As leaders in the treatment for GERD, our surgeons offer a comprehensive diagnostic evaluation to determine an appropriate treatment plan.

Causes

Gastroesophageal reflux disease comes from the failure of the natural reflux barrier. The failure can occur in several ways. Some of these common causes include a hiatal hernia, a weak or short lower esophageal sphincter, pregnancy, delayed gastric emptying, and certain diets.

Diagnosis

Just like other diseases, GERD progresses over time. Often times patients start early in their life with symptoms that cause their physician to diagnose them with GERD. The patients are then started on an acid-suppressing medication like a Proton Pump Inhibitor, or PPI. Usually, patients have already exhausted over the counter medications to help with the symptoms of GERD. Using the PPI will alleviate the heartburning symptom which will essentially make the diagnosis of gastroesophageal reflux disease. However, the true test for an absolute diagnosis is a pH study, such as a 24 hour pH catheter or a probe. These tests will demonstrate elevated levels of acid in the esophagus which definitively makes the diagnosis of GERD. These tests have become less common to diagnose GERD because the disease is extremely common and is easier done by a trial with a PPI.


Probe placement in the esophagus
 

In either situation, the diagnosis of gastroesophageal reflux disease is reliably made and can be treated. The progression of the disease will often exceed the ability of the PPI to control the symptoms of GERD. Patients will often return several times to their prescribing physicians for the persistent symptoms and complaints. Physicians will titrate to a higher dose and frequency of the medications and emphasize a strict regimen. But with continued use of PPIs, the symptoms will often return as the disease progresses. At this point, PPIs will no longer control the symptoms and surgery is indicated to stop the gastroesophageal reflux.

Treatment Options

Surgery is indicated for patients that have failed management with medications (such as PPIs), have a desire to no longer take medications, or have a hiatal hernia. The knowledge of the physiological changes with regard to GERD have been studied extensively and surgical treatments have improved. The steps to repair gastroesophageal reflux disease with surgery are at the discretion of the surgeon. With the expertise of our surgeons, the below procedures are recommended after careful consideration and the procedure is matched to each individual patient.


 

Hiatal Hernia – see the drop down section on Hiatal Hernias

Fundoplication – Laparoscopic fundoplication is the most well studied surgical procedure for the treatment of GERD. A small portion of the stomach is used to reinforce the natural reflux barrier by wrapping it around the bottom of the esophagus and suturing it into place. This will prevent the backflow of bile and stomach contents into the esophagus. Potential side effects include bloating, trouble swallowing, and an inability to belch or vomit due to the newly reinforced valve. It is important that a surgeon who possesses significant training and experience does this procedure to minimize or prevent these side effects. Our surgeons typically recommend this operation for those patients with large hiatal hernias or advanced GERD. The ability of the surgeon to tailor the fundoplication to the patient's needs have improved greatly. There is a preoperative workup that needs to be undertaken for the surgeon to determine the best fundoplication for the patient.


Complete fundoplication (Nissen)


 

Magnetic Lower Esophageal Sphincter Augmentation  – This procedure has been performed in Europe before 2012, but in March of that year, the FDA approved the device used for the procedure in the United States. This procedure is where an implant that also reinforces the natural reflux barrier at the bottom of the esophagus, but does it in a slightly different way. It consists of a string of magnetic beads that are placed around the lower esophageal sphincter that opens and closes using magnetic forces in response to food. In addition, the device will resist the natural forces from the stomach to prevent GERD, but can be overcome in instances were belching or vomiting need to occur. The procedure for implantation is much shorter than the fundoplication because the stomach anatomy is not disrupted. In cases of a hiatal hernia, the device can still be implanted after the hiatal hernia is repaired.

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Other Options -  There has been a significant effort to establish endoscopic techniques for treating GERD, but have fallen short when compared to the superior outcomes of Magnetic Lower Esophageal Sphincter Augmentation and fundoplications. These procedures are called TIF (transoral incisionless fundoplication) and Stretta. Although immediate improvements in symptoms have been shown in some studies, the durability of these procedures beyond one year is compromised and symptom recurrence is common. BSW Center for Advanced Surgery will consider using these procedures in special cases to avoid patient dissatisfaction.


Quality of Life Improvement

At BSW Center for Advanced Surgery  the goal of GERD treatment is to improve quality of life and relieve life altering chronic symptoms. All patients are managed under a research registry to track the progress of patients and detect any aberrations in their quality of life. GERD is a disease that needs to be closely managed for optimal outcomes. Extensive research at our facility has shown symptom relief and patient satisfaction with LINX® and fundoplications. Patients can count on a three year 85 percent or better rate of GERD symptom remission allowing patients to be off all anti-reflux medications. In addition, they experience a drastic improvement in their quality of life, which allows patients to eat the food they enjoy, get a more restful night of sleep, and rid themselves of heartburn and regurgitation.