What is GERD?
Gastroesophageal reflux disease or GERD for short is a common digestive condition. It occurs when gastric content frequently flows back up into the oesophagus, resulting in a “burning” sensation along the throat or chest. It can lead to severe chest pain and throat discomfort.
Anyone, including infants and children, can have GERD. If not treated, it can lead to more serious health problems. In some cases, medicines, or surgery. However, many people can improve their symptoms changing certain lifestyle habits which we will touch on later.
GERD Rate Worldwide
Nearly everyone will experience heartburn at some point in their life.
Based on a population-based study in Norway in 2010 , the prevalence of weekly heartburn rose nearly 50% over the last decade.
Between 20-30% of adults worldwide experience acid reflux symptoms weekly and this present causes for concern in us as doctors to assess if a patient requires more advanced treatment.
A large study in Sweden also found that patients with reflux symptoms had a higher risk of developing oesophageal cancer compared to those who did not have reflux.
Hence, patients with such symptoms are advised to seek medical attention early to do an assessment and evaluation of their symptoms.
Symptoms of GERD
One of the more common symptoms encountered in our line of work is patients coming in with Heartburn. Heartburn results in a painful burning feeling in the chest or throat and usually occurs after consuming certain food in their diet.
If a patient experiences frequent Heartburn. They are diagnosed as having GERD.
A number of food can cause heartburn. The common ones include:
• Alcohol, particularly red wine
• Black pepper
• Raw onions
• Spicy foods
• Citrus fruits and products, such as lemons, oranges and orange juice
• Coffee and caffeinated drinks, including tea and soda
Other Common Symptoms related to GERD:
• Odynophagia (difficulty in swallowing),
• Chest pain
• Acid brash
• Dry coughing
Complications of untreated GERD
GERD if untreated would lead to serious complications. Complications could include:
• Reflux oesophagitis (inflammation of the lining of the oesophagus from acid reflux)
• Oesophageal strictures (abnormal narrowing of the esophageal lumen)
• Barrett’s oesophagus (thickening and reddening of oesophageal lining)
• Esophageal malignancy (cancer of the oesophagus)
Impact of GERD
GERD can negatively affect the quality of life of a patient. Night-time reflux can compromise sleep for people who sleep in a typical horizontal position. This can in turn affect alertness and productivity the following day.
Patients with GERD would also be required to follow stricter dietary restrictions including regimented timing of meals and the need to avoid consuming foods and beverages that trigger reflux.
Who are at Risk of Developing GERD?
Conditions that can increase your risk of GERD include:
• Bulging of the top of the stomach up into the diaphragm (hiatal hernia)
• Connective tissue disorders, such as scleroderma
• Delayed stomach emptying
Factors that can aggravate acid reflux include:
• Eating large meals or eating late at night
• Eating certain foods (triggers) such as fatty or fried foods
• Drinking certain beverages, such as alcohol or coffee
• Taking certain medications, such as aspirin
Non-medical Treatment for GERD
GERD can be treated with a series of lifestyle modification and dietary habit changes along with medication. By advising patients to make a change in their dietary habits and lifestyle, the condition can improve.
Advices may include:
• Consuming less spicy & acidic food
• Consuming smaller portions of meals many times a day
• Eating 4 hours before sleeping
• Elevating head when sleeping
• Losing Weight
• Ceasing consumption of alcohol
• Quit Smoking
• Keeping a active lifestyle
Medical Treatment for GERD
For patients with manageable symptoms of GERD, medication targeted at reducing the stomach acidity and increasing motility would suffice.
Proton Pump Inhibitiors (PPIs) can be considered either as a step-up or step-down approach.
• Step-up approach: Incrementally increasing dosage of PPI until symptom control achieved
• Step-down approach: Starting with high dose PPI and titrating till minimal dosage to achieve control
Monitoring of the patient will then be advised to observe for the need to proceed to more advanced treatment options.
When does a patient qualify for surgery?
A patient would qualify for surgery when the following conditions are met:
• 3 to 6 months of daily symptoms
• High dose medication
• Severe disruption to lifestyle
• Development of Barrett’s oesophagus (thickening and reddening of oesophageal lining)
However, there are also various factors to be considered if a patient would like to proceed with surgery despite not meeting the above conditions:
• Failed medical treatment
• Inadequate symptom control
• Medication side effects
• Complication of GERD
• Severe oesophagitis
• Peptic stricture
• Opt for surgery despite successful medical therapy
• Quality of life considerations
• Lifelong need for medication and expense
Surgery for GERD
Laparoscopic Anti-reflux Surgery (Nissen Fundoplication)
Laparoscopic anti-reflux surgery (also called Nissen fundoplication) is used in the treatment of GERD when medicines are not successful. Laparoscopic antireflux surgery is a minimally-invasive procedure that corrects gastroesophageal reflux by creating an effective valve mechanism at the bottom of the oesophagus.
The aim of the surgery if to restore a physiological Lower Esophageal Sphincter (LES).
Nissen fundoplication results in less acid exposure and increased LES pressure compared to medical therapy. It also helps improve the quality of life of the patient compared to medical therapy and has an increased patient satisfaction rates overall.
There are also several benefits to opting for Laparoscopic fundoplication as opposed to traditional fundoplication. Patients have:
• Fast recovery
• Average of 2.5 days or less hospital stay
• Average of 7.5 days or less to return to normal activity
• Less surgical complications
• Four incisions –– each measuring about 0.5-1.5cm.
• Similar post-operative outcomes
Procedure for Nissen Fundoplication
• The fundus of the stomach is wrapped around the lower esophagus
• This tightens the lower esophageal sphincter and reduces acid reflux into the esophagus.
• Passage of gastric fundus behind esophagus to encircle distal 6cm of esophagus
Variables when conducting Nissen Fundoplication:
• Approach (transthoracic or transabdominal)
• Portion of stomach used (anterior and posterior or anterior only)
• Combination with other procedures
• Looseness of wrap
• Completeness of wrap (180 ° anterior wrap Dor or 270 ° posterior wrap Toupet)
Complications arising from Nissen Fundoplication:
There are several risk of complication which may arise following the procedure:
• Dysphagia (8-12%)
• Vagus nerve injury
• Failure of treatment
• Conversion rate (2.5%)
• Pneumothorax (0-1.5%)
• Perforation (0-4%)
• Herniation of wrap (0.8%-26%)
Other forms of GERD treatment surgery
Hiatus Hernia Repair
Surgery can repair a hiatal hernia by pulling the stomach back into the abdomen and making the opening in the diaphragm smaller. At least 3-5cm of oesophagus should be in the abdomen during repair.
The procedure may also involve surgically reconstructing the oesophageal sphincter or removing hernial sacs.
Complications arising from Hiatus Hernia Repair
There are other forms of consideration when considering Hiatus Hernia Repair.
• Erosion into oesophagus
• Recurrance of symptoms and migration
• Injury to surrounding organs
Post Surgery Findings
• 80% to 90% of the patients who undergo the Nissen Fundoplication report a control of their symptoms
• 10-20% of patients experience persistence of recurrence of symptoms
• 3-6% of patients eventually need a 2nd anti-reflux operation
Review of possibility of failure in anti-reflux surgery
A series of investigations were launched to detect the possible causation for failure in anti-reflux surgery. The following factors have to be considered:
1) Barium swallow and gastroscopy
• Identifies anatomical problems including herniated wrap or wrong configuration
2) Esophageal manometry
• To assess pressure and relaxation of LES and quality of esophageal peristalsis
• Important to rule out achalasia
• Postop achalasia type picture can be caused by too-tight or too-long fundoplication
3) Ambulatory pH monitoring
• Many studies have shown that in patients with recurrent heartburn, abnormal reflux is present in only 23-39%
4) Anatomic Failures
Various anatomic failure could also occur that results in failure of anti-reflux surgery
• Type 1A hernia: both GEJ and wrap are above the diaphragm
• Type 1B hernia: wrap located below diaphragm, GEJ located above diaphgram, usually caused by limited mediastinal dissection with only 1-2cm of esophagus below diaphragm
• Type II hernia: stomach located above the wrap and herniated through diaphragm usually caused by faulty closure of hiatus and redundant fundoplication
• Type III hernia: body rather than fundus is used to construct the wrap, both wrap and GEJ in subdiaphgramatic position
When should patient undergo Re-Operation?
Re-operation usually involves taking down prior wrap, bringing fundus of stomach to its original position in left upper quadrant, assessing hiatal closure and position of gastroesophageal junction (GEJ) in relation to diaphragm.
Operation would be determined by the following:
• If GEJ is still too high, higher mediastinal dissection should be performed
• If GEJ is still not reduced below diaphragm, Collis-Nissen lengthening procedure might be necessary
• Esophagectomy is usually the last resort after multiple failed redo fundoplications.
Risk of Re-Operation
Re-operation is complex, often with higher morbidity rates and longer hospital stay.
Studies have reported:
• Mortality rate 0.9%
• Intraoperative complication rate 21.4%
• Postoperative complication rate 15.6%
• Success rate of only 65-70%
It is important to assess what is the best option available for the patient prior to embarking on re-operation.
GERD is a common problem in Singapore and around the world and is on the rise due to factors like unhealthy lifestyle and increasing rate of obesity.
It negatively affects health and quality of life, and increases the likelihood of developing Barrett’s oesophagus, peptic stricture and oesophageal cancer.
The appropriate use of medicine under the supervision of healthcare providers has been shown to be a safe and effective way for most established cases but close observation is required to identify possible complications resulting from GERD.
A change in dietary habits and lifestyle can also help to reduce the recurrence of GERD symptoms.
In severe cases, GERD can be treated effectively with laparoscopic fundoplication.
Antireflux surgery is safe, effective and durable in well selected patients and although rarely required, may be an important option to tackle severe and complicated GERD, especially when medical therapy fails.