Foregut

Gastrointestinal Reflux Disease is one of the largest and fastest growing disease states in

the US that affects 1 in 5 adults1 with over 20 million patients taking Reflux medications. Gastroesophageal Reflux disease (GERD) is one of the most important gastrointestinal diseases in the United States in terms of its chronicity, overall cost, adverse impact on quality of life, and potential for complications, such as Barrett’s esophagus and esophageal adenocarcinoma.

In this condition, stomach acids reflux or “back up” from the stomach into the esophagus. Heartburn is described as a harsh, burning sensation in the area in between your ribs or just below your neck. The feeling may radiate through the chest and into the throat and neck. Many adults in the United States experience this uncomfortable, burning sensation at least once a month. Other symptoms may also include vomiting or regurgitation, and difficulty swallowing.

In many patients, GERD may also lead to conditions such as:

• Asthma
• Chronic Coughing
• Hoarseness
• Throat clearing

When you eat, food travels from your mouth to your stomach through a tube called the esophagus. At the lower end of the esophagus is a small ring of muscle called the lower esophageal sphincter (LES). The LES acts like a one-way valve, allowing food to pass through into the stomach. Normally, the LES closes immediately after swallowing to prevent back-up of stomach juices, which have a high acid content, into the esophagus. GERD occurs when the LES does not function properly allowing acid to flow back and burn the lower esophagus. This irritates and inflames the esophagus, causing heartburn and eventually may damage the esophagus. A few patients may develop a condition in which there is a change in the type of cells in the lining of the lower esophagus, called Barrett’s esophagus. This is important because having this condition increases the risk of developing cancer of the esophagus.

Some people are born with a naturally weak sphincter (LES). For others, however, fatty and spicy foods, certain types of medication, tight clothing, smoking, drinking alcohol, vigorous exercise or changes in body position (bending over or lying down) may cause the LES to relax, causing reflux. A hiatal hernia is found in many patients who suffer from GERD. This refers to the condition in which the top part of the stomach bulges above the diaphragm and into the chest cavity. This phenomenon is thought to contribute to the development of acid reflux. Surgery for GERD also fixes the hiatal hernia.

GERD is generally treated in three progressive steps:

Lifestyle changes
In many cases, changing diet and taking over-the-counter antacids can reduce how often and how harsh your symptoms are. Losing weight, reducing or eliminating smoking and alcohol consumption, and altering eating and sleeping patterns can also help.

Drug therapy
If symptoms persist after these lifestyle changes, drug therapy may be required. Antacids neutralize stomach acids and over-the-counter medications reduce the amount of stomach acid produced. Both may be effective in relieving symptoms. Prescription drugs may be more effective in healing irritation of the esophagus and relieving symptoms. This therapy needs to be discussed with your primary care provider and your surgeon. Proton pump inhibitors (PPIs) are the most widely prescribed medication for the treatment of GERD.

Surgery
Patients who do not respond well to lifestyle changes or medications or those who do not wish to continually require medications to control their symptoms, or experience side effects with medications may consider undergoing a surgical procedure. Surgery is very effective in treating GERD.

• RoboticAssisted antireflux surgery: Laparoscopic antireflux surgery is the most recent treatment advancement for GERD when medications are not successful. Laparoscopic antireflux surgery is a minimally-invasive procedure that corrects gastroesophageal reflux by creating an improved valve mechanism at the bottom of the esophagus. Nonetheless, the laparoscopic approach has wellknown disadvantages and limitations. For that reason, surgeons at Tulane, in an effort to eliminate some of the impediments of laparoscopic surgery have adopted robotic assistance as a suitable alternative. Robotics has provided new technology, which allows laparoscopic surgeons to perform these advanced procedures with more accuracy, finer detail, and less difficulty.
  • Fundoplication: The standard surgical therapy for GERD is laparoscopic fundoplication. A fundoplication involves fixing a hiatal hernia, if present, and wrapping the top part of the stomach around the end of the esophagus to reinforce the lower esophageal sphincter, and this recreate the “one-way valve” that is meant to prevent acid reflux. Today this can be done by using minimally invasive techniques using several small incisions, called either laparoscopic or robotic surgery.
• • LINX®: is a mechanical device placed around the LES to restore the incompetent LES and maintain a closed position to protect the esophagus from harmful gastric Reflux.

What causes a Hiatal hernia?

In some people, the hiatus in the diaphragm weakens and enlarges; it is not known why this occurs. In some patients it may be due to heredity while in others it may be caused by obesity, exercises such as weightlifting, or straining at stool. 

There are 2 types of hiatus hernia.

1. The sliding type: Occurs when the junction between the stomach and esophagus slides up through the esophageal hiatus when the pressure in the abdominal cavity increases. When the pressure is relieved, the stomach falls back down with gravity to its normal position.
2. The paraesophageal type: In this type of hernia a portion of the stomach remains stuck in the chest cavity and does not come back to its normal position below the diaphragm. This type of hernias tends to be larger than sliding hernias.

What are the symptoms of hiatal hernia?

Hiatus hernias, especially the sliding type, do not produce symptoms in most patients. When symptoms do occur, they may only be heartburn and regurgitation as a result of the acid in the stomach refluxing back into the esophagus (gastro-esophageal reflux). Belching, coughing and hiccups may be other symptoms related to hiatus hernia. In some patients longstanding reflux of acid into the esophagus may cause injury to and bleeding from the lining of the esophagus. This causes anemia or a low red blood cell count. Further, chronic inflammation of the lower esophagus may produce narrowing (stricture) in this area. This, in turn, makes swallowing difficult, and food does not pass easily into the stomach.

At times, a paraesophageal hiatus hernia causes chest or upper abdominal pain when the stomach becomes trapped above the diaphragm through the narrow esophageal hiatus. The patient may get persistent vomiting and become unwell if the blood supply of the trapped stomach is cut off. Although a hiatus hernia can cause chest pain very similar to heart pain do not assume that such pain is caused by the less serious condition of the two. When in doubt, it is safer to be seen by a doctor immediately in order to rule out more problems related to the heart.

What are the treatment options for hiatal hernias?

Lifestyle modifications
In many cases, changing diet and taking over-the-counter antacids can reduce how often and how harsh your symptoms are. Losing weight, reducing or eliminating smoking and alcohol consumption, and altering eating and sleeping patterns can also help.

Drug therapy
If symptoms persist after these lifestyle changes, drug therapy may be required. Antacids neutralize stomach acids and over-the-counter medications reduce the amount of stomach acid produced. Both may be effective in relieving symptoms. Prescription drugs may be more effective in healing irritation of the esophagus and relieving symptoms. This therapy needs to be discussed with your primary care provider and your surgeon. Proton pump inhibitors (PPIs) are the most widely prescribed medication for the treatment of GERD.

When is surgery required for hiatal hernias?

Most hiatal hernias do not require surgery unless they present symptoms.

For patients with a sliding hiatus hernia surgery is required only if patients have symptoms of gastroesophageal reflux, if not willing to take long-term medications, cannot tolerate long term medication or develops complications of reflux disease (strictures, Barrett’s esophagus).

Patients diagnosed with paraesophageal hernia are recommended surgery only if they have symptoms from their hernia such as reflux symptoms, chest pain, difficulty swallowing, respiratory symptoms, recurrent pneumonias, anemias, weight loss, etc.

The esophagus is the hollow, muscular tube that moves food and liquid from the mouth to the stomach. If the muscles of your esophagus don’t squeeze properly, it will be harder for the food and liquids to reach the stomach. This condition is known as an esophageal motility disorder. Esophageal motility disorders make it difficult for a person to swallow, cause food to come back up into the mouth, and sometime cause chest pain.

Achalasia

One type of motility disorder is called achalasia. Achalasia occurs with the muscle of the esophagus stop working and the valve at the lower end of the esophagus called the lower esophageal sphincter (LES) does not open. The condition is believed to affect 1-2 people in every 100,000, with about 3,000 new cases diagnosed each year in the United States.

Treatment options for Achalasia offered at Tulane:

• Esophageal Dilation
• Botox
• Heller Myotomy
  • Robotic-Assisted Heller myotomy for esophageal achalasia. Achalasia is a disorder of the esophagus characterized by a progressive inability to swallow solids and liquids. Surgical treatment has become the treatment of choice and offers long-term symptomatic relief to those who have the disorder. This surgical procedure (Heller myotomy) destroys the muscles at the gastroesophageal junction, allowing the valve between the esophagus and stomach to remain open. Laparoscopic surgery is less invasive, reduces the pain and postoperative recovery time, and is correlated with shorter hospitalization. With the advent of robotics, surgeons at Tulane have acquired significant experience with robotic-assisted Heller myotomy. The robotic system is ideally suited for advanced esophageal surgery and has shown to be as effective as laparoscopic surgery with fewer complications.
• Peroral Esophageal Myotomy (POEM)
  • Using esophagoscopy, a hole is made from the inside of the esophagus creating a tunnel to divide the esophageal and stomach muscles.  The hole is sealed with a clip or suture at the end of the procedure. 

More information to come.