GERD, acid reflux, and hiatus hernia all refer to the same condition, where stomach acid flows back into the esophagus, often treated through laparoscopic fundoplication surgery. Diet strategy is integral to long-term relief from GERD or acid reflux. In fact, diet is a very important factor in maintaining digestive health, not just digestive health but overall health. A healthy diet will help you achieve all the parameters of health. Be it digestion, heart function, brain and neurology, psychology, hormones, or muscle and bone health.
A lot of unhealthy restrictions in diet that are imposed on an individual suffering from GERD are taken care of by a fundoplication surgery. GERD/Acid reflux, a lifestyle disease, often leads to such dietary limitations. Thus, after a fundoplication surgery, there are no restrictions in consuming healthy food like citrus fruits, calcium-rich milk products, prebiotics like onion and garlic, probiotic-rich curd, and pickles. The restriction to the quantity of diet that comes with the severity of GERD also improves after fundoplication surgery. However, this happens gradually over time after surgery.
We very commonly see patients with severe acid reflux who have a very restricted diet due to the severity of their symptoms. Weight loss in the range of 5-10 kgs is extremely common in this group of individuals. I have seen patients with up to 30 kgs of weight loss in patients with severe GERD. Weight loss is just one marker; in fact, such patients have a range of nutritional deficiencies and hampered immunity due to a restricted diet. The main goal of laparoscopic fundoplication surgery in all such patients is to lead them back to a normal diet after surgery and to stop the PPI antacid medications. In most patients, we are able to restore a normal, healthy diet after surgery. Leading them to regain lost weight, get overall nutrition, and have a healthy immune system.
After surgery, the primary concern in the initial days is difficulty swallowing. Most of the patients would have some degree of difficulty in swallowing after surgery. It would depend on the function and motility of their food pipe (esophagus) and the details of surgery (degree of wrap, 360 Nissen, 270 Toupet, 180 or 90 Dor). Difficulty in swallowing is also influenced by their stress levels and the way they eat.
At our hospital, we start soft food on the day of surgery about 4-6 hours after surgery. Oral intake is started with liquids, and once they are comfortable with liquids, a soft diet is started. At this stage, we advise them to chew the food properly and to eat slowly in a relaxed state of mind. Most of the patients can eat soft food with reasonable comfort. They are likely to feel that the food is moving down a bit slowly, or they feel a few seconds delay at the lower end of the food pipe before entering the stomach. They may feel the need to take a sip of water to facilitate swallowing in a few bites, which is not a problem.
Restricting the patient to only liquids for a couple of weeks is not mandatory. There should be no fear of having a soft diet in the initial days. This protocol has been followed at our hospital for many years, and most patients are comfortable with it. We believe that starting a diet early helps the patient adjust to the new changes in their food pipe faster. It also helps us confirm that the newly created wrap is not too tight very early. If the wrap is too tight, redoing the wrap is most straightforward in the initial couple of days. It would help us prevent long-term dysphagia, which is a troubling complication of this surgery. Thus, this will prevent the late redo surgery, which is technically more challenging for the surgeon and more morbid (causing poor outcomes and complications) for the patient.
The difficulty in swallowing that a patient feels on day one improves gradually in the following days. Suppose a patient is comfortable with soft food in the initial 2 days. In that case, we allow them to start other routine food options like roti. We do this assessment when they come for follow-up and wound dressing 2-3 days after surgery. For those having a certain degree of difficulty with soft food, we delay this progression to 7-10 days after surgery. This is true for all our patients irrespective of the degree of wrap (Nissen 360 or Toupet 270).
In roughly 50% of patients, we can make this progression (from soft food to roti) in 2-3 days, and almost all our patients are able to eat roti and similar food 7-10 days after surgery. Gradually, when they are comfortable with these food options, we allow them foods that are more difficult to swallow, like meat, chicken, and dry vegetarian food options. As more days pass, the number of swallows who experience difficulty reduces gradually, and by 6-8 weeks, almost all the patients are able to eat all food normally. We do 360 Nissen in most of our patients, and these outcomes are true for our Nissen fundoplication patients.
You are advised to restrict all the unhealthy food as much as possible. All fried food and food with too much oil, ghee and butter should be avoided. Food with too much spice and additives should be avoided. Whenever you have such food, you should eat less than your regular meal quantity. You should restrict the frequency of having such food in your diet. Restricting such food helps achieve lasting relief from GERD and acid reflux and prevents other digestive problems. Eating such food frequently is the primary reason for all the chronic health problems of the current times, including cardiac problems, fatty liver, diabetes and other major health issues. Hence, following this advice will improve your overall health.
All food items that are processed and available in a store, packed on a shelf, should be avoided as much as possible. This advice is not only applicable to GERD, acid reflux, and fundoplication but also to digestive problems in general. As any patient with GERD surgery would like to be free of all digestive problems, these food items are best avoided to get rid of all the digestive problems (consider constipation, IBS and other functional problems).
All fizzy and carbonated drinks should be avoided very strictly. They are very highly likely to cause bloating and uneasiness and are likely to build pressure at the newly created valve or wrap. Alcohol, tobacco and smoking should also be avoided strictly for long-term good results.
Yes, you can. Our advice is that you can have tea/coffee in moderation. A small cup twice a day should be fine. Tea would be preferable to coffee. Tea and coffee affect not just the stomach and food pipe but also the function of the intestines. So, there are people who have a tummy upset with tea or coffee. If it is so in your case, then you need to understand that your digestive system, to a certain degree, is intolerant to these beverages. And you should make changes in the quantity and frequency of its consumption to suit your tummy.
As I wrote earlier in this article, a healthy diet is one that is good for all the body systems. And that is what is advised to all our patients who are suffering from GERD. All patients, irrespective of their treatment, whether they need surgery or are treated just with medications. If they are not able to eat a normal healthy diet, then we are wrong somewhere in our treatment. There is an exception to this, where patients are intolerant to certain food due to their genetic make-up, or due to a gross imbalance in their gut microbiome due to past illness or treatments, or a major change in their digestive system due to past major Gastro Intestinal surgery. Even in these exceptional cases, a normal healthy diet is possible with restrictions on a few foods that the person is intolerant to.
Hence, citrus fruits are no longer restricted. All forms of vegetables in the traditional diet of that patient (from whatever region the patient belongs to), including onion, tomatoes, and garlic, are no longer a restriction. After the improvement in swallowing difficulty in the initial days, non-vegetarian food, such as meat, chicken, and fish, can also be consumed very well. Although, one should keep in mind that it is cooked in a healthy manner, and the non-vegetarian food is not fried, too oily or spicy. If I say most simply, you can eat all the traditional food you have been eating since childhood and your forefathers have been eating for generations.
This advice applies even to the initial days of surgery. The main concern for the initial days is the consistency of food. All the food in the initial days should be soft to avoid difficulty in swallowing.
To get the best results after a fundoplication surgery, we advise the patients to eat in a relaxed state of mind, chew the food properly and eat slowly. This principle applies to water and other liquids, and it is important to drink slowly. In the initial few weeks, this advice is very important, as it helps reduce difficulty in swallowing.
Later, even when there is no difficulty in swallowing, we advise patients to continue to chew properly and to eat or drink slowly for the rest of their lives. This habit will help them get lasting relief from food pipe and stomach-related problems. Eating fast leads to poor chewing and poor coordination of the multiple muscles used in swallowing, which also leads to frequent overeating. Thus, the habit of eating fast can lead to a variety of symptoms, even if your digestive system is working normally.
Patients should eat only when hungry and stop eating when they feel full. After fundoplication surgery, initially, some patients may feel full with a smaller quantity of food and then get hungry in a few hours. Hence, they may need to eat more frequently. It improves gradually over 6-8 weeks, and they can eat normal quantities of food in one go. But the advice to eat only when hungry and to stop as soon as one feels full has to be followed lifelong. It is an ideal way of eating for any person, irrespective of any digestive problem or fundoplication surgery.
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ADROIT is one of the few centres for GERD treatment that offers everything required for GERD treatment under one roof. It provides all the evaluation tests including Endoscopy, Esophageal manometry, 24-hour pH with impedance study and where the treatment includes not only surgery but also nutrition and psychological support along with regular follow-up for a long time, resulting in the best long-term results for our patients.
Dr Chirag Thakkar is a gastrointestinal surgeon. He has been carrying out gastrointestinal and weight loss surgery in Ahmedabad, Gujarat, India for the past 18 years. Surgery for GERD, Hiatus hernia and Obesity are his core areas of interest and expertise. Even in the case of laparoscopic hernia surgery for complex and recurrent hernias, patients recover faster with minimal post-surgery pain and the best functional outcome. He also has vast experience in laparoscopic surgery for gallstone removal.
Dr. Chirag Thakkar
Founder Director of ADROIT Centre for Digestive and Obesity Surgery
Senior Gastrointestinal and Bariatric Surgeon
GERD and Esopahgeal Motility Expert
Hernia Surgery Specialist