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GERD/Acid reflux/Hiatus hernia: The role of surgery

A lot of patients suffer from poor quality of life due to acid reflux or GERD. Many of them are on medications for years. Even with medications, many are suffering for years. Long term medications also cause many other problems like osteoporosis and gut infections. The whole situation also affects the thinking process and psychology of the patients. Fortunately, an end to all these problems is possible. That needs through evaluation, surgery, adherence to a healthy lifestyle and if needed psychotherapy. It is possible to get back to an absolutely normal life.

GERD/Acid reflux a lifestyle disease

         Acid reflux is a lifestyle disease. Due to today’s stressful and hectic lifestyle, the burden of this problem is increasing significantly. Thus, lifestyle change and correcting the way we eat is not just necessary to get a good solution to the problem of acid reflux and heartburn, it is also needed to prevent it.

Mechanical factors like hiatus hernia and your body’s general tendency to the weakness of muscles are contributory factors for heartburn and acid reflux. But the major reason for the increase in the occurrence of Acid reflux (GERD) is the changing lifestyle. Even with the above factors which cause GERD, a healthy lifestyle and diet pattern can prevent or decrease the severity of acid reflux.

GERD/Acid reflux: When is surgery needed?

Treatment for Acid reflux or GERD is decided on the basis of the severity of the problems faced by the patient. The main aim of treatment is to relieve symptoms and improve the quality of life. And to prevent further damage to the food pipe leading to future complications. 

GERD/Acid reflux: Severity of problem

Most of the patients have a mild problem that just needs few weeks of antacid and lifestyle change.

But some patients with severe disease would need the PPI antacid medications for years. Many of these patients are ideal candidates for surgery. For them, surgery is a better alternative to continuous medications. Especially if they are young, and taking PPI antacids for more than 2 years. 

Some patients also have bothering symptoms even when they are on medications. This affects their quality of life and productivity. These group of patients surely benefits from surgery.

GERD/Acid reflux: Duration of problem

The duration of the problem has important implications in the treatment. Those having this problem for a few weeks or months are highly likely to be back to normal health even after stopping medications. But they need to focus on improving the diet and lifestyle.

Those who are having on and off symptoms for many years and requiring PPI antacids frequently should be evaluated by endoscopy. They also need  longterm regular PPI medications. Diet and lifestyle change should be done properly before trying to wean off the medications. 

Many patients are already taking PPI antacid medications for more than 2 years, and are unable to stop them. They should understand that mostly they would need lifelong medications, unless they go ahead for surgery. Of course, surgery is done after a thorough evaluation by esophageal manometry and 24 hr pH Impedance study.

Refractory GERD/Acid reflux: Not responding to medication  

There, are patients who do not respond to medications at all. They need a thorough evaluation by an endoscopy, esophageal manometry, and 24 hr pH Impedance study. 

One reason or not responding to medications is the wrong diagnosis. Many such patients may be having a different motility disorder of the food pipe. This can be detected in a manometry study. The treatment of these patients is different from GERD and can be planned once diagnosed.

Another reason for the non-effectiveness of medication could be very severe acid reflux or non-acid reflux. This will be confirmed on a 24 hr pH Impedance study. All such patients will benefit from Laparoscopic antireflux or fundoplication surgery.

 The third possibility is that the problems faced by patients are functional. Which means there is no disease and still patients have disturbing symptoms. In such cases manometry and pH Impedance study are normal. These problems can also be very effectively resolved once diagnosed. Hence, you can understand the importance of these tests for patients who are suffering for a long time with no improvement with medications.

PPI dependent GERD: Patients who cannot stop medications and Side effects of PPI medications

There are patients who respond well to medications but are unable to stop them. The symptoms start immediately on stopping medications. For many missing the medications for even a day is a

Side effects of long term use of PPI Antacid medication

nightmare. And many such patients are taking these acid-suppressing medications for years.  

To all such patients, I would like to tell them, that this not without its negative effects. Although these medications are not having immediate and severe side effects. But taking them for years that significant effects on your digestive system and other important organs. Changes in your gut bacteria leading to repeated GI infections, IBS and C-difficile infection are one of them. Others are impaired absorption of vitamins leading to vitamin deficiency, osteoporosis, respiratory or lung infections are the other common problems of long term PPI or acid-suppressing medications.

Hence, for all such patients, surgery is a better one-time solution. It goes without saying that all such patients should get a proper evaluation by manometry and pH Impedance study. The evaluation is important to confirm the diagnosis and to be sure that surgery is needed for sure and will improve the symptoms. If done properly after evaluation, acid-suppressing medications can be stopped after surgery.  

GERD/Acid Reflux: Quality of life

All the patients who have suffered from acid reflux for a long time, have a significantly affected quality of life. Sleep disturbances, inability to work efficiently due to lack of focus and frequent breaks at work are some of the important issues. Fear of symptoms, the constant focus at symptoms and disturbing thoughts are also very common. These issues increase the severity of the overall problems and makes treatment difficult. In such situations, an aggressive treatment strategy to control the symptoms and addressing the psychological issues are needed to break this vicious cycle.  

I would like to emphasize that, the situation is not hopeless as many such patients feel. If addressed in a systematic manner, it can be resolved and normalcy in daily life can be achieved with minimum or no medications. But to do so thorough evaluation is needed. Also needed is the understanding that it is now not just an acid reflux problem, it has associated functional or IBS or psychological problem also (varies with each individual patient). And these issues also need to be addressed.
 

GERD/Acid reflux: Investigation and evaluation

Thorough investigation is of utmost importance for all those patients who have symptoms of GERD or acid reflux for a long time. It is more important if medications are not improving your symptoms or you need constant medications. 

Endoscopy:

Endoscopy is the primary investigation. It is advisable to get the

Upper G I endoscopy

endoscopy done if your heartburn does not improve with medication or if it occurs again after one course of acid suppression medications. It is not needed for all the patients who have developed heartburn for the first time. Especially if it responds to medicines.

But endoscopy is a must if you have the sensation of food getting stuck on swallowing. It is also needed for some red flag symptoms life heartburn along with weight loss, anemia, black stool or blood in the vomitus.

Esophageal manometry and 24 hr pH Impedance study

This a very important study for all patients who have acid reflux symptoms for a long time. It gives a very clear picture of the food pipe problems. It not only confirms acid reflux, but it also gives information about the severity of reflux and other esophageal motility problems. All this information helps in deciding the plan of treatment.

It should be a must before GERD/ Acid reflux and hiatus hernia surgery. pH with Impedance study is also extremely important for all those patients who are suffering despite taking medications for a long time.

CT scan/ Barium swallow

These tests are not routine tests of GERD. Occasionally they are needed if there is a very large hiatus hernia, before planning surgery. Also sometimes it is needed to rule out other diseases when a doctor has suspicion based on your problems. Usually, it is for those patients whose symptoms are not improving with medications.  

GERD/Acid reflux: Who needs surgery

Patients who strongly need surgery

All the patients who have a confirmed diagnosis of GERD, and still not having complete relief with medications should undergo surgery. Many such patients have a long history of GERD problems. Most of these patients have initial improvement with medications, but with time when problems worsen. And the patients have symptoms even with medications.

Some of these patients have a large amount of non acidic food or water coming up the troat even with medications. Hence, they have problems even on medication and are likely to improve significantly with surgery. Some others have over a period of time gained the problem of IBS or psychological comorbidity. They also improve if GERD is controlled aggressively with surgery followed by psychomodulation with medicines and psychotherapy.  

Hence, comorbid functional GI problems and psychological comorbidity do not mean that surgery for GERD should not be done. Rather, if ph Impedacne study shows significant GERD, aggressive control of GERD symptoms helps in controlling the functional and psychological issues in a better way. But surgery should be done after thorough evaluation, understanding of the functional problems and its severity. And all these things should be discussed in detail with the patients prior to surgery. Actually this explanation is an important part of the treatment of the functional problems faced by such patients.

Patients who have both options, medicine and surgery. But surgery is a more preferred option

There a large number of patients who have a very well response to acid-suppressing medications. Almost normal quality of life and no symptoms when on medications. But they are on these medications for a long time and cannot stop them. The symptoms appear on stopping the medications.  

For all such surgery is a better treatment option. More so for a comparatively young people. Although continuing medications is also the right treatment option. Especially if you are on PPI medications for more than 2 years. The younger you are, the more strongly you should consider the option of surgery.   

If you are taking acid-suppressing medicines for more than 2 years. And are unable to stop them due to reoccurring symptoms, then it is highly likely that you will need to take these medicines life long. Unless you get the mechanical problem of a lax valve or hiatus hernia repaired surgically.

The mechanical problem in this disease cannot be addressed by medication

You must understand that increased acid production is not the problem. The problem is mechanical, poor function of the valve between your foodpipe and stomach. Which allows the acid and food from your stomach up into the foodpipe. And we are suppressing the acid (which is a part of the normal physiology of our body and is important for digestion, absorption of some vitamins and calcium and maintaining the gut bacteria) by medications, as we cannot improve this valve mechanism by medications.

Hence, medicines are fine for the initial period and for those patients who do not have a very severe problem. For all the patients who need temporary medications and can get off medication by following a healthy lifestyle, medical treatment is good enough. All those who have failed the attempt of stopping medication even with lifestyle change, need to accept that it is highly likely that they will need these medicines lifelong. And hence, laparoscopic surgery is a much better option.

Patients who should avoid surgery

All the patients who have not responded to medication needs a thorough evaluation by an endoscopy, esophageal manometry and 24 hr pH study. These tests confirm if you have a GERD problem or not. All those who have some other motility problem or have functional symptoms should not undergo surgery. All such patients are likely to have more problems after surgery.

Also, elderly patients (above 65 years) who have multiple medical problems that increase the risk of surgery should avoid surgery. Especially if their symptoms are controlled on medications. Some such patients who have severe problems not managed by medications can consider surgery with due risk (this situation is quite rare).     

Also, all the patients who have a problem for a long period (more than 2 years) but need intermittent medications, can avoid surgery. But they should adhere to the lifestyle change so that their chances of need for surgery in the future are reduced.  

GERD/Acid reflux/Hiatus hernia: Outcomes of surgery 

For a properly selected group of patients, the outcomes of surgery are excellent. Studies suggest that 95 % of patients have a long term favorable outcome and are able to stop the acid suppressing medications. These surgeries are being done laparoscopically for more than 25 years around the globe. Hence, we have an understanding of the long term outcomes, risks, and problems after this surgery. 

Immediate outcomes after surgery

The initial recovery from surgery is quite fast and smooth. In our unit, all our patients are out of bed within 3 hours of surgery, with minimal pain. No urinary catheter is required and all patients go to the washroom in a few hours of surgery. Oral liquids and diet are also started the same day. All the patients are discharged the next day of surgery, less than 24 hours after surgery.

Initial dietary changes after surgery

As a new valve is being made from your stomach during the surgery, there is a possibility of initial minor problems while eating. You are likely to have some difficulty while swallowing food in the initial days. But his is a temporary problem and resolves on its own. You will need to eat more slowly and chew properly during the initial days after surgery. You may occasionally need a sip of water to help the food bolus pass through the new valve.

Most of these patients have mild problems and improves within a week to 10 days. Occasionally, some patients may face this problem for a longer period of about 4-6 weeks. But almost all patients have complete improvement and not likely to need any further procedure.

Also, as a part of your stomach is used to make the valve, you will feel full with a lesser amount of food. So, initially, you will have to have a lesser amount of food at one time. You can eat more frequently to compensate for this change. Again, this is a temporary issue and improves gradually in 4-6 weeks time.

Risk of major complications

All surgeries have their own risks. Although this surgery is technically challenging and is done a few selected centers, it is one of the safest surgeries offered in today’s time. The risk profile is similar to the routinely done laparoscopic hernia and gallbladder surgeries when done by an experienced surgeon.

Need for medications

In properly selected patients, and when the surgery is done in a standardized manner, most of the patients are able to stop the PPI acid-suppressing medications completely. 

When patients do have associated other GI problems like constipation and IBS, medications for these problems may be needed after laparoscopic surgery for GERD. Although, once acid reflux improves and PPI is stopped, it is highly likely that medicaation for these problems is needed less frequently.

Quality of life

Those patients who have a poor quality of life even on medications have a very significant improvement in the quality of life post-surgery. Their eating pattern, social life and professional like can return to normal levels. 

Even for those patients who are symptom-free on medications, quality of life after surgery is better than with medications. Large international studies have concluded this after analyzing the results of thousands of patients.

Long term outcomes

Most of all the patients have a concern whether the surgery will last throughout their life or not.  And my answer to them is that, if you follow the basic norms of a healthy lifestyle this should be a permanent solution. 

And we never ask the same question about the medical treatment, when we compare surgery with medical treatment.

Long term studies have shown 90-95% good outcomes even over a long time. But we must understand that surgery is a part of treatment and general measures in day to day life and diet are an important component of treatment

Conclusion

I would conclude by saying that laparoscopic surgery is a great tool for the treatment of GERD/Acid reflux. It is a solution to a very severe and hopeless situation faced by many patients of GERD. So those patients of GERD who have a poor quality of life, have suffered for many years and are taking PPI or acid-suppressing medications for many years, should at least consider the option of surgery. They should meet a surgeon expert in dealing with such patients and get a thorough evaluation. All active steps should be taken to get the best outcomes and quality of life.  

Listen to some of our patients to understand the immediate and long term outcomes 

 

Also Read

HEARTBURN: CAUSES, INVESTIGATION, TREATMENT

GERD/Acid reflux/Heartburn: Diet and Lifestyle

GERD / Acid Reflux / Heartburn: Does surgery really solve the problem?

Dilemma of a patient with Heartburn: How long to suffer? When to seek a permanent solution?

Patient’s Guide to Bariatric Surgery

Gallbladder stone and Diet

Fight against Obesity: Respective roles of Bariatric (weight loss) surgery and Lifestyle Modification

Activity and Exercise After Hernia Surgery

Gallbladder stone surgery: Know what happens before, during and after surgery

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