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Hiatal Surgery

Gastroesophageal reflux disease (GERD)

This is a common disease. In lay terms, this refers to a condition where juices from the stomach regurgitate abnormally backwards into the oesophagus

This causes symptoms of heartburn and reflux commonly. Sometimes, it may also lead to chest pain, dysphagia, cough and hoarseness of voice.

Almost everyone in their lifetime have experienced heartburn and reflux occasionally. When this becomes a regular affair and causes distress and interferes with daily life, it is labelled as a disease – GERD. Physicians and surgeons also have an objective scoring system to define the disease.

What causes GERD?

There are many causes of GERD- spicy food, smoking, alcohol, stress, tea, coffee and poor lifestyle. Sometimes, people may have a structural defect called hiatus hernia that can cause it. This means that a part of the stomach goes into the chest and therefore stomach acid and juices wash the lower oesophagus causing heartburn and reflux

What happens if GERD is left untreated?

The acid and juices from the stomach can damage the mucosa of the lower end of the oesophagus in GERD. This may in the long-term lead to inflammation (scientifically called esophagitis), ulcers, precancerous lesions known as Barrett’s, and even cancer.

What is the treatment of GERD if it is due to hiatus hernia?

If it is a small hiatus hernia, it should be managed conservatively. However, a large hiatus hernia demands a surgical repair by a procedure called fundoplication.

What is fundoplication or antireflux surgery and how is it done?

Simply put, the fundoplication operation entails bringing the stomach back to the chest, putting stitches to make the hole through which the stomach enters the chest smaller and wrapping the stomach on itself so that it does not go back to the chest.

It is done laparoscopically. Patients typically get a surgery with 4-5 small holes, each of 5 mm in width leaving behind tiny scars. The pain is minimal and can be managed on oral analgesics for 2-3 days. Patients are usually discharged 24 hours after surgery. They are asked to take a soft diet for the first few days before they get a full solid diet.

I have heartburn and reflux for a long time. My gastroenterologist has given me pantoprazole which keeps me fine most of the time but not always. Should I get a fundoplication?

This would require evaluation by clinical assessment and some tests. They are – endoscopy, manometry, and pH study. Endoscopy may pick up a hiatus hernia or esophagitis or Barrett’s and, in these situations, surgery is indicated. Manometry helps in confirming GERD and excluding other causes of similar symptoms. It is important to remember that long term use of pantoprazole has been associated with side effects and patients should discuss the risk-benefit ratio with their doctors regarding different modalities of treatment.

Can GERD cause cough and breathlessness?

Many  patients with GERD are referred by ENT colleagues because they suffer from cough and breathlessness. This happens because the acid vapour from the reflux destroys the surface lining of the upper and then lower airway tract over a long period of time. Tests such as pH metry and endoscopy can usually confirm the correct diagnosis

Achalasia Cardia

This is a condition where the lower end of the oesophagus becomes spastic. Patients are unable to eat their food and drinks which gets worse with time. It happens because the nerves in the oesophagus ceases to function. The reason for this is unknown.

I have progressive difficulty in swallowing food and drinks. I have been advised endoscopy but I am scared to do it. Should I do it?

Yes. Difficulty in swallowing is a sinister symptom and may signify a dangerous disease such as achalasia or cancer. It is best to do it. You may ask for anaesthesia or sedation if you are too scared to undergo endoscopy. This will make the procedure comfortable.

I have been diagnosed as achalasia and an endoscopic procedure called POEM has been advocated. What should I do?

POEM is a new procedure for achalasia cardia. Certain types of achalasia deliver better results than surgery. The major advantage is that it can be done endoscopically. The downside is that patients may experience a higher incidence of reflux after the procedure. Have a discussion with your physician or surgeon for choosing the right procedure.

How is surgery for achalasia cardia done?

It is done by keyhole method generally using 4-5 tiny holes. Patients are usually discharged 24-48 hours after surgery.

What is the long term treatment for Achalasia cardia?

Achalasia cardia is a lifelong disease and therefore the follow up is lifelong. There is a  risk of recurrence that may need serial interventions. Have an annual checkup.