One of the most common complaints of patients with esophageal reflux is heartburn, the sensation of pain or burning below the breastbone. This complaint frequently follows meals, though some patients experience these symptoms between meals, at bedtime or upon arising. Patients with more severe symptoms complain of food or fluid coming up into the mouth, being awakened at night coughing or wheezing due to aspirated fluid or difficulty swallowing as a result of stomach acid causing an ulcer or narrowing of the esophagus.
The cause of these symptoms is a decrease in the strength of the lower esophageal sphincter (similar to a valve) which is then unable to prevent food or fluid from coming back up the esophagus after it enters the stomach. Patients with complaints of reflux are often treated with medication which lowers the acidity of the stomach contents coming up into the esophagus. Occasionally another medication is added which causes the stomach to empty more rapidly, reducing the amount of material entering the esophagus. Despite treatment with medication, many patients continue to experience symptoms and are referred for evaluation for surgery.
The surgery most commonly done for patients with reflux disease is called a Nissen fundoplication. This surgery involves bringing a portion of the upper stomach up around the lower esophagus and suturing it in place, creating an "artificial valve." This procedure is usually done laparoscopically by inserting a small camera through the stomach wall through a one half inch incision; four other one-quarter inch incisions are made for the instruments. Most patients are able to return home one to two days after the surgery and resume most activities, including work, in two to three weeks. Possible risks and complications include, but are not limited to, needing to convert the operation to an "open" procedure, meaning that a several inch incision is made over the stomach area to complete the procedure, perforating the esophagus, development of a stricture (narrowing) of the esophagus, wound infection and minimal symptom relief. These complications are rare with 80 to 90% of patients experiencing symptom relief and the ability to discontinue medications.
Evaluation prior to surgery usually includes an upper endoscopy (looking down your esophagus with a camera), esophageal manometry (measuring the pressure in your esophagus) and a gastric emptying scan (measuring how long it takes your stomach to empty). We may also need a 24-hour pH probe to measure how often acid comes up into your esophagus if your upper endoscopy does not show evidence of inflammation. Having these procedure results available at the time of consultation for surgery will expedite your care. Necessary studies can be performed at UC Davis, if the facilities in your area are not equipped to complete them.
Over the past 15 years, there has been a notable rise in the number of cases of esophageal cancer diagnosed in the United States. Early diagnosis followed by a combination of surgery and/or radiation and chemotherapy has resulted in an improvement in the survival rates for patients with this disease. One precursor to esophageal cancer that is also being more commonly diagnosed is a condition called Barrett’s esophagus, thought to be caused by gastroesophageal reflux (heartburn). In the early stages, this may be treated by an anti-reflux procedure (described above). In the later stages when early signs of developing cancer are found, this may need to be treated with more aggressive surgery. At UC Davis, cases of Barrett’s esophagus and cancers of the esophagus are evaluated by a multidisciplinary team, with input regarding treatment provided by gastroenterologists, gastrointestinal and thoracic surgeons and oncologists based on each individual’s findings. Surgical procedures including laparoscopic fundoplication, laparoscopic esophagectomy and colon interpositions are use to treat the patient with pre-malignant or malignant disease.
Strictures of the esophagus can be caused by several factors. A complete evaluation beginning with a barium swallow, upper endoscopy and also sometimes including pH probe and manometry may be necessary to determine the cause. Achalasia is condition of the esophagus in which the normal motility is absent with a narrowing of the esophagus which can cause difficulty swallowing, regurgitation of food and chest pain. Other strictures (narrowing) of the esophagus can be caused by acid reflux which can cause scarring that narrows the esophagus or tumors of the inside or outside wall of the esophagus. The gastroenterologists and gastrointestinal surgeons at UC Davis Medical Center work together in completely assessing the patient to assure a correct diagnosis and appropriate treatment plan are made for each individual. Laparoscopic and thoracoscopic surgery can often solve these problems with a minimally invasive approach that involves small incisions in the chest or abdomen.