Antireflux Surgery Gastroesophageal reflux disease is the result of acid in the stomach splashing up into the esophagus, or swallowing tube. This happens because the valve at the bottom of the esophagus sometimes opens at the wrong time. When the sensitive lining of the esophagus is exposed to acid from the stomach, a burning pain, commonly called heartburn, may result. This problem can range from a mild occasional inconvenience to a severe debilitating problem. Bariatric Surgery Weight Loss Surgery Laparoscopy Bariatric Surgery Weight Loss Surgery Laparoscopy Pleatman Surgical Bariatric Surgery Mark A. Pleatman M.D. weight loss surgery weight loss surgery Bloomfield Hills Michigan 248 334-5444 Hiatal Hernia The junction between the esophagus and stomach is normally attached below the diaphragm, or breathing muscle, in the abdominal cavity. When this attachment becomes weak, the stomach can slide up into the chest, resulting in a hiatal hernia. This condition by itself is very common and may cause no problems on its own, but it can also be associated with reflux disease. This is because the abnormal position of the stomach contributes to poor function of the lower esophageal sphincter, allowing reflux of acid into the esophagus to occur. Chronic reflux can lead to a number of serious problems, such as bleeding ulcers in the esophagus, and scarring leading to narrowing of the esophagus, (stricture). This results in difficulty swallowing solid foods. Chronic reflux may also be associated with Barrett's esohagus, a condition that may lead to cancer.    Treatment of Reflux Esophagitis Standard medical treatment of reflux esophagitis includes avoidance of foods and drugs which relax the lower esophageal sphincter muscle pressure, such as: fried, fatty, or spicy foods, whole milk, chocolate, coffee, caffeine, alcohol, and cigarettes. Medications which reduce gastric acidity such as antacids or Zantac, Tagamet, Pepcid, or Prilosec are also prescribed. Surgery Since reflux disease is a mechanical problem, it is clear that medical treatment will never cure the problem, but only relieve the symptoms. The majority of patients can, however, be successfully treated with lifestyle changes and medications. For some patients, however, this is not enough. Some patients continue to have severe symptoms despite medications. Some develop severe esophagitis, while others are simply unable to comply with a lifetime ordeal of expensive medications and the inconvenience of dietary and lifestyle modifications. These patients are candidates for surgical treatment. In addition, patients who develop complications such as stricture or Barrett's esophagus are also candidates for surgical treatment. There are several types of operations done to treat reflux disease, though all are similar in that they aim to repair the lower esophageal sphincter valve and thereby prevent reflux of acid into the esophagus. This can be done through the chest or through the abdomen. All the techniques if performed properly, can be successful.. Recently it has been possible to perform these procedures by techniques of Minimally Invasive Surgery, where operations are done through very small incisions under the guidance of a telescope and video camera. By eliminating the large painful incision, hospital stay is shortened from five to seven days to only one or two days, with most patients returning to regular activities without restrictions in one week. Types of Operations The operations all have several similar features. If there is a hiatal hernia, it is repaired by returning the stomach to the abdominal cavity and reducing the size of the esophageal hiatus (the opening in the diaphragm through which the esophagus passes). This in itself will not prevent reflux. The other part of the operation is the repair of the lower esophageal valve. This is the tricky part of the operation, and there are a number of variations in surgical technique to solve the problem. The commonest technique is to use the top of the stomach, the fundus, as a support to wrap around the end of the esophagus where the lower esophageal sphincter is. This increases the resting pressure of the valve and prevents reflux. The only problem is that if the wrap is made too tight or too long, the patient may have difficulty swallowing or belching. We try to prevent this problem by constructing the wrap while there is a large tube inside the esophagus, hopefully preventing the surgeon from making the wrap too tight. This operation is commonly called the Nissen Fundoplication, named after Rudolf Nissen. There are several variations of the operation which try to prevent problems with the wrap being too tight. Instead of wrapping the fundus of the stomach all the way around the esophagus as in the Nissen procedure, it is possible to only wrap the stomach part way around the esophagus, suturing the wrap to the esophagus itself rather than the stomach on the other side of the wrap. This modification is called the Toupet Fundoplication. Some surgeons choose to perform the operation through the chest. This involves going into the chest and bringing the stomach up from the abdomen into the chest, where the fundoplication is performed. The stomach is then returned to the abdominal cavity and the diaphragm is then repaired. This operation is called the Belsey Mark IV procedure. In the Belsey procedure, the stomach is also wrapped only partially around the esophagus. The Belsey procedure can also be done by minimally invasive techniques. Recovery from Surgery The operations I most commonly perform are the Nissen and Toupet fundoplications. The type of operation is chosen based on the size of the hiatal hernia, the amount of weakness of the lower esophageal sphincter, as well as operative findings such as the ease of mobilizing the fundus of the stomach from its attachment to the spleen. All this is done through five small incisions, all less than half an inch (1 centimeter). Most patients are very sore after the surgery, though they are able to get up and walk around shortly after the operation. Except for the intravenous catheter, there are generally no tubes connected to the patient after the operation is done. A clear liquid diet is started shortly after the surgery, and most patients go home either one or two days after the operation. Complications of Surgery As with any operation, infection and bleeding can occur. There may be other problems, such as injury to the esophagus, stomach, or spleen, which may make it necessary to make a larger incision. Though most patients will be able to eat solid foods shortly after the operation, some experience temporary difficulty with solid foods and must chew their food carefully. This difficulty is almost always temporary, resolving within a month of the operation. Occasionally the difficulty with swallowing persists, requiring dilation (stretching open) of the esophagus or even reoperation to loosen the wrap around the esophagus. Long-term results of the procedure are about the same as those for the open procedure, which has been around for many years; 90% of patients followed for as long as 10 years are satisfied with the results of surgery. Endoscopic Approaches... EsophyX A number of devices have been developed to attempt to create a fundoplication without an abdominal operation.  These procedures are done by passing instruments into the stomach through the mouth.  The most recent development is the EsophyX device, which uses “fastners” similar to those used to attach tags to clothing.  These fastners are applied through the upper part of the stomach into the esophagus, producing a 270 degree fundoplication.  The procedure is only indicated in patients without significant hiatal hernias.  Though the procedure appears promising, there is no long-term data on its efficacy, and most insurance companies don’t pay for it.  It’s main advantage is that the procedure can be done through the mouth without an abdominal incision, and recovery is very rapid. Treatment of Reflux Esophagitis Hiatal Hernia GERD Antireflux Surgery Michigan Bloomfield Hills MI Treatment of Reflux Esophagitis Hiatal Hernia GERD Antireflux Surgery Michigan Bloomfield Hills MI Treatment of Reflux Esophagitis Hiatal Hernia GERD Antireflux Surgery Michigan Bloomfield Hills MI Complications Mark A. Pleatman, M.D. 43494 Woodward Ave. #202, Bloomfield Hills, MI 48302 Office Hours: 9:00 a.m. to 5:00 p.m. Phone: 248-334-5444, Fax: 248-334-5484 email: