Foregut Surgery For Acid Reflux

Acid reflux can be an uncomfortable and frustrating experience. While over-the-counter medications may give some relief, sometimes they can’t fully help. In more serious cases, foregut surgery may be the best option to treat your reflux.

Kirpal Singh, MD, a general surgeon at Franciscan Physician Network North Indy Surgical in Carmel, Ind., discusses the complications of acid reflux and how robotic foregut surgery can address it.

Key Takeaways: Acid Reflux Surgery

• Acid reflux is common but shouldn’t be ignored.
• The esophagus plays a significant role in controlling reflux, until a valve becomes weakened.
• There are surgery options available for acid reflux, but it depends on the patient’s condition.
• The recovery process requires some dedication to diet. Still, after a few months you’ll get your lifestyle back from constant acid reflux.

How Common Is Acid Reflux?

Studies show that acid reflux and GERD affect 20% of adults in the United States. Even though acid reflux is common, many people may not understand how it happens or how it affects them.

“Acid reflux is a fairly common finding,” said Dr. Singh. “Everybody can have it, especially if you eat too much or eat hot foods. We all have acid in our stomachs, and it’s there for a purpose. It helps us digest food and kill any bacteria or viruses that might be present in it.”

How Does Our Esophagus Impact Acid Reflux?

The esophagus is supposed to be the stopping point for potential acid reflux. Still, when there are valve problems, it can make reflux more complicated.

“We have a valve that is a flap that is at the lower portion of our food pipe, the esophagus,” Dr. Singh said. “So right where the esophagus meets the stomach, there's a valve that's supposed to prevent reflux or minimize it.”

He explained that the flap may eventually become lax or people may get a hiatal hernia, where the flap starts to sit in the chest and not in the abdomen. And the acid that's supposed to be in our stomach may come up to the esophagus, resulting in acid reflux.

When Should I Talk To A Doctor About Acid Reflux?

While acid reflux can be brief for some, it can be a constant bother for others. Either way, it’s essential to know when to talk to a doctor.

Dr. Singh explained that people may take over-the-counter medications for acid reflux before considering an appointment with a doctor.

“There isn’t really a good way to know when a person might decide to talk to a doctor about their acid reflux, except when the acid starts to interfere with their daily activities,” Dr. Singh said. “When someone can’t eat their favorite food, experiences daily occurrences, constant bad breath or even interrupted sleep, I would recommend over-the-counter stuff for two weeks. If your troubles go beyond that, I would highly recommend that you talk to your primary care provider.”

Over-the-counter and prescription medications are used to treat most cases of acid reflux. Acid reflux surgery is often considered a last resort.

What Are Surgery Options For Treating Acid Reflux?

Even though foregut surgery treats conditions affecting the upper digestive tract, including acid reflux, you’ll have surgery options depending on your condition.

“There are endoscopic options,” Dr. Singh said. “Meaning a procedure can be done through the endoscopy with a scope down the throat, so there are no cuts made on the abdominal area. And then, there are surgical options where you actually have to make cuts in the abdominal wall to get in and do the procedure.”

Hiatal hernia and reflux surgery

Dr. Singh explained that the option to choose between endoscopy or surgery depends on whether you have a hiatal hernia or not. He explained that most people with reflux almost always have a hernia, which is typically addressed by supporting the lower esophageal muscle through surgery.

“If you have a small hiatal hernia diagnosed with endoscopy or an EGD, then you should be a candidate for endoscopic therapy,” Dr. Singh said. “Still, if you have a bigger hernia, then the options will be surgical to help find the hernia.”

Robotic Or Laparoscopic Reflux Surgery

The effectiveness of robotic or laparoscopic surgery for acid reflux can revolve around a patient’s condition and the surgeon's perspective.

“Early on, we had open operations, and we used to do these surgeries with about six to eight-inch incisions,” Dr. Singh said. “Patients would be in the hospital for a long time, almost sometimes a week or so before they go home.”

Using laparoscopy now helps get foregut surgery patients home quicker and back to their normal activities with less pain. The introduction of robotic surgery gives patients even more options. Still, the available options depend on the patient.

“The laparoscopy limitation has been that it's called ‘chopstick surgery’, where you have these sticks, which are the instruments that we go in and work on the tissue,” Dr. Singh said. “The limitation is that it doesn't have wrist motion for precision and accuracy. With robotics, you can suture much easier than you could laparoscopically and be more accurate about it.”

Dr. Singh explained that robotic surgery provides the surgeon with better magnification and a 3D view, whereas laparoscopic surgery is performed through a 2D screen.

How Effective Is Foregut Surgery For Acid Reflux?

Foregut surgery can be very effective in treating acid reflux.

“Overall, the consensus is that anti-reflux surgery is very effective at 80 to 90% effectiveness,” Dr. Singh said.

What Are The Complications Or Risks Of Foregut Surgery?

“The biggest complication that we worry about during the procedure would be having an injury to something around the area we are operating. For example, let’s say there's a complication of injuring the spleen, which means we may have to actually take the spleen out due to bleeding.”

He explained that there is potential for injury to the esophagus and stomach, which is a known complication.

“And then, after the operation, if you make the wrap too tight or close the hiatus too tightly, people can have trouble swallowing, which will result in another endoscopy to try to stretch that area.

Complications can include weakening of tissue.

“There are some failures over time, such as tissue weakening over time after a repair,” Dr. Singh said.

What Can I Expect Before, During And After Foregut Surgery?

It’s not only essential to be prepared to make lifestyle adjustments before and after any surgery, but also to know what to expect during foregut surgery itself.

Preparing for foregut surgery

“Before the procedure, we recommend that you not eat or drink anything after midnight,” Dr. Singh said. “And in terms of intraoperatively, you'll come to the hospital around two hours before the procedure.”

At the hospital

During your two-hour wait, you'll be in the pre-op area where they’ll review your medical history again, get an IV and go through your allergies, for example.

“Once we’re ready for the operation, you’ll be moved to the operating room, where the anesthesiologist will put you to sleep,” Dr. Singh said.

Dr. Singh explained that the procedure will take approximately 1.5 to 2 hours, with a 1-hour recovery period after you wake up. After the recovery room, you’ll go to the surgical floor for overnight care to make sure that the pain is okay and no nausea symptoms. You’ll return home the next day.

Do I Need To Make Diet Changes After Foregut Surgery?

Diet changes after foregut surgery is necessary for the recovery process.

“Dietary changes are a huge ordeal,” Dr. Singh said. “I counsel my patients beforehand, but people hear what they want to hear. I usually have to reinforce the importance of dietary changes at least two or three times before it sinks in.”

He explained that there shouldn’t be any problems while eating before the surgery. Still, after surgery, they fix the hernia and take a portion of the stomach to reinforce the valve.

Eating after foregut surgery

“The opening is about two centimeters for most people after surgery,” Dr. Singh said. “If you take a bite bigger than that and you don't chew, it will get stuck and it will not pass. Some of my patients have taken a big bite of food without chewing properly. Once it gets stuck, we have to take them back for an endoscopy to either push the food in or pull it out. Even if you drink water, sip slowly.”

Dr. Singh explained that patients are on a liquid diet for two weeks, starting post-operation, with Jell-O or juice, and soups later on if they can swallow without any problems.

Transitioning to a regular diet

“For two weeks, patients will be on a liquid diet before we see them back in the office,” Dr. Singh said. And as long as they're not having any trouble swallowing, they’ll advance to a regular diet.

Still, the caveat is that anything eaten must be cut into small pieces

“Overall, it’ll be a very strict diet for the first three months of slowing things down, which can be frustrating but it’s worth it,” Dr. Singh said.

Like other surgeries, robotic foregut surgery requires an understanding of the process, some preparation before the surgery, along with patience and dedication towards recovery. The detailed care from surgeons at Franciscan Health can ensure that your constant acid reflux stops impacting your lifestyle.