Hoarseness. Hiatal hernia surgery can often be performed as a laparoscopic, or “minimally invasive,” procedure. During this type of surgery, a few small (5 to 10 millimeter) incisions are made in the abdomen. The laparoscope that allows the surgeon to see inside the abdomen and surgical instruments are inserted through these incisions. The surgeon is guided by the laparoscope, which transmits a picture of the internal organs to a monitor. The advantages of laparoscopic surgery include smaller incisions, less risk of infection, less pain and scarring, and a more rapid recovery.
Core tip: Given the high prevalence of gastroesophageal reflux disease (GERD) and the various complications which can result from inadequate treatment, it is important for practioners to have a proper understanding of the current approach to its diagnosis and management. Diagnostic tools including various previous methods of pH testing are discussed. Furthermore, it is important to understand the indications and contraindications to anti-reflux surgery in order to optimize our patient’s surgical outcomes. Management of GERD in the obese patient may involve bariatric surgery and this is also further discussed.
A third type of endoscopic treatment involves the injection of materials into the esophageal wall in the area of the LES. The injected material is intended to increase pressure in the LES and thereby prevent reflux. In one treatment the injected material was a polymer. Unfortunately, the injection of polymer led to serious complications, and the material for injection is no longer available. Another treatment involving injection of expandable pellets also was discontinued. Limited information is available about a third type of injection which uses gelatinous polymethylmethacrylate microspheres.
If symptoms of GERD do not respond to maximum doses of PPI, there are two options for management. The first is to perform 24-hour pH testing to determine whether the PPI is ineffective or if a disease other than GERD is likely to be present. If the PPI is ineffective, a higher dose of PPI may be tried. The second option is to go ahead without 24 hour pH testing and to increase the dose of PPI. Another alternative is to add another drug to the PPI that works in a way that is different from the PPI, for example, a pro-motility drug or a foam barrier. If necessary, all three types of drugs can be used. If there is not a satisfactory response to this maximal treatment, 24 hour pH testing should be done.
The usual way that GERD is by its characteristic symptom, heartburn. Heartburn is most frequently described as a sub-sternal (under the middle of the chest) burning that occurs after meals and often worsens when lying down. To confirm the diagnosis, physicians often treat patients with medications to suppress the production of acid by the stomach. If the heartburn then is diminished to a large extent, the diagnosis of GERD is considered confirmed. This approach of making a diagnosis on the basis of a response of the symptoms to treatment is commonly called a therapeutic trial.