IS
THE SAME OPERATION DONE TO ALL
PATIENTS? ARE THERE SPECIAL TESTS NEEDED BEFORE THE
OPERATION?
Besides
the tests run to ensure the
general health of the patient and
the safety of the operation and
the anesthetic, certain
specialized tests are needed to
help select the appropriate
operation for the patient. When
reflux esophagitis and ulceration
has existed for a long time there
is the possibility that the layers
of muscle and nerves in the wall
of the esophagus can be damaged.
This may result in the esophagus
being unable to propel or push the
food into the stomach. If the LES
pressure is now raised too much
surgically, the patient may have
difficulty swallowing or
experience dysphagia. The patient
may not be a candidate for surgery
at all or may benefit from a
partial wrap. The Toupet
fundoplication brings up both
posterior and anterior walls of
the stomach, suturing the
posterior wall to the right of the
esophagus and the anterior wall to
the left of the esophagus. This
produces a 270-degree wrap around
the esophagus rather than the
360-degree or complete wrap of the
Nissen operation. The Dor brings
the anterior wall only and sutures
it to the anterior wall of the
esophagus, when the muscles of the
lower esophagus have been split,
in a condition called achalasia of
the esophagus. The Gazayerli
fundoplication is a variation of
these procedures. These tests also
help differentiate between
patients with reflux disease and
other conditions particularly a
condition called ACHALASIA in
which the esophagus is paralyzed.
IN OTHER WORDS, THE OPERATION IS
TAILORED TO EACH PATIENT’S NEEDS
AND CONDITION, THERE IS NOT ONE
OPERATION THAT IS APPLICABLE TO
ALL PATIENTS.
HOW
LONG DOES THE OPERATION TAKE TO
DO?
This
is probably the least important
factor in the operation, because
it should take as long as is
necessary to ensure a safe and
meticulous operation. It also
depends on the weight of the
patient, the size of the left lobe
of the liver, the degree of
inflammation around the esophagus
as well as the size of the hiatal
hernia. Surprisingly enough, the
sex of the patient seems to affect
the distribution of fat in the body. men seem to have more fat
around the esophagus than women
do. This however is not a hard and
fast rule. It has taken me as
little as 25 minutes to do a
Nissen, but the average operative
time is about one hour. In huge
hernias it can take much longer.
IS
THERE ANY CHANCE THAT THE
LAPAROSCOPIC OPERATION MAY BE
CONVERTED TO AN OPEN OPERATION?
In
our experience this is a very rare
occurrence, but this is an
important safety feature of all
laparoscopic or minimally invasive
operations, that they can be
converted to open surgery. If
bleeding or an injury to an organ
occurs or is suspected after the
operation conversion to an open
procedure or early postoperative
laparotomy is the safe way to go
and should not be considered as a
complication. It should be
remembered that less than a decade
ago, these operations were the
best line of treatment for GERDS
and could only be done by the open
method.
HOW
WILL I EAT AFTER THIS OPERATION?
Dysphagia
or difficulty swallowing always
occurs after these operations;
luckily it will usually improve in
a few days or weeks. In some
patients it can persist to some
degree for some months. It would
be stupid not to expect some
dysphagia after operating on the
esophagus and to rush in to undo
the operation as has occurred in
some cases. After any surgery, body
fluids and cells accumulate at the
site of the operation. These are
necessary or rather essential for
the healing process. At first the
body rushes more than is necessary
until the healing process is
completed or matured. Since the
esophagus is a tubular organ and
all foods and liquids ingested
have to go through the operative
area to reach the stomach, the
fluid and cell collection at the
operative site will narrow the
esophagus and limit its muscle
function for some time. It is
impossible to predict who will
have difficulty swallowing or for
how long. patients need to be
warned about that before the
surgery and constantly reassured
postoperatively. Some of the best
long term clinical results have
occurred in patients who had very
long periods of postoperative dysphagia, but that is not a
prerequisite for the success of
the operation.
DO
I NEED TO LOSE WEIGHT BEFORE THE
OPERATION?
Any
weight loss is healthy if you are
overweight, and is also welcome
from the surgeon and
anesthesiologist’s point of
view. We have however performed
the operation on patients who are
quite obese.
If
during the operation we find the
left lobe of the liver is markedly
enlarged, and this can occur in
patients who do not look
particularly overweight, we would
rather abandon the operation and
put the patient on a strict diet
and exercise program to shrink the
fatty liver and return at a later
date to perform the operation. In
close to three thousand cases we
had to do so in a handful of
cases. We were able to carry out
the operation the second time
safely. This is our preferred
approach because an enlarged left
lobe of the liver hampers the open
surgery approach even more than
the laparoscopic procedures.
WHAT
ABOUT EXERCISE BEFORE THE SURGERY?
If
your medical condition allows it
we strongly recommend exercising
in the form of walking before the
surgery. We used to recommend a
brisk walk daily to improve the
cardiopulmonary reserve and help
ensure a safe operation. We now
know that any walking be it brisk
or leisurely will be beneficial as
long as it exceeds 20 minutes and
preferably is an hour or more.
Strenuous
exercising in the form of heavy
lifting should be avoided
especially if the surgery is
delayed for a long time or if the
hernia is of the large type. The
huge paraesophageal hernias are
urgent if not emergent cases as
the danger of strangulation is
very real particularly with
strenuous lifting or straining. IN
ESSENCE AEROBIC EXERCISES ARE
BENEFICIAL AND ANAEROBIC CAN BE
HARMFUL.
Aerobic Exercise: Type of exercise
that involves major muscle groups working together in a manner that causes
the heart and lungs to work harder to provide the body with an adequate oxygen
supply. Examples of aerobic exercise include cycling, jogging, swimming
and aerobic dance. Aerobic exercise is required to burn body fat.
Anaerobic Exercise: Type of exercise
that does not require the body to provide a tremendous amount of oxygen
and is used to strengthen, shape and train muscles in the skeletal muscle
system (not heart, lungs, etc). Examples of anaerobic exercise include
push-ups, crunches, squats, and arm curls. Anaerobic exercise is necessary
to increase muscle strength, shape and tone of the body.
DO
I NEED TO STOP SMOKING BEFORE THE
OPERATION?
The
cessation of smoking, for as little
as one or two weeks, can have a
very beneficial effect on the
outcome of the operation,
decreasing postoperative lung
infections and complications
DO
I NEED TO STOP SMOKING AFTER
SURGERY?
The
lung is very vulnerable to
postoperative complications of
atelectasis (collapse) and
infections such as pneumonia,
particularly in smokers. Any
period of time that is kept free
of smoking is beneficial. Also
smoking increases the swallowing
of air and that can be
uncomfortable in the early
postoperative period, as we will
discuss in the gas-bloat syndrome.
WILL
I BE ABLE TO BELCH AFTER THIS
OPERATION?
Belching
is usually interfered with in the
early postoperative period. Most
patients do regain that ability.
Most patients with GERDS get
relief from belching before the
surgery, they learn to swallow air
and induce belching. The flap and
raised pressure at the lower
esophagus that prevent the reflux
of gastric contents also prevent
the belching of air. As the
swelling of surgery subsides, they usually
regain some belching capability. I
often tell patients that they were
champion belchers, but after this
surgery they will become puny
belchers and champion farters.
Most
people swallow a couple of teaspoonfuls of air with each
bite of food swallowed, belchers
swallow much more than that. This
subconscious act that used to give
relief before surgery will take
some time to be corrected.
Some
patients are able to belch in the
early postoperative period and
that does not affect the outcome
of the surgery.
WILL
I BE ABLE TO VOMIT AFTER THIS
OPERATION?
Vomiting is extremely difficult after the
open Nissen operation as
originally described, but so is belching. Since most patients
eventually regain their ability to
belch, vomiting must also be
possible.
There
are now available some very
effective antiemetic medications
that can prevent vomiting. They
should be used in the early
postoperative period if there is
an increased risk of vomiting such
as during a flu epidemic or if the
patient travels overseas.
Violent
retching and vomiting should be
avoided in the early postoperative
period as we have seen recurrence
of the hernia when that occurred.
We were able to repair that laparoscopically. Zofran is a very
effective antiemetic medication,
but unfortunately it is very
expensive.
WITH
DIFFICULTY BELCHING, DO I FILL
UP WITH GAS?
Yes,
GAS-BLOAT syndrome as this
condition is called, used to be a
very aggravating condition after
open surgery. However, since a
degree of belching is regained, it
usually is only transient lasting
from a few days to a few weeks,
but can last much longer. As
mentioned above, air-swallowers
will suffer more of this syndrome.
Certain foods such as beans,
broccoli and cauliflower tend to
produce more gas and should be
avoided.
The
treatment of gas-bloat syndrome
consists of activated charcoal, simethicone, digestive enzymes and
less frequently now since the FDA
warning, prokinetics.
Activated
charcoal acts by absorbing or
binding the tiny gas bubbles to
the charcoal particles. Tablets or
capsules are available over the
counter in drug stores and health
food stores. They are best taken
at the end of a meal which is the
time that gas-bloat syndrome is
usually felt. Most brands
recommend that two be taken at a
time, but since it is not absorbed
from the intestine and this
condition can be more disturbing
than the average bout of gas, I
recommend that my patients take as
many as will give relief and as
often as needed. Some brands
combine simethicone with the
activated charcoal. Incidentally
activated charcoal is very
effective in preventing the bad
breath resulting from eating
garlic or onions.
Simethicone
acts by decreasing the surface
tension of gas bubbles thereby
causing them to join and form
larger bubbles. The larger bubbles
of gas are easier for the
intestine to expel. Small bubbles
tend to churn in the intestines
and cause more discomfort, as well
as take longer to expel. Simethicone comes in many
different brand names such as
Mylicon or GasEx. It can be found
over the counter in drugstores or
health food stores.
Digestive
enzymes can also be found over the
counter or in health food stores,
but we often have to resort to
prescription strength doses to be
effective.
Prokinetics
are effective in relieving
gas-bloat by increasing the
motility and expelling the gas,
but we now hesitate to use them
due to the depression that one
causes as well as the many side
effects mentioned above in the
medical treatment section.
HOW
LONG DOES A PATIENT STAY IN THE
HOSPITAL AFTER A LAPAROSCOPIC OPERATION?
Most
patients present themselves to the
hospital the day of surgery. They
drink non-carbonated liquids
shortly after the anesthetic wears
off and go home the next day after
breakfast or lunch. Patients who
have heart or lung problems or who
for any reason feel they are not
up to going home the next day,
are kept longer. Again, it is worth
remembering that after open
surgery patients are kept in the
hospital much longer.
WHAT
WILL I BE ABLE TO EAT AFTER THIS
SURGERY?
Some
foods are more difficult to
swallow than others as we
mentioned under the question of dysphagia, e.g. steak. Most people
tend to bite down on a piece of
steak a few times then swallow it
essentially as a whole piece. That
will cause the food to stick in
the esophagus and may cause spasms
and vomiting. So avoid steak and
hard to chew foods initially.
Dry
foods such as toast and bread are
often hard to chew and swallow.
Certain gooey and fibrous foods,
such as bananas and watermelon can
be difficult to swallow. Stringy
fresh vegetables and salads are
also difficult to swallow
initially.
Always
keep a warm liquid available when
sitting to eat. Coffee, tea, hot
soup, hot milk, hot cider or just
warm water are some suggestions.
Use only small sips of warm or hot
liquids. These have the same
soothing effect to the healing
esophagus that a warm compress
would have on a healing skin
wound.
Large
amounts of liquids, especially
cold liquids, may cause the
esophagus to spasm with
regurgitation or vomiting of the
liquids. Always take small sips of
liquids and avoid ice cold drinks.
If it is very hot and you would
like a cold drink, be sure to keep
it in your mouth long enough to
warm it.
Avoid
eating quickly and if you feel
that a bite is sticking in the
esophagus DO NOT TAKE ANOTHER BITE
TO FORCE IT DOWN, this is a sure
method of causing retching or
vomiting. Instead you should slow
down, relax and take a sip of warm
liquid.
Carbonated
drinks should be avoided to
prevent the above mentioned
gas-bloat syndrome.
IT
IS VERY IMPORTANT THAT YOU TAKE
SMALL BITES, CHEW YOUR FOOD WELL
AND EAT SLOWLY. If however you
retch or vomit food that is still
in the esophagus, do not panic,
many patients do so until they
learn better eating habits, with
no harm done to them.
WILL
I LOSE WEIGHT AFTER THIS SURGERY
AND HOW LONG WILL THIS WEIGHT LOSS CONTINUE?
After
any surgery there is a certain
amount of weight loss. This is
more so after reflux surgery
because in addition to the
metabolic weight loss [that will
be explained more fully under
postoperative fatigue], both dysphagia [or difficulty swallowing], and the
air trapping in the stomach prevent patients from having big meals because of an early sense
of fullness. These three factors
combine to produce weight loss in
the early postoperative period. Weight loss of ten to forty pounds
is not uncommon depending on how
overweight the patient is
preoperatively. Unfortunately if
you persist in force-feeding
yourself the weight can be put on
again, since both the dysphagia
and lack of belching are only
short term.
It
is not uncommon for patients to
regain more weight than they had
lost, most of them giving the same
story that the food tastes so much
better after surgery now that they
have no heartburn and the gas
trapping in the stomach has
disappeared.
This
weight gain can contribute to
recurrence of the symptoms by
stretching the anterior flap of
the fundoplication.
WILL
I FEEL TIRED AND FOR HOW LONG?
After
any surgery there is a feeling of
tiredness that lasts for about six
weeks. This never was a problem
before laparoscopic surgery,
because the pain of the incision
usually kept the patient from too
much activity. Now that the
postoperative pain is minimal and
often disappears in one to two
weeks, patients attempt to do much
more physical activity and earlier
than after open surgery.
The
reason for that fatigue is a
process called catabolism. For six
weeks the body will break down
muscle proteins to use them as
building blocks in healing. This
is a valuable function for species
preservation. If an animal is
injured it will crawl into a cave
or climb a tree and often have to
heal in starvation. The example I
give is if you have a ten-room
house and one room burns down, you
would clean it out and go to the lumber yard and get bricks and planks to fix it. The body cannot
do that. It cleans it out, then
goes to every room and takes every
tenth brick and stick and fixes
the damage. Since we have no
bricks and sticks in our body the
organism uses muscle proteins to
heal. The body is essentially in a
state of starvation and needs rest
just like a starving person. After
six to eight weeks the body goes
into a process of rebuilding the
muscles or replenishing the muscle
proteins and the energy is
restored.
DO
I NEED VITAMINS AFTER THIS
SURGERY?
The
value of vitamins has not been
appreciated or stressed
sufficiently by doctors. Vitamins
have been shown to prevent cancer
and decrease the aging process.
Certainly in a group of patients
who are highly vulnerable to
cancer, as GERDS patients are,
every precaution to help prevent
cancer should be taken. A group of
vitamins called antioxidants
should be used before and after
surgery. These are the ACE
vitamins consisting of vitamins A.
C. and E and other factors.
Cardiologists recommend these to
heart patients and GERDS patients
should use them also.
A
well-balanced multivitamin and
mineral supplement also is very
beneficial and promotes a sense of
well-being, decreases fatigue and
probably speeds up healing.
WHAT
CAN I DO AND WHAT CAN I NOT DO?
WHAT ARE MY RESTRICTIONS?
In
the last ten years that I have
been doing this surgery I have
learned a lot about the
restrictions needed after this
surgery. After most open surgeries
including open inguinal hernia
repairs we used to advise patients
to go back to normal activities in
six weeks and if their work was very strenuous we would extend
that to eight or at most twelve
weeks. Unfortunately that advice
does not hold true for hiatal
hernia surgery. The sutures placed
in the crura or pillars of muscle
around the opening (or hiatus)
through which the esophagus
travels from the chest into the
abdomen are placed in muscle
tissue that has no tendon in it as
opposed to inguinal hernia
surgery. Heavy lifting, straining
or repetitive movements of bending
or straining as occurs in
abdominal crunching exercises or
in some jobs, MUST BE AVOIDED AND
FOR A LONG TIME.
A
very small percentage of patients
will recur after this surgery. However,
with the total experience
approaching three thousand
patients, this has now given me a
clear insight into what is needed
as far as restrictions. Over two
thirds of our experience with
recurrence come from patients
operated elsewhere or many years
ago by the open method. Those
patients who experienced both the
open followed by the laparoscopic
surgery are the best advocates of
the laparoscopic approach. A few
anecdotal cases will be mentioned
because they are typical of what I
call "acts of ignorance or acts of fate".
A
very good friend of mine operated
on very early in our experience,
was told that he would be able to
resume normal activities six weeks
after surgery. Stimulated by his
weight loss, AS TOO MANY OTHER
PATIENTS ARE, he decided to carry on
this momentum and ordered off the
TV an abdominal crunching machine.
It arrived at his home five weeks
postoperatively. He tested it out
for fifteen minutes that evening
and for the first time since his
surgery he had heartburn that
night. It progressed to
increasing recurrence of symptoms
requiring a revision of his
surgery. This I call "an act of
ignorance" on our part. We just did
not have the necessary information
available at the time and were
trying to extrapolate from our
inguinal hernia experience.
WE
ARE NOW RECOMMENDING THAT PATIENTS
NOT LIFT OVER 10 POUNDS (ROUGHLY A
GALLON OF MILK) AND NOT OVER 20 TO
30 POUNDS FROM THE FOURTH TO THE
END OF THE SIXTH MONTH
POSTOPERATIVELY.
Another
dear friend had a giant
paraesophageal hernia repaired and
about three months later was
traveling to Atlanta when she
unconsciously lifted a heavy
suitcase off the airline carousel.
She felt a tearing sensation and
the symptoms became progressively
worse.
We
have been able to trace
recurrences to moving a heavy tree
pot, to auto accidents resulting
in blunt trauma to the abdomen, to
falls on the ice or off a porch,
to the intestinal flu with severe
retching or vomiting, to too early
vigorous exercising, BUT
UNFORTUNATELY, ALL TOO OFTEN TO
PATIENTS WITH PHYSICAL JOBS BEING
REQUIRED TO RETURN TO WORK TOO
EARLY.
