8/8/2012 10:09:00 AM Dr. K for August 8, 2012 Surgery for heartburn is effective for most sufferers
DEAR DOCTOR K: I have severe heartburn that hasn't responded to the many medications I've tried. Are there any surgical treatment options?
DEAR READER: Yes, there are, and they're quite effective. But first you need to be absolutely sure that you've given medication a fair trial. The medicines that are available today, in comparison to when I graduated from medical school, are very potent and work for most of my patients.
As you well know, heartburn is an uncomfortable burning sensation that radiates up the middle of your chest. The pain can be so intense that you think you are having a heart attack.
Heartburn is a symptom of a condition known as gastroesophageal reflux disease (GERD). It is often called "reflux." To understand what causes GERD, we need a short anatomy lesson.
After you swallow food, it drops into your esophagus, a long tube that connects the mouth to the stomach. At the bottom of the esophagus as it enters the stomach, there is a circular group of muscles called the lower esophageal sphincter (LES).
The LES helps move food along into the stomach. More important, when it squeezes down, it narrows the size of the opening between the esophagus and stomach. This keeps the digestive juices, which are rich in acid, from squirting back up into the esophagus and irritating the wall of the esophagus. While the lining of the stomach is built to withstand the stomach acid, the lining of the esophagus is easily injured by acid.
If the LES relaxes too much, irritating stomach fluids surge up into the esophagus. This is the most common cause of heartburn. Some commonly prescribed medicines can cause the LES to relax too much, causing heartburn. (I have a list of them on my website.)
The different kinds of surgery for stomach acid all are aimed at tightening up the LES.
The most common procedure is the Nissen fundoplication. This surgical procedure takes a portion of the top of the stomach and loops it around the lower end of the esophagus and LES. The wrap must be tight enough to prevent the acid from coming back up, but it shouldn't be so tight that food can't enter and a satisfying belch can't escape.
Partial fundoplication, in which the stomach is wrapped only partway around the esophagus, is another option.
The operations are generally effective. They can eliminate the need for all GERD medications. Over time, however, the stomach wrap can loosen. If that occurs, you may need to resume medications and, less often, undergo surgery to redo the procedure.
We have more information on treatments for GERD in our Special Health Report, "The Sensitive Gut." (Learn more about this report at AskDoctorK.com, or call 877-649-9457 toll-free to order it.)
Fundoplications are increasingly being done as laparoscopic procedures, which feature special instruments and cameras inserted into tiny incisions in the upper abdomen. With laparoscopic surgery, patients recover much faster than from open surgery.
(Dr. Komaroff is a physician and professor at Harvard Medical School. To send questions, go to AskDoctorK.com, or write: Ask Doctor K, 10 Shattuck St., Second Floor, Boston, MA 02115.)