Gastroesophageal reflux disease also known as GERD or chronic acid reflux is a condition that affects millions of Americans and a significant number of prospective bariatric surgery patients. While we all experience some acid reflux during our lives, when the condition becomes chronic (two or more times a week for 6 weeks or longer), it may cause significant damage to the esophagus not to mention discomfort and pain.
The Causes of GERD
We don’t yet know all the various causes of GERD, but we have a pretty good idea of the main risk factors. As it relates to obesity, excess abdominal fat pushes on the stomach creating intra-abdominal pressure and pushing gastric juices into the sensitive lining of the esophagus.
A significant number of bariatric surgery patients also have hiatal hernias, which are usually diagnosed and corrected during the primary bariatric procedure. A hiatal hernia occurs when the upper portion of the stomach pushes through the hiatus, an opening in the diaphragm that allows the esophagus to come through. As a result of this increased pressure on the stomach, hiatal hernias can cause GERD.
The Lower Esophageal Sphincter or LES may be weak in some people. This may or may not be directly related to excess weight and can even be genetic. A weak LES allows the valve between the esophagus and stomach to remain slightly open, allowing gastric juices to flow upwards rather than remain in the stomach.
Even some surgical procedures can cause GERD to occur or worsen. This is especially true for the gastric sleeve. A number of patients undergoing the gastric sleeve may experience new or worsening GERD symptoms. The surgeon takes an already pressurized vessel – the stomach – and cuts away about 75% of it. Because none of the rest of the anatomy is changed, the pressure within the stomach may increase and force acid up into the esophagus. Gastric band patients may also find that their GERD does not improve or possibly even worsens after surgery.
The Consequences of Untreated GERD
Many patients believe they can tough it out through their chronic GERD problem. Even if symptoms aren’t severe, the damage occurring to the esophagus can be significant and cumulative. When harsh acid washes up into the lining of the esophagus, it can cause irritation and inflammation, causing the trademark pain known as heartburn. However, if this occurs chronically, the lining of the esophagus can become damaged and create a stricture, which is a narrowing of the esophagus. This can cause trouble swallowing and in extreme cases, difficulty breathing. Long-term damage to the esophagus can also change its cellular lining and create a condition known as Barrett’s Esophagus. This is a pre-cancerous condition that leads to full-blown esophageal cancer in about 10% of patients. Of course, if left untreated, esophageal cancer can be very aggressive and quite deadly.
Treatment for GERD
Mild to moderate cases of GERD are often treated with lifestyle change including improved diet and exercise regimens as well as antacids such as Tums. If these fail to offer significant relief or if the GERD persists, H-2 receptor blockers, like Pepcid and Proton Pump Inhibitors (PPIs) such as Prilosec or Nexium may be used to reduce the amount of acid being produced in the stomach. However, these medications are only approved for use in the short term.
Longer-term, patients may need to have a surgical procedure to correct their GERD. There are a couple viable and proven options:
For patients looking to have bariatric surgery and who also have severe uncontrolled chronic acid reflux, the gastric bypass may be an excellent option. Gastric bypass can improve or eliminate the symptoms associated with GERD in many patients.
Patients who are not having bariatric surgery may consider a fundoplication, during which the upper part of the stomach is wrapped around the lower part of the esophagus to add pressure to the Lower Esophageal Sphincter and minimize stomach acid that pushes up into the esophagus. Most patients are able to get off their GERD medication and are very satisfied with the results.
The LINX Reflux Management System is a new implanted device about the size of a quarter and made up of small titanium beads and a magnetic clasp. During a quick 15-to-20-minute procedure, the surgeon wraps the device around the LES adding pressure to reduce the upward movement of stomach juices. While the LINX is a permanent implant, it does address many of the significant drawbacks of fundoplication.
- Zak Y, et al. The use of LINX for gastroesophageal reflux. Advances in Surgery. 2016;50:41.