Gastroesophageal reflux disease (GERD) is the reflux of stomach and duodenal contents into the esophagus, causing symptoms such as heartburn, acid reflux, dysphagia, and even pathological damage to the esophageal mucosa – reflux esophagitis (reflux esophagitis,
RE), as well as damage to tissues outside the esophagus, such as the pharynx and airway. Gastroesophageal reflux is classified as physiological or pathological. Physiologic GERD is seen in normal individuals, where the reflux is quickly cleared by the esophagus and no damage to the esophageal mucosa occurs and symptoms are not clinically significant. GERD is a gastrointestinal dysfunctional disease caused by a variety of factors, including impaired anti-reflux barrier function of the esophagus, reduced esophageal clearance and reduced esophageal mucosa. GERD is caused by several factors, among which impaired esophageal anti-reflux barrier function, impaired esophageal clearance and impaired esophageal mucosal barrier function play a major role.
The clinical manifestations of GERD are diverse and vary in severity, with four main groups of manifestations.
1. Reflux symptoms predominate
Acid reflux, regurgitation, regurgitation, belching, etc. It is mostly obvious or aggravated after meals, and is most likely to occur when lying down or when the torso is flexed forward; acid reflux with heartburn is the most common symptom of GERD. Regurgitation is the influx of stomach contents into the mouth without nausea and exertion.
2. Symptoms caused by irritation of the esophagus by reflux
Heartburn, chest pain, difficulty in swallowing, etc. It is caused by chemical stimulation of the sensory nerve endings under the epithelium of the esophagus by the regurgitated stomach acid. Typical symptoms of burning pain are located below the sternum and dissipate upward. Depending on the distribution of the vagus nerve, it can sometimes radiate to the neck, palate or ear. Commonly, it radiates to both sides of the back between the scapulae. The burning sensation may be relieved by drinking water or taking acidulants or sugar cubes to stimulate salivation and primary peristalsis of the esophagus. It is most likely to occur especially after eating certain spicy foods, and can be caused by bending, straining or lying down, and is relieved in the upright position, which is due to the action of taking an upright position to walk around to promote esophageal clearance. Postural burning pain is aggravated, highly suggestive of reflux; swallowing pain is caused by food mass stimulating the inflamed esophagus or esophageal spasm, spasmodic pain and heartburn distribution and radiation sites are the same;
3.Symptoms other than esophagus
Such as cough, asthma and laryngitis.
A small number of patients have cough with asthma as the first or main manifestation. Asthma caused by reflux is not seasonal and is often characterized by paroxysmal, nocturnal cough with shortness of breath. Other patients present with pharyngeal discomfort, foreign body sensation or blockage, but no real difficulty in swallowing.
4.Complications
(1) Upper gastrointestinal bleeding;
(2) Esophageal stricture;
(3) Barrett’s esophagus.
During the repair process of esophageal mucosa, the esophageal squamous epithelium above 2cm of the dentate line at the junction of esophageal cardia is replaced by special columnar epithelium called Barrett’s esophagus, which is the main precancerous lesion of esophageal cancer, and the incidence of its adenocarcinoma is 30-50 times higher than that of normal people.
Endoscopy can determine the extent of esophageal lesions, and barium X-ray can detect coexisting esophageal hiatal hernia.
GERD treatment should be comprehensive, and changing the diet and lifestyle is the first step of treatment. Depending on the severity of the disease, pharmacological treatment can include antacids, H2-blockers, and proton pump inhibitors. Approximately 25% of patients whose disease worsens during medical treatment will require surgical treatment with the goal of improving the patient’s quality of life.
Surgical anti-reflux surgery can be considered if medical treatment is not effective. The indications for surgery are.
①Paraesophageal hiatal hernia;
(2) Cleft hernia combined with reflux esophagitis with recurrent symptoms that have not been treated with medical therapy;
③ Although the medical treatment is effective, the patient cannot tolerate long-term medication;
(iv) Reflux esophagitis has developed serious complications such as recurrent respiratory inflammation, esophageal ulceration, bleeding, and scarring strictures;
⑤ Those with huge hiatal hernia showing symptoms of compression or obstruction.
The aim of anti-reflux surgery is to re-establish a closure mechanism. The surgical methods include the Nissen fundoplication, Belsey Mark
IV procedure, Hill procedure, Collis-Belsey procedure, etc. Traditional dissection for anti-reflux surgery has a history of success for more than 40 years, but the surgery is more invasive and has a higher rate of complications such as intraoperative splenic injury. Since Dallemagne et al. first reported the application of laparoscopic fundoplication for GERD in 1991, laparoscopic anti-reflux surgery has been rapidly promoted, and its efficacy is the same or even better than that of dissection. Compared with traditional surgery, laparoscopic surgery has the advantages of less trauma, clear operative field, fewer complications, lower mortality and faster recovery, and the patient can tolerate the surgery as long as he or she can tolerate general anesthesia. During surgery, only 4-5 operating holes of about 0.5 – 1 cm in length are created in the upper abdomen to complete the esophageal fissure repair and fundoplication. In developed countries, laparoscopic esophageal hiatal hernia repair and fundoplication has been regarded as the gold standard for the treatment of esophageal hiatal hernia. From our current clinical observation, almost 100% of the postoperative patients are effective, with significant reduction of esophageal reflux symptoms and either no need for medication or a significant reduction in the amount and frequency of medication after surgery.