More than 44% of all adults, 61 million people, experience heartburn at least once a month. 20% of the population have heartburn at least once a week and 9% have heartburn each day. 5% of the population, will at some point, require physician directed surgical therapy.

The stomach produces acid for the digestion of food. The esophagus carries food from the mouth to the stomach. A muscular valve located at the top of the stomach separates the esophagus and stomach. This valve is commonly referred to as the antireflux valve, or gastroesophageal valve (GEV). When operating properly this valve between the esophagus and stomach opens to allow food to pass after swallowing. When not operating properly, the valve allows acid to escape from the stomach, leak back into the esophagus (reflux) and travel all of the way back into the throat. GERD (gastroesophageal reflux disease) is caused by this stomach acid that passes into the esophagus, producing symptoms of heartburn and acid regurgitation. Damage to the lining of the esophagus may occur, as well as damage to the lungs if the acid is inhaled.

Along with malfunction of the valve, other problems may contribute to reflux such as a hiatus hernia, which is an abnormal sliding of the upper stomach into the chest, obstruction of the stomach outlet, overproduction of acid in the stomach or impaired function of the muscles of the esophagus.

The most common symptoms of GERD are heartburn and acid regurgitation. But it is possible to have GERD without those symptoms. Other symptoms include, problems swallowing, chest pain, hoarseness, a sensation of food being stuck in the throat, choking, throat tightness, dry cough and bad breath. Many people occasionally suffer from reflux with one or several of these symptoms. When the GERD symptoms are no longer occasional, and are constant, then medical advice is advised. Self-diagnosis for GERD can lead to severe problems. It is highly recommended that you seek professional diagnosis for proper treatment. Once you have GERD, it usually does remains with you forever unless you seek medical intervention.

NORMAL VALVE

DYSFUNCTIONAL VALVE

Several tests may be performed to prove that a defective valve is causing your symptoms. These include: endoscopy, or looking into the esophagus with a telescope to see if there is damage to the wall of the esophagus, contrast x-ray to see the anatomy of the esophagus and 24-hour esophageal pH monitoring to demonstrate abnormal acid in the esophagus. In some patients a gastric emptying study may be performed.

Manometry examines the"squeeze" pressure of the valve by placing a tube into the nose and into the esophagus. If the valve pressure is low and the 24-hour pH test indicates significant reflux of acid into the esophagus, surgery is indicated. If the esophageal muscles are weak, alternative procedures may be performed.

Patients that suffer from chronic GERD may develop severe esophagitis, ulcers or Barrett's esophagus, which is the transformation of the esophagus cells into intestinal cells. Barrett's may be a precursor to cancer of the esophagus. Other patients may develop scarring or strictures in their esophagus which block the passage of food.

Medical treatment begins with behavior modification. Changing one's diet may help to control the frequency and severity of some of these attacks. Spicy foods, caffeine, coffee, alcohol, chocolate and peppermint should all be avoided. Weight loss may also help as well as decreasing the amount of food that you eat at each meal. After eating one should allow 2-3 hours for digestion prior to attempting to sleep. Raising the head of the bed 6-8 inches or placing a wedge under one's mattress may help to prevent the onset of symptoms. Despite these attempts almost all patients will need medication.

For many patients certain medications can alleviate GERD symptoms. However, that is not always the solution to the underlying anatomical problem. The medications generally do not stop the progression of the disease. As the antireflux valve deteriorates, the dosage may have to be increased, and may have to be taken for a lifetime. Major studies now show the long-term use of these medications have an adverse effect and suggest an increased risk of bone deterioration.

Currently there are three types of medical treatment. After the development of symptoms one may decide to take over-the-counter medications such as Rolaids, TUMS, Mylanta or Milk of Magnesia. These medications function to neutralize stomach acid. Histamine II receptor blockers are a stronger family of medications. These are Tagamet, Zantac, Pepcid and Axid. These work to reduce the acid production in the stomach and have been found to be successful in many patients.

The most powerful class of medications available are proton pump inhibitors (PPI). These medications block the acid producing pump that is located in the cells on the lining of the stomach wall. PPI's can block most all acid when used in high dosages and can be used for many years. However, recent studies show that long-term usage may result in bone deterioration. PPI’s may be purchased over-the-counter or prescribed by a physician and include omeprazole, prilosec, nexium, dexilant, protonix, aciphex, and zegerid. Although these medications stop the symptoms, the refluxing of stomach contents into the esophagus will still occur.

NO MORE PILLS! NO MORE PAIN!

FINALLY, EFFECTIVE LONG-TERM SOLUTIONS
FOR CHRONIC ACID REFLUX!

You may be a candidate for Esophyx, the revolutionary new incisionless procedure to cure GERD. Fairfield County Bariatrics and Sugical Specialists, Connecticut's most prominent surgical center performs this procedure in conjunction with Norwalk Hospital. Commonly performed antireflux operations are the laparoscopic Nissen fundoplication and the laparoscopic Toupet fundoplication. These procedures include repair of all types of hiatal and paraesophageal hernias.

Dr. Neil Floch and Dr. Craig Floch of Fairfield County Bariatrics & Surgical Specialists, P.C. can provide you with the permanent solution to these problems. Both surgeons are highly acclaimed laparoscopic pioneers in the procedures, having performed acid reflux surgeries for 12 years and offer Lap Nissen, Lap Toupet, Esophyz/TIF , Hiatal Hernia and Paraesophageal Hernia repair surgery. They will offer the most safe professional surgical care to help you through the process of reclaiming your life. You will be able to return to a healthy full life eating the foods you love and doing all of the activities that brought you so much enjoyment before you started to suffer with GERD.

• if they repeatedly return after the medication is stopped
• as an alternative to lifelong medication
• if you are unwilling or unable to take medication for prolonged periods
• if there is severe damage to the esophagus due to reflux. A large hiatus hernia, esophageal ulcer , narrowing or change in the lining of the esophagus, such as Barrett’s esophagus may be further indications for surgical therapy.

For sixty years surgeons have performed an operation known as a fundoplication to prevent reflux. Before 1991 it was necessary to make a long incision between the breastbone and the"belly button". This resulted in significant discomfort and a hospital stay of about five to ten days, with an average time for return to normal daily activities of about six to eight weeks.

Since 1991, surgeons have used a laparoscope to do the fundoplication. This is a long, thin telescope the size of a finger, which is placed into the abdomen. Five small incisions, each about a centimeter wide, are used to gain access to the abdomen.

Dissecting instruments, thread and other materials can be inserted and removed through these small holes, allowing the surgeon to perform the operation. If there is a hiatus hernia, which is a slippage of part of the stomach through the diaphragm into the chest, this is repaired by pulling the stomach into the"belly". Then the hole in the diaphragm is sewn closed so that it only allows the esophagus to pass through. A small portion of the upper stomach is loosened from the surrounding tissues and wrapped around the lower esophagus. As a result the valve between the esophagus and the stomach is tightened. The operation is performed in one to three hours.

Other variations of this procedure may be performed. The most common of which is the partial wrap or Toupet in which the stomach is wrapped around two thirds of the lower esophagus. This procedure is used for people who have weakened muscles of the esophagus.

Patients usually have little pain and discomfort after laparoscopic surgery when compared to open surgery, therefore they recover more quickly. Some patients may go home on the day of surgery but most leave the hospital in one or two days. Return to social and work activities may occur in one to three weeks, which is much sooner than with the open surgical technique.

Surgical complications are rare but do occur in 2 to 4 % of patients who undergo laparoscopic surgery. With any surgery performed under general anesthesia, there is a less than one in a thousand chance of severe complications from the anesthesia medications. There is a less than 1 in 500 possibility of severe bleeding that may require transfusion. All surgeries carry the risk of wound infection, postoperative pneumonia or blood clots forming in the deep veins in the legs. These risks are reduced by the use of antibiotics, anticoagulant medication and the laparoscopic technique, which allows the patient to be active soon after surgery.

There are complications specific to the surgery. Damage to organs such as the stomach, esophagus, spleen or liver may occur. This may or may not be identified by the surgical team during surgery and could result in serious infection but these problems can usually be repaired at the time of laparoscopic surgery. Tracking of air into the chest cavity or the space around the lungs may occur. In our experience of over 400 cases, complications were rarely encountered and were appropriately handled.

Occasionally it is not possible to complete the operation with the laparoscopic technique because of difficulty with visualization or because of a complication. The need to convert to an open operation with an upper abdominal incision is necessary in less than one in two hundred cases. In Dr. Floch's experience there have been no mortality or conversions.

Other complications may arise after surgery. If the wrap is too tight there may be persistent difficulty in swallowing. This can occur in 20% of patients immediately after surgery but drops to about 5% after one to two months. Four percent of patients will need dilation of the esophagus. The wrap may slip into the chest or become undone resulting in difficulty swallowing or recurring symptoms. If this occurs, reoperation may be required.

Half of the patients have difficulty eating solid food for several weeks after surgery. This is due to swelling at the site of the stomach wrap. As the swelling goes down, solid food will pass more easily. Belching can create some discomfort. Diarrhea and distention of the"belly" may also occur; all these problems improve with time. Rarely, the gastric wrap may become too tight or too loose. This may result in the need for medication or further surgery.

Pain from the incisions is common during the first 24 to 48 hours after surgery. You may also experience abdominal discomfort and shoulder pain from retention of carbon dioxide gas in the abdominal cavity. Carbon dioxide gas is used to inflate the abdominal cavity during surgery to allow access to the esophagus, stomach and surrounding organs by the surgical team. Pain medications will be prescribed by your physician while in the hospital and prior to discharge to help relieve this discomfort. You will be given a prescription for a liquid painkiller when you leave the hospital. Narcotics may cause constipation. For relief, we recommend using a stool softener such as Milk of Magnesia or call the doctor's office for assistance. You should not take narcotic pain medications on an empty stomach or drink alcohol.

The evening after surgery you will be given a clear liquid diet. Take small sips and drink slowly. The newly created valve may be swollen and liquids may move slowly through the esophagus. Swallowing large amounts of liquid or"gulping" may cause chest pain or excessive belching. Occasionally cold or carbonated beverages may also cause chest pain; they should be avoided. The morning after surgery, you may be given a pureed diet. These foods are easily chewed and swallowed.

There are usually 5 small abdominal incisions; each is covered by steri-strips and translucent bandages. These may be removed or left on at discharge from the hospital. Either is acceptable. A small amount of bloody discharge from the incisions is normal and is usually seen through the bandage. You may shower immediately if you have the translucent bandages. Steri-strips will be removed in our office at your first postoperative visit. If they fall off they do not need to be replaced.

When you arrive home you should remain on a liquids and pureed food for one week. You may eat cereal with milk, soups, tuna fish, mashed potatoes, banana, milk shakes, and cottage cheese. In the second week you will be advanced to cooked vegetables, toasted bread, cereal with milk, pasta and cooked fish. In the third to fourth week you may be advanced to: dry bread, chunks of meat, hard fruits such as melon and apple and dry foods such as crackers. If you encounter a food that sticks in your esophagus, go back to eating softer foods for a few days. As the swelling in the esophagus subsides solid food is better tolerated. Most patients can eat all foods by 3-4 weeks following surgery.

The way you eat after surgery is as important as the foods you eat. With all meals, but particularly with foods like bread, steak, and chicken, eat slowly, take small bites, and follow with sips of liquid. Allow each bite to pass through the esophagus to the stomach before swallowing the next. Eating too much food, too fast may cause a delay in the passage of food for several seconds, causing pain and occasionally vomiting. A few bites of food or sips of liquid may fill the stomach, because part of the stomach was used in creating the new valve, the capacity of the stomach is smaller. This is a temporary condition because the stomach tends to dilate to its original size over a few weeks. In this period plan to eat 5-6 small meals per day, instead of 3 larger meals.

All usual physical activity may be resumed as indicated by your ability. Initially, you will be tired after short periods of activity but in time your energy level will increase. This is normal. Remember that although you do not have a large incision, you have had major surgery so plan on frequent rest periods. You may expect to return to your normal activity level and resume work in about 1-2 weeks depending upon your type of work. You may drive about one week after hospital discharge. More importantly you must feel well, be off narcotic pain medications and be able to move your feet to press the pedal. Remember that you are responsible for your safety, as well as that of others on the road. If you feel you would like to participate in sports, please contact your doctor. If you are still in school, you may go back to school about one week after you have been discharged.

The doctor or nurse should be notified if you experience the following: discomfort that becomes worse, or is severe, excessive drainage from the incisions, redness or swelling of the incisions, temperature greater than 101.5 degrees Fahrenheit, nausea, vomiting, diarrhea or constipation which continues for more than 1 to 2 days. You are also encouraged to talk to your surgeon or nurse if you have any questions about your surgery or recovery.

Complete unedited responses from our patients to this question follow:

J.E. is a 39 year old man:
"It's like being reborn!"

B.S. is a 39 year old man:
"Very satisfied with the procedure and education about this by Dr. Floch and his staff. I appreciated being able to talk with other patients before the procedure. I felt comfortable or able to come off the post-procedure pain medication four days after surgery. I was eating solid foods within my second week after surgery. I had some difficulty swallowing it I ate too fast or ate certain foods such as bread, rice, pasta or french fries. Since surgery, I have not experienced heartburn, even when eating hot, spicy-greasy food."

S.S. is an 88 year old man:
"Before surgery my life was a 2 and now it is an 8." (1 worst and 10 best)

D.S. is a 34 year old man:"The procedure totally eliminated all of my reflux symptoms. I was skeptical of such a positive outcome after relying on Prilosec twice a day for four years to control the problem. I strongly feel that this operation is a minor miracle. Dr. Floch embodies all the qualities of a great doctor, knowledge, skill, caring, and an excellent attitude. Thank you!"

M.H. is a 68 year old woman:
"I was frightened by the severe spasms of the chest and the back pain after the first one. I haven't had any since the second. I am very relieved and grateful. No more severe stomach pain or bouts of diarrhea or need to vomit. No reflux. Before surgery my life was a 1 and now it is a 10."

C.L.B. is a 67 year old woman:"I was very well prepared for this procedure. Fifteen years ago I would not allow surgery because I could not afford to be down and out of work for a long time. This time the procedure was necessary due to extreme shortness of breath and shallow breathing. This procedure improved my quality of life. The shoulder pains ended after 5-7 weeks. By 8 weeks I was no longer needing anything (pillow) to protect tender areas from another. Now that my stomach is back where it belongs and my hiatal hernia is stitched down I am breathing properly. I am swimming after 4 weeks, walking immediately and having sexual intercourse after 3 weeks. My bowel movements and digestive gasses react to fibrous foods. After 10 days I was able to dance at a party with a teddy bear protecting my sensitive areas. After 7 weeks I left for a 3 week and 5 country trip to Europe. I had no trouble carrying luggage and driving in Europe after 8 weeks. No pain medication other than Extra Strength Tylenol after 5 weeks. I was hospitalized for 2.5 days and I was home alone after 4.5 days. I had a 20 year old college girl to help me with heavy work in the house for a few weeks and another for 2 weeks to help me pack up home for interior painting and carry books and suitcases two flights down to the basement, a garage and office. Four level house, many steps, no trouble with steps ever."

If you would like to meet with Dr. Neil Floch or Dr. Craig Floch,
find out more about the different procedures,
and determine if you qualify for them,
please click on the link below to contact our office.

or call toll free: 877-659-0011

TIF (Transoral Incisionless Fundoplication) treats the underlying cause of GERD without incisions. This innovative procedure reconstructs the antireflux valve and restore's the body's natural protection against reflux.

	The Esophyx device and the endoscope are gently inserted through the mouth.
	The device forms and fasten tissue folds to reconstruct the antireflux valve at the junction of the esophagus and the stomach.

• No external skin incisions - no scarring
• No internal cutting or dissecting of the natural anatomy - more rapid recovery
• Fewer adverse events and complications
• Does not limit future treatment options
• Can be revised if required

• TIF has been proven safe in thousand of procedures worldwide.
• To date, side effects have been minimal.

• TIF is performed under general anesthesia and will require you not to eat or drink for several hours prior to the procedure. The procedure itself will generally take 90 minutes.
• Most patients can go home the next day and can return to work and most normal activities within a few days.
• Patients should expect to experience some discomfort in their stomach, chest, nose and throat for the first few days to a week after the procedure.
• Patients will be asked to restrict physical activity for the first week and will be given dietary guidelines to help maximize their success while the tissue heals.

The valve between the esophagus and the stomach is reinforced by wrapping the upper portion of the stomach around the lowest portion of the esophagus. This is analogous to the way a bun wraps around a hot dog. Our surgeons use small incisions to enter the abdomen. The laparoscope, a thin telescope-like instrument, is connected to a tiny camera and then inserted through the small incision. This enables our surgeons to have a magnified image of the patient’s internal organs projected on a television screen. The abdomen is inflated with gas, causing it to expand, and thereby allowing our surgeons to perform the procedure.

• Reduced post-operative pain
• Shorter hospital stay
• Faster return to work
• 5 tiny scars instead of one large abdominal scar. Improved cosmetic result

• Light activity is encouraged while recuperating at home
• Most often post operative pain is mild. Some patients may have need for prescription pain medication
• Normal activities should begin in 1-2 days
• There may be temporary difficulty in swallowing, but that will

The floppy portion of the upper stomach is partially wrapped around the esophagus to create a valve. This is the valve that prevents the reflux of stomach acid into the esophagus. Our surgeons use small incisions to enter the abdomen. The laparoscope, a thin telescope-like instrument, is connected to a tiny camera and then inserted through the small incision. This enables our surgeons to have a magnified image of the patient’s internal organs projected on a television screen. The abdomen is inflated with gas, causing it to expand, and thereby allowing our surgeons to perform the procedure. The floppy portion of the upper stomach is placed behind the esophagus and with sutures is attached to either side of it. It is also attached to the diaphragm muscle that separates the abdominal and chest cavity

• 5 tiny scars instead of one large abdominal scar. Improved cosmetic result
• Reduced post-operative pain
• Shorter hospital stay
• Faster return to work

• Light activity is encouraged while recuperating at home
• Most often post operative pain is mild. Some patients may have need for prescription pain medication
• Normal activities should begin in 1-2 days
• There may be temporary difficulty in swallowing, but that will resolve within one to three months after the surgery

HELLER MYOTOMY

This surgical procedure is used to treat achalasia, a disorder in which the lower esophageal sphincter fails to relax properly and causes food and liquids to have difficulty reaching the stomach. Almost all patients with achalasia have dysphagia (difficulty swallowing) of solids, and 66% have dysphasia of liquids. Patients initially feel heaviness or constriction in the chest when under stress. Food itself cause some stress, eventually resulting in obstruction. Retrosternal (behind the breast bone) chest pain may occur in up to 50% of patients but improves over time. Patients eventually become afraid to eat as symptoms of dysphasia, chest pain, and regurgitation of food develop. Regurgitation of undigested food occurs in 60% to 90% of patients. Most patients maintain their nutritional status with little weight loss. Pneumonia is common in elderly patients from the regurgitation and aspiration of food.

Five or six small incisions are made in the abdominal wall and laparoscopic instruments are inserted. Our surgeons use small incisions to enter the abdomen. The laparoscope, a thin telescope-like instrument, is connected to a tiny camera and then inserted through the small incision. This enables our surgeons to have a magnified image of the patient’s internal organs projected on high definition television screens in the operating room. This affords our surgeons the opportunity of having a better view of internal organs in greater detail than the traditional open procedure provides. The abdomen is inflated with gas, causing it to expand, and thereby allowing our surgeons view the abdominal cavity and perform the procedure. The myotomy is a lengthwise cut along the esophagus, starting above the lower esophageal sphincter or LES and extending down a little way onto the stomach. The myotomy only cuts through the outsider muscle layers of the esophagus which are squeezing it shut. The inner mucosal layer remains intact.

Food can easily pass downward after the myotomy has cut through the lower esophageal sphincter, but stomach acid can easily reflux upward. For that reason this surgery is often combined with partial fundoplication for the purpose of reducing the incidence of postoperative acid reflux.

This surgery usually eliminates most of the achalasia symptoms but not the underlying cause of it. However, it does, greatly improve the ability for the majority of patients to eat and drink. It is a long-term treatment and considered the definitive treatment for achalasia. Most patients will not require any further treatment. However, there are instances when some might require additional treatment somewhere further down the road.

• Ability to eat and swallow more easily
• 5-6 tiny scars instead of one large abdominal scar. Improved cosmetic result
• Reduced post-operative pain
• Shorter hospital stay
• Return to work in 3 days to a week

• Recurrence of difficulty swallowing
• Surgery to lower spleen, pancreas or bowel
• Bleeding
• Injury to esophyx
• Reflux

• Most patients are able to drink clear liquids late in the same day. A soft diet is started the day after surgery
• Post operative pain is mild. Some patients may have need for prescription pain medication
• Ability to swallow much easier
• Some patients may develop mild reflux
• Constant cough or shortness of breathe

PARAESOPHAGEAL HERNIA REPAIR

A paraesophageal hernia is a protrusion of the stomach through the diaphragm into the chest cavity. This surgery is performed to correct the defect in the diaphragm that allows it to occur. When the stomach herniates (bulges) upward into the chest it may move around or even twist on itself. Paraesophageal hernias occur when the stomach moves up along the side of the swallowing tube or esophagus. They are generally larger than sliding hiatal hernias, which are a direct upward protrusion into the chest.

Normally, the esophagus (food pipe) goes through a hiatus (small opening) in the diaphragm. The diaphragm is a muscular wall that separates the chest and abdomen (stomach). With PHR, the hiatus in the diaphragm is too large or the muscles around the hiatus are too weak. A sac can squeeze through this large opening and position itself next to the esophagus. This herniated sac may contain a part of the stomach. When this herniated sac gets trapped in the chest, it causes stomach acid to back up into the esophagus and damage the esophagus. The hernia may range from less than an inch of the stomach to one that includes all of the stomach and sometimes, other organs as well. The opening of the diaphragm may be very small or up to 4-5 inches in diameter. Patients with paraesophageal hernias will most likely suffer from heartburn, reflux, regurgitation or many of the other symptoms associated with GERD. In the most serious situations the stomach may develop ulcers, bleeding or twisting that could result in decreased blood flow and perforation of the stomach.

A paraesophageal hernia is commonly fixed with the laparoscopic technique involving 5 small incisions to make the enlarged opening smaller. Our surgeons use small incisions to enter the abdomen. The laparoscope, a thin telescope-like instrument, is connected to a tiny camera and then inserted through the small incision. This enables our surgeons to have a magnified image of the patient’s internal organs projected on high definition television screens in the operating room. This affords our surgeons the opportunity of having a better view of internal organs in greater detail than the traditional open procedure provides. The abdomen is inflated with gas, causing it to expand, and thereby allowing our surgeons view the abdominal cavity and perform the procedure. During the surgery, the stomach is replaced back down into the abdomen. The opening in the diaphragm is made smaller and stitches or mesh material will be used to close or decrease the size. The procedure is combined with either a partial Toupet or a complete (NIssen) fundoplication.

• Resolution of life threatening problems such as bleeding, perforation and pneumonia
• Resolution of heartburn and reflux
• Ability to stop antacid medications in 90% of patients

• Recurrent hernia
• Vagotomy
• Recurrence of reflux
• Difficulty swallowing
• Gas bloating
• Problems may happen during the laparoscopic procedure that would necessitate converting the procedure to a laparotomy (open procedure).
• Blood clot
• Injury to nearby structures
• Bleeding and pneumothorax (collapsed lung)

• You will be on a pureed diet for one week
• Your diet will be advanced slowly to a regular diet in 2 to 6 weeks.
• You may return to activity in 1 to 2 weeks
• Prevent swallowing excess air by not using straws. Do not chew gum or tobacco. Avoid foods that cause gas

If you would like to meet with Dr. Neil Floch or Dr. Craig Floch,
find out more about the different procedures,
and determine if you qualify for them,
please click on the link below to contact our office.

or call toll free: 877-659-0011