Reflux and esophagus
In addition to traditional treatments, we also offer the latest methods in the field of reflux surgery, which can be individually tailored to our patients.
Reflux disease occurs when stomach contents flow back into the oesophagus. This triggers various symptoms and the oesophagus is damaged by stomach acid.
At the end of the oesophagus is the lower oesophageal muscle, which normally prevents the backflow of acidic gastric juice into the oesophagus. If this muscle is weak, this barrier is restricted. The mucous membrane of the oesophagus is not as resistant to acid as the stomach lining and can not only be irritated by the refluxing gastric juice (heartburn), but also damaged. This can lead to inflammation and scarring. Chronic reflux can even lead to cell changes, so-called Barrett’s esophagus, and ultimately to esophageal cancer (esophageal carcinoma).
Dr. Jörg Zehetner is an internationally recognized expert both as a surgeon and as a researcher with vast experience in the field of reflux surgery.
What diseases are common in connection with reflux?
Diaphragmatic hernia
Also known as hiatal hernia, paraesophageal hernia
or upside-down-stomach
This hernia (diaphragmatic hernia) is caused by a weakness and expansion of the diaphragm where the esophagus passes from the chest into the abdominal cavity. This causes part of the stomach to slide upwards into the chest.
This impairs the function of the lower esophageal sphincter, resulting in chronic reflux.
In some patients, the stomach can become acutely trapped or twisted in the diaphragm; this situation requires emergency surgery.
Some patients constantly lose blood due to the mechanical irritation and the resulting inflammation in the esophagus and stomach. Anemia can develop.
Treatment: Small (<3cm) hiatal hernias without symptoms do not require surgical treatment. However, surgery is necessary for patients with reflux or larger hernias.
We will discuss the various surgical methods for reflux in more detail below.
Inflammation of the esophagus (esophagitis)
While acid in the stomach is normal and usually tolerated by the stomach, the esophagus is sensitive to prolonged exposure to acid. The “regurgitation” of acid, also known as heartburn, is referred to as reflux.
The oesophagus can become irritated with increased reflux and is referred to as mild, moderate and severe inflammation (oesophagitis).
Diagnosis is made with an endoscopy (oesophagoscopy and gastroscopy).
Therapy: The initial therapy is medication with gastric acid inhibitors (PPI) to heal the inflammation. In the case of long-term inflammation, a visit to the surgical consultation is necessary to find out whether reflux surgery is required.
Barrett’s esophagus
Barrett’s esophagus occurs when there is a visible cell change at the end of the esophagus. This is caused by chronic reflux and can also be present in patients who are completely symptom-free.
A distinction is made between low-grade and high-grade dysplasia (cell changes), which are precancerous lesions.
Depending on the findings, these changes must be removed endoscopically or followed up (at 6 to 12-month intervals).
Treatment: If necessary, this altered mucosa can be removed either endoscopically or using radiofrequency ablation (with a halo balloon). Our specialists at our partner practice www.ggp.center are at your disposal here, especially Dr. Ioannis Linas and Dr. Michaela Neagu are familiar with this method.
Subsequently, either long-term drug therapy with PPI (proton pump inhibitors = acid blockers) or surgical treatment of the reflux problem is necessary.
What symptoms does reflux cause?
In addition to the typical symptoms such as heartburn, belching and difficulty swallowing, there are also many non-typical symptoms that can also be caused by reflux. These include chronic coughing, tooth enamel erosion, chronic sinusitis, lung disease, asthma, vocal cord changes and the feeling of having a lump in the throat, also known as a globus sensation. A hiatal hernia often exacerbates the symptoms.
What diagnostics are necessary before an operation?
A gastroscopy (gastroscopy) and pH monitoring (acid measurement) are required to diagnose reflux disease: This involves measuring the acidity in the esophagus over 24 or 48 hours (outpatient examination). A so-called DeMeester score takes several factors into account and describes the severity of the reflux.
In addition, a swallowing x-ray is performed, which describes the dynamics of the swallowing act or reflux.
If the examinations have not yet been carried out externally, they will be carried out in our “Reflux Center” in the GGP Gastroenterology Group Practice.
The collaboration between surgeons and gastroenterologists results in a high level of expertise. We are the only center apart from the University Hospital to have all the possibilities for functional assessment of the esophagus, including manometry, pH-metry (with probe or with the Bravo capsule) as well as the Endoflip examination, which we can perform exclusively at the Beau-Site Clinic. More information on this can be found on the website www.ggp.center.
What are the surgical treatment options for reflux?
Fundoplication
The aim of reflux treatment is to narrow the passage between the oesophagus and stomach to prevent gastric contents from flowing back into the oesophagus. At the same time, however, it must still be possible for food to pass through into the stomach without any problems. The classic reflux operation is fundoplication. The gastric fundus is mobilized using laparoscopy and a sleeve is created around the lower oesophageal sphincter. Any hiatal hernia is closed during the operation.
LINX Reflux Management System
Swiss1Chirurgie offers the LINX reflux management system, which was developed in 2007. Since 2012, it has also been used outside of studies in selected reflux centers in Europe and the USA. In this respect, there are now 17 years of experience with the LINX system.
This small implant is placed around the lower esophageal muscle using laparoscopy. It is a small, flexible band of interlinked titanium beads with magnetic cores. The force exerted when swallowing briefly separates the beads. No reflux is possible in the closed state, but the ring opens if there is more pressure (air is expelled or vomiting occurs). Any diaphragmatic hernia is also operated on during this operation. Depending on the size of the diaphragmatic hernia, 2-3 sutures are placed here, or a special mesh is also used. These meshes are either quickly resorbable (dissolve) within 6-12 weeks, or slowly resorbable within 10-18 months.
RefluxStop
The RefluxStop, which has been known since 2018, can also be used. Here, the lower oesophageal sphincter is held in the correct position in the abdominal cavity by sutures to the gastric fundus, and the fundus is stabilized by a silicone ball (weighing only 9g, 1cm radius).
Dr. Zehetner is also a co-investigator in a European registry study in which all patients with a hiatal hernia of up to 3 cm are included; all other patients are also followed up in a separate feasibility & safety study in order to collect data on the results anonymously and compare them later. In the RefluxStop method, Dr. Zehetner is the world’s most renowned trainer of this surgical technique, and he has trained more than 20 surgeons in 18 centers in 2023 alone.
Are there other diseases of the esophagus?
Esophageal cancer
The two most common types of esophageal cancer are squamous cell carcinoma and adenocarcinoma.
While smoking and alcohol are the main risk factors for squamous cell carcinoma, reflux plays the main role in adenocarcinoma. Patients with reflux changes in the oesophagus have a 44 times higher risk of developing cancer than the normal population.
The initial symptoms are often belching and heartburn, but more often difficulty swallowing. The diagnosis is made by means of a gastrointestinal endoscopy (oesophago-gastro-duodenoscopy).
An ultrasound examination of the esophagus, a CT (computed tomography) scan of the chest and abdomen and sometimes a supplementary PET-CT scan are necessary in order to determine the exact treatment plan and prognosis.
All findings are discussed at the interdisciplinary tumor board (with oncologists, radiologists, radiotherapists, pathologists and us surgeons) so that a therapy tailored to the patient can be recommended.
Treatment: If the tumor only affects the surface of the mucous membrane, it can be removed endoscopically. In the case of tumors in deeper layers, the decisive factor is whether adjacent lymph nodes are also affected. In this case, chemotherapy and radiotherapy are often recommended before surgery.
The removal of the esophagus is performed by Dr. Jörg Zehetner at the Beau-Site Clinic using minimally invasive surgical techniques; open surgery is only necessary in the rarest of cases. The oesophagus is usually replaced by a gastric pull-up. The operation takes between 3 and 6 hours. A hospital stay of 5-10 days is to be expected.
In the case of tumors that have spread to other organs (distant metastases), radiotherapy and chemotherapy are usually advisable.
Achalasia
In achalasia, the oesophagus can no longer move food forward into the stomach due to a lack of muscle peristalsis on the one hand and excessive pressure in the lower oesophageal sphincter on the other. As a result, food remains in the esophagus, expands, is regurgitated or vomited. Other symptoms include pain in the chest or upper abdomen, or a feeling of tightness in the throat.
The diagnosis is made with a contrast medium X-ray swallow and/or a pressure measurement of the esophagus (manometry).
Therapy: Unfortunately, there is no sensible drug therapy available. There are endoscopic procedures (balloon dilatation) and surgical procedures (laparoscopic myotomy).
In the minimally invasive surgical method, the Heller myotomy, the lower oesophageal muscle is split through 4-5 small incisions in the abdomen using laparoscopy, without opening the mucous membrane of the oesophagus. This allows food to pass from the oesophagus into the stomach without resistance. The procedure takes about 1 hour and the hospital stay is usually 1-3 days.
Diverticula of the esophagus
Diverticula are bulges in the esophagus and are caused by a weakness in the esophageal muscles.
The bulges can occur in the neck (Zenker’s diverticulum) or at the end of the esophagus. Very rarely, they can also be found in the middle of the esophagus, usually due to diseases or changes in the lymph nodes located there.
Therapy: Diverticula of the oesophagus do not necessarily have to cause problems. They are usually discovered when the patient experiences difficulty swallowing, frequent belching or heartburn. Treatment can be carried out either endoscopically or surgically. Dr. Zehetner prefers open removal in the neck area, as the recurrence rate is the lowest. Laparoscopic surgery can be performed further down the oesophagus from the abdominal cavity.