GEORGE S. FERZLI, M.D., F.A.C.S.

Until Always: Freedom, passion, integrity and the constant quest for innovation.
This web site is dedicated to the memory of my father Salem.

Dr. Ferzli's Procedures

Specializing in Minimally-Invasive Surgery

Esophagus & stomach

Heartburn/GERD

What is heartburn?

Heartburn is described as a harsh, burning sensation in the area in between your ribs or just below your neck that occurs 30 to 60 minutes after a meal. The feeling may radiate through the chest and into the throat and neck. Most often this is a symptom of improper digestion, but other conditions may produce this sensation. (It is important to note that any severe chest pain, lasting more than 15 minutes that does not respond to treatment requires immediate attention to rule out heart disease or a heart attack.)

Everyone is prone to heartburn, especially after overeating, but it is estimated the some 17 million Americans suffer frequently enough to require evaluation. This chronic heartburn is most commonly a symptom of gastroesophageal reflux disease (GERD). It can be aggravated by exercise, bending over, and eating right before bed. Other symptoms may also include vomiting, difficulty swallowing and chronic coughing or wheezing.

What is GERD?

In order to understand GERD, it is necessary to take a look at the esophagus. The esophagus is the muscular tube, about 9 1/2 inches long the moves the food from your mouth to your stomach. Near the end of the esophagus, where it enters the stomach there is a ring of muscles called the lower esophageal sphincter (LES). It relaxes when it needs to pass food into the stomach, and then it closes off to keep the food in the stomach while digestion begins. If the lower esophageal sphincter cannot maintain enough pressure to keep it closed, the stomach juices can come back up, or reflux into the esophagus. This causes irritation of the lining of the esophagus and can even cause permanent damage. This can be aggravated when eating just before bed. Lying down makes it easier for the acid to seep back into the esophagus.

What are the long-term consequences of GERD (a brief review of Barrett's Esophagus)?

Long-term exposure of the lining (or mucosa) of the esophagus to acidic gastric juices can result in changes in the normal esophageal tissue. These changes are known as Barrett's esophagus. Barrett's mucosa is pre-disposed to undergoing cancerous changes. Surgery for GERD can help, not only the discomfort associated with GERD, but also to halt the transformation of Barrett's to cancer in many cases. Barrett's esophagus requires frequent evaluation by a gastroenterologist.

What Causes GERD?

The primary cause of GERD is the abnormal relaxing of the LES (lower esophageal sphincter). In most cases, it is not clear why the LES is weak. Some people are born with a weak LES.

Some of the things we ingest may either relax the LES or delay the emptying of the stomach. These include: fatty foods, peppermint, chocolate, alcohol and smoking. Strongly acidic foods like tomato products, citrus fruit, spicy foods and coffee can cause irritation of an already sensitized esophagus. The nonsteroidal anti-inflammatory drugs (NSAIDs), notably aspirin, also can irritate the esophagus directly.

Hiatal Hernia

Some people have a physical distortion of the lower esophageal sphincter that prevents it from building up enough pressure to keep it closed. A hiatal hernia is a condition where the stomach protrudes up through an abnormally large opening in the diaphragm. The condition has been estimated to exist in 40% of Americans, and is usually of no significance in people who don't have heartburn. While it does not always cause GERD, a hiatal hernia may cause LES incompetence in some individuals, especially when the hernia is severe. Over 90% of patients who present with severe esophagitis will have a hiatal hernia.

It is important to look for other causes of GERD like poor esophageal clearance, medical conditions such as scleroderma, certain medications, and prior radiation treatments to this area of the body. Finally, delayed gastric emptying will also produce GERD. This may due to a weakening of the stomach action due to diabetes or an obstruction at the outlet of the stomach.

Patients with long-standing GERD, may develop scarring of the lower esophagus making their GERD even worse.

Is there anything I can do to help prevent an episode of heartburn due to GERD?

There are several options in the treatment of GERD. These options range from lifestyle changes, to medications, to surgery for severe disease.

Smaller, more frequent meals helps as well as avoiding eating for 3 to 4 hours before bed. You can also use 6-inch blocks to elevate the head of your bed or a foam wedge to help prevent reflux. Also avoid those foods mentioned above and check your medication as a possible cause. Tight-fitting clothing or abdominal straining, lifting or bending can cause stress reflux.

What criteria does a doctor use to determine if a patient has GERD?

The diagnosis of GERD is considered a clinical diagnosis. This means that for most patients with the typical symptoms of heartburn and regurgitation and no complications (signs of bleeding) will be treated with medication and then evaluated.

In those patients with severe GERD, with complications, or who are unresponsive to therapy, the doctor may choose to have the patient undergo certain tests to see what is the cause of GERD and whether surgery might help.

What tests are performed to evaluate severe GERD?

Upper endoscopy is a long flexible tube equipped with a video camera that is passed through your mouth and throat into the esophagus. Besides directly viewing the condition of the esophagus, the doctor can do a biopsy (take a small sample of tissue). Some patients with severe cases of GERD can develop a condition called Barrett's esophagus. This is a change in the cells of the esophagus due to prolonged exposure to stomach acid. It is considered a pre-cancerous lesion which needs to be followed closely with endoscopy.

Barium Esophagography is a type of x-ray that is used to look at the outline of the barrel of the esophagus. This test looks at the anatomy and function of the esophagus.

Ambulatory pH Monitoring is the best way to document acid reflux. A probe is used to check the acidity of the lower esophagus at multiple times. This is useful when endoscopy appears normal, but patient does not respond to medication.

Esophageal Manometry is a way of measuring the pressure changes within the esophagus, and can be used to check the functioning of the esophagus.

Hiatal Hernia

Some people have a physical distortion of the lower esophageal sphincter that prevents it from building up enough pressure to keep it closed. A hiatal hernia is a condition where the stomach protrudes up through an abnormally large opening in the diaphragm. The condition has been estimated to exist in 40% of Americans, and is usually of no significance in people who don't have heartburn. While it does not always cause GERD, a hiatal hernia may cause LES incompetence in some individuals, especially when the hernia is severe. Over 90% of patients who present with severe esophagitis will have a hiatal hernia.

It is important to look for other causes of GERD like poor esophageal clearance, medical conditions such as scleroderma, certain medications, and prior radiation treatments to this area of the body. Finally, delayed gastric emptying will also produce GERD. This may due to a weakening of the stomach action due to diabetes or an obstruction at the outlet of the stomach.

Patients with long-standing GERD, may develop scarring of the lower esophagus making their GERD even worse.

GERD Surgery

If your symptoms are debilitating and your doctor has decided that medical therapy cannot ensure relief, you may have a surgical procedure to help strengthen the LES function thereby preventing reflux. The Nissen fundoplication is the most commonly performed procedure for GERD. It involves wrapping the top of the stomach (fundus) around the lower end of the esophagus, creating a cuff that acts as a valve. This procedure is also used to treat hiatal hernia, another cause of GERD.

A variation of the Nissen fundoplcation is the Toupet procedure. This involves a looser wrap around the esophagus. Today, most surgical treatment for GERD (Nissen or Toupet) is performed laparoscopically. The patient usually does not spend more than one or two days in the hospital after surgery.

Results are seen immediately, with many patients finding that they never need antacids again.

Hernia hiatal
Esophageal Cancer Surgery

Cancer of the esophagus is a disease that is becoming more frequent in Western countries. One reason for the rise in this type of cancer is because of the increase in Barrett's esophagus (changes in the normal lining of the esophagus) in the West. (See the section on GERD). Esophageal cancer was once considered a uniformly deadly disease. Today, advances in surgery, chemotherapy and radiation therapy are greatly improving survival of this disease.

There are several options in the surgical treatment of esophageal cancer. Not long ago, resection of cancer of the esophagus meant a large painful incision on the chest or abdomen or both. Today, laparoscopic techniques are being used to completely resect esophageal cancer and to reconstruct the esophagus. Laparoscopic surgery for cancer of the esophagus results in a shorter and less painful recovery than traditional open surgery, without compromising the cure.

Esophageal Surgery for Benign Disease

There are a variety of benign (but difficult and uncomfortable) conditions of the esophagus that can treated with surgery.

Achalasia is a condition that results in inability to move food easily through the esophagus to the stomach. It is thought that the lower esophageal sphincter (LES) cannot relax and this results in stretching and dysfunction of the body of the esophagus. The result is a dilated esophagus that fails to empty properly. Minimally invasive surgery to release the tight LES is now the standard of care for this disease.

Esophageal diverticulum is the term to describe an out-pouching of the lining of the esophagus through its muscular wall. A diverticulum can result in difficulty swallowing, regurgitation of swallowed food and bad breath. Diverticula can be found along any segment of the esophagus. A Zenker's diverticulum is a diverticulum that occurs at the very first portion of the esophagus in the neck. Recently, Zenker's diverticula have been treated with minimally invasive surgery that does not even require a cut in the skin.

Surgery for the Stomach

Cancer of the Stomach:

In the US, there are about 22,00 new cases of stomach cancer each year. There are several different risk factors that may lead to stomach cancer such as certain infections, environmental exposures and genetic risks. The best chance for cure of cancer that is confined to the stomach is to treat it with surgical resection, followed by chemotherapy and radiation. Small cancers of the stomach can be removed laparoscopically while maintaining good outcomes for cure.

Benign Disease of the Stomach and Duodenum:

Peptic Ulcer Disease

A peptic ulcer is a deep erosion into the lining of the stomach or duodenum (first portion of the small intestine). Peptic ulcer disease (PUD) may result from the excess secretion of acid, poor protection against normal acid secretion, infections, or too much intake of non-steroidal anti-inflammatory drugs (NSAIDs).

Usually, PUD can be treated with medications such as antibiotics or antacid medications. Occasionally, peptic ulcers can result in serious complications such as perforation, bleeding, and obstruction of the outlet of the stomach.

Surgery is sometimes needed to treat the acute or chronic complications of PUD. Surgery may be performed to decrease acid secretion, stop bleeding, repair a perforation, or redirect the flow of gastric contents in the case of obstruction.

Paraesophageal Hernia / Gastric Volvulus

Gastric volvulus is a twist of the stomach that usually occurs in association with a large hiatal hernia. The stomach can twist up next to the esophagus through it's opening in the diaphragm. This is known as a paresophageal hernia. A paraesophageal hernia may cause pain, difficulty eating or obstruction. This is an indication to surgically repair the problem to prevent a life-threatening problem.