# Houston Heartburn and Reflux Center

> Acid Reflux Treatment

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#### "Don't Super Size Me"...Control Your Portion Size and Stop Acid Reflux
Restaurants in Houston have super-sized everything, from drinks to meals. We have developed overeating habits inside and outside our homes. Large meals over-stretch the stomach, which in turn pulls the lower esophageal sphincter, LES, wide open. Over time, repetitive overeating and pulling on the LES results in irreversible damage. A damaged LES allows acid to escape into the esophagus, leading to chronic acid reflux or GERD.
How to avoid overeating?

Do not skip breakfast. Breakfast is the most important meal of the day. Eating a healthy and balanced breakfast controls your hunger throughout the day, especially in the evening. Most individuals who skip breakfast in the morning tend to overeat at dinnertime. A heavy meal close to bedtime is a recipe for acid reflux.
Eat slowly. Do not eat while driving or watching TV. Develop the habit of what we call mindful eating. Listen to your body cues for hunger and satiety. Put down your fork between each bite and chew your food very well.
Eat small meals. Do not “super-size” your meals. Try using a smaller plate at home. One serving of cooked meat is the size of your palm.

 If these tips don’t help minimize your frequent heartburn, contact Houston Heartburn and Reflux Center. Dr. Darido offers comprehensive heartburn evaluation and effective treatment solutions for acid reflux.

#### 100% Houston Heartburn Patient Satisfaction
Today we reached 100 google reviews for Houston Heartburn and reflux Center reflecting one of the highest patient satisfaction rates in the healthcare industry. On behalf of Houston Heartburn and reflux Center physicians, nurses and supporting staff I would like to extend a big thank you to our patients. It has been a privilege to take care of you and we are very appreciative for your positive and encouraging reviews. Some patients have traveled from out of town remote areas seeking state of the art acid reflux management and treatment. We are happy we met your expectations and we are excited you are leading a healthier and happier life.
We have started Houston Heartburn and reflux center with one mission: educate, treat and prevent acid reflux related symptoms and complications. We have successfully fulfilled our mission so far, and we pledge to continue our fight against acid reflux using the most reliable and durable solutions for GERD.
Many treatment options have become more available for acid reflux over the past few years like LINX™ surgery, Stretta, and TIF. However, Nissen fundoplication (a properly performed Nissen fundoplication) remains the gold standard treatment for acid reflux disease. We only offer the best for our patients because we treat patients like we treat our own family members. We only offer what is best for heartburn and acid reflux patients because we don’t accept anything short of excellent outcome. Once again thank you for trusting us and thank you for choosing Houston heartburn and Reflux Center.

#### 2016 Resolution: Cure Acid Reflux Disease in Houston
Houston Heartburn and Acid Reflux Center is setting a new goal for the new year: Empower patients to cure acid reflux. Do you suffer from daily or weekly heartburn, chest pain, sore throat and food regurgitation? Do you wake up at night choking and coughing? Have you been taking antacid medications for the past few years? Is your quality of life deteriorating? Are you concerned about esophageal cancer?
Let 2016 be the year you understand acid reflux disease. Knowledge is power and Houston Heartburn and Reflux Center is raising awareness across the greater Houston area to educate and empower acid reflux and heartburn sufferers.
Acid reflux is a chronic but potentially curable problem. Rather than adopting the “status quo” treatment plan of long-term daily proton pump inhibitors, patients are invited to consider our approach to GERD. We want to make a difference in Houston and change lives forever. We want to alleviate a problem not simply mask symptoms. Here are the steps:

Consult with an Acid Reflux Specialist. Don’t be satisfied with your PCP or gastroenterologist opinion. Ask an expert in the field. There is more to acid reflux than a pill.
Change your lifestyle. Stop smoking and reduce alcohol. Loose weight and eat healthy. Exercise. Not only will your heartburn improve, but also your overall health will benefit.
Avoid OVEREATING. This is a major cause for acid reflux in our society today. Large meals are destroying the delicate barrier against acid reflux. Eat small meals throughout the day and give your stomach a break. Please don’t fast. Starvation is not a solution for weight loss or acid reflux.
Avoid trigger foods. Certain individuals are sensitive to certain food items that trigger an acid reflux episode. If fried chicken gives you heartburn go for baked chicken. Don’t take a proton pump inhibitor and eat a bucket of fried chicken. You may not feel the symptoms but the reflux is occurring and you are slowly damaging your anti-reflux valve without knowing it.
Stop using proton pump inhibitors. Consider less powerful medications if needed to control symptoms. Proton pump inhibitors are associated with a growing number of serious side effects. Osteoporosis, renal failure, cardiac arrhythmias, pneumonia, clostridium difficile colitis, and changes in the gut microbiome. No wonder why so many acid reflux patients I see in the office suffer from irritable bowel syndrome
Take control of your acid reflux today and change your life forever. If your symptoms are difficult to control with lifestyle changes, consider the Nissen fundoplication. This minimally invasive, anti-reflux surgery, when properly performed, is the most reliable treatment for acid reflux disease

Houston Heartburn and Reflux Center invites you this year to understand acid reflux disease to better control your problem. No matter how severe your symptoms are we have the appropriate solution for you.

#### A Cancer Linked Compound Found in Zantac
The FDA found a cancer causing chemical in Zantac, a popular heartburn medication that reduces stomach acid. Thousands of Houstonians use prescription and OTC Zantac to control their acid reflux symptoms. The carcinogenic contaminant known as NDMA, N-nitrosodimethylamine, was recently found in Valsartan, a blood pressure medication that led to massive drug recall. So far, NDMA levels detected in Zantac are not high enough to trigger a recall. There are speculations, however, that the Ranitidine (Zantac) molecule, is inherently unstable and can degrade during digestion to create higher amounts of NDMA.
NDMA can cause liver and colon cancer. It is found in very low amounts in cured meats like bacon as well as tobacco products. Acid reflux patients who depend on daily Zantac intake to control heartburn are at increased cancer risk secondary to NDMA contamination. Until this issue is clearly resolved, Houston Heartburn and Reflux Center recommends substituting Zantac for other heartburn medications.
*Update:  In 2020, the FDA requested all manufacturers of ranitidine to withdraw their products from the market. Ranitidine has been discontinued worldwide due to the instability of this molecule leading to production of NDMA during storage or digestion.
In 2021, Sanofi, the pharmaceutical company that manufactured Zantac, replaced Ranitidine in Zantac with Famotidine and called its new product, Zantac 360.
To date, the FDA’s testing has not found NDMA in famotidine (Pepcid), cimetidine (Tagamet), esomeprazole (Nexium), lansoprazole (Prevacid) or omeprazole (Prilosec).

#### A GERD Patient with An Asymptomatic Peptic Stricture
The case of the week for this blog is a 67 year-old female with long standing history of GERD related symptoms. She has been treated with a variety of proton pump inhibitors over the past few years with incomplete symptom control. She has been sleeping in a recliner for the past 4 years. Her nighttime symptoms include heartburn and food regurgitation. She reports waking up from her sleep several times during the week with sore throat, cough and choking. Her acid reflux work up included an upper endoscopy that showed distal esophagitis with no evidence of Barrett’s esophagus in the setting of a moderate size hiatal hernia. No evidence of esophageal lumen narrowing was appreciated. In preparation for hiatal hernia repair and Nissen fundoplication she underwent an esophageal manometry that showed normal peristalsis with normal resting lower esophageal sphincter pressure. With every swallow, however, the patient showed evidence of compartment pressurization starting in the mid esophagus up to the lower esophageal sphincter. The lower esophageal sphincter relaxation showed delayed relaxation. In other words, the lower esophageal pressure did not drop at the beginning of the swallow. It only decreased towards the end of the compartment pressurization after the fluid has passed through the sphincter. These findings were highly suggestive of a subtle distal esophageal stricture. A barium esophagogram was performed including the use of a 12.5 mm barium tablet. It showed a short stricture just above the gastro-esophageal junction.
The stricture was successfully dilated and the patient underwent a laparosocopic hiatal hernia repair and a 360 degree wrap with no complications. Post-operatively her GERD symptoms resolved and she did not experience any difficulty swallowing food.
GERD is the most common cause of benign esophageal strictures. A stricture results in luminal narrowing of less than 13 mm and results in dysphagia. Subtle strictures are easily missed on upper endoscopy and a contrast study with a barium tablet are highly sensitive in detecting the abnormality. In our case, high resolution esophageal manometry picked up the slight increase in compartment pressure due to fluid build-up above the stricture. Most benign strictures respond to balloon dilation. A high grade and long stricture that does not respond to balloon dilation requires resection.

#### A New Hybrid Procedure for GERD: Anterior Fundoplication-Sleeve
I read with interest the article titled “Safety and effectiveness of anterior fundoplication sleeve gastrectomy in patients with severe reflux”. The study is recently published in the current issue of SOARD (Surgery for Obesity and Related Disorders) by M.A. Jawad et al. The authors claim that bariatric surgeons are hesitant offering sleeve gastrectomy for patients with severe GERD. To avoid performing gastric bypass surgery to achieve weight loss in the setting of severe GERD, the authors have come up with a new approach; Anterior fundoplication is added to sleeve gastrectomy to reinforce the anti-reflux barrier. Part of the gastric fundus is preserved during sleeve gastrectomy. The remnant fundus is then used to construct an anterior fundoplication. It is sutured to the right crus, arcuate ligament and left crus. A total of 31 patients were enrolled in the study and 21 of them underwent concomitant hiatal hernia repair. Most patients showed improvement in their GERD score analysis. The authors do not use pre and post operative ambulatory pH testing and upper endoscopy to objectively evaluate acid reflux disease.
This is a limited study and solid conclusions cannot be made. However, the concept itself of using a small remnant fundus to reinforce the anti-reflux barrier is worth discussing. Does fundoplication stop acid reflux when part of the stomach was resected? Does a fundoplication work when most of the gastric fundus has been resected and a small remnant is used to fold over the anterior distal esophagus?
The answer to these questions is difficult because the exact mechanism of action fundoplication for treatment of GERD remains poorly understood. The common belief of mechanically reinforcing the lower esophageal sphincter with a stomach wrap is a simplistic explanation of a complex problem. Indeed, narrowing the distal esophagus by any means does not resolve GERD. Concomitantly, the fundoplication itself does not increase resting lower esophageal sphincter pressure as it is evident on post-Nissen fundoplication esophageal manometry. Rather, a floppy and short fundoplication that does not mechanically restrict the distal esophagus is the recommended surgical technique.
An alternative mechanism of action is related to inhibition of transient lower esophageal sphincter relaxation (TLESR) events. TLESR events are believed to be the cause of GERD. Gastric fundus anatomy, physiology and motility affect TLESR event frequency and duration. Nissen, toupet or Dor fundoplication alters gastric fundus wall tension, distention, and motility and consequently it inhibits TLESR events leading to GERD resolution. I have previously hypothesized that gastric fundus resection may be partly equivalent to fundoplication in terms of TLESR control. Therefore, a properly performed sleeve gastrectomy resulting in complete gastric fundus resection without narrowing of the incisura angularis is associated with GERD resolution. Therefore, leaving a small remnant fundus to fold over the anterior esophagus in the setting of gastric sleeve surgery may be a useless step.
I agree with the authors that a concomitant hiatal hernia repair must be performed to re-establish the intra-abdominal position of the lower esophageal sphincter. I also agree with the idea that if the lower esophageal sphincter resting pressure is low, sleeve gastrectomy and hiatal hernia repair by themselves are not enough to fully control acid reflux disease. Roux- en-Y gastric bypass in this case may be a better option.

#### Achalasia and Obesity: Changing Treatment Paradigms
Achalasia is a rare esophageal dysmotility disorder of unknown etiology. It is characterized by loss of esophageal peristalsis and failure of the lower esophageal sphincter to relax. Patients develop dysphagia to solids and liquids. They also develop food regurgitation and heartburn. Heartburn is secondary to the inability of the esophagus to clear physiologic gastric content reflux. Furthermore, retained food in the dilated esophagus tends to ferment resulting in increased acid content and burning sensation. Most achalasia patients presenting to Houston heartburn and Reflux Center reports heartburn as their main complaint.
A 50-year-old male, BMI=49, presented to my office with worsening heartburn and food regurgitation of one year duration. He reports that almost a year ago he had developed fever for two weeks. An extensive fever work up was performed that yielded no answers to the origins of his fever. Following those two weeks, patient reports that his heartburn has progressively worsened along with new onset difficulty swallowing food. He likes to eat fruits like oranges, but due to acid reflux and dysphagia he started avoiding fruits, vegetables, and meat products. He started consuming more ice cream, cookies and other soft, high sugar and high fat content food items that led to a 40-pound weight gain in one year.
Upper endoscopy, esophageal manometry and upper gastrointestinal series confirmed the diagnosis of type one achalasia in the setting of a small sliding hiatal hernia. A heller myotomy was offered to patient to alleviate his symptoms. A partial fundoplication and hiatal hernia repair are traditionally added to prevent GERD related symptoms from developing after sphincter myotomy. However, given the patient morbid obesity a gastric bypass was recommended instead of a Toupet fundoplication. Gastric bypass surgery has the advantage of excellent postoperative GERD control as well as obesity resolution. Gastric bypass also preserves the stomach reservoir for any potential future use in case esophageal resection is needed.
POEM or endoscopic myotomy has been shown to be quite effective in terms of achalasia treatment. However, POEM is associated with a higher incidence of post-myotomy GERD development and in the setting of morbid obesity food regurgitation and heartburn may be quite difficult to control with medications only. At Houston heartburn and Reflux Center, we consider obesity to be a contraindication for POEM and a strong indication for gastric bypass and Heller myotomy for achalasia treatment.
Reference:
The surgical management of achalasia in the morbid obese patient.
Fisichella PM1, Orthopoulos G, Holmstrom A, Patti MG. J Gastrointest Surg. 2015 Jun;19(6):1139-43.

#### Achalasia Treatment
How does per-oral endoscopic myotomy (POEM) work for Achalasia Treatment?
Achalasia is a rare condition where the lower esophageal sphincter (LES) fails to relax during food swallowing. As a result, food and liquids get stuck in the esophagus and patients report difficulty swallowing and food regurgitation. Achalasia patient may initially present with heartburn symptoms. Acid is trapped above the non-relaxing LES mimicking acid reflux. The traditional surgical treatment for achalasia is Heller Myotomy. Myotomy is a Latin word that means cutting a muscle. During a Heller myotomy, the LES muscle is cut open to alleviate the narrowing and allow normal swallowing. A partial fundoplication is then constructed; the gastric fundus is partially wrapped around the LES to prevent acid reflux without hampering swallowing.
POEM is a very interesting novel procedure for treating achalasia. Dr. Haruhiro Inoue, from Showa University, Northern Yokohama Hospital in Japan, has been developing this procedure since 2008. He has performed 900 cases so far with an excellent success rate. In a recent study, 370 patients followed for one to two years after POEM, showed improvement in symptoms with an overall success rate of 91%. A downside of POEM therapy is the inability to construct a barrier against acid reflux. Indeed, one in five patients complains of heartburn or regurgitation after POEM procedure. A key to a successful POEM procedure is complete dissection of circular muscle at the level of the lower esophageal sphincter, LES. By weakening the LES to treat achalasia, patients are put at risk for acid reflux and food regurgitation. During Heller myotomy surgery, after cutting open the LES, a partial fundoplication is constructed to prevent acid reflux. For this reason, patients undergoing POEM need to be followed closely for acid reflux symptoms. At Houston Heartburn and Reflux Center, we recommend yearly upper endoscopy for the first 3 years after POEM.
 

#### Achalasia, Hiatal Hernia and Heartburn
Mary from Humble, TX sent us this question: “I have a Hiatal Hernia with Achalasia. Can surgery on these be done at the same time? What type of surgeon does these? A GI doctor, Thoracic Surgeon, or regular Surgeon? I live around Cypress, Humble area.”
Thanks,
Mary
Dear Mary,
Achalasia is a rare esophageal motility problem that may coexist with a hiatal hernia. Both achalasia and hiatal hernia are associated with heartburn. The treatment in your case consists of hiatal hernia repair with Heller myotomy and Toupet fundoplication. All three procedures are concomitantly done laparoscopically, i.e. through tiny incisions. The success rate of this approach is very high along with a very low complication rate. Heller myotomy open the non-relaxing lower esophageal sphincter associated with achalasia. Consequently, swallowing improves and dysphagia resolves. Hiatal hernia repair and Toupet fundoplication reliably stop acid reflux without affecting swallowing.
The best surgeon to perform this surgery is a competent surgeon who specializes in acid reflux management. Thoracic surgeons do not typically specialize in acid reflux, but some offer hiatal hernia repair and fundoplication surgery. A regular general surgeon does not perform these surgeries on a regular basis and surgery outcome is typically poor. GI doctors are not surgeons. They may perform balloon dilation of lower esophageal sphincter. This approach is typically reserved for older patients who cannot tolerate general anesthesia.
There are very few heartburn and acid reflux centers in Houston dedicated to the management of esophageal problems like achalasia. Houston Heartburn and Reflux Center is proud to offer state-of-the-art treatment solutions for acid reflux, and esophageal dysmotility like achalasia. Give us a call at 832-945-8717 and one of our friendly receptionists will help you schedule an appointment.

#### Acid and Bile Reflux following Stomach Surgery
I read with great interest the recent study “Esophagogastric junction function and gastric pressure profile after minigastric bypass compared with Billroth II” published in SOARD journal. The authors compared two small group of patients each containing around twenty patients. First group consisted of obese individuals who underwent mini-gastric bypass for weight loss. Second group underwent distal gastrectomy and Billroth II reconstruction for refractory ulcers. All patients did not have evidence of clinical acid reflux or hiatal hernia prior to surgery. Weight loss patients were evaluated prior to mini gastric bypass surgery and at one and five year follow up, with GERD questionnaire, upper endoscopy, esophageal manometry and 24-hour pH-impedance study. Billroth II patients underwent upper endoscopy, manometry and impedance studies after surgery.
Results showed increased acid and alkaline reflux, and distal esophagitis in Billroth II patients only. Manometry showed decreased lower esophageal sphincter in Billroth II patients only favoring GERD. Furthermore, gastric pressure in Billroth II patients significantly dropped compared to mini-gastric bypass patients favoring bile reflux across the gastro-jejunostomy. The authors observe that bile stasis in the gastric remnant leads to deterioration of the anti-reflux barrier and increased incidence of GERD in the setting of classical Billroth II reconstruction. In a classic Billroth II reconstruction gastric fundus and part of the gastric body are preserved. This is in sharp contrast to the sleeve like gastric pouch created in the setting of mini-gastric bypass surgery. There is no doubt in my mind that gastric fundus resection, similar to plication, alters the anti-reflux barrier. Studies have shown increased lower esophageal sphincter pressure following gastric sleeve surgery as well as increased gastric emptying. Therefore, it is no surprise to me that a Billroth II reconstruction in the setting of mini-gastric bypass is associated with lower GERD and bile stasis incidence when compared to a classic Billroth II. Unfortunately, the current study has a number of limitations that significantly weakens its results. It does point however, to an important concept in GERD pathophysiology: the stomach and in particular the gastric fundus plays an important role in the acid reflux barrier and pathogenesis of acid reflux disease. Gastric fundus surgery in the form of Nissen fundoplication or sleeve gastrectomy accelerates gastric emptying and moves the gastric acid bubble away from the gastro-esophageal junction. These physiologic changes contribute to heartburn control independent of lower esophageal sphincter pressure increase. The purpose of fundus plication is neither to create a mechanical valve around the distal esophagus nor to create a high-pressure area. Nissen fundoplication mechanism of action is much more complicated than LINX™ device for acid reflux management. For this reason, a floppy and short fundoplication is as effective as a bulky and tight fundoplication in terms of acid reflux control. The advantage of a floppy fundoplication is the lack of postoperative dysphagia.

#### Acid Reflux after Gastric Bypass Surgery
Question of the week from Katy in Houston: “I had RNY surgery 16 years ago. 2 months ago, I started with bad acid reflux. My PCP prescribed Prilosec 40 mg 1 a day in the morning and Zantac 300 mg 1 hour before bed.
I’ve changed my diet and all day long I feel a bad tasting acid leak into my throat. Nothing is helping. I need your opinion please. Thank you”
Dear Katy,
Gastric bypass surgery for morbid obesity protects against acid reflux. The procedure does not reinforce the anti-reflux barrier like Nissen fundoplication but diverts most of the gastric acid away from the esophagus. Furthermore, the Roux limb, also called alimentary limb, that channels food from the small gastric pouch into the common channel acts as a negative pressure system. It favors gastric pouch rapid emptying rather than reflux back into the esophagus. If a hiatal hernia is present, the gastric pouch is exposed to the negative intra-thoracic pressure favoring reflux into the esophagus. Concomitant esophageal dysmotility demonstrated by esophageal manometry and contrast pooling in distal esophagus on UGI further exacerbates acid reflux in the setting of a hiatal hernia.
Furthermore, a short alimentary limb (typically less than 30 cm), favors bile reflux into the gastric pouch and distal esophagus. A gastro-gastric fistula can also cause severe acid reflux and may develop years after initial surgery. Such fistula develops following staple line breakdown between gastric pouch and gastric remnant.
As you can see, Katy, many factors contribute to severe reflux following gastric bypass. Starting Prilosec and Zantac without proper and comprehensive evaluation by a reflux specialist will only mask your symptoms. Your workup must include upper endoscopy, and UGI contrast study. Ambulatory pH testing and esophageal manometry may be added if needed. You need to treat the underlying cause, (not the symptoms), of acid reflux for permanent and effective relief.

#### Acid reflux and Heartburn after Gastric Bypass Surgery
Suzie from Houston sent us this question: “I had gastric bypass surgery in 2009. I suddenly developed acid reflux this year. I had an endoscopy that came back clear. I am on 80mg of pantoprazole and have changed my diet. I still have acid coming up – not every night but an average of twice a week. It is now happened at 4 AM. I’m sleeping in a recliner which doesn’t seem to help when it decides to come up. I take a lidocaine cocktail when it happens to help me with the aftermath of reflux. What else can I do?”
Dear Suzie,
The first step in acid reflux and heartburn management is good diagnosis. Upper endoscopy must be performed by a reflux specialist to check for obvious and subtle signs of acid reflux. In addition to upper endoscopy ambulatory pH testing and/or impedance testing are crucial to further demonstrate and quantify the severity of acid reflux. Additional testing in the form of contrast studies to elucidate the anatomy of gastric bypass are particularly helpful in your case. An upper gastrointestinal contrast study may demonstrate a fistula (connection) between gastric pouch and remnant stomach leading to severe acid reflux. A Ct scan may show internal hernia and/or partial bowel obstruction leading to bile back up into the Roux limb and gastric pouch. Bile reflux can cause severe heartburn similar to acid reflux.
The fact that you partially responded to high-dose pantoprazole points towards acid reflux. However, an additional workup is needed to confirm and stage the diagnosis of GERD. Treatment is subsequently tailored to your particular situation.

#### Acid Reflux and Heartburn after Lap Band Removal
Ginger from West Houston sent us this question: “I had a lap band removal after 5 years of it. I have GERD and I still have the ability to regurgitate my food. I never felt like they removed the band”
Dear Ginger,
Lap Band procedure for weight loss weakens the anti-reflux barrier. The longer Lap band has been in place and the more restricted you have been the higher the likelihood of persistent acid reflux related symptoms after Lap Band removal. In most cases, Lap band removal, by itself, does not result in heartburn and food regurgitation resolution. This is unfortunately a common occurrence because most Lap Band patients have been over-restricted in hopeless attempts at promoting weight loss. Forcing a patient to eat less does not reverse the metabolic abnormalities of obesity and does not result in durable weight loss.
Consequently, the end result of Lap Band over-restriction is not weight loss. Rather, Lap Band over-restriction leads to gastric pouch dilation, hiatal hernia formation and esophageal dysmotility. Both hiatal hernia formation and weak esophageal contractions contribute to acid reflux and difficulty swallowing. Following band removal, esophageal motility may recover, but hiatal hernias do not resolve without surgical repair.
Most bariatric and general surgeons are not considered acid reflux specialists. If you continue to have heartburn, food regurgitation and difficulty swallowing food after Lap Band removal, you need to consult with an experienced Houston acid reflux specialist to evaluate your problem and offer the most suitable treatment for your condition. An upper endoscopy and esophageal manometry are offered at Houston Heartburn and Reflux Center for patients with persistent acid reflux after Lap Band removal. If hiatal hernia is found, then hiatal hernia repair is recommended with Toupet or Nissen fundoplication depending on the integrity of esophageal contractions. Hiatal hernia repair and weight loss procedure like sleeve gastrectomy or gastric bypass are also good options especially in the setting of morbid obesity. A solid hiatal hernia repair by an acid reflux specialist is associated with high success rate and significant improvement in your quality of life.

#### Acid Reflux and Heartburn with Keto Diet
Jeff from Houston sent us this question: “I’m experiencing acid reflux, or at least pressure and discomfort in the esophagus, while doing Keto. My sense is that it is the result of high-fat foods. I’ve taken proton pump inhibitors for GERD for years, and now I’m concerned I may not be able to continue the diet. There is no information on this anywhere on the internet. My question: how can I avoid GERD symptoms while on Keto?
Dear Jeff,
Certain food items may exacerbate acid reflux related symptoms. Diet, however, is not a cause of acid reflux. This is a very common misconception.  Underlying cause of acid reflux disease or GERD is a weak anti-reflux barrier. The anti-reflux barrier consists of a complex anatomical and physiological mechanism that prevents gastric content from refluxing back into esophagus.
Whether you eat fatty food or simply drink water, acid reflux is likely to happen if you have a weak anti-reflux barrier. The weaker the barrier the higher the frequency and severity of acid reflux episodes.
Hiatal hernia, poor esophageal motility, delayed gastric emptying are some of the factors that contribute to a weak anti-reflux barrier. If you have been taking proton pump inhibitors for years, it is time to get evaluated. At Houston Heartburn and Reflux Center, we offer comprehensive acid reflux evaluation to stage your acid reflux disease and prescribe the appropriate treatment.
Restoring the anti-reflux barrier allows you to enjoy keto or any other diet you choose. Stop the BURN!! Get tested and enjoy normal life again.

#### Acid Reflux and Pain with Swallowing after Nissen fundoplication
Wendy from North Houston sent us this question: “I am suffering severe acid reflux after Nissen fundoplication done in March. My surgeon has stretched it once since surgery when I was having severe pain upon swallowing. I am obese as well and wanted to see if gastric sleeve would offer me more relief. Is it possible to do a gastric sleeve following the Nissen fundoplication?”
Heartburn, and pain or difficulty swallowing after Nissen fundoplication are indicators of poorly performed surgery. Properly performed Nissen fundoplication is associated with immediate and complete resolution of heartburn. Properly performed Nissen fundoplication is associated with extremely low rates of swallowing issues. Indeed, our rate of postoperative dysphagia at Houston heartburn and Reflux Center is almost zero.
Consequently, you may need revision surgery for acid reflux. In the setting of obesity, weight loss surgery may be preferred over Nissen fundoplication as it allows for both weight loss and acid reflux control.
Can a sleeve gastrectomy be done after Nissen fundoplication? The answer is yes. Sleeve gastrectomy when properly performed in association with hiatal hernia repair is an effective anti-reflux procedure. Poorly performed gastric sleeve surgery that narrows the incisura angularis results in severe post-operative acid reflux.
Proper surgical technique, experience, and sound knowledge of acid reflux and obesity pathophysiology affect surgery outcome. Pre-operative patient work-up and selection are equally important.

#### Acid Reflux on Thanksgiving Day: Do You Need To Call An Acid Reflux Specialist?
It is estimated that the average American consumes around 4500 calories on Thanksgiving Day including 229 grams of fat. Adding copious amounts of alcohol to this rich buttery meal and the end result for many is severe heartburn. Heartburn is the hallmark symptom of acid reflux. It is a burning sensation behind the breastbone that may radiate up to the throat. Acid reflux occurs when the valve between esophagus and stomach relaxes allowing gastric juice to splashes up into the esophagus. Occasional heartburn is treated with acid neutralizing medications like Tums, Zantac, Prilosec… Most of these medications are available over the counter and have a high safety profile when taken over short periods of time. Home remedies are also effective. Baking soda, apple cider vinegar, raw cabbage… can temporarily alleviate a heartburn attack.
If, however, you suffer from acid reflux on a daily or weekly basis then this is a sign that there is something wrong. Your stomach is sending you an important signal that you should neither ignore nor mask with over the counter antacid medications. Houston Heartburn and Acid Reflux specialists strongly recommend you to be evaluated by an acid reflux expert. Acid reflux disease is a progressive and chronic problem that affects the quality of your life, damages the lining of the esophagus and increases your chance of esophageal cancer. Early diagnosis and effective treatment by a specialized doctor will help you regain your life, take control of acid reflux and enjoy many holidays to come.
On behalf of the Houston heartburn and reflux center team, and myself, I would like to wish you a happy Thanksgiving Day and an acid reflux free holiday.

#### Acid Reflux Surgery: Are You A Candidate?
The objective of acid reflux surgery is to restore the lower esophageal sphincter (LES) function to prevent acid from refluxing into the esophagus. Hence, acid reflux surgery addresses the cause of the problem. The cause of acid reflux is a weak barrier (LES) between the esophagus and stomach. By restoring this barrier, anti-reflux surgery eliminates acid reflux symptoms and liberates the patient from daily anti-reflux medication intake.
There are quite a few reasons why someone would consider surgery. More and more patients are seeking surgery as an alternative to a lifetime of anti-reflux medication intake. These powerful medications like proton pump inhibitors (PPIs) have a number of serious side effects: Osteoporosis, vitamin B12 and Magnesium deficiency, pneumonia and Clostridium Difficile bacteria infection, complications with anti-clotting agents like Plavix…Peter is a 30-year-old engineer that has been taking PPIs every single day for the past 10 years. He was rightly concerned about his treatment regimen. “It doesn’t make a lot of sense to me to stay on PPIs the rest of my life”, he said to me during his consultation. Peter was fully aware of the side effects of PPIs taking over a long period of time. “ I don’t want to go through the rest of my life taking PPIs”. After a complete evaluation and workup, I recommended anti-reflux surgery for Peter.
Another common indication for acid reflux surgery, in Houston, is failure of medical therapy. This means that the maximal dosage of anti-reflux medication has failed to provide relief. I saw a patient today who takes 2 PPI (proton pump inhibitor) a day and one Zantac (Histamine receptor blocker) at night. However, the patient’s symptoms are not controlled. She continues to suffer from heartburn and intermittent coughing especially at night. She has obviously failed medical therapy. There is no need to continue suffering like this. Surgery is an excellent solution and is strongly recommended in this particular situation.
Some patients have a large hiatal hernia. A hiatal hernia occurs when the stomach pushes upward into the chest through a defect in the breathing muscle (diaphragm). A large hiatal hernia allows food and acid to back up into the esophagus. Patients usually report food regurgitation when bending over. A laparoscopic (surgery through tiny cuts) hiatal hernia repair with Nissen Fundoplication is the treatment of choice in this situation. Surgery restores the functions of the lower esophageal sphincter and stops food and acid back up into the esophagus.
At Houston Heartburn and Reflux Center, we offer our patients comprehensive treatment solutions for our acid reflux. If you suffer from acid reflux symptoms and would like to explore your treatment options please give us a call.

#### Acid Reflux Treatment in Houston: What is Esophageal Manometry?
Esophageal Manometry is a test used to assess pressure and motor function of the esophagus (food pipe). In addition, it aids in the evaluation of how well the muscles in the esophagus work to transport liquids or food from your mouth into your stomach.
Esophageal Manometry may be performed to evaluate the causes of gastric reflux, heartburn, difficulty swallowing and functional chest pain. In addition, this test may be used in pre-operative evaluation if you are being considered for anti-reflux surgery or to ensure proper placement of pH probes in other diagnostic tests.
How it works?
The study will be performed by Houston Heartburn and Reflux nurse and only takes about 10 minutes. Generally, you will be in a comfortable, semi-reclining or reclining position. Your nose and throat may be numbed with a spray or gel. This will minimize any discomfort associated with the placement of the small catheter through your nose and into your stomach. During this time, you will be able to breathe, swallow and talk with ease.
During the study you will be asked to take deep breaths or swallows a number of times. The pressures resulting from these actions will be detected and recorded by tiny sensors located on the catheter. Dr. Elias Darido will then transfer the recording to a report for review and interpretation. According to the result interpretation, Dr. Darido will recommend the appropriate treatment for you.

#### Acid reflux, Bile reflux, and Gallbladder Surgery
Hello,
I had my gallbladder removed a few years ago and am having a recurrence of bile reflux symptoms. I’m normal weight, don’t smoke, eat healthy and sleep elevated. PPI’s have no benefit. Is Ursodiol an appropriate medication to try? How often and how much? Thank you!
Dear Kelly,
Gallbladder disease and acid reflux or GERD are two common but different medical problems. 30% of the population in Houston have gallstones and 30% suffer from heartburn. Not all patients with gallstones need to have their gallbladder removed. Similarly, not all patients with heartburn qualify for acid reflux disease. Gallbladder surgery or laparoscopic cholecystectomy is indicated for acute or chronic cholecystitis as well biliary dyskinesia. Acid reflux surgery in the form of Nissen fundoplication with hiatal hernia repair is offered to patients with documented GERD. The diagnosis and staging of GERD are made using a number of tests mainly upper endoscopy and ambulatory esophageal pH testing. Bile reflux typically co-exist with acid reflux. Nissen fundoplication re-establishes the anti-reflux barrier and stop any form of reflux from the stomach into the esophagus. Proton pump inhibitors, PPIs, mask symptoms of acid reflux but do not cure GERD.
There is evidence to suggest that bile reflux increases following gallbladder resection. Furthermore, one study showed that PPIs reduce gallbladder function and possibly increase the incidence of gallbladder stone formation and symptomatic biliary dyskinesia. Consequently, patients with acid reflux disease on chronic PPI treatment are more likely to have their gallbladder removed then the general population. This is my personal observation in my own practice as I have noticed a higher incidence of laparoscopic cholecystectomy in patients presenting for acid reflux management. If you suffer from GERD and you undergo a cholecystectomy, gallbladder resection, your GERD related symptoms may get worse after surgery due to increased bile reflux.
Ursodiol, a naturally occurring bile acid, prevents the formation of cholesterol gallstones. Ursodiol does not stop or decrease bile reflux.
I recommend evaluation by a reflux specialist. If you suffer from GERD, laparoscopic hiatal hernia repair and Nissen fundoplication are recommended. This approach is considered the gold standard treatment for GERD. Nissen fundoplication and hiatal hernia repair when properly performed are safe, effective and durable.
Healthy Regards,
Dr. Darido

#### Acid Reflux: Try Not to Self-Treat Heartburn in 2021
Justin from Houston sent us this question: “I have been using Omeprazole for a long time, one pill a day to stop GERD. I now have come to realize, I probably have a low acid stomach, so I stopped taking it. I am now using HCL by Solara. Trying to figure out how many to take with each meal. I still get acid reflux in the esophagus, watching what I eat. Does it take time, with the HCL, before the reflux stops? I get it after each meal. I am 74 yrs. Will acupuncture help? I got over Covid-19 a month ago, that’s when I noticed an increase with the reflux. Any suggestion would be appreciated. Have not seen a MD yet, trying to get over it myself. Thank you.
Dear Justin,
Acid reflux is a complex disease best treated by an acid reflux specialist. The underlying pathophysiology of acid reflux disease is often misunderstood by doctors and heartburn patients alike. As a result, misconceptions about acid reflux disease management are prevalent. Your inquiry highlights a number of these misconceptions:

Omeprazole stops GERD
I have low stomach acid
I am supplementing with HCL
HCL stops reflux
Does acupuncture help?
I haven’t seen an MD yet, trying to get over it myself

Acid reflux occurs when the acid reflux barrier between stomach and esophagus is weak. Consequently, stomach content leaks up into the esophagus leading to several symptoms like heartburn, cough and food regurgitation. Stomach content is acidic by nature. All stomachs secrete enough acid to digest food. Acid reflux patients have as much acid in their stomach as anyone else. Consequently, Omeprazole, a proton pump inhibitor, reduces stomach acid secretion, but it does not stop GERD. Omeprazole is simply a Band-Aid for your acid reflux symptoms. Omeprazole is not a cure for acid reflux. For this reason, you have been using Omeprazole for a long time, and you continue to have acid reflux. By the same token, heartburn patients don’t need to supplement with acid capsules because they don’t have low stomach acid.
If you suffer from heartburn on a daily or weekly basis, contact our acid reflux specialists at Houston Heartburn and Acid reflux Center to properly manage your problem. Acupuncture does not restore your weak anti-reflux barrier. An experienced acid reflux specialist can restore it. Let 2021, be the year you get rid of reflux and gain back your quality of life.

#### Advanced Acid Reflux and Fasting
Travis from Katy sent us this question: “I have Barrett’s esophagus. I do intermittent fasting, but I notice that in the periods I don’t eat I get a burning sensation, why is that? Thank you.”
Dear Travis,
Barrett esophagus indicates stage 4 GERD. Patients with stage 4 GERD have a very weak or no acid reflux barrier. Since acid is always present in the stomach, stage 4 GERD patients experience acid reflux related symptoms independent of food intake.
Acid reflux is a direct consequence of a weak anti-reflux barrier. It is a common misconception to attribute acid reflux to food intake. In the presence of a competent anti-reflux barrier, heartburn and food regurgitation don’t occur whether you feast or fast.
The treatment for stage 4 GERD relies on re-establishing the anti-reflux barrier. The most reliable solution for stage 4 GERD is Nissen fundoplication and hiatal hernia repair.
Nissen fundoplication and hiatal hernia repair, when properly performed, stops all reflux from stomach into esophagus. Surgery success rate is 100% in properly diagnosed patients. Complication rate is less than 1%. Recovery is fast because surgery is done through tiny incisions resulting in little pain and discomfort.

#### An Evidence Based Approach to the Treatment of GERD
I read with great interest this elegant review on acid reflux disease by Dr. Marco Patti from the University of North Carolina in Chapel Hill. The study was recently published in JAMA Surgery, previously known as Archives of Surgery. Dr. Patti conducted a PubMed review of English written articles from 1985 till 2015 including terms like heartburn, regurgitation, dysphagia, cough, aspiration, laryngitis, GERD, manometry, pH monitoring, proton pump inhibitors and fundoplication. His review is thorough, accurate, and straight to the point. The analysis is objective and reflects the latest advances in our understanding of GERD and its treatment.
Dr. Patti starts by examining the pathophysiology of GERD. GERD pathophysiology is multifactorial. The lower esophageal sphincter is only part of the problem. 40% of patients with GERD have a normal lower esophageal sphincter muscle length and pressure. In these patients, transient lower esophageal sphincter relaxation, TLESR, contributes to acid reflux and is partly due to gastric fundus compliance and motility abnormalities. Other factors contributing to GERD include esophageal peristalsis, hiatal hernia and trans diaphragmatic pressure gradient. He rightly points to the fact that GERD and hiatal hernia can exist independently and that GERD in obese patients has a different pathophysiology compared to lean patients.
The author then discusses the tools we use to evaluate and work up GERD patients. He nicely shows that the “PPI trial” technique adopted by most primary care physicians and gastroenterologists, is not a reliable diagnostic approach. 30% of patients on PPI treatment for GERD have normal reflux scores on pH monitoring. Therefore, these patients are committed to long-term therapy and subjected to many side effects for no reason. Ambulatory pH monitoring allows for confirmation of the disease and allows for correlation between symptoms and episodes of reflux. Upper endoscopy helps rule out other pathologies like eosinophilic esophagitis, gastritis, peptic ulcers, Barrett esophagus and other malignancies. Endoscopy also allows for hiatal hernia evaluation. Both esophageal manometry and Barium swallows are of limited use in GERD diagnosis. However, they are valuable tools in preparing the patient for fundoplication surgery.
At the end, Dr. Patti discusses GERD treatment. Lifestyle changes like weight loss and smoking cessation are always recommended to help alleviate GERD related symptoms. He doesn’t offer however any evidence based data on the effectiveness of these changes except for weight loss. Weight loss is crucial to control GERD especially in the morbidly obese patient. Medications in the form of PPIs are effective in controlling erosive esophagitis and alleviating heartburn. All 7 different available PPIs are equally effective with no difference in symptom control. PPIs are associated with serious side effects and do not eliminate reflux but mask symptoms. Endoscopic therapies like Stretta (radiofrequency ablation) and TIF (Transoral incisionless fundoplication) are ineffective and in my personal opinion should be banned. Surgery in the form of fundoplication is the most reliable treatment with excellent symptom control in 90% of the patients in ten-year follow up studies. I fully agree with the author on the importance of proper preoperative workup and meticulous execution of surgical technique to ensure a durable, reliable and effective outcome following fundoplication surgery.
Lastly, the author briefly touches on LINX™ device as a new surgical modality for treatment of GERD. He mentions that some patients with severe GERD symptoms are reluctant to undergo a laparoscopic fundoplication. LINX™ may be a less invasive approach though less effective than fundoplication. I think by the time this article was published the author did not have access to the 5 year LINX™ FDA trial results showing around 25% complication rate.
Overall, I enjoyed reading this excellent high quality review by a renowned esophageal surgeon. Our understanding of acid reflux disease has greatly evolved. Our surgical technique has been perfected over the past 70 years. It is time to put this knowledge and expertise in centers of excellence dedicated to the treatment of GERD. A complex disease that affect more than 20% of the population cannot be limited to “PPI trials” and ineffective endoscopic therapies. If you suffer from heartburn, food regurgitation, chronic cough… you ought to seek the opinion of a GERD expert to stop the symptoms and improve your life.

#### Are Proton-Pump Inhibitors Associated with Increased COVID-19 Risk?
Almario et al recently published an online survey in the New England Journal of Medicine, NEJM, that suggests a dose-dependent association between PPI use and risk for testing positive for COVID-19.
“In a population-based online survey conducted in the U.S. in May and June 2020, 53,130 adults noted ever having upper GI symptoms. Among them, 3386 (6.4%) reported having received a positive COVID-19 test. A regression model found an odds ratio of 2.15 for having a positive COVID-19 test in those on once-daily PPIs and an odds ratio of 3.67 with twice-daily use. No such relationship was found with histamine-2 receptor antagonist use. All reasonable statistical methods were used to control for confounding factors.”
Proton-pump inhibitors (PPIs) are the most commonly prescribed medication for treatment of acid reflux. PPIs are also available over the counter. Thousands of patients in Houston use PPIs daily to control heartburn. Many acid reflux patients on daily PPI use have never been evaluated by an acid reflux specialist. Multiple studies published in the past several years show associations with increased risks for both infectious and noninfectious conditions, particularly when taken at higher-than-indicated dosages. This is the first report of an increased risk for COVID-19 test positivity in PPI users.
If you suffer from acid reflux related symptoms like heartburn, food regurgitation, cough, hoarseness, bloating and excessive burping get evaluated by an expert acid reflux specialist. At Houston Heartburn and reflux Center we offer several effective and safe solutions for acid reflux disease. PPIs are not your only hope to get rid of heartburn and have a decent quality of life. If you have been taken PPIs, give us a call at 832-945-8717 to get properly evaluated and counseled on the best GERD treatment option that best suits your condition.

#### Are You a Candidate for Nissen Fundoplication?
Julia from Humble sent us this question:
“If one is not a candidate for a Nissen Fundoplication due to poor motility and a previous Nissen, would it be possible to have Roux-en-Y gastric bypass surgery to alleviate reflux?
Thank you.”
Dear Julia,
At Houston Heartburn and Reflux Center, very few acid reflux patients are not candidates for Nissen fundoplication, the gold standard treatment for GERD. Weak motility and previous Nissen fundoplication surgery are not absolute contraindications for Nissen fundoplication surgery. Indeed, most acid reflux patients have poor esophageal motility due to longstanding GERD. Esophageal motility improves after Nissen fundoplication and stopping acid reflux. Certain patients, however, have severe esophageal dysmotility with ineffective swallows on manometry and poor bolus clearance. In such cases, a partial fundoplication is preferred to avoid post-operative dysphagia. If a GERD patient is obese with a BMI more than 40 then weight loss surgery in the form of Roux-en-Y gastric bypass or sleeve gastrectomy is preferred over fundoplication. Weight loss surgery results in significant weight loss that helps control acid reflux. Nissen fundoplication in the setting of morbid obesity and constantly elevated intra-abdominal/ intra-gastric pressure, tends to fail over time. Another indication for Roux-en-Y gastric bypass surgery is poor gastric fundus tissue following multiple Nissen fundoplication revisions. At this stage, there is not much gastric fundus to work with to properly construct a fundoplication. The only option left is to resect gastric fundus and convert t0 gastric bypass.
Last but not least, revision acid reflux surgery requires a competent and skilled acid reflux specialist and surgeon to achieve best outcome. Decisions have to properly made based on clear and comprehensive evaluation to achieve success and avoid complications.

#### Are You Contemplating Sleeve Surgery in 2018?
Eighty percent (80%) of obese patients have acid reflux disease. Weight loss is associated with improvement and sometimes resolution of GERD related symptoms. The most effective weight loss solution, in 2018, remains weight loss surgery. Gastric sleeve surgery is the most commonly performed procedure in Houston, TX. Sleeve gastrectomy is safe, effective and minimally invasive. There is, however, a concern regarding the effect of gastric sleeve surgery on GERD. Several published studies have shown an increased incidence of de novo as well as worsening pre-existing acid reflux symptoms following sleeve gastrectomy. The interpretation of these studies is, however, quite challenging. The diagnosis and severity of acid reflux is evaluated using GERD symptom analysis and use of proton pump inhibitors. Very few studies use objective measures of GERD evaluation like upper endoscopy with biopsies and pH monitoring before and after surgeries to study sleeve gastrectomy effect on GERD. Furthermore, sleeve gastrectomy technique is not yet standardized. Gastric sleeve size and shape varies from surgeon to surgeon and sleeve size and shape plays an important role in GERD pathophysiology. At Houston Heartburn and reflux Center, we have found that a properly performed sleeve gastrectomy is an excellent anti-reflux procedure for the obese patient. A properly performed sleeve gastrectomy follow three basic principles:
1. Preserve the incisura angularis to prevent reflux
2. Resect the gastric fundus to promote weight loss
3. Preserve the antrum to maintain gastric emptying
Unfortunately, the blind use of a small diameter bougie mutilates the stomach and results in functional and sometimes anatomical narrowing at the incisura angularis. The incisura angularis is an important anatomic landmark that separates gastric antrum from gastric fundus. Gastric content movement across the incisura angularis between fundus and antrum is highly coordinated. The Magenstrasse gastric emptying pathway, among others, depends on such coordination. Narrowing stomach angularis and resecting the gastric antrum impair gastric emptying pathways are likely to cause GERD.
Studies are much needed in this field to confirm these theories. Our outcomes, however, at Houston Heartburn and reflux Center, clearly indicate that a contoured sleeve that follows the above mentioned privciples, is equivalent to a Nissen fundoplication in terms of GERD symptom control. Concomitant hiatal hernia repair is crucial as most obese patients have a sliding hiatal hernia. The resected stomach has low wall compliance and can easily transmit the negative intra-thoracic pressure inside its lumen. This results in the creation of a pressure gradient that favors cephalad gastric content movement. A proper hiatal hernia repair moves the gastro-esophageal junction into the abdominal cavity and shields the sleeve lumen from the negative intra-thoracic pressure.
In summary, if you have acid reflux disease and suffer from morbid obesity a PROPERLY performed gastric sleeve and hiatal hernia surgery may be an excellent solution for you.

#### Are You Looking for a Heartburn Specialist in Houston?
Acid reflux disease is a complex medical problem that affects every aspect of your life. Acid reflux prevents you from sleeping, resting, enjoying food, exercising … GERD is a chronic and progressive problem that slowly but surely takes over your life. Most heartburn patients self-medicate with over the counter acid suppressants. Some consult with their primary care physicians who typically start GERD patients on prescription heartburn medications. Others are referred to a gastroenterologist who performs an upper endoscopy, very rarely uses ambulatory pH testing and most commonly end up prescribing heartburn medications. Robert is a 55-year-old Math teacher who presented last week at Houston Heartburn and Reflux Center with worsening heartburn of 30 years. He was particularly bothered by constant belching and bloating. He felt heavy and uncomfortable after a regular meal. He responded poorly to heartburn medications. He consulted with a number of physicians including his gastroenterologist who, like his primary care physician, downgraded his acid reflux symptoms and escalated his heartburn medications. Patient, however, did not improve.
When Robert was finally evaluated at Houston Heartburn and Reflux Center, he was found to have stage 4 GERD with Barrett’s esophagus. He had severe acid reflux in the setting of a hiatal hernia and poor esophageal motility. Robert underwent hiatal hernia repair and 270-degree fundoplication. the minimally invasive approach resulted in less than 24-hour hospital stay and fast, painless and uneventful recovery.  Robert returned to work in one week. Overnight, Robert became GERD symptom free. Robert risk of developing esophageal cancer in the future was greatly reduced.
If you are looking for a heartburn and acid reflux specialist in Houston, look carefully. You have one chance at doing it right from the get-go: don’t miss the opportunity that will change your life forever. If you are not satisfied with your acid reflux management don’t settle for a lower quality of life. There are many effective, safe, and reliable solutions for heartburn. Proper acid reflux diagnosis and tailored GERD treatment in the hands of Houston heartburn experts can greatly improve your quality of life.

#### Are You Taking Omeprazole after Nissen fundoplication?
Jonah from Houston sent us this question: “I had Nissen fundoplication in 2014 and was told no heartburn meds. All they ever say is take omeprazole. I have an EGD every year. One report said loose wrap. The next couple said no not loose. My EGD shows antral ulcer. Very red congested mucosa. I don’t know where to go next, my gastro says it is my anxiety, but I am in constant burning, nausea, throat clearing, stomach pain. Am I crazy? Yes, I have stress. Is there help for this?”
Dear Jonah,
I understand your frustration. Acid reflux treatment in Houston, has unfortunately been reduced to an Omeprazole pill. At Houston Heartburn and Reflux Center we instruct our patients to follow up with our specialists for any recurrent acid reflux symptom after Nissen fundoplication. We insist that they get back to us for proper evaluation and workup to avoid what you are going through.
A properly performed Nissen fundoplication is the most reliable and durable treatment for acid reflux disease. Nissen fundoplication eliminates all acid reflux related symptoms like heartburn and food regurgitation. Heartburn, the most common symptom of acid reflux disease, is however, not diagnostic of acid reflux. In other words, you may feel heartburn without necessarily having acid reflux.
Proper evaluation, especially after Nissen fundoplication, is crucial to rule in or rule out acid reflux. Ambulatory pH testing is always added to upper endoscopy to evaluate heartburn after Nissen fundoplication. Upper endoscopy must be performed by an acid reflux specialist who performs Nissen fundoplication surgery on routine basis. Gastroenterologists have no role in evaluating acid reflux related symptoms following Nissen fundoplication.
I don’t think you are crazy. On the contrary, you are frustrated by a debilitating symptom that greatly affects your quality of life. Proper evaluation by an expert acid reflux specialist in Houston is the answer to all your questions. At Houston Heartburn and Acid Reflux center, we offer state-of-the-art acid reflux testing. Our experts will help you effectively and expeditiously solve the problem. Give us a call at 832-945-8717.

#### Avoiding Heartburn
If you have heartburn, you’re probably all too familiar with the burning sensation felt in the chest behind the breastbone. It’s due to stomach acid refluxing back into the esophagus. Unlike many conditions, fortunately, heartburn, aka gastroesophageal reflux disease (GERD), might be controlled through both diet and lifestyle. Here are some general tips to help you prevent heartburn:

Lose weight
Obesity and being overweight is the leading cause of heartburn because extra stomach fat places pressure on your abdomen, pushing gastric juices up into your esophagus. Even moderate weight loss makes many people feel better.
Avoid certain foods
Certain foods are known to cause and aggravate reflux. It can differ from person-to-person, but in general, try to avoid the following:

Fatty foods
Spicy foods
Acidic foods, like tomatoes and citrus
Mint
Chocolate
Onions
Coffee or any caffeinated beverage
Carbonated beverages
Alcohol

Smaller meals
Large meals fill your stomach and empty slowly, putting pressure on the LES, making reflux and GERD more likely. Instead, try eating smaller meals more often
Don’t lie down after eating
In the first three hours after a meal, acid production peaks because gravity plays a role in reflux. Wait at least three hours before lying down after a meal. Avoid large meals late in the day and try to make your main meal midday.
Elevate your bed.
Simply raising the head of your bed six-eight inches helps keep gastric acid in your stomach down. Consider a wedge-shaped support to keep your esophagus above the stomach. Use extra pillows to also raise your entire upper body for relief from GERD.
Your medications
A number of medications can promote heartburn because they either relax the LES, interfering with digestion, or further irritate an already inflamed esophagus. Always swallow medication in the upright position with plenty of water. Some medications known to increase your risk are:

Non-steroidal anti-inflammatory drugs
Calcium channel blockers (to treat high blood pressure)
Certain asthma medications, including beta-agonists like albuterol
Anticholinergics, medications used to treat conditions, like seasonal allergies and glaucoma
Bisphosphonates to boost bone density
Sedatives and painkillers
Some antibiotics
Potassium
Iron tablets

Stop smoking
Nicotine can also relax the LES  muscles and interfere with your saliva’s ability to clear acid out of the esophagus.
Wear loose-fitting clothes
Tight clothes or belts can constrict your stomach, putting you at risk for heartburn.
Try a gluten-free diet
Gluten is a protein found in grains like barley, rye, and wheat and may cause or exacerbate heartburn symptoms. Try eliminating it from your diet to see if it helps.
Temporary relief
Antacids temporarily relieve heartburn by neutralizing stomach acid.
Hopefully, these tips will help you. If you try them and still have GERD, contact Houston Heartburn to find relief today.

#### Avoiding Heartburn on Halloween
With Halloween right around the corner, people are already making their plans for enjoying the spooky holiday.  More and more people are hitting the stores for costumes, decorations, treats, and party themes.  Heartburn sufferers know it’s the beginning of the fall holiday season.  That means there will be candy, filling foods, and sweets that can potentially put a damper on holiday fun.  That’s why they need to do a little extra planning before the Halloween festivities begin.
Let’s face it, adults and children love Halloween and both can get heartburn.  Fortunately it is possible to avoid discomfort while indulging in certain treats that will be joyfully distributed on that day.  Here’s how you can pick and choose which sweets to eat and avoid in your candy bag.
The scary ones – chocolate bars, peppermints, Starburst
These are likely to be the top heartburn-inducing Halloween treats you might find in your candy stash.  Chocolate’s combination of caffeine and fat can always be a problem.  Peppermints can also be a problem on Halloween or any time of the year.  The presence of spearmint can trigger heartburn.  Did you expect to see Starburst in the “scary” list?  Believe it or not, it belongs.  It’s a candy with its own set of acidic ingredients that trigger heartburn.
The not-so-scary ones – hard candies, sour treats, licorice, gummies, candy corn
See?  There are still plenty of popular Halloween treats that can be enjoyed without the heartburn, and these are at the top of the list.  It’s hard to imagine a trick or treat walk or a Halloween party without the presence of candy corn.  You can indulge in it without a big threat of heartburn.
Gummy and sour candies (Sour Patch Kids, Gummy Bears) should be a safe choice.  In fact, some of the sour elements of candy might help lower the chances of acidic problems.  Since the fruit taste doesn’t come from actual citrus properties, they’re not going to cause heartburn.
Licorice treats like Twizzlers tend to be low in fat and calories, so it’s a safe bet.  Candies that allow you to chew or suck on (jaw breakers and gum) help generate saliva and should, therefore, keep bad heartburn flare-ups at bay.
If we can answer your questions about heartburn on Halloween or any time of the year, contact us to schedule a visit.

#### Be Aware of Drugs That Cause Heartburn
When we take medications, we generally expect it to relieve or fix a certain issue…not cause us more problems.  However, there are several drugs that have certain side effects or ingredients that can increase heartburn.
Here are some examples:
Pain relievers
You’ve probably heard how acetaminophen (Tylenol) is “easier” on the stomach and it’s true.  Proof is how other pain relievers (like ibuprofen and Motrin) can increase the amount of uric acid produced in the stomach.  It’s important to talk with a physician if you find yourself needing to take pain meds on a regular basis.
Osteoporosis drugs
Drugs taken to help prevent bone fractures can produce a heartburn side-effect.  This is primarily due to the presence of Alendronate.  If you take these drugs and experience severe heartburn or problems swallowing, it’s important to talk to your physician right away.
Antibiotics
Antibiotics are also known for causing heartburn.  If you start to experience problems, consult your doctor about a different medication or prescribing medication that will reduce the acid.
Blood pressure medication 
Certain blood pressure medications can make it easier for acid to seep into the esophagus.  Specifically, calcium channel/beta blocker medications are known to cause heartburn.  If you experience this side effect, it is possible to look into alternative medications.
Sleeping pills
Like blood pressure medication, sleeping pills relax the esophageal sphincter, allowing acid to make its way into your esophagus.  One of the common reasons people shouldn’t eat late at night is because lying down can also trigger acid reflux.  So mixing a heartburn-causing pill with sleep can be counter-productive.
Anti-depressants & Anti-anxiety drugs
Heartburn is not an uncommon side-effect of anti-depressants like Vanatrip, Tofranil, and Aventyl, as well as anti-anxiety meds like Valium or Antivan.  This is another case where if you experience these issues, you can seek out alternative medication.
Iron supplements
It’s a good idea to be aware of the potential side effects of an iron supplement.  To reduce the risk, take it with food and avoid taking it before going to bed.
If you are experiencing severe, persistent acid reflux/heartburn problems, it could be the medication you’re using or something else.  The most important thing you can do is get informed and take action.  Talk to your doctor or heartburn specialists about any problems you’re having.

#### Best Diet for Acid Reflux and Heartburn
Georgia from Houston sent us this question” “I have severe acid reflux. I took 3 kinds of PPIs, the doctor prescribed to me.  I finished all the medicine but still in pain? What should I do? I have already lost 4 pounds because I am on a diet to reduce my acid reflux. But I am still in pain ?. Please help!!”
Dear Georgia,
The first step towards effective acid reflux treatment is finding a competent acid reflux specialist in Houston. You cannot treat severe acid reflux using diet and lifestyle changes alone. By the same token, Proton pump inhibitors, PPIs, are not a cure for acid reflux. PPIs are a band aid for heartburn and chest pain. Once you stop PPIs symptoms come back very fast.
An in person or virtual encounter with a competent acid reflux specialist in Houston puts you on the right tract towards recovery from heartburn and chest pain. A comprehensive workup for acid reflux confirms and stages GERD. In some cases, chest pain may not be secondary to GERD. It may be secondary to heart or lung disease. Acid reflux diet and PPIs will not help you at all in this situation.
If severe GERD is confirmed, several effective solutions are available to alleviate your symptoms and improve your quality of life. Effective solutions for GERD re-create the anti-reflux barrier to stop acid reflux. The most reliable solution for acid reflux disease is a properly performed hiatal hernia repair and Nissen fundoplication.
Fundoplication surgery reliably restores weak anti-reflux barrier. Acid, bile and food no longer reflux back into esophagus. As a result, chest pain, heartburn, and food regurgitation resolve. Your quality of life improves, and you can now enjoy a regular diet. Furthermore, following fundoplication surgery, you no longer need to take any antacid medications including PPIs. PPI use over prolonged periods of time is associated with serious side effects like osteoporosis and kidney disease.

#### Best Treatment for Gastroparesis?
Question of The Week from Debbie in Houston:
“I have gastroparesis and I am not responding to medication. My GI doctor recommended that I have pyloroplasty done. While I know this will not cure the gastroparesis, what other recommendations do you have to treat it? I am meeting with the surgeon next Friday. I have a list of questions written down. What do you think I should ask him? My GI doctor told me my other options are a gastric pacemaker or eventually I am going to be put on a feeding tube. I am not holding a lot of food down. I am nauseous every time I eat, I’ve been drinking a lot of Ensure. I need some kind of relief. I don’t know what to do.”
Almost 10 years ago, I developed a procedure for a case of severe refractory gastroparesis. The patient was a 40-year-old male with constant nausea, vomiting, and abdominal pain. He was unable to tolerate any solid food and he was dependent on TPN (nutrition supplied intravenously). On day one after surgery, patient’s gastroparesis symptoms completely resolved. He was started on liquid diet and he was then successfully advanced to regular diet.
The procedure consisted of laparoscopic longitudinal gastrectomy and duodenojejunostomy. The duodenojejunostomy was added because this patient had, in addition to stomach dilation, a large and dilated duodenum. I published this case report in 2012 in the SOARD journal (https://pubmed.ncbi.nlm.nih.gov/22963822)
Over the past few years, I have applied the same concept (without the duodenojejunostomy) on around 65 cases of severe gastroparesis. Almost all patients had great outcome with complete gastroparesis symptom elimination. I have followed some of these patients for years and they remained symptom free. I have repeated gastric emptying study after surgery, and I have demonstrated normalization of gastric emptying rate. The etiology of gastroparesis in this group of patients included idiopathic, diabetic and post-surgical gastroparesis.
Consequently, I may be a bit biased when it comes to recommendations for best treatment for gastroparesis. However, mechanical drainage, like pyloroplasty and gastro-jejunostomy, of an atonic stomach are associated with poor outcome. Similarly, G-POEM (per-oral endoscopic pyloromyotomy) and pylorus Botox injection are not likely to work.
Gastric pacemakers are proven ineffective for gastroparesis treatment in randomized studies. Subtotal gastrectomy for gastroparesis has been historically associated with poor outcomes while gastric bypass studies show suboptimal results.
As a result, I believe that an antrum sparing laparoscopic longitudinal gastrectomy is currently a safe, and effective treatment for gastroparesis. Randomized and prospective studies are needed to prove my concept. In the absence of such strong evidence, my procedure is still considered experimental. However, in the absence of treatment guidelines for medically refractory gastroparesis, an antrum preserving longitudinal gastrectomy makes the most sense to me.

#### Best Treatment for Hiatal Hernia and Diabetic Gastroparesis
Patient Question from Austin, TX
Courtney from Austin sent us this question: 
“I suffer from diabetic gastroparesis, a hiatal hernia, and diverticulosis. In 2017, I had bowel obstruction surgery repaired with mesh. I wish I were local to Houston to be your patient, as local doctors only prescribe medicine that is not helping. I want to lose weight but struggle with digestive, food, and medication sensitivities.  Could you refer me to a surgeon in Austin, TX, who shares your mindset? I’m interested in Gastric Sleeve surgery for weight loss and relief from gastroparesis and diabetes. Thank you”. 
Our Expert Response
Dear Courtney,
The surgical treatment of medically refractory diabetic gastroparesis is not well established. Indeed, there is no agreed upon guideline for treatment of severe gastroparesis in general, and diabetic gastroparesis in particular.
Most bariatric surgeons recommend gastric bypass surgery to treat gastroparesis, especially if you are overweight and diabetic. Furthermore, gastric bypass surgery is often preferred over gastric sleeve surgery for GERD treatment in the setting of hiatal hernia and obesity.
However, our approach to gastroparesis and GERD management, in the setting of diabetes and obesity, is radically different. I am not aware of any surgeon in Austin or anywhere else in Texas who has adopted our treatment algorithm for diabetic gastroparesis.
Why We Avoid Traditional Bariatric Surgeries
The procedure I offer for medically refractory gastroparesis is neither sleeve gastrectomy nor gastric bypass. Both gastric sleeve and gastric bypass surgeries do not improve gastric emptying and do not alleviate nausea, bloating, pain, and vomiting.
It is very important for you to understand that gastric sleeve surgery, as it is performed by most bariatric surgeons, entails the resection of part of the antrum. The antrum is the lower one-third of the stomach and is considered the gastric pump. It is made of thick muscular layer that propels food down into the intestines.
The stomach pump (gastric antrum) must be preserved in any gastroparesis surgery to promote gastric emptying. Therefore, I caution you against undergoing traditional sleeve gastrectomy for medically refractory gastroparesis.
Our Recommended Approach: Antrum-Preserving Longitudinal Gastrectomy
Instead, I recommend an antrum-preserving longitudinal stomach resection. This procedure, unlike a sleeve gastrectomy, preserves the stomach pump (antrum) to promote gastric emptying.
The hiatal hernia is concomitantly repaired with antrum-preserving longitudinal gastrectomy to reliably stop acid reflux. I have been using this approach since 2015 at both Houston Heartburn Reflux Center and Houston Weight Loss Surgery Center with excellent results.
This approach, however, is still considered experimental. However, it is safe and much more reliable than any other available solution for medically refractory gastroparesis.
Struggling with Symptoms?
If you struggle with daily nausea and vomiting after eating, give us a call at 832-945-8717.

#### Bile Reflux after Mini Gastric Bypass Revision to Roux-en-Y Gastric Bypass
Lisa from Cypress, TX asked us this question:
“I had a mini gastric bypass over ten years ago and suffered from ulcers, bile and acid reflux, hiatal hernia and malnutrition so I had an RNY revision and hernia repair in June 2018. For six weeks I was GERD free, now I have it all back with a vengeance, it is burning my esophagus and throat and is here 24/7 with no real symptoms of reflux except the burning. It happens whether I eat, drink or don’t, but feels better when I do for the time I am ingesting. I also have Barrett’s esophagus mild, one cm at bottom of esophagus, but I feel like this is really damaging it further and all the way up the esophagus. I wonder if my operation to RNY was not completely done correctly? I had an upper GI to see what was going on and it says no evidence of hernia and mild upper reflux in the esophagus. Can you help? No PPI’s are working they don’t even make the pain a little less”
Dear Lisa,
Mini gastric bypass is associated with bile reflux and ulceration and revision to Roux-en-Y gastric bypass is the right solution. Hiatal hernia repair is also indicated to protect against esophageal gastric content reflux and help promote Barrett’s esophagus healing as well as prevent Barrett’s esophagus progression to cancer. Acid and bile reflux surgery when properly performed in the form of hiatal hernia repair and gastric bypass is very effective in stopping reflux. The surgery, however, has to be flawlessly executed to work. The distal esophagus must be properly dissected and mobilized to reduce the hiatal hernia. The Roux limb must be of sufficient length to prevent bile reflux. The jejuno-jejunostomy must be wide enough to prevent bile flow obstruction… Assuming all of these steps were taken into consideration, acid and bile reflux are not likely to occur. I definitely agree with you that an upper GI in addition to upper endoscopy and pH impedance study are needed to rule in or rule out acid or bile reflux. The sensation of burning in the throat and esophagus is indicative of acid or bile reflux but not enough to confirm GERD. A comprehensive and reliable work-up by a reflux specialist is required in your case.

#### Bile reflux after Nissen Fundoplication
Denise from Houston sent us this question: “I am having recurrent reflux even after 2 months of LAP Nissen Fundoplication 360. At 6 weeks surgeon did an endo and found out too much bile stasis and gastritis due to bile reflux while wrap is intact. I am on PPI now but that’s not helping at all as it’s Bile reflux which is causing pre op symptoms like chest pain left and right and bile coming up and irritating the throat and bitter taste tongue especially at night. Do I wait and watch my diet or again ask for revision? Thank you.”
Dear Denise,
Nissen fundoplication when properly performed, along with hiatal hernia repair, reliably stops any kind of reflux (bile and acid) from stomach into esophagus. The mere presence of bile in stomach does not necessarily translate into bile reflux following Nissen fundoplication. PPI treatment does not help in this case.
Recurrent or persistent reflux symptoms following hiatal hernia repair and Nissen fundoplication are evaluated by upper endoscopy and ambulatory pH testing. Ambulatory pH testing measures acid but not bile reflux into esophagus. pH impedance test measures acid, and non-acid acidic reflux and it may be a better option to evaluate bile reflux. If any of these tests are positive for reflux, wrap is most likely poorly constructed and revision surgery is indicated. An intact wrap and negative reflux testing reliably rule out GERD.
Excessive backflow of bile from duodenum into stomach indicates a gastro-duodenal motility problem. Gastro-duodenal dysmotility is not only associated with GERD, but it is most likely an integral part of GERD pathophysiology. Our understanding of GERD as an esophago-gastro-duodenal motility disorder is quite limited. Nissen fundoplication promotes gastric emptying, and it most likely mitigates bile stasis in stomach to a degree.
Lastly, excessive bile accumulation in stomach may indicate gastroparesis. Gastroparesis or delayed gastric emptying may co-exist with GERD or result from vagus nerve injury during anti-reflux surgery. A gastric emptying study is needed to confirm diagnosis. Gastroparesis symptoms include nausea, vomiting, bloating and abdominal pain as well as heartburn. Bile gastritis is common with gastroparesis. PPIs are obviously not effective in this case. At Houston Heartburn and Reflux Center, we recommend an antrum preserving longitudinal gastrectomy to restore gastric emptying. (https://houstonheartburn.com/best-treatment-for-gastroparesis)

#### Bile Reflux and Gastroparesis
Leslie from Houston sent us this question: “Hello there. I have been having severe Bile reflux with Bile vomiting, gastritis, and GERD. I am managing with prokinetics, bile binders and sucralfate, but I am still extremely nauseous and losing weight. (I went from a BMI of a healthy 21 to now 18.7) PPIs are not effective. I can taste the Bile in my mouth and my asthma has gotten progressively worse. Because of the low QoL and the gastritis that does not heal my doctors are thinking about surgery. I have been offered a choledochojejunostomy, but I am a bit worried about the high rates of strictures and reflux cholangitis. I have also seen that the Duodenal Switch seems to be a very good option for bile reflux, but it is rarely used in my country of origin. (The original DS from DeMeester for Bile Reflux and not weight loss). I am wondering if fixing the gastric emptying can reduce Bile reflux and severe type C gastritis? The prokinetics only help shortly and it seems in some studies that the Gastric emptying improves after surgery for Bile reflux. I also have the feeling that since gastritis I have much more problems with gastric emptying than beforehand. Luckily, I could manage very well beforehand without medication. I would really like your feedback and discuss my options, what you think might be best in my situation. I am not sure if treating gastric motility would normalize bile reflux, but I am intrigued by the thought… Best wishes”.
Dear Leslie,
In general, there are two kinds of treatment in medicine: palliative and curative. Curative treatment is always preferred as it eradicates the root cause of the problem and eliminates symptoms. In your case, the root cause of all your symptoms and problems is gastroparesis. Gastroparesis results in GERD including bile and acid reflux. GERD exacerbates asthma and result in heartburn, sore throat… and poor quality of life. Gastroparesis also results in bile and food stasis in stomach causing gastritis and discomfort. Furthermore, gastroparesis is associated with impaired gastro-duodenal motility. Impaired gastro-duodenal motility exacerbates duodenogastric bile reflux. Indeed, you may be suffering from gastroduodenoparesis, a condition characterized by absent duodenal motility in addition to impaired gastric motility. Duodenum is typically dilated in these cases. Gastroparesis is a heterogeneous disorder with different subtypes that we still don’t fully understand.
The root cause of your problem is impaired gastric, possible duodenal, motility. There are no effective medications for gastroparesis treatment. Surgical options are not standardized and most adopted surgical options for medically refractory gastroparesis are not effective.
An antrum preserving longitudinal gastrectomy along the Magenstrasse line is a procedure I have developed to promote gastric emptying. I have had great success with this surgical approach in all 50 gastroparesis patients I have treated so far. This approach would be my first line treatment recommendation for you. It is much less invasive than a duodenal switch and choledochojejunostomy. It does not burn any bridges for potential future interventions. It is very safe and minimally invasive with fast recovery. Most importantly, an antrum preserving longitudinal gastrectomy is a curative and not palliative procedure that addresses the root cause of your problem. By normalizing gastric emptying, GERD and bile stasis are expected to resolve without the need to divert bile from duodenum.

#### Biologic Mesh Use in Hiatal Hernia Repair
The diaphragmatic hiatus is a dynamic structure. It contracts and relaxes with every breath you take and dilates with every swallow. Supporting this moving structure is a thin layer of fibrous tissue called the phreno-esophageal membrane, PEM. PEM is an extension of both the endo-thoracic and transversalis fasciae and binds the distal esophagus to the hiatus without impairing motility and function of either structure. PEM is completely dissected during a hiatal hernia repair leaving the distal esophagus “naked” as it crosses the newly formed hiatus.
There is no replacement for PEM once dissected. Fortunately, the fundoplication mechanism of action restores the anti-reflux barrier. Preventing the wrap from herniating into the chest improves its anti-reflux barrier function. The most important key to preventing hernia recurrence is proper esophageal mobilization. Proper closure of the hiatus also helps decreasing hiatal hernia recurrence. At Houston Heartburn and reflux Center we routinely use pledgeted sutures to close the hiatus. Soft pledgets prevent sutures from tearing through muscle. In addition, pledgets cause local fibrosis that reinforces the repair.
In certain cases, the crural muscles are weak and atrophic. A biologic mesh like Gore BIO-A or Surgisis is used to reinforce the suture closure. The mesh is secured using a fibrin sealant like Evicel or Tisseel. I rarely suture the mesh to the underlying muscle to avoid injury to mediastinal and chest cavity structures. The use of biologic mesh in hiatal hernia repair is safe and is not associated with increased complications. The hernia recurrence rate however is not decreased when a mesh is added. A recent article by Oelschlager et al published in Surgical Endoscopy showed no difference in the recurrence rate among patients undergoing primary hiatal closure, and closure with mesh reinforcement with or without a relaxing diaphragmatic incision.
The key to improving hiatal hernia repair outcome is clearly early intervention. Living with a large hiatal hernia for many years result in atrophy and lateral retraction of the crura. It also results in esophageal shortening and fibrosis. Biologic mesh, while safe, lack the durability and strength to maintain the hiatal opening closed. We currently do not have a surgical solution to firmly close the hiatus short of using a permanent mesh. Unfortunately, permanent mesh use is contraindicated in hiatal hernia repair as it ends up eroding into the esophagus.
If you or someone you know suffer from GERD or have a hiatal hernia, get evaluated by a reflux specialist. The earlier you are diagnosed and properly treated the better are the outcomes.

#### Bloating after Nissen Fundoplication
Mike from Cypress sent us this question: “Is it common to have bloating only at night preventing me from getting a good night sleep after Nissen fundoplication?”
Dear Mike,
Bloating and excessive burping are very common acid reflux symptoms. Stage 3 and 4 acid reflux patients tend to constantly and unconsciously swallow saliva and air to quench acid reflux. This results in air accumulation in the stomach leading to gastric distention and the sensation of bloating. Concomitantly, air in the stomach escapes back into the esophagus due to weak lower esophageal sphincter and through the mouth leading to excessive burping.
When a Nissen fundoplication is performed for stage 3 and stage 4 acid reflux, at Houston Heartburn and Reflux Center, less than 10% of patients develop what we call gas bloat syndrome. Patients feel bloated for approximately 3 weeks after surgery because they continue to swallow air even after acid reflux has stopped. It takes 3 weeks to get over the habit of swallowing air. 3 weeks after Nissen fundoplication patients report bloating resolution.
A minority of patients continue to have bloating 3 weeks post-surgery. Most of them report increased flatulence too. Excessive gas production by colon bacteria causes both bloating and increased flatulence. Constipation, irritable bowel syndrome, (IBS), and dietary related indigestion (FODMAPS, gluten) are common causes of bloating and flatulence independent of acid reflux disease. I have successfully treated patients with these conditions using gas absorbing medicine like Simethicone also known as Gas-X and probiotics. For patients with constipation, supplementation with a daily non-psyllium fiber helps alleviate bloating. An osmotic laxative may be added for non-responders. In some cases, dietary modification like gluten-free diet is all what is needed to eliminate bloating and flatulence.
Of note, we know that proton pump inhibitors negatively affect colon health and microbiota. Acid reflux patients who have been maintained on medications like Nexium and Dexilant for many years prior to Nissen fundoplication, have a damaged colon microbiome. Nissen Fundoplication gives acid reflux patients the opportunity to stop proton pump inhibitors. The resumption of normal stomach acid production restores a healthy colon microbiome. A balanced gut microbiome is essential for normal digestion free of bloating and flatulence.
Finally, a poorly performed Nissen fundoplication may be associated with persistent bloating among other symptoms. Obviously, the solution in this case is to redo the fundoplication. A properly performed Nissen fundoplication improves quality of life. A properly performed Nissen fundoplication for the right acid reflux patient effectively resolves acid reflux symptoms without increasing the risk of maldigestion, bloating and discomfort.

#### Budd-Chiari Syndrome, GERD, Schatzki’s ring, and Nissen Surgery
The patient is a 30 year-old female with symptomatic acid reflux in the setting of Schatzki’s ring and hiatal hernia. The ring was previously successfully dilated for dysphagia. However, heartburn and food regurgitation especially at night persisted due to the associated hiatal hernia. Esophageal manometry showed normal peristalsis and contractile wave amplitude. Accordingly, the patient was offered a hiatal hernia repair and Nissen fundoplication as the most reliable cure for her GERD related symptoms.
Intra-operatively, an enlarged caudate lobe was noticed after opening the gastro-hepatic ligament at the level of the pars-flaccida. The caudate lobe occupied most of the lesser sac and was abutting the spleen. The left gastric artery was prominent and a dilated branch emanating from the left gastric artery coursed toward the mediastinum between the right crus and esophagus. The spleen was slightly enlarged too and after taking down some of the short gastric blood vessels along the greater curvature, we noted massively dilated splenic hilum blood vessels. The posterior gastric artery was also dilated and several other tortuous blood vessels coursing along the left crus and entering the mediastinum were also noted. The liver surface was smooth with no apparent evidence of cirrhosis.
All these findings were suggestive of compensated portal hypertension in the setting of normal liver enzymes and normal looking liver surface suggestive of Budd-Chiari syndrome. Budd-Chiari is a rare syndrome affecting 1.4 per million people. It is characterized by hepatic venous outflow obstruction and is asymptomatic in 20% of the patients. Myeloproliferative disorders must be ruled out and long-term treatment depends on chronic anticoagulation and close follow ups. Patients who fail anti-coagulation require more aggressive interventions like porto-systemic shunting and liver transplantation.
I thought this was an interesting case to share. I have never encountered such findings in a completely asymptomatic patient. Do no harm is a guiding principle in my practice. Taking down these blood vessel collaterals to dissect the hiatal hernia would have led to liver decompensation and serious injury. This is one of the few GERD cases where I think long-term Nexium or Prilosec is definitely much safer than Nissen fundoplication surgery.

#### Burping after Nissen fundoplication
Question from Dianne in North Houston:
“Had lap fundoplication for GERD 8 weeks ago and am still burping a lot and having epigastric pain, no nausea, vomiting, bowels not back to baseline normal am worried about gastroparesis. Is this normal and is gastroparesis common or rare. Surgery was a redo of same surgery 25 yes ago.”
Dear Dianne,
I tell all my Nissen fundoplication patients at Houston Heartburn and Reflux Center that they should have almost no pain 2 to 3 days after surgery. Laparoscopic Nissen fundoplication is a minimally invasive procedure performed through tiny incisions. Consequently, recovery is fast, and it is associated with very little discomfort. Epigastric pain 8 weeks after laparoscopic Nissen fundoplication, primary or revision, is not common. Burping after Nissen fundoplication is not common either. Patients may have small burps results from small amount of air trapped above the wrap. However, “big burps” after Nissen fundoplication may indicate wrap failure. Gastroparesis is not common at all following Nissen fundoplication performed by expert hands. The risk of injuring the vagus nerves may be higher in revision surgery. I typically order a baseline gastric emptying study prior to revision Nissen fundoplication surgery to make sure there is no vagal nerve injury to start with. Gastroparesis symptoms include postprandial epigastric pain (pain after eating), bloating, nausea and vomiting.
At Houston Heartburn and Reflux Center, we ask our Nissen fundoplication patients to report back to us for any question or concern after surgery. Thorough evaluation, good physical exam and comprehensive symptom evaluation can help guide additional treatment if needed.
Healthy Regards,
Dr. Darido

#### Can Breathing Reduce Heartburn?
It sounds like a no brainer. We all breathe; therefore, we can reduce our heartburn! Deep belly breathing is the idea here. Try a few days without medication and see if this works for you.

According to a recent clinical trial published in the American Journal of Gastroenterology, deep-breathing exercises can help those suffering from mild GERD. Regular breathing exercises are believed to build stronger muscles of the diaphragm, preventing acid flowing up into the esophagus.
Researchers from the Medical University Graz, in Austria, studied 19 men and women who suffered from frequent heartburn. Half of the group carried out abdominal breathing exercises for 30 minutes each day. The other half carried on as normal with their medication.  It was found the first half of the group, the ones exercising, found a reduction in the amount of acid flowing up into the esophagus. This was measured by using a tiny catheter threaded through the nose and into the esophagus.
The other half of the group, using medications, were then instructed to do the deep-breathing exercises, too. After 9 months, they suffered from less acid reflux, as well as using less medication.
It is difficult to make the time to exercise in a hectic day. Only 11 out of the 19 participants stuck with the exercises. Some revealed they would rather just take the medicine, while others revealed they were simply too lazy to exercise.
Simply incorporating some breathing exercise into your day can reduce heartburn, so give it try! If not, make an appointment at the Houston Heartburn and Reflux Center to talk about how to handle your heartburn.

#### Can Chewing Tobacco Cause Heartburn?
Smokeless Tobacco and Heartburn
A number of studies have implicated cigarette smoking as an etiological factor for acid reflux and heartburn. Nicotine relaxes the lower esophageal sphincter favoring acid reflux. Furthermore, smoking reduces saliva production. Saliva is rich in bicarbonates and help neutralize acid. Chewing tobacco is a type of smokeless tobacco commonly used in Houston, TX. Unlike smoking, chewing tobacco delivers a constant dose of nicotine into the blood stream. Constant nicotine action on the lower esophageal sphincter may further exacerbate acid reflux and heartburn compared to cigarette smoking. Acid reflux pathogenesis, however, is more complicated than lower esophageal sphincter pressure. Nicotine may affect gastric fundus relaxation and motility leading to either reduction or exacerbation of acid reflux. There are limited studies in the literature examining the effect of chewing tobacco on acid reflux. One study published in the Scandinavian Journal of Gastroenterology and published in 2017 shows a reduction in GERD related symptoms in daily users of Snus. Snus is a form of smokeless tobacco product commonly produced and used in Sweden.
So, does chewing tobacco cause heartburn?
The answer is not clear. Tobacco products of any kind have deleterious effects on your health beyond heartburn and acid reflux. The combination of tobacco use and acid reflux increases the incidence of Barrett’s esophagus and esophageal cancer. Smoking and tobacco chewing cessation are strongly recommended by Houston Heartburn and Reflux Center. If you are a smoker or if you chew tobacco and you are currently experiencing heartburn, we recommend evaluation by an experienced reflux specialist.

#### Can COVID Infection Cause Gastroparesis?
A small number of gastroparesis cases have been reported after presumed viral illness. Patients developed nausea, vomiting, and bloating immediately or several months after onset of viral infection. Gastric emptying study confirms delayed gastric emptying or gastroparesis. Management relies on pro-motility and anti-nausea medications. However, when symptoms persist, an antrum preserving partial gastrectomy is indicated to restore normal gastric emptying and improve quality of life.
Since the onset of COVID-19 pandemic, we have encountered one case of gastroparesis flare-up and one case of new onset gastroparesis and esophageal dysmotility immediately following COVID-19 infection.
The first case is a 22-year-old female with a 4-year history of idiopathic gastroparesis managed with medications. The patient developed acute onset cough, sore throat, and shortness of breath. She tested positive for COVID-19. She concomitantly experienced worsening nausea, vomiting, and abdominal pain. She was initially managed at home, but her respiratory symptoms got worse, and she was admitted to hospital. For 6 months, the patient struggled with worsening nausea and vomiting despite the resolution of her respiratory symptoms. Repeat gastric emptying study confirmed worsening gastroparesis. The patient’s inability to tolerate regular diet and significant weight loss necessitated placement of a feeding tube. Upon presentation to Houston Heartburn and reflux Center, the patient was dependent on tube feeding and narcotics for abdominal pain control. Her weight has stabilized, and she was tolerating a minimal amount of soft food.
The patient underwent an antrum preserving longitudinal gastrectomy with no complications. Her recovery was fast, and her gastroparesis symptoms resolved immediately following surgery. Repeat gastric emptying study 2 months after surgery showed normal gastric emptying rate.
The second case is a 63-year-old female who presented with new onset difficulty swallowing, bloating, nausea, and dry heaving 2 years after hiatal hernia repair and Nissen fundoplication. Patient concomitantly developed these symptoms along with high fever, sore throat, and cough. She tested positive for COVID. She was managed conservatively at home. In two weeks, her viral infection and respiratory symptoms resolved. Nausea, bloating, early satiety, and difficulty swallowing persisted. Upper endoscopy showed intact Nissen fundoplication and no evidence of recurrent hiatal hernia or acid reflux. Gastric emptying study revealed delayed gastric emptying. Manometry was ordered. The patient was started on Reglan and gastroparesis friendly diet. We think COVID-19 infection damaged esophageal and stomach nerves, leading to decreased motility. We don’t know yet whether this damage is transient or permanent.

#### Can Distal Esophageal Narrowing Be A Solution For GERD?
In 1979 Jean Pierre Angelchick developed a doughnut-like prosthesis made of nylon and filled with silicone gel. He assumed that the device, when placed around the distal esophagus, would prevent GERD by reinforcing the lower esophageal sphincter, LES. Around 30,000 devices were implanted around the world before the Angelchick band was discontinued.  The Angelchick device caused dysphagia, erosion and most importantly, it failed to control reflux.
Gastroesophageal reflux disease is a complex multifactorial problem. Our understanding of GERD pathophysiology is still limited. The human mind tends to find and adopt common sense explanations and solutions for complex problems. GERD is a perfect example. Dr. Jean Pierre Angelchick assumed that GERD results from a weak lower esophageal sphincter and sphincter augmentation by a compression device applied externally to the lower esophagus would fix the problem. The lower esophageal sphincter is only one component of a complex structure called the gastro-esophageal junction, GEJ. GEJ is a dynamic structure responding to a myriad of factors like esophageal contractions and gastric fundus relaxation and distention. Lower esophageal sphincter relaxation by itself does not lead to GEJ opening. Esophageal shortening, crural diaphragm inhibition and a positive pressure gradient between stomach and esophagus are also needed. Furthermore, GEJ opening during transient lower esophageal sphincter relaxation (TLESR) events, is only occasionally associated with pH evidence for reflux. In addition, not all reflux events are considered pathologic. “Physiologic” reflux does occur and is considered part of a normal GEJ function. Consequently, other mechanisms, besides TLESR, are at play in GERD pathophysiology. Of course, closing the GEJ will obviously stop reflux completely and by the same mechanism prevent swallowing. The trick to GERD management is restoring the one-way valve at the GEJ that allows for food passage into the stomach while preventing reflux. This is perfectly achieved using the short and floppy Nissen fundoplication. A properly performed 360 degree wrap does not mechanically narrow the distal esophagus. Rather, the newly positioned gastric fundus decreases the incidence of GEJ opening following TLESR events. A floppy Nissen wrap is a physiologic valve rather than a fixed mechanical esophageal constriction. It responds to gastric pressure increases and maintains a positive pressure gradient between the intra-abdominal esophagus and gastric lumen preventing backflow of gastric content and GEJ opening. At the same time, esophageal motility and food bolus passage from the esophagus into the stomach is unhampered. The end result is reflux control without impeding esophageal motility.
Today, there is no other alternative solution that matches the Nissen fundoplication in its efficacy in controlling GERD. Houston Heartburn and Reflux Center is proud to offer the safest, and most effective treatments for GERD.

#### Can Gastritis Cause Acid Reflux?
Jamie from Houston sent us this question: “Hello, I have Gerd for 5 years now, I got the diagnosis after pH bravo testing. PPIs unfortunately don't help that much with my symptoms, I don't have a hiatal hernia, so I'm still not sure what causes my GERD. My manometry was normal, the only thing that was found in my endoscopy was a chronic gastritis type C, so I don't have helicobacter. One doctor told me that the gastritis probably causes my reflux so he wouldn't recommend surgery because it probably wouldn't help, another doctor said chronic gastritis doesn't cause reflux. So, I don't know what to believe or to do now, I don't even know if the gastritis or the GERD started first. I wonder if too much acid production or chronic gastritis causes acid reflux. Can a Nissen fundoplication still help to reduce reflux? Or is it even possible that gastritis can be the only cause for acid reflux?

Dear Jamie,

Gastritis or stomach lining inflammation does not cause acid reflux disease or GERD. Gastritis may co-exist with GERD. H pylori is a common cause for gastritis and H pylori does not cause acid reflux disease. Smoking, stress, and daily use of non-steroidal anti-inflammatory drugs, NSAIDs, can also cause gastritis without having any effect on acid reflux.

A weak anti-reflux barrier results in stomach acid backwash into esophagus. Specialized stomach lining cells secretes acid to digest food. Stomach acid levels are tightly regulated, and stomach acid level is not elevated in GERD cases. Most acid reflux patients have a hiatal hernia. However, hiatal hernia is not necessarily a cause of acid reflux disease. There is a difference between cause and association. Indeed, many individuals have a hiatal hernia, but they don’t have acid reflux. Hence, you can have severe acid reflux in the setting of a small hiatal hernia not appreciated by you gastroenterologist on upper endoscopy. By the same token, you can have a normal manometry in the setting of GERD. Manometry is not a diagnostic test for GERD. Ambulatory pH testing, pH Bravo, measures the amount of acid in your esophagus over 4 days. A positive pH bravo study confirms GERD.

Nissen fundoplication restores the anti-reflux barrier. When properly performed, Nissen fundoplication reliably and safely stops acid reflux. Hiatal hernia repair is concomitantly performed with Nissen fundoplication. Hiatal hernia repair restores normal anatomy by repositioning the stomach and lower esophageal sphincter in the abdominal cavity below your diaphragm or breathing muscle. Hiatal hernia repair, however, does not restore normal anti-reflux physiology. Consequently, if you have severe acid reflux symptoms in the setting of positive pH bravo study and small or no hiatal hernia, you can greatly benefit from Nissen fundoplication surgery to stop acid reflux.

#### Can I Have LINX™ Surgery for GERD and Gastroparesis?
Andrea from Cypress, TX sent us this question: “I have a sliding hiatal hernia and acid reflux. My surgeon wants to repair my hiatal hernia and add LINX™ metal ring for severe acid reflux. I am concerned about LINX™ safety. I already have gastroparesis and my vagus nerve has already been damaged. Should I even consider this surgery?”
Dear Andrea,
Nissen fundoplication and hiatal hernia repair is a more reliable treatment for acid reflux disease when compared to LINX™ device placement. In addition, fundoplication surgery promotes gastric emptying. Therefore, in cases of concomitant GERD and gastroparesis, I recommend Nissen fundoplication over LINX™ device implantation. I have treated several LINX™ patients who presented to my office with gastroparesis after LINX™ implant surgery. Corrective surgery entailed LINX™ device removal, and conversion to Nissen fundoplication. A concomitant partial gastrectomy is added depending on the severity of gastroparesis.
For mild gastroparesis cases, Nissen fundoplication surgery is enough to cure GERD and gastroparesis. For moderate or severe gastroparesis, I add a partial gastrectomy along the greater curvature to further promote gastric emptying. I have had great success using this approach.

#### Can I Vomit after Nissen Fundoplication?
Kristina sent us this question: “How effective are partial fundoplications? I have a 3 cm sliding hiatal hernia. I’m concerned about the inability to vomit with Nissen fundoplication?”
Dear Kristina,
Partial fundoplication also known as Toupet fundoplication is as effective as Nissen or 360-degree fundoplication in terms of acid reflux control. Fundoplication surgery, partial or full, creates a one-way valve; Food gets inside the stomach, but stomach content cannot reflux back into esophagus. Consequently, both Nissen and Toupet fundoplications prevent vomiting.
So, what happens if you get food poisoning or catch a stomach bug? You will dry heave and feel nauseated, but you will not vomit. Instead, your stomach will empty its content downward into intestines. You may develop diarrhea as your intestines are flushing the bug out. You will not feel any additional discomfort or pain because you cannot vomit in the setting of Nissen or Toupet fundoplication.
At Houston Heartburn and Reflux Center, Nissen fundoplication is offered to most of our acid reflux patients. Nissen fundoplication is the gold standard treatment for acid reflux. A properly performed Nissen fundoplication, in expert hands, is durable, effective, reliable, and safe. Toupet Fundoplication is only used when patient has poor esophageal motility on manometry testing. In rare cases, gastric fundus is too small to construct a floppy Nissen fundoplication and a partial wrap is offered instead.

#### Can the Heat Make Heartburn Worse?
The thought of long summer nights, filled with yummy foods, drinks and BBQ’s can get anyone excited! However, according to the National Heartburn Alliance, the 50 million Americans suffering from heartburn, experience worse symptoms during the summer months.

There couldn’t be a worse time than summer to experience heartburn. Even if you make sure to eat the right foods, the blaring heat alone may trigger your heartburn. Here are a few findings from a study carried out by Wakefield Research, for Proctor & Gamble, the company which brings us Prilosec OTC:

46% of Americans suffering from frequent heartburn identified summer as the time of year where they experience the most heartburn symptoms.
63% revealed their symptoms interfered with them being able to have fun and enjoy the BBQ season.
75% of sufferers revealed it would be worse if they forgot their heartburn medication over sun block when going on vacation.
75% sadly said their heartburn has inconvenienced friends and family.
1 in 3 admitted to purposely avoiding a BBQ because of their heartburn symptoms.
60% of sufferers had to adjust plans when on vacation because of heartburn.
78% of Americans suffering heartburn said they have been held back from doing what they love most due to regular heartburn symptoms. Events such as happy hour, family parties and sporting events were all on the list!

How do I stop heartburn ruining my summer?
Letting heartburn stop you in you tracks of having fun and spending time with loved ones, shouldn’t be the case. Don’t let this condition stop you from living your daily life.
Be sure to avoid the common heartburn triggers:

Caffeine – coffee and soda
Chocolate
Tomato based products
Spices

Make sure you maintain a healthy lifestyle and exercise. Obesity is a major trigger for heartburn, as excess weight can put pressure on your stomach, pushing acid up into the esophagus.
If you are a smoker, summer can be the best time to quit. Smoking relaxes the valve at the top of the stomach, allowing a flow of acid into your esophagus.
The staff at Houston Heartburn and Reflux Center are here to help in solving your summer heartburn problems. Make an appointment today, and start enjoying the summer while it lasts!
 

#### Can Vinegar Help Your Heartburn?
It’s National Vinegar Day and what better way to celebrate than to drink a drop of vinegar to help ease that burning pain. There are many types of vinegar; however, apple cider vinegar has been known to help with heartburn.

Even though heartburn is caused by excess acid in the stomach making its way into the esophagus, some acid is still needed in the stomach in order for it to function correctly. There are some theories as to how apple cider vinegar can help with heartburn:

The acidity in the vinegar is believed to help break down the fats in the stomach.
The acid can help with balancing acid production in the stomach. Acetic is the main component of apple cider vinegar and is weaker acid than hydrochloric acid, the acid produced by our stomachs.

Whether it works one way or the other, apple cider vinegar has been used as a home remedy for acid reflux successfully.
How to take apple cider vinegar
Simply mix 1 or 2 teaspoons in 8oz of water and drink before a meal or when you feel heartburn. You can even take it on its own. The only way to find out is by trial and error.
However, there are some possible side effects of using this vinegar to ease heartburn:

Damaged tooth enamel – the acid is highly acidic, which can damage your teeth. Drink with a straw to avoid the vinegar touching your teeth and rinse your mouth after.
Interference with medications – laxatives, diabetes drugs, and heart disease medications.
Aggravate ulcers – the acidity from the vinegar can actually worsen your stomach ulcer.

As a home remedy for heartburn, apple cider vinegar gets some good reviews. However, if you’re suffering from major heartburn and nothing is helping, contact Houston Heartburn today and let our specialist take a look.

#### Can Your Beverage Cause Your Heartburn?
We all know the common trigger foods that cause heartburn, from fried foods to spicy foods. However, did you know there are certain drinks you could be drinking that are causing your heartburn more easily than some of the common food triggers?

Coffee, carbonated drinks, and alcohol are the major heartburn triggers. Kevin Ghassemi, a gastroenterologist at the University of California, Los Angeles, mentions alcohol directly has an effect on your stomach and causes heartburn. The esophageal sphincter’s function is to keep food and beverages in the stomach. The sphincter is to remain closed expect when food passes down the esophagus into the stomach. However, alcohol can relax the sphincter and create an opening, causing acid to be pushed back up into the throat causing heartburn.

The same goes for coffee, as the caffeine can cause the same problem as alcohol does.
With summer in full swing – parties, BBQs, and family gatherings, cutting back on alcohol and sodas may be difficult. Cutting your usual morning cup of coffee may not sound like the best way to start your day either. Gradually reducing can help. Here are some alternative beverages that are “heartburn friendly” you can try instead:

Non-citrus juices, such as apple juice
Water
Decaffeinated, non-mint herbal teas, such as green tea

To prevent heartburn, it is advised to drink small amounts of water to stop your stomach from over working, as this will create excess acid in your stomach.
If you have already tried to cut these addictive beverages, and nothing has helped, or you simply can’t live without your morning cup of coffee, make an appointment with Dr. Darido today to start a life without heartburn.
 

#### Case of the Week: GERD, Silent Reflux and Laryngospasm
A 62 year-old male presented to my office this past week with a 12 year history of recurrent attacks of shortness of breath, chest tightness, wheezing and difficulty breathing. The patient has been diagnosed with COPD. He has never smoked or been exposed to harmful gas or fumes. For years he has been treated with multiple inhalers as well as steroids to control his lung disease. Secondary to steroids he has gained around 50 pounds, has developed central obesity, hypertension and became insulin resistance. He has received many antibiotic treatments for pneumonia and bronchitis. On average, he has received an antibiotic/steroid treatment every 6 to 7 weeks over the past 12 years. Concomitantly, the patient suffers from GERD with occasional heartburn and food regurgitation and silent reflux related symptoms like chronic sore throat, hoarseness and cough. He has recently been diagnosed with Barrett’s esophagus and is currently maintained on Dexilant and Famotidine. Recently, his gastroenterologist has recommended LINX™ procedure for GERD treatment.
This case is particularly interesting for several reasons:

The patient suffers from laryngospasm or laryngeal stridor that is easily heard on physical exam and reported by the patient himself. While he may have some distal bronchiolar involvement it is obvious that his main airway problem is more proximal and involves the trachea and larynx. There are very few causes of laryngospasm in a 62 year-old male.
The underlying cause of all these symptoms is GERD. Yet not a single physician including his primary care physician, gastroenterologist and pulmonary specialist has made this connection. They labeled the patient with COPD and treated him with steroids and antibiotics for twelve years, and masked his heartburn with proton pump inhibitors and H2 receptor blockers. Silent reflux and GERD for many physicians seems like a nuisance rather than a true medical problem. No one wants to give it any serious attention or make the effort to understand it, diagnose it and properly treat it. For twelve years a Band-Aid was placed over the patient’s symptoms
Silent reflux causes Barrett’s esophagus and proton pump inhibitors do not protect the esophagus and prevent the development of Barrett’s metaplasia. Gastric juice contains many other substances like bile acids and pepsin besides acid that can damage the delicate esophageal and laryngeal lining. Proton pump inhibitors are clearly not the gold standard of GERD treatment. For GERD is not a state of acid hypersecretion but rather a condition of gastric juice reflux into the esophagus, throat, voice box and lungs.
Nissen surgery is the most reliable and durable treatment for GERD. Nissen procedure recreates the barrier against reflux keeping gastric juice in the stomach. There is no role for LINX™ surgery in this severe GERD case. There are no data on the long-term efficiency of LINX™ procedure in the setting of Barrett’s esophagus. LINX™ may actually exacerbate Barrett’s esophagus and laryngeal symptoms by delaying esophageal clearance of gastric juice. I wholeheartedly invite my gastroenterology colleagues to look closely at the complexity of GERD, its underlying pathophysiology and conclude that a stricture made of magnetic beads is not a treatment for a complex multifactorial problem like GERD.

This patient will finally undergo the treatment that he deserves: a laparoscopic Nissen fundoplication with hiatal hernia repair after weaning his steroids and optimizing his cardio-pulmonary status in preparation for general anesthesia. I hope that the laryngeal damage that he has suffered from over the past 12 years is still reversible after stopping gastric juice reflux into his esophagus.

#### Case of The Week: Perfect TIF - Severe Reflux
Nissen fundoplication surgery is the gold standard treatment for acid reflux disease or GERD. Dr. Nissen first introduced the procedure more than 50 years ago. He astutely observed that by wrapping the gastric fundus around the distal esophagus acid reflux resolved. Interestingly, the first case Dr. Nissen performed was following a distal esophagectomy. The wrap worked independent of the presence of a lower esophageal sphincter. Indeed, Nissen surgery offers a different level of acid reflux control independent of lower esophageal sphincter. The surgery has been extensively studied and perfected over time. A key component to the success of Nissen fundoplication is the adequate mobilization of the gastric fundus. The gastric fundus is a posterior structure that constitutes the upper part of the stomach. It is attached to blood vessels and adjacent structures. During surgery the gastric fundus is completely released and mobilized to serve as a floppy wrap around the esophagus. Failure to do so results in a poorly constructed fundoplication with several side effects like dysphagia and bloating as well as poor long-term acid reflux control. How does gastric fundus wrapping around the esophagus stop acid reflux is not fully understood. One thing for sure, mobilizing the gastric fundus and changing its position relative to the gastro-esophageal junction is key to anti-reflux surgery.
Bunching up some gastric tissue around the lower esophagus using an endoscope, also called TIF (Transoral Incisionless Fundoplication) is not a Nissen fundoplication by any stretch of the imagination. Yet, the procedure has been developed, labeled and advertised as a fundoplication for treatment of GERD.
A 42-year-old female patient presented to my office with longstanding history of GERD related symptoms including heartburn and food regurgitation. She underwent TIF procedure in 2012 with absolutely no symptom improvement. She therefore continued daily PPI therapy and bedtime Zantac. She reports multiple breakthrough symptoms like coughing, throat clearing, and heartburn. She suffers from weekly nocturnal symptoms preventing her from sleeping. She denies dysphagia but reports bloating. An upper endoscopy showed no hiatal hernia, and bunched up gastric tissue around the distal esophagus with some pledgets sticking out of the mucosa. Ambulatory pH testing showed evidence of severe acid reflux with elevated DeMeester score.
Decision was made to convert TIF to Nissen to cure GERD. Luckily, the patient had minimal intra-abdominal adhesions. She tolerated the procedure with no complications. Postoperatively, all GERD related symptoms resolved.
I don’t want to make a guideline from this single case. However, I have serious doubts about TIF as a reasonable solution for GERD. Does it work like a Nissen? Is it durable and reliable? The answer in my opinion is NO.

#### Case of the Week: Recurrent Gastroparesis Symptoms
Jane is a pleasant 51-year-old female with history of idiopathic gastroparesis diagnosed in 2008. She underwent a subtotal gastrectomy with Billroth 2 gastrojejunostomy and insertion of feeding tube jejunostomy in 2009. Post-operatively the patient had difficulty tolerating per-oral diet for about 5 months. She was placed on Reglan and erythromycin and maintained on tube feeding. After 5 months she improved, and her PO diet was successfully advanced to regular. Patient continued to do well for about 8 years. In 2016 she started experiencing epigastric pain, abdominal fullness and bloating as well as a burning sensation extending from the epigastrium to the throat level. An upper endoscopy was performed, and patient was found to have a friable and inflamed gastric mucosa as well as an irregular Z line. She was diagnosed with bile gastritis and decision was made to convert her B II gastrojejunostomy to Roux-en-Y gastric bypass. The gastric bypass was done laparoscopically, and patient recovered without complications. Her symptoms however did not improve. She continued to have the same burning sensation, constant bloating exacerbated by food intake and epigastric pain. She denies vomiting or food regurgitation. When she presented to my office, she was maintained on high dose PPIs, Ranitidine, Carafate, Domperidone, and Welchol.
The patient may have had an element bile gastritis, but her symptoms were most likely due to recurrent gastroparesis. I have no explanation for the initial improvement in in her gastroparesis symptoms 5 months after subtotal gastrectomy. She has most likely developed a duodenal pacemaker to drive intestinal motility. For unknown reasons, the pacemaker failed after several years and her gastroparesis symptoms (fullness, pain and burning sensation) recurred. Bile gastritis may cause a similar symptom profile, but bile gastritis, unlike gastroparesis, responds very well to a Roux-en-Y gastric bypass. Jane did not respond to gastric bypass. She most likely has recurrent gastroparesis symptoms and in the absence of a stomach there is very little I can do from a surgical point of view. This particular case demonstrates one more time that gastric bypass surgery is not a solution for gastroparesis. Subtotal gastrectomy is not an option either. The stomach antrum and lesser curvature must be preserved in gastroparesis. After resecting the greater curvature above the antrum, gastric motility improves. I have performed this procedure on a dozen of severe gastroparesis patients with 100% success rate. An antrum based gastric pacemaker restores normal gastric emptying and results in complete symptom resolution. Resecting the antrum in a subtotal gastrectomy burns an important bridge for treatment of gastroparesis. Of note, the burning sensation extending from the epigastric area to the mouth is not uncommon in gastroparesis patient. It is not secondary to acid reflux and is different from heartburn. Patients typically report a burning sensation in the oral cavity that may involve the lips sometimes that does not respond to acid suppressant medication. This sensation, in addition to pain, are likely secondary to sensory abnormalities involving the gastro-intestinal sensory neurons.

#### Chest pain after Toupet Fundoplication
Michael from Pasadena sent us this question: “I had a Toupet fundoplication for severe acid reflux. I had no acid reflux for 5 days then the flood gate opened, severe chest pain beneath sternum, and burping that last 8-10 seconds all day long.  All these symptoms are new. Did a barium study and they say wrap is intact? What should I do?
Dear Michael,
Severe chest pain beneath the sternum five days after Toupet fundoplication is not normal. It may indicate wrap failure, recurrent hiatal hernia, and recurrent acid reflux. In this case one would expect other symptoms to occur too like heartburn and food regurgitation. A barium swallow is not the best test to check for wrap integrity. Upper endoscopy is a more sensitive test. The wrap may be twisted or slipped. A recurrent hiatal hernia involving the posterior aspect of gastric fundus may also occur resulting in chest pain.
If anatomy is intact, a pH bravo capsule can be placed during endoscopy to measure esophageal acid exposure.
Other causes for chest pain after fundoplication include esophageal spasm. Manometry is a test we commonly use prior to fundoplication surgery to check for esophageal contractions and sphincter pressure.
Of course, other organs in the chest like the heart may cause chest pain. I recommend you get thoroughly evaluated by your surgeon to help identify the cause of your symptoms.
To summarize, a properly performed hiatal hernia repair and Nissen or Toupet fundoplication is associated with very little discomfort after surgery as well as fast recovery. Severe chest pain after Toupet fundoplication is not normal and thorough evaluation by expert acid reflux specialist is recommended.

#### Chest Pain Two Years Following LINX™ Surgery
The case of the week is a 40-year-old male with chest pain and discomfort 2 years after LINX™ placement. The patient underwent LINX™ surgery for symptomatic GERD poorly responsive to proton pump inhibitor therapy. He had significant food regurgitation and daily heartburn. Concomitantly, he had symptomatic biliary dyskinesia confirmed by HIDA scan. He had an uneventful laparoscopic cholecystectomy and LINX™ procedure. His abdominal pain and GERD related symptoms have resolved following surgery and he was happy with the outcome of his surgical intervention. Two years later, he started developing chronic chest pain and discomfort worse with sitting and not related to activity or food intake. He started having occasional heartburn attacks but denied any significant food regurgitation. He went back to the surgeon who placed the LINX™ device and underwent upper endoscopy and a barium swallow. Both studies were unremarkable and the surgeon reassured him. He was then referred to a gastroenterologist who performed an esophageal manometry and gastric emptying study and both studies were normal too. Patient however continued to suffer from his chest pain and presented to Houston Heartburn and reflux Center for a second opinion.
Upon presentation the patient has been having chest pain and discomfort for approximately one year. He has lost around 80 pounds due to lack of appetite secondary to pain. He denied cough, sore throat and hoarseness. He had no food regurgitation and no dysphagia. I decided to perform a video esophagogram to evaluate his esophagus and contrast movement across the gastro-esophageal junction. I use thin Barium for these studies. It was evident from the first few swallows that the esophagus was struggling to move contrast across the LINX™ device into the stomach. Multiple tertiary esophageal contractions can be seen as well as delayed contrast movement requiring several dry swallows to clear the esophagus. Consequently, an esophageal impedance manometry was performed to further elucidate esophageal motility. Interestingly, the study was almost normal except for incomplete bolus clearance on most swallows. The Lower esophageal sphincter pressure was slightly low. The contractile wave amplitude, peristalsis and intra-bolus pressure were within normal.
The genesis of chest pain and discomfort in this particular case may be attributable to esophageal wall strain activating tension-sensitive afferent nerves in the submucosa and muscularis propria. Pain due to esophageal spasm immediately following LINX™ placement has been reported. LINX™ device removal several years after implantation for chest pain has also been reported. Asti et al have published a study in Annals of Surgery titled “Removal of the Magnetic Sphincter Augmentation Device: Surgical Technique and Results of a Single Center Cohort Study”. The study followed 164 LINX™ patients over 4 years and 11 patients, 6.7%, underwent LINX™ explantation. 5 patients had recurrent heartburn and food regurgitation, 4 patients had dysphagia and 2 patients had chest pain. Is it possible that magnetic sphincter augmentation device creates a partial obstruction leading to tertiary esophageal contractions on barium swallow and incomplete bolus clearance on impedance manometry? How common are these findings and is esophageal dysmotility the cause of pain in certain patients?
We still don’t have answers to these important questions. A cause effect relationship between LINX™ surgery and esophageal dysmotility is difficult to establish in this particular case but is highly suspected. LINX™ device removal and conversion to a short floppy Nissen fundoplication is probably the only option left for this patient.

#### Chronic Cough and Acid Reflux
Cindy from Houston sent us this question: “Starting almost 6 months ago, I developed a persistent cough and at times had difficulty catching my breath. This would happen during day and night. I first was diagnosed with reflux. I then had an upper GI and told no reflux, but chronic inflammation, but was prescribed generic Protonix which caused me to cough up creamy white substance. Three months into this current ordeal, I was diagnosed with pertussis verified by 3 different types of immune globulin. I continued having pain and coughing specifically in vocal cord area. I saw an otolaryngologist who diagnosed paradoxical vocal cord motion disorder. He said to continue treating for reflux, taking Prilosec and Pepcid as needed. I didn’t feel I needed them and only took either maybe once or twice a week. 5 months into this, I had followed up with GI provider. I had been having continued inflammation in my throat, roof of mouth, inflamed tongue, uvula, and deep in throat. This very disturbing discomfort and pain seemed to move around and caused a very thick clear, tenacious, stringy mucus/substance, almost consistency of jelly at times.  I didn’t know if this was from the continued inflammatory response from pertussis or gastric reflux. I asked the GI doctor and he prescribed Omeprazole 20 mg to be taken before twice each day before morning meal and noon meal and also famotidine 40 mg every bedtime. He said to take this all for a month. I thought too much and took one Prilosec in morning and half of famotidine (20 mg) at bedtime. I did this faithfully for two weeks but then I actually did start having reflux up into throat when sleeping, first time this had happened, and so I figured the meds were making things worse for me. I also was having stomach/abdominal pains, generalized bloating, nausea, no appetite and slowed motility causing constipation and feeling like I was blocked up. I quit taking the Prilosec but continued the famotidine at 20 mg at bedtime for few nights and then now have cut down to 10 mg of famotidine at night and taking Mylanta as needed instead. My problem is I still am having trouble with my GI tract not working. It’s been about two weeks since I stopped Prilosec. I want to quit famotidine too and just take Mylanta as needed. I was so bloated up yesterday and seems like bowels not working. I had a ruptured diverticula un my early 40s with partial colectomy and colostomy and subsequent reversal. I have been careful with diet since but taking this Prilosec has seemed to really mess up my digestion and I hope I can get this reversed. I usually take one Metamucil capsule each day for bowel health, but I’m not sure if that is helping or hurting right now while trying to get over effects of Prilosec”.
Dear Cindy,
Cough has many causes and acid reflux is one of them. The diagnosis of acid reflux may be challenging. However, a competent acid reflux specialist in Houston can help you get the answers you need. Indeed, a certain level of expertise is required to properly evaluate and effectively manage patients with chronic cough. If acid reflux is the cause of your symptoms, several effective solutions are available to help alleviate your symptoms and improve your quality of life.
At Houston Heartburn and Reflux Center, we offer state of the art acid reflux testing. We strongly believe that patient testing is the first important step towards cure. We aim at confidently confirming the diagnosis of acid reflux and staging GERD. Accordingly, an effective and safe solution is tailored to alleviate acid reflux related symptoms like cough, sore throat, and globus.
Blindly prescribing medications at different dosages is not a practice we advocate for treatment of cough related acid reflux. PPIs reduce gastric acid secretion, but these medications do not stop reflux. Heartburn may respond to PPIs but cough is less likely to resolve unless you re-establish the anti-reflux barrier.
The most effective and reliable solution to re-establishing the acid reflux barrier is hiatal hernia repair and Nissen fundoplication. This minimally invasive procedure has a very high success rate and low complication rate. When properly performed, acid reflux patients report a very high satisfaction rate.

#### Chronic Cough, Throat Clearing, and Hoarse Voice: Are these symptoms related to acid reflux?
Laryngo-pharyngeal reflux (LPR), also known as silent GERD, occurs when acid reflux reaches the throat area and sometimes the back of the nasal airways. Patients with LPR often complain of sore throat, hoarse voice, throat clearing and dry cough, bitter or sour taste, difficulty swallowing, and a sensation of drainage from the back of the nose. Interestingly, most patients with LPR do not experience heartburn that is typically associated with GERD.

LPR or silent GERD is typically mistaken for other diseases like common cold, allergic rhinitis or sinusitis, laryngitis and sometimes asthma. Many patients with silent reflux go through life not feeling 100% right. A few weeks ago, Dr. Darido encountered a patient that has been diagnosed with asthma since the age of 15. He was recently treated with high dose steroids for 6 weeks for severe laryngitis. He has had a hoarse voice and recurrent nighttime cough for the past 30 years of his life. A throat examination by an ENT specialist showed an ulcer and inflammation in the voice box. All findings pointed to one cause: acid reflux. An upper endoscopy showed inflammation throughout the esophagus. After a complete evaluation, the patient underwent Nissen fundoplication surgery. For the first time in his life, he feels normal. The cough disappeared, and he can sleep at night without waking up every hour to clear his throat. He is off all medications he was taking for asthma and allergies. His voice has improved and his throat does not heart anymore.
Silent reflux is a precursor of esophageal cancer, the fastest growing cancer in America. It is crucial to recognize your symptoms and seek help from a qualified GERD expert. Any patient with silent LPR symptoms deserves an endoscopic evaluation of the larynx and esophagus. At Houston Heartburn and Reflux Center, we offer effective and minimally invasive solutions for silent reflux.

#### Chronic Sinusitis, Balloon Sinuplasty and GERD
Patients with acid reflux or GERD are at increased risk of chronic rhinitis and sinusitis. Gastric content refluxate travels up the esophagus into the throat area. There, acid, bile and possibly pepsin irritate the sensitive lining, or mucous membranes, of the nose. Chronic irritation leads to chronic inflammation which results in thickening mucous membranes and increased mucous production. When excess mucous builds up, patient feels congested. Breathing through the nose becomes difficult and patients report feeling blocked. Furthermore, sinus drainage into nasal cavity through tiny opening in the mucous membranes is hampered. This further increases congestion, post nasal drip, cough, globus, hoarseness and throat clearing.
Patients in Houston who present with chronic rhinosinusitis symptoms are typically assumed to have allergy as the cause of their symptoms. Treatment consists of saline nasal sprays, decongestants, and all sorts of allergy medications. Most of these medications can be obtained over the counter. Patients whose symptoms persist are referred to an allergy specialist. Allergy specialist preferred treatment consists of repetitive allergy shots given over a long period of time. However, if reflux is the root cause of the problem, allergy treatment is not likely to benefit patients. At some point in time, the reflux patient struggling with chronic rhinosinusitis is referred to an ENT physician. ENT or ear, throat and nose specialists offer balloon sinuplasty to unblock sinuses and facilitate drainage. The procedure is a safe, minimally invasive and does not require anesthesia or hospital stay. During a balloon sinuplasty, a small balloon catheter is inserted through the nose and into the sinuses. The balloon is inflated to enlarge the sinus opening and facilitate sinus drainage. The procedure is effective in alleviating symptoms but once again the root cause of the problem, reflux, is missed and not addressed. Consequently, several months after balloon sinuplasty, sinusitis symptoms recur.
If you struggle with cough, hoarseness, globus, sore throat, bad breath, constant throat clearing, postnasal drip and chronic rhinosinusitis consider acid reflux as a potentially curable cause for your symptoms. A properly performed hiatal hernia repair and Nissen fundoplication eliminates acid reflux. Once you stop gastric content from reaching your throat, chronic inflammation subsides, and healing begins. This approach to chronic rhinosinusitis is a cure that targets the root cause of the problem. Allergy medications like decongestants and procedures like balloon sinuplasty are a temporary solution for reflux induced rhinosinusitis.

#### Contraindications for Nissen Fundoplication Surgery
Rick from Houston Sent us this question: “Hello, I just got my results back from esophageal manometry test and my acid reflux specialist said I have almost no motility. He said it’s like being gravity fed into my stomach. He also told me that I was not a candidate for a fundoplication surgery. I have mild esophagitis and cannot seem to get rid of it, I am burning up every day. Is there anything that can be done?
Dear Rick,
Thank you for submitting this interesting question to Houston Heartburn and Reflux Center. Proper work up and diagnosis prior to Nissen fundoplication surgery is crucial to any heartburn surgery success. Manometry is one of the tests we routinely perform at Houston Heartburn and Reflux Center prior to Nissen fundoplication surgery. The purpose of this test is first to rule out esophageal motility disorders like achalasia that require a different surgical treatment than GERD. Achalasia is a rare esophageal motility disorder characterized by lack of esophageal peristalsis. Patient may present with constant heartburn mimicking acid reflux disease. The treatment for achalasia is different from that of GERD and Nissen fundoplication is contraindicated in the setting of achalasia. Second, manometry measures esophageal contractions and help us differentiate between normal and weak or ineffective motility. Patients with very weak motility, you’re your case most likely, present a relative contraindication for Nissen or 360-degree fundoplication and are better served with partial or Toupet fundoplication. Partial fundoplication is believed to be associated with a lower post-operative dysphagia rate. I personally prefer to offer a loose two stitch Nissen fundoplication in cases of weak motility. I have found over the years and after performing hundreds of anti-reflux surgery that a floppy two stitch Nissen fundoplication creates minimal resistance to esophageal emptying and is associated with a very low post-operative dysphagia rate. Scleroderma patients with zero motility may still benefit from partial fundoplication or in case they are obese a gastric bypass is offered.
In my opinion, Rick, you still have many options. I recommend you consult with an expert acid reflux specialist to complete your acid reflux evaluation and find the best heartburn solution that fits your particular condition to achieve the best outcome possible. Hope this brief synopsis helps.
Best,
Dr. Darido.

#### Cough and sore throat: Cold, Flu or Acid Reflux?
The recent sudden temperature drop in Houston ushers the beginning of Cold and Flu season. Sore throat, cough, congestion are common symptoms that most of us associate with viral upper respiratory tract infections. Silent reflux, however, also known as laryngopharyngeal reflux or LPR causes similar symptoms. Gastric content reflux including acid, bile and digestive enzymes like Pepsin are believed to occur in LPR. As a result, mucosal inflammation of throat, vocal cords and nasal passages develop mimicking a viral infection. While Cold and Flu symptoms are seasonal, LPR causes chronic hoarseness, congestion, cough and constant throat clearing. Most LPR patients presenting to Houston Heartburn and Reflux Center have already underwent balloon sinuplasty for chronic sinusitis. Chronic LPR induced mucosal inflammation blocks sinus drainage and results in chronic sinusitis. Silent reflux patients typically report transient relief with balloon sinuplasty. Symptoms, however, soon recur, since the underlying etiology of sinusitis has not been addressed.
LPR is difficult to diagnose and treat. Ambulatory pH testing is typically negative in LPR patients. Upper endoscopy may reveal a small hiatal hernia and distal esophagitis.  Ambulatory multichannel intraluminal impedance testing may be better suited to LPR testing as it can detect acid, non-acid and gas reflux. In my experience, however, impedance testing for LPR has shown limited sensitivity and negative predictive value. Laryngoscopy performed by ENT physician shows redness and swelling around the voice box and throat. Such findings are not specific to LPR. Salivary pepsin testing is a promising testing modality that still lacks sensitivity and specificity to rule in or rule out LPR.
LPR is commonly treated with high dose PPIs. The response rate varies from patient to patient. PPIs are less likely to neutralize the erosive effect of bile and pepsin on laryngopharyngeal mucosa. The success rate of hiatal hernia repair and Nissen fundoplication is lower in eradicating LPR related symptoms than classic GERD symptoms like heartburn and food regurgitation. Such discrepancy in outcomes may be secondary to irreversible damage to laryngopharyngeal mucosa that persists after stopping reflux. It may also be related to our lack of understanding of LPR pathophysiology as well as the absence of standardized LPR testing and staging.
At Houston Heartburn and Reflux Center, we have helped many patients with chronic cough, adult onset asthma, hoarseness and persistent throat clearing overcome their symptoms. Nissen fundoplication and hiatal hernia repair remains the best treatment for silent reflux. Our success rate in completely eradicating LPR related symptoms is around 80%. The remaining 20% of LPR patients experienced improvement in symptom severity but not complete eradication at 6 months and one year follow up. It would be interesting to re-evaluate patients 5, 10 and 20 years after fundoplication surgery for LPR to check for complete symptom resolution or lack of symptom progression.

#### Cut the Cravings, Cut the Heartburn
Overeating is one of the most common heartburn triggers, especially when overeating foods high in sugar and salt. Here are some healthy alternative foods you can eat that will combat your sweet and salty cravings.

Sunflower seeds – can regulate nerves and muscles and are packed with nutrients.
Air popped popcorn – rather than snacking on salty chips, eating popcorn can actually reduce overeating.
Fruit – a flavorful snack packed with nutrients and fiber. Melons are high in water content and low acidity and berries, such as strawberries and blueberries, are high in fiber and natural sweetness.
Plain frozen yogurt with fresh fruit – less fat than ice cream, but packed with more protein, keeping you fuller for longer. The fruit will add great flavor and vitamins.
Dark chocolate – filled with antioxidants, a small piece of dark chocolate hits the sweet tooth every time.
Whole-wheat pretzels – packed with fiber to help keep you fuller for longer. This will prevent you from overeating on a higher calorie food.
Pistachios – will satisfy your craving for salt. This nut is also packed with more natural antioxidants than other nuts. Peeling each shell will slow down your eating also.
Baked chips – move away from indulging in salty chips and opt for baked chips instead. Much healthier and will satisfy your salt craving.

   
There are lots of alternative foods for all different cravings. Crunchy vegetables, such as carrots and bell peppers, are high in water and will help to suppress your appetite. It’s even more tempting to reach for some carb packed comfort food. Instead of gorging into a big bowl of pasta with tomato sauce, no doubt causing heartburn, turn to the popular high fiber food – oatmeal. It’s not just for breakfast! Rice pudding and applesauce are also good comfort snacks.
Fried foods are another major heartburn trigger. When you are craving something fried, try oven baked, crispy chicken strips instead. Instead of greasy French fries, try the healthier alternative – baked sweet potato fries. This will satisfy your sweet and crunchy cravings, too!
Next time you crave something you shouldn’t be eating, either at a meal or late at night, remember there are a variety of foods that are healthier and will satisfy the same craving you are having. If you are already following these simple steps and still experience heartburn, contact Houston Heartburn to schedule an appointment.

#### Daily Habits to Reduce Heartburn
Popping an antacid to control your heartburn is easy and convenient. In some severe cases, surgery is required. However, making some lifestyle changes and introducing a few daily habits can help reduce your heartburn.
Eat smaller, frequent meals
Eating heavy meals, especially at one time, will add excess pressure to your stomach. This will cause the lower valve to relax, allowing acid to gush through into your esophagus. Instead of the usual three meals per day, try eating a smaller portion at frequent intervals. This will help to control your acidity levels. Remember not to eat your last meal close to bedtime, as this will cause heartburn.
Eliminate certain foods
There is a long list of foods that will trigger heartburn. Spicy foods, caffeine, chocolate, fatty foods, processed foods, tomatoes, butter and citrus fruits are all on the list. Try to avoid these foods throughout the day, as there are always great heartburn free alternatives out there. Switch out a cup of coffee for herbal tea, and instead of eating fries soaked in oil, try homemade fries by baking them instead.
Exercise 
With work and lifestyle stresses, making the time to exercise can be tough. However, incorporating even 30 minutes a day can reduce your chances of heartburn. A 2003 study of more than 10,000 people in the International Journal of Epidemiology found a strong link between GERD symptoms and body mass index (BMI). Excess fat can place more pressure on the stomach, but can also make chemical and hormonal changes, making our bodies more prone to acid reflux.
Avoid happy hour
To avoid your 5pm flare up, avoid alcohol. Alcohol relaxes the lower esophageal sphincter, allowing acid to rush into the esophagus. The more units you drink, the higher the chances are of a flare up.
Don’t wear tight clothes
Especially in the summer, wearing tight clothes can be uncomfortable .Tight clothes can also trigger heartburn! Clothing that is tight around your midsection can push excess acid from your stomach into your esophagus. If you are suffering from heartburn daily, avoid wearing belts, hosiery, waistbands and undergarments that are too tight.
Change how you sleep
Many of us may not realize the position we sleep in can make heartburn worse. To prevent heartburn at night while you sleep, make sure to prop your head up higher to avoid acid lingering in your throat. Use extra pillows or a foam wedge to help you get a heartburn free night of sleep.

If you have changed your lifestyle, and even tried some of these daily habits, but still suffer from heartburn, call the Houston Heartburn and Reflux Center.

#### Demystifying the Role of Hiatal Hernia Repair and Nissen Fundoplication Surgery
There is widespread belief that hiatal hernia repair and Nissen fundoplication are a last resort for GERD patients. Indeed, most primary care physicians and gastroenterologists do not refer a GERD patient for surgery until it is too late. GERD patients are typically subjected to escalating dosages of proton pump inhibitors over many years. While GERD related symptoms like heartburn are masked, giving the patient a false sense of security, the disease is slowly progressing. The hiatal hernia is getting bigger, esophageal motility is deteriorating, esophageal length is shortening and the risk of esophageal cancer is increasing. Furthermore, PPIs are quite ineffective for patients with silent GERD also called LPR (laryngopharyngeal reflux). Most LPR patients have poor symptom control despite high dose PPIs. Uncontrolled LPR results in irreversible vocal cords and upper respiratory tract damage. Such damage causes chronic cough, hoarseness and sometimes COPD.
A more logical approach to GERD is to offer hiatal hernia and Nissen fundoplication surgery early in the disease process especially when patients are young. Young patients have many productive years ahead of them. Masking GERD related symptoms with PPIs does not address the underlying disease pathophysiology and these patients are committed to PPIS for most of their life. Years of PPI use result in early dementia, renal and heart failure, osteoporosis, magnesium deficiency, clostridium difficile colitis, pneumonia…
Laparoscopic hiatal hernia surgery and Nissen fundoplication when performed by an experienced acid reflux specialist, is the safest, most effective, reliable and durable solution for GERD. PPIs are no match to hiatal hernia surgery that restores normal anatomy and Nissen fundoplication that re-establishes normal physiology. The overall morbidity and mortality of the procedure is less than 1%. The recovery is fast and painless. Most patients resume regular activity in less than one week.
The earlier we intervene in a chronic disease like GERD, the more effective the treatment can be and the longer it can last. Don’t wait until it is too late. If you suffer from heartburn and acid reflux call Houston Heartburn and Reflux Center.

#### Diet After Nissen Fundoplication Surgery and Hiatal Hernia Repair
Most patients are concerned about what they can eat after Nissen fundoplication. Immediately after the surgery, swelling around the esophagus prevents you from swallowing regular food. For this reason, for the first two weeks after surgery you will be permitted liquids only. As healing progresses and swelling goes down, you will advance to mechanically soft diet or blended food. For those two weeks, you will consume moist and soft diet before you introduce regular foods.
This nutritional guideline was put together by Dr. Darido to help you make the right dietary choices after surgery. Advancing your diet too fast may lead to complications. The most common complication is food impaction at the lower esophageal sphincter. Retching and dry heaving due to food impaction immediately after surgery may disrupt the wrap. Eat slowly, avoid carbonated beverages, and drink plenty of water to avoid dehydration. Protein shakes are an important source of proteins for healing after surgery. Avoid protein shakes with high sugar content as these may cause dumping. Dumping occurs when too much sugar is emptied fast from stomach into intestines leading to nausea, diarrhea and abdominal discomfort.
DIET GUIDE After Surgery
Week 1 & 2: Liquid Diet
Anything you can pour out of a cup is considered liquid
Day 1: Clear liquid diet:

Water, Crystal light
Clear broth
Jello-O
Tea and coffee
Diluted fruit or vegetable juice
Gatorade

Day 2 and after: Full liquid diet

Blended soups with no chunks (strained pureed soup): Cream of mushroom soup, potato soup
Yogurt: no added fruit chunks
Milk
Pudding
Ice cream
Protein shakes: Premier, Boost, Ensure
Cream of wheat
Apple sauce

Week 3 & 4: Soft Diet

Anything you can blend in a blender is considered mechanically soft diet.
You can also buy a variety of packaged pureed meals.
Scrambled eggs
Pureed meats: chicken, pork, beef or fish
Cottage cheese
Pureed fruits or cooked vegetables
Canned fruits
Mashed potatoes with no skin

Foods to avoid:

Raw vegetables, dried fruits like raisins, nuts and seeds, popcorn, chips, pretzels, and bread.

Week 5 & 6: Solid Diet
Start to gradually add solid foods to your diet. Advance diet as tolerated.
Week 7 & After
Add bread, tough/chewy meats, and stringy vegetables like asparagus

#### Difficulty Swallowing with LINX™ Surgery for Heartburn
Barb from Houston sent us this question: “I had Linx surgery about 9 weeks ago. Yesterday I ate good up to 2:00pm. Then I was not able to swallow. Now today is Sunday and I have the same problem. Able to eat Ritz’s crackers but drinking or eating a meal won’t go down. Will this clear up?
Dear Barb,
Dysphagia or difficulty swallowing after LINX™ surgery is a common problem. It is one of the many reasons I don’t offer LINX™ surgery. I offer Nissen fundoplication surgery as the most reliable treatment for GERD. At Houston Heartburn and Reflux Center, our post Nissen fundoplication dysphagia rate is less than 1%
Dysphagia 2 months after LINX™ placement may not resolve by itself. I strongly recommend you call your surgeon and schedule a consultation. Upper endoscopy with balloon dilation may be required to break down scar tissue formation around LINX™ device. Excessive scar tissue formation narrows the esophagus and causes dysphagia. Other causes of dysphagia include food impaction, esophageal dysmotility, recurrent hiatal hernia and LINX™ device displacement into the chest.
At Houston Heartburn and reflux Center, we advise our patients to contact our center for any question or concern at any point in time after Nissen fundoplication surgery. Prompt expert advice help GERD patients avoid complications after reflux surgery.

#### Do Allergies Cause GERD?
Patients with asthma are twice as likely than the normal population to have GERD (Gastro-esophageal reflux disease). Most patients who suffer from hard-to-treat asthma have acid reflux disease. The esophagus and trachea (wind pipe) are in close proximity. Acid that back flows into the esophagus can reach the trachea. When acid is inhaled from the trachea into the airways, the delicate lining of the bronchioles is irritated. Repeated injury to the airway lining leads to or exacerbates existing asthma.
Another explanation for GERD-induced asthma is that when acid enters the esophagus, a protective nerve reflex is triggered, causing the airways to narrow. Narrowed airways result in cough, wheezing and shortness of breath.
Irrespective of mechanism, if you suffer from asthma and GERD, controlling acid reflux is an important aspect of asthma treatment. This is especially true in certain cases of adult onset asthma. If you have never had asthma or allergy problems in the past, and you now suffer from cough, wheezing and shortness of breath especially after eating or lying down, you may have GERD. Acid reflux can cause asthma-related coughing and wheezing in the absence of heartburn. Before escalating your asthma therapy, get tested for GERD. Request a GERD expert evaluation. There are many treatment solutions for GERD that will effectively control acid reflux and consequently your asthma. You can start by modifying your lifestyle (see previous blogs) and adopting certain habits like raising the head of your bed by 40 degrees. At Houston Heartburn and Reflux Center, Dr. Darido offers a comprehensive and thorough evaluation for GERD. Depending on your GERD stage, we tailor our treatment strategy to give you the best possible results.

#### Do Hiatal Hernias Increase in Size with Weightlifting?
Ron from Houston sent us this question: ” I was diagnosed with Barret’s Esophagus and a small hiatus hernia 2 years ago during an endoscopy as I had excessive burping.
However even after that I avoided certain foods but still continued to lift weight like max 60 kgs cable biceps curl, leg presses for around 200 lbs, and sometimes chest press of 80 lbs…Is it possible my hiatal hernia has grown overtime? How likely would my hernia be grown?
Dear Ron,
Thank you for your question. Hiatal hernias tend to grow with time especially in the setting of uncontrolled acid reflux. The fact that you have Barrett’s esophagus indicate severe acid reflux disease irrespective of initial hiatal hernia size diagnosed with upper endoscopy. Heavy weight lifting is associated with increased intra-abdominal pressure. An increase in abdominal pressure stresses any abdominal wall hernia as well as hiatal hernias.
There are no studies addressing the long-term impact of weight lifting on hiatal hernia growth. Few studies raise the concern of weightlifting as a cause of hiatal hernia development. However, it is common sense to avoid heavy weight lifting when one is diagnosed with a hiatal hernia. Most importantly, it is crucial to control acid reflux to prevent disease progression and hiatal hernia growth.
The best solution for stage 4 acid reflux is hiatal hernia repair and Nissen funduplication. Properly performed Nissen fundoplication reliably, effectively and safely stops acid reflux. Furthermore, Nissen fundoplication prevents the progression of Barrett’s esophagus to cancer.

#### Do I have Gastroparesis or Heartburn?
Jane from Houston sent us this question: “I have been taking PPI’s since July, omeprazole (20mg 2x/day), then I was switched to Carafate, then come August 21, I was prescribed pantoprazole (40mg 2x/day) AND famotidine (40mg before bed). I had an upper endoscopy done and was told I had gastritis. I’ve tried to express to my medical team that, even on the medications, I was experiencing burning sensations, abdominal pain, and heartburn, but my concerns were dismissed, and they just ordered a gastric emptying test. I’ve made the decision to wean myself off pantoprazole, so I started taking only one a day since October 03. October 13, I did the gastric emptying test. Now, I was told I have gastroparesis—and my stomach empties “a little” slower than normal… could I really have gastroparesis? I am not experiencing sudden fullness, vomiting, or nausea. Thank you.”
Dear Jane,
Gastroparesis or delayed gastric emptying is a rare disease that affects less than 4% of the population in Houston. Stomach in gastroparesis patients does not empty food into the intestine. As a result, patients with gastroparesis often complain of postprandial fullness, bloating, nausea and vomiting. Abdominal pain in the epigastric area may be present throughout the day and exacerbated by food intake. Typically, patients report early satiety and inability to finish a regular size meal. A positive gastric emptying study is diagnostic of gastroparesis. However, symptom severity does not always correlate with gastric emptying rate.
Several gastroparesis patients present with heartburn in addition to epigastric pain and bloating. Early and mild gastroparesis cases are not typically associated with nausea and vomiting. Subtle findings on upper endoscopy include gastritis from bile and food stasis. Hiatal hernia and distal esophagitis that is classic acid reflux signs are typically absent or barely present in gastroparesis cases.
Proper workup and diagnosis are crucial to differentiate GERD from gastroparesis. We don’t recommend blind treatment with PPIs before diagnosis. We also prefer to perform a gastric emptying study off PPIs since PPIs may delay gastric emptying. Finally, ambulatory pH testing may further help in differentiating GERD from gastroparesis.
Nissen fundoplication, the gold standard treatment for acid reflux, promotes gastric emptying and may help alleviate mild cases of gastroparesis. I offer hiatal hernia repair and Nissen fundoplication only for patients with severe acid reflux and mild gastroparesis. For severe acid reflux and moderate to severe gastroparesis cases, I perform a Nissen fundoplication with hiatal hernia repair and I add a partial longitudinal gastrectomy along the greater curvature. I have had great success with this approach.
For medically refractory gastroparesis patients with no acid reflux, I offer an antrum preserving longitudinal gastrectomy without hiatal hernia repair. Our success rate using this approach has been very high. I currently recommend a partial gastrectomy as opposed to gastric bypass or pyloromyotomy for all cases of severe gastroparesis.

#### Does Acid Reflux Develop Suddenly?
Pam from Houston Sent us this question: “These acid reflux symptoms came over me suddenly. I am slim and eat very healthy. Never have digestion issues. ?
I am seeing a Chiropractor for adjustments for a spinal compression injury, which has finally taken its toll (6 months later). Sciatica/Piriformis pain.
Two nights ago, pain was so relentless I took severe measures: stacking pillows high under my ankles to butt, with head lying down lower on a small neck pillow.
Next day:  Sour taste in mouth, burning, nauseated feeling from throat to stomach and sharp pain from middle of back to stomach. Swallowing difficulty. Just feel like I need to throw up.
Dear Pam:
Acid reflux is a chronic and progressive disease. GERD symptoms start mild and barely noticeable. Initially, you may feel some heartburn after a heavy or spicy meal. You may experience occasional food regurgitation when bending over or when sleeping at night. With time, however, symptoms like heartburn, cough, sore throat and food regurgitation increase in intensity and frequency. GERD symptoms become independent of food intake. At this stage, you may develop heartburn just by drinking water or without eating anything.
Weight gain is a risk factor for acid reflux. However, the main underlying cause of acid reflux disease is a weak anti-reflux barrier. Several tests are available to check the integrity of your anti-reflux barrier. Proper evaluation and testing are crucial to effectively treat acid reflux disease. Hiatal hernia repair and Nissen fundoplication surgery are typically performed to restore the acid reflux barrier and reliably stop acid reflux. Surgery is performed through tiny incisions in an outpatient setting. GERD related symptoms resolve immediately following surgery. Swallowing slowly improves as inflammation resolves and esophagus regains its contractile functions.

#### Does Anxiety Affect Nissen Fundoplication Outcome?
The relationship between acid reflux and anxiety is circular. Acid reflux exacerbates anxiety and anxiety exacerbates acid reflux related symptoms. Acid reflux or GERD is a chronic disease with debilitating symptoms that significantly decrease quality of life. Daily heartburn, bloating, and pain as well as constant burping and coughing worsen in intensity and severity as GERD progresses over time. These symptoms can take a toll on a patient’s mental health. They may lead to or, most commonly, worsen pre-existing anxiety and depression. One study did indeed show increased incidence of anxiety and depression in GERD patients. By the same token, psychiatric disorders alter pain perception. Stress and anxiety heighten the perception of acid reflux symptoms like heartburn and chest pain without necessarily increasing the frequency and severity of acid reflux events. Furthermore, some studies show that stress and anxiety decrease lower esophagus sphincter, LES, pressure.  A drop in LES pressure may favor acid reflux.
A properly performed hiatal hernia repair and Nissen fundoplication reliably stops acid reflux. It is fair to assume that eliminating acid reflux improves anxiety and depression symptoms. However, we have noticed at Houston Heartburn and Reflux Center, a category of anxious patients with acid reflux who do not seem to improve after anti-reflux surgery. Typically, this group of patients present to our center with severe GERD related symptoms and poorly controlled anxiety symptoms. In addition to classic acid reflux symptoms like heartburn and food regurgitation, patients report nonspecific chest and abdominal pain. Following successful hiatal hernia repair and Nissen fundoplication, patients with severe anxiety continue to report a plethora of acid reflux related and unrelated symptoms. Consequently, they start to lose faith in the Nissen fundoplication as a reliable solution for their acid reflux. In most cases, I end up repeating upper endoscopy and pH Bravo study after surgery to demonstrate the absence of acid reflux and to prove GERD resolution.
It seems that laparoscopic Nissen fundoplication in patients with anxiety “improves GERD symptom burden but satisfaction is rarely achieved in long-tern follow up” according to a study published in Surgical Endoscopy in 2020 by K Perry et al. The authors retrospectively analyzed 271 Nissen fundoplication patients. 103 patients had depression and 44 had anxiety. They found out that patients with anxiety have higher subjective reporting of GERD related symptoms compared to control, before and after Nissen fundoplication. Both anxiety and GERD are common disorders affecting 25 % of the Houston population. Therefore, it is not uncommon for a patient with acid reflux disease to suffer from co-existing anxiety and/or depression.
At Houston Heartburn and Reflux Center, we recommend anxiety control prior to anti-reflux surgery. We often refer GERD patients with severe anxiety for a psychiatric evaluation and management prior to Nissen fundoplication. We do not proceed with surgery until patient anxiety and depression are well controlled. We also educate our patients to help them differentiate and separate acid reflux from anxiety related symptoms. For instance, we explain to our patients that irritable bowel syndrome, if present, is not related to GERD and it is not likely to resolve after Nissen fundoplication. These pre-operative measures help anxious patients manage their expectations and improve their satisfaction level after Nissen fundoplication.

#### Does Bile Reflux Increase Following Cholecystectomy?
“Gastroesophageal Mucosal Injury after Cholecystectomy: An Indication for Surveillance?” is a new study published by T. Walsh et al in the current issue of JACS (Journal of the American College of Surgeons). The authors evaluate the incidence of stomach bile pooling detected by endoscopy in patients before and after cholecystectomy. They further measure the bile reflux index, cellular proliferation marker Ki67 and tumor-suppressor gene p53 in biopsies taken from the gastro-esophageal junction and gastric antrum. The analysis show that cholecystectomy increases the incidence of bile reflux and bile induced damage of gastric and esophageal mucosa. Chronic bile induced esophagitis and gastritis increase the incidence of gastric and esophageal cancer. The role of bile reflux in the pathogenesis of Barrett’s esophagus is well established and 10% of patients with Barrett’s esophagus develop esophageal adenocarcinoma.
At Houston heartburn and Reflux Center, more than 50% of patients presenting for GERD evaluation have already underwent a cholecystectomy. Chronic proton pump inhibitor use by GERD patients may increase the incidence of biliary stasis and choleltihiasis. However, many patients have had their GERD symptoms mistaken for biliary colic. Cholecystectomy is a very common procedure performed by general surgeons. Primary care physicians tend to order a gallbladder ultrasound/HIDA scan for epigastric pain much more commonly than upper endoscopy and ambulatory pH testing. Cholelithiasis is present in 30% of the population. Most cholelithiasis cases need no intervention. It is crucial to differentiate GERD pain from biliary colic prior to committing a patient to any surgical intervention. A healthy gallbladder has several important functions some of which we still don’t know about. This study shows that cholecystectomy increases the risk of bile reflux and esophago-gastric mucosa injury. I suspect the risk of bile reflux and mucosal injury is highest in GERD patients who undergo an unindicated cholecystectomy. Biliary colic and GERD pain may have overlapping presentations. A thorough history taking and sharp clinical acumen coupled with proper testing and evaluation are therefore needed to avoid doing harm and unnecessary surgery.
Reference
Cahan MA: Proton pump inhibitors reduce gallbladder function. Surg. Endosc. 20 (9): 1364–1367.

#### Does Coffee Give You Heartburn?
Coffee is the most commonly consumed beverage after water. Coffee fuels our culture and is readily available around every corner in Houston. Coffee is rich in caffeine and tannins, two substances that are known to cause heartburn. It is believed that caffeine and tannins relax an already weak lower esophageal sphincter favoring acid reflux. If you are like many Houstonians who suffer from acid reflux and giving up coffee is hard, what can you do?
First, if you suffer from recurrent heartburn, giving up coffee may not make a huge difference in terms of heartburn frequency and severity. If the reflux barrier is already too weak, coffee consumption is not going to make it weaker. In this situation, Houston Heartburn and Reflux Center recommends evaluation by a reflux specialist. Following a full GERD workup and staging, hiatal hernia repair and Nissen fundoplication may be offered to restore the acid reflux barrier.
Second, if you develop heartburn only when you drink coffee, Houston Heartburn and Reflux Center strongly recommends reducing the amount and frequency of coffee consumption. Heartburn secondary to coffee consumption is a signal from your food pipe to your brain that something not right is happening. Do not mask the signal with a heartburn pill. Heartburn pills do not cure acid reflux. Rather try to solve the problem to prevent further damage from acid reflux. You may try a lighter cup of coffee, decaf coffee or other caffeinated drinks like tea, and yerba mate. Avoid consuming coffee on an empty stomach or shortly before you go to bed. Most importantly, avoid coffee consumption along with other heartburn trigger items like smoking. For instance, if orange juice gives you heartburn, try not to have a cup of orange juice and coffee at the same time. Lastly, you may want to consider coffee substitutes. These are non-coffee products that may or may not contain caffeine. Coffee substitutes imitate coffee taste and color. The taste may not be to your liking, but heartburn is less likely to occur.

#### Does Fasting Increase Heartburn?
Sherman who suffers from weekly heartburn that is partially controlled with medications sent us this question: “Does fasting increase heartburn?”
Dear Sherman,
There is a strong association between food intake and heartburn. Trigger food items like tomato sauce, and spicy dishes can precipitate a heartburn attack that may last for several hours. Similarly, overeating stretches the gastric fundus and lower esophageal sphincter leading to GERD development and progression over time. Furthermore, the stomach secretes more acid following meal consumption. A postprandial acid pocket forms and sits on top of the ingested meal, just below the gastro-esophageal junction. In GERD patients, this acid pocket migrates well above the gastro-esophageal junction leading to heartburn development. Consequently, eating late at night and going to bed greatly exacerbates acid reflux symptoms in GERD patients. During fasting, stomach secretion of ghrelin, the hunger hormone, increases. A study has shown that there is an inverse relationship between ghrelin blood levels and heartburn. Thus, fasting may be associated with GERD symptom improvement and less acid reflux events. Furthermore, fasting decreases blood sugar level. Elevated blood sugar is associated with delayed gastric emptying especially in diabetic patients. Delayed gastric emptying increases  acid reflux frequency and duration. Finally, fasting decreases insulin resistance. Decreased insulin resistance promotes weight loss. Weight loss in overweight GERD patients is associated with decreased heartburn and acid reflux.
If you suffer from advanced acid reflux disease, like Stage 3 and 4 GERD patients, acid reflux symptom frequency and severity become less dependent on food intake. After all, stomach content is always acidic and in the setting of a weak or absent anti-reflux barrier, acid reflux is likely to occur more frequently. Fasting in this situation may not alleviate heartburn. Indeed, GERD patients at this stage tend to consume food more frequently to neutralize acid reflux and decrease heartburn. If you constantly experience heartburn during intermittent fasting, we recommend a comprehensive GERD evaluation to stage your disease and tailor treatment accordingly.

#### Does Gastroparesis Cause Heartburn?
Denise from Houston sent us this question: “I have been diagnosed with gastroparesis, GERD, and gastritis. I’ve been dealing with burning in my stomach for 3 years. I take Nexium, Gaviscon and Pepcid, but I still have burning. Can the gastroparesis cause the burning in my stomach?”
Dear Denise,
Gastroparesis is associated with pain in the stomach especially after eating. Stomach pain may be burning in nature. Heartburn is defined as a burning sensation under the sternum or breastbone. Gastroparesis commonly results in acid reflux leading to heartburn and food regurgitation. Heartburn is more likely to respond to Nexium and Pepcid than gastroparesis-related stomach pain.
It is important to differentiate between acid reflux causing and gastroparesis as a cause for heartburn because treatment is different. Acid reflux is reliably and effectively treated with hiatal hernia repair and Nissen fundoplication to restore the anti-reflux barrier. Gastroparesis is treated with an antrum preserving longitudinal gastrectomy to promote gastric emptying. In some cases of late-stage GERD and hiatal hernia formation, gastroparesis or delayed gastric emptying may co-exist with GERD. In this case, after completion of hiatal hernia repair and Nissen fundoplication, an antrum preserving and fundus sparing longitudinal gastrectomy is performed to promote gastric emptying.
I recommend you get properly evaluated by expert acid reflux specialist in Houston to choose the best treatment option for your case. A tailored solution to your acid reflux or gastroparesis alleviates your symptoms and improves your quality of life.

#### Does LINX™ Device Cause Chest Pain?
Amy and Rebecca from Houston Sent us these two heartburn acid reflux related questions over the past few days:
Amy,
“I have had the Linx procedure about 2 years ago and have suffered with chest pain many times. Feels like a heart attack and pain takes hours and a lot of pain meds to make it go away. I am just beside myself at this point and want a second opinion.”
Rebecca,
“My husband had a Linx device implanted approximately 5 years ago. Over the past several weeks he has been complaining of chest pain at device area and has dealt with off and on pain the entire time, occasionally w/heartburn and reflux. It has escalated only recently. Recommendations?”
Dear Amy and Rebecca,
Chest pain is a serious complaint. The causes of chest pain are numerous and may range from anxiety, to acid reflux and up to heart attack. Therefore, any time someone complains of chest pain, thorough medical evaluation is warranted. Pain related to LINX™ device is not uncommon and may result from the device itself or uncontrolled acid reflux. Uncontrolled acid reflux in the setting of LINX™ is easily detected using upper endoscopy and ambulatory pH testing. Treatment of acid reflux in the setting LINX™ device ranges from lifestyle changes to LINX™ removal and conversion to Nissen fundoplication and redo hiatal hernia repair. In the absence of acid reflux, additional testing is recommended including esophageal manometry and contrast study to evaluate esophageal motility and emptying. Poor esophageal motility may be associated with pain especially during swallowing. Dysphagia or difficulty swallowing is commonly present. Treatment of esophageal dysmotility, pain and dysphagia secondary to LINX™ device requires LINX™ device removal and conversion to partial fundoplication with redo hiatal hernia if necessary. Esophageal spasm secondary to LINX™ device is first treated with antispasmodic medications and if symptoms do not improve, LINX™ device removal is indicated. LINX™ device erosion is fortunately rare and may be associated with pain, fever and dysphagia. In the case of LINX™ erosion, device removal using endoscopy or laparoscopy is needed.
In certain cases, there is no identifiable cause for pain in the setting of LINX™ device. Work-up is negative and shows no abnormalities. We still don’t understand the exact etiology and pathophysiology of LINX™ related pain in these cases. Luckily, LINX™ device removal in these cases results in pain resolution.
Whatever your case may be, please do not ignore chest pain and get evaluated not only by an acid reflux specialist but also by a cardiologist to avoid missing a serious condition that may adversely affect your health and life.

#### Does LINX™ Surgery Cause Bloating and Fullness?
Dana from Houston sent us this question: “I had a LINX™ put in June 2020 and I think it cleared the acid reflux but I have been getting progressively uncomfortable with severe bloating, gas and feeling of fullness. If I would have it removed will everything go back to normal? Thank you.”

Dear Dana,

Bloating, fullness, and excessive burping are common acid reflux symptoms. Bloating and fullness are also common gastroparesis or delayed gastric emptying symptoms. During LINX™ surgery, the vagus nerve may be accidentally cut resulting in gastroparesis. Gastroparesis symptoms may also include heartburn, nausea, vomiting and abdominal pain after eating. Gastroparesis diagnosis is confirmed by gastric emptying study.

I recommend you get evaluated by a competent acid reflux specialist in Houston. Your workup may include upper endoscopy, ambulatory pH testing and gastric emptying study. If you have gastroparesis, LINX™ device removal by itself is not enough to alleviate your symptoms. At Houston Heartburn and Reflux Center we recommend a tailored longitudinal gastrectomy to promote gastric emptying and alleviate gastroparesis related symptoms. If you continue to suffer from acid reflux after LINX™ surgery, LINX™ removal and conversion to Nissen fundoplication is recommended.

If you don’t have gastroparesis and your acid reflux is controlled with LINX™ surgery, I don’t recommend LINX™ removal. Constipation, IBS, food insensitivity, bacterial overgrowth… are associated with bloating and gas. Evaluation along those lines is recommended.

#### Does Nissen Fundoplication Affect the Magenstrasse?
In his seminal paper, “A Stomach Road or Magenstrasse for Gastric Emptying”, James Brasseur concludes that the coordination of contractile waves between gastric fundus and antrum determines the magnitude of the Magenstrasse. Surgical manipulation of gastric fundus in the form of Nissen fundoplication alters gastric fundus wall geometry, compliance, and contractions. As a result, Nissen fundoplication may change the Magenstrasse emptying pathway. Indeed, post-Nissen fundoplication contrast studies demonstrate rapid contrast emptying along the lesser curvature into the duodenum (see above picture). Several studies have demonstrated accelerated gastric emptying following Nissen fundoplication. Some patients, especially children, experience dumping. Post-prandial dumping following Nissen fundoplication in children has been associated with increased levels of GLP-1. GLP-1 secretion is closely associated with food particle emptying along the Magenstrasse.
Reinforcement of the Magenstrasse emptying pathway may be an unintended consequence of wrapping the gastric fundus around the distal esophagus. It may also be one of the main anti-reflux mechanisms created by Nissen fundoplication. Indeed, abnormal gastric emptying and gastric fundus relaxation result in GERD. In other words, a dysfunctional Magenstrasse may be contributing to, if not the root cause, for GERD. Nissen fundoplication cures GERD by restoring the Magenstrasse emptying pathway.
Using Brasseur’s computer simulation model of the stomach, one can numerically calculate intra-gastric fluid motions and study the effect of Nissen fundoplication on the Magenstrasse emptying pathway. The same model can evaluate the effect of antrum preserving longitudinal greater curvature gastric resection. This is a procedure I developed to treat gastroparesis. I suspect that both gastric fundus wrapping, and resection alter the Magenstrasse emptying pathway to favor acid reflux control and promote gastric emptying.
Gastric motility patterns and emptying are complex and poorly understood. Many diseases like GERD and gastroparesis, that have reached epidemic levels in our society, are partly, if not mostly, the result of gastro-duodenal motility disorders. Understanding the basic physiology and pathophysiology of gastric motility and emptying will help elucidate the etiology of complex problems like GERD and gastroparesis. This is sure way to develop reliable therapies that target the root cause of disease rather than its consequences.
When it comes to GERD treatment, targeting the consequences of gastric motility disorders by reinforcing the lower esophageal sphincter, is associated with poor acid reflux control. Stretta, TIF, and LINX surgery are perfect examples of LES reinforcement techniques that have unacceptably low success and durability rates. Currently, the most reliable treatment for GERD is a properly performed Nissen fundoplication and hiatal hernia repair. At Houston Heartburn and Reflux Center, we guarantee 100% success rate. If you struggle with heartburn, food regurgitation, bloating, excessive burping, cough or hoarseness give us a call at 832-945-8717.

#### Dor vs Nissen Fundoplication for Heartburn Treatment
Johane from Houston, TX sent us this question: “I had a 270-degree Dor fundoplication in January 2020 with paraoesophageal hernia repair. I did not have a myotomy. I understand that the Dor is rarely performed today and usually only with a myotomy.
Seven months later, my fundoplication has slipped, and my hernia has returned although currently not as large as before. It does not seem to have ever controlled my acid reflux and I have Los Angeles Stage D damage to much of my esophagus. My PH score is 84.
Your article says that Dor fundoplication is rarely performed today. I’ve searched and searched and cannot find many references to a Dor without also mentioning myotomy. My surgeon insists that it isn’t true that Dor is not common today. After reading up on it, I do not understand why she chose this technique for someone who wasn’t having a myotomy.
In addition, I suspect I have vagus nerve damage from the fundoplication. I have breathing problems, an IBS-like digestive disorder, food intolerances, what seems like vastly increased stomach acid, and tingling in my feet and legs on a daily basis. I never had any of these symptoms before having a Dor fundoplication. Is it possible that Dor is more likely to cause damage to the vagus nerve? Please comment — thanks!”
Dear Johane,
Dor fundoplication is rarely performed in Houston for treatment of acid reflux disease. The most commonly performed is Nissen fundoplication or 360-degree wrap. Nissen fundoplication is a reliably and effective procedure when properly performed. The gastric fundus that is used to wrap around the esophagus is a posterior structure. Therefore, it is much easier to swing the fundus posterior to esophagus to perform a loose and floppy Nisse fundoplication. On the other hand, during a Dor fundoplication, your acid reflux surgeon rotates the gastric fundus from lateral to medial anterior to esophagus to create a partial wrap. Dor fundoplication is most commonly performed in the setting of Heller myotomy as you mentioned. It is believed that the fundoplication protects the newly myotomized esophagus. I personally prefer a Toupet fundoplication in this setting for the same reason I mentioned previously: gastric fundus is anatomically located posterior to esophagus. A posterior wrap makes more sense to me to perform.
Vagal nerve injury is not higher with Dor fundoplication. Slippage and recurrent hiatal hernia are not higher with Dor fundoplication. Both complications are minimized by meticulous surgical technique, comprehensive acid reflux work up and patient selection. I strongly recommend you consult with an acid reflux specialist to evaluate your symptoms and check the anatomy of your current fundoplication. A treatment tailored to your condition will help you stop acid reflux and improve your quality of life.

#### Dysphagia and Persistent Acid Reflux after LINX™ Surgery
Sunny from San Antonio, TX sent us this question: “I had LINX™ device placed on September 1, 2020.  I have realized that eating fast causes Dysphagia.  My two questions are:
Q1. Even chewing food well before swallowing I have experienced dysphagia, where taking a few sips of warm water gets my food down.  Is this normal?
Q2. Even with LINX™ can one experience spontaneous reflux? Thank you.”
Dear Sunny,
Dysphagia or difficulty swallowing is not uncommon after LINX™ surgery. LINX™ device creates a barrier against normal swallowing. This physical barrier has three components: lower esophageal sphincter pressure, esophagus wall compliance and diameter. As scar tissue forms around LINX™ device, both esophageal wall compliance and opening decrease. Furthermore, LINX™ device, a bracelet of magnetic beads, increases lower esophagus sphincter resting and residual pressures. As a result, your esophagus works harder to push food across this barrier leading to dysphagia. The weaker your esophageal contractions the more likely you are to feel dysphagia. You may have to drink some water to help food go down. In some cases, food doesn’t go down and it gets impacted in the esophagus. Over time, esophagus motility may further deteriorate leading to worsening dysphagia.
Endoscopic balloon dilation is utilized to break down scar tissue formation around LINX™ device. This approach may improve early dysphagia developing shortly after LINX™ implantation. Balloon dilation success rate decreases significantly when dysphagia develops several years after LINX™ surgery. Esophageal manometry is typically performed to evaluate esophageal motility. Results can be compared to pre-surgery manometry. If there is evidence of esophageal motility deterioration, LINX™ device removal is indicated to prevent further damage to esophageal function.
At Houston Heartburn and Reflux Center, our dysphagia rate with over 1000 consecutive Nissen fundoplications is 0%. Nissen fundoplication mechanism of action does not rely on augmenting pressure in lower esophagus sphincter. Rather, Nissen fundoplication creates a new anti-reflux barrier thereby leaving swallowing process undisturbed.
Regarding your second question: “can reflux occur in the setting of LINX™?”. The answer is yes.

#### End Stage Acid Reflux Disease
A 63-year-old female presented to my office with severe heartburn and food regurgitation uncontrolled with high dose antacid medications. As a teenager, she started having heartburn. Over the years, her GERD related symptoms including heartburn and food regurgitation have slowly progressed. About 10 years ago, she started feeling more bloating, maldigestion and post-prandial vomiting. Her nighttime symptoms worsened forcing her to sleep in a semi-sitting position. Her treatment consisted initially of daily Tums and Rolaids. When proton pump inhibitors were introduced in the 1990s, she was started on once daily dose and was later increased to twice daily. She has been on high dose proton pump inhibitors for many years now with poor symptom control.
The patient GERD workup showed a large hiatal hernia, distal esophagitis, undigested food in the stomach suggestive of gastroparesis, and esophageal dysmotility. Esophageal manometry showed poor peristalsis with multiple failed swallows and decreased contractile wave amplitude. Upper GI contrast study showed severe contrast reflux in the Trendelenburg position and minimal contrast emptying from the stomach into the duodenum further supporting the existence of gastroparesis. Whether her esophago-gastric motility disorder is secondary to long-term acid reflux or a contributing cause of acid reflux is hard to determine. Up to 40% of GERD patients are believed to have delayed gastric emptying. Most GERD patients presenting for Nissen surgery at Houston Heartburn and Reflux Center have esophageal abnormalities on manometry.
In my opinion, GERD is an esophago-gastro-duodenal motility disorder. The lower esophageal sphincter is controlled by this motility axis. Transient lower esophageal relaxation, TLESR, is believed to be the main cause of GERD rather than a weak lower esophageal sphincter. TLESR is however a direct result of esophago-gastro-duodenal motility disorder that is yet to be fully understood. An interesting study titled “Effect of Atropine on the frequency of Reflux and Transient Lower Esophageal Sphincter Relaxation in Normal Subjects” illustrates my point. The study was published by Mittal et Al in the journal Gastroenterology in 1995. It shows that atropine injection in the lower esophageal sphincter decreased its pressure but did not cause acid reflux in healthy volunteers. Indeed, following atropine injection, the frequency of transient lower esophageal sphincter relaxation events decreased leading to decreased reflux. One potential explanation for such a finding is that when atropine is injected in the sphincter muscle it causes gastric fundus relaxation, and inhibits esophageal longitudinal muscle fiber shortening. One may assume that increased gastric fundus tone and esophageal longitudinal muscle contractions can lead to increased acid reflux episodes. In other words, certain patterns of esophago-gastric motility that are still poorly understood may result in increased transient lower esophageal sphincter relaxation events leading to GERD. Accordingly, Nissen fundoplication can be viewed as a motility altering procedure rather than a lower esophageal sphincter reinforcement operation. Indeed, we now perform a short and floppy 360-degree fundoplication for best anti-reflux results. Rather than increasing lower esophageal sphincter pressure, Nissen fundoplication promotes stomach motility and increases gastric emptying. These altered motility patterns stop acid reflux. The same phenomenon is observed with sleeve gastrectomy. Gastric sleeve surgery when properly performed is in fact, an excellent anti-reflux procedure.
Nissen fundoplication and gastric sleeve surgery are gastric motility altering procedures. Unless motility is altered, GERD will continue to progress with time. Proton pump inhibitors, PPIs, do not alter gastric motility and one study has shown decreased gastric emptying with chronic PPI use. Patients with severe acid reflux disease maintained on PPIs are likely to end up with end stage GERD like the patient I presented in this blog. GERD is a surgical disease and early surgical intervention is more likely to be effective than medical therapy.
The surgical treatment of end stage GERD requires more than hiatal hernia repair with fundoplication. A greater curvature resection with antrum preservation must be added to promote gastric emptying and alleviate acid reflux. I therefore recommend hiatal hernia repair, Toupet fundoplication and antrum preserving longitudinal gastrectomy. I have so far obtained excellent results adopting this approach for end stage GERD.

#### Endoflip for Heartburn Treatment: Tailoring the Fundoplication
Proper acid reflux testing is a crucial element of any successful heartburn and GERD management program. Endoflip, functional luminal imaging probe, is a relatively new testing modality that is finding its way into clinical practice. Endoflip uses an inflated balloon that is positioned within the esophageal lumen during upper endoscopy. Balloon is then inflated mimicking a food bolus. Intraluminal pressure and the corresponding cross-sectional area are then calculated to generate a compliance index. Traditional tests like high resolution esophageal manometry and barium contrast swallow do not assess esophageal wall compliance. Manometry measures esophageal peristalsis, contractile and lower esophagus sphincter pressure using a thin pressure catheter. UGI contrast study can detect esophageal strictures and diverticula as well as bolus clearance. Wall compliance, however, requires concomitant pressure and radius measurement to generate a compliance index.
A compliance index measurement is particularly useful in dysphagia patients with normal contrast study and esophageal manometry. Achalasia patients with recurrent dysphagia after Heller myotomy or acid reflux patients with persistent dysphagia after loose and floppy Nissen fundoplication are best evaluated with Endoflip. LINX™ patients suffer from high rates of post-operative dysphagia and may benefit from intra-operative Endoflip measurement to determine magnet ring size. I don’t see a role for intra-operative Endoflip to size hiatal hernia repair and Nissen fundoplication at Houston Heartburn and Reflux Center for a number of reasons. First, our post-operative dysphagia rate is very low. Second, we perform a loose, and floppy Nissen fundoplication. Third, we avoid overtightening the hiatal opening to avoid esophageal angulation and narrowing. I also avoid closing the anterior aspect of the hiatus unless the gap is quite large. Consequently, Endoflip is not likely to improve intra-operative technique or anti-reflux surgery outcome at Houston Heartburn and Reflux Center.

#### Endoscopic Acid Reflux Treatment: Stretta
Sandy from Houston sent us this question: “I have had two Strettas procedures in the past, which were very successful in stopping my LPR symptoms; however, the procedures were undone by a pregnancy and some medications that I must take. I’m looking for a more permanent fix. My LES has been shown to be completely patent on endoscopy, I reflux into my throat on a Barium Swallow, and I’ve had evidence of reflux found on biopsies of my esophagus. All these issues improved after having Stretta. Would I be a candidate for Nissen fundoplication surgery at your clinic? Thank you.”
Dear Sandy,
Stretta, an incisionless procedure, is not a reliable treatment for acid reflux disease, including LPR. I am not surprised your LPR recurred following two Stretta treatments. At Houston Heartburn and Reflux Center, Stretta is not offered. Rather, we recommend laparoscopic Nissen fundoplication and hiatal hernia repair for both GERD and LPR.
In your question, you present strong evidence for acid reflux. Contrast reflux on barium swallow, inflammation of distal esophagus on biopsies, and patient lower esophageal sphincter due to hiatal hernia are clear indications for Nissen fundoplication to stop reflux.
We recommend esophageal manometry prior to Nissen fundoplication and hiatal hernia repair. Esophageal manometry evaluates esophageal contraction. Most acid reflux patient qualify for Nissen fundoplication. However, in the case of very weak esophageal contractions, a partial (Toupet) fundoplication is preferred over a 360 degree or Nissen fundoplication to avoid post-operative dysphagia (difficulty swallowing).

#### EndoStim: A Novel Anti-Reflux Procedure
EndoStim is a bipolar lead implanted in the lower esophageal sphincter, LES. It is connected to a subcutaneous electrical generator that generates electrical impulses according to a proprietary algorithm. The purpose of this device is to improve LES function in the hope of controlling gastro-esophageal reflux disease.
Neuro-modulation is a very interesting treatment modality for many diseases like gastroparesis, anal sphincter incompetence, urinary incontinence and even morbid obesity and diabetes. The pathophysiology of GERD is partly related to LES dysfunction and improving LES function may theoretically improve GERD control. The problem is that our understanding of esophago-gastro-duodenal motility is very limited. Neuro-modulation is only feasible when we decipher the complex neuro-muscular physiology of the gastrointestinal tract. There are one million gastrointestinal neurons talking to each other and coordinating hundreds of functions that we still don’t understand or even know about. The best example for neuro-modulation comes from our experience with gastroparesis treatment. Gastric pacing has been studied extensively in gastroparesis. The results have been controversial and most patients experience minimal improvement in gastric emptying with gastric pacing. If we don’t understand the basic pathophysiology governing gastric emptying how can we develop an effective gastric stimulator to treat the underlying problem?
The same rational applies to GERD. GERD is a multifactorial problem that results not only from LES incompetence. Transient Lower Esophageal Sphincter Relaxation, TLESR events do contribute to GERD but they are only part of a more complex pathophysiology. Preventing TLESR may theoretically improve GERD but the question is how and is it enough? How to stop reflux events associated with TLESR? Some advocate applying a chain of magnets around the sphincter like the LINX™ system and others are pushing for electrical stimulation like EndoStim. For mild reflux and in the absence of a hiatal hernia these approaches may work. Their mechanism of action is based on naïve assumptions more so than solid science. The most reliable treatment and only cure for reflux remains the Nissen fundoplication. We hope that continued research will improve our understanding of GERD. In particular, we need to study the neuromuscular functions of the gastrointestinal tract and how is gastric emptying regulated to understand diseases like gastroparesis, GERD, type-two diabetes and obesity. Short of improving our knowledge of these complex functions, we will continue to target the LES with constricting devices while ignoring the root cause of GERD.

#### Esophageal Hypersensitivity and GERD
Sensory neurons within the esophagus wall detect mechanical and chemical stimuli like lumen distention, resulting in pain, and acid reflux, causing heartburn. Patients with a hypersensitive esophagus have a more intense perception for the same degree of stimulation compared to patients without a hypersensitive esophagus. The etiology and underlying pathophysiology of esophageal hypersensitivity are not well understood. It is well known, however, that stress, anxiety, depression and panic attacks exacerbate esophageal hypersensitivity.
Around 5% of patients, on chronic long-term PPI treatment, presenting to Houston Heartburn and Reflux center, have no evidence of elevated esophageal acid exposure when properly evaluated with upper endoscopy and esophageal pH testing. Consequently, PPI treatment and especially high dose PPI treatment are not warranted. Patients with a hypersensitive esophagus who don’t have evidence of GERD are not candidates for anti-reflux surgery either. Rather, treatment should concentrate on stress reduction, depression management and the use of neuromodulators like Amitriptyline, a tricyclic antidepressant.
It is crucial to distinguish esophageal hypersensitivity from GERD. Both esophageal hypersensitivity and GERD related symptoms are equally bothersome and negatively affect quality of life. However, Nissen fundoplication, a reliable treatment for GERD, does not help patients with esophageal hypersensitivity. Two years ago, a young female patient presented to my office with severe heartburn in the setting of irritable bowel syndrome associated with diarrhea and morbid obesity. Patient suffered from chronic anxiety and panic attacks. Interestingly, she reported that OTC PPIs alleviated her heartburn as well as the diarrhea episodes associated with IBS. Upper endoscopy with ambulatory pH testing showed no evidence of GERD and negative symptom-reflux association. Esophageal manometry was also normal. I reassured the patient and clearly explained to her that she has an intact anti-reflux barrier. As a result, I advised her to stop PPI intake. My first line of treatment was referral to a specialist for a thorough psychiatric evaluation to manage her anxiety and panic attacks. Stress reduction along anxiety/panic attack control helped her IBS as well as esophageal hypersensitivity symptoms. Patient was able to adopt a healthier diet and with the addition of probiotics like yogurt and sauerkraut she had excellent IBS symptom control. She subsequently underwent sleeve gastrectomy without hiatal hernia repair and did very well. Patient continues to be heartburn free 2 years after initial evaluation.
Thorough and comprehensive acid reflux evaluation, high index of suspicion and careful patient selection is crucial when it comes to GERD management.

#### Esophageal Hypersensitivity and Nissen Fundoplication
Angela from Houston sent us this question: “Do you see esophageal hypersensitivity come and go at Houston heartburn and Reflux Center? Does Nissen fundoplication make hypersensitivity goes away? Thank you for your opinion.”
Dear Angela,
I have never performed a Nissen fundoplication for a case of pure esophageal hypersensitivity (no hiatal hernia, no esophageal inflammation and negative esophageal ambulatory pH testing). Nissen fundoplication is primarily indicated for stage 3 and stage 4 acid reflux disease. It reliably stops acid reflux and allow patients to regain their quality of life.
Esophageal hypersensitivity patients report heartburn and chest pain in response to normal and physiologic acid reflux due to a lower threshold for symptom perception and reporting. The anti-reflux barrier is intact in esophageal hypersensitivity cases. Patients with depression, anxiety, somatization disorders and fibromyalgia have a higher prevalence of esophageal hypersensitivity. Therefore, first line treatment relies on stress reduction and pharmacologic neuromodulation.
If this approach fails to alleviate symptoms, Nissen fundoplication may be considered for acid hypersensitivity. Several small studies in the literature support this claim. Indeed, Nissen fundoplication is a supraphysiologic procedure. Patients with esophageal hypersensitivity may benefit from eliminating the few acid reflux episodes that physiologically occur under normal circumstances. Furthermore, Nissen fundoplication reduce distal esophageal wall compliance and limits volume expansion and stretching in this area. This may help reduce symptoms because esophageal balloon distention results in heartburn and pain in patients with acid hypersensitivity.
To summarize, a thorough and proper evaluation of patients with acid reflux related symptoms by an experienced acid reflux specialist in Houston is strongly recommended to choose the best treatment solution and ensure best outcome.

#### Esophageal Kinking, Heartburn and Hiatal Hernia Surgery
Once or twice a year a GERD patient presents to Houston Heartburn and Reflux Center with heartburn and sometimes dysphagia following hiatal hernia repair and Nissen fundoplication performed around the Houston area. Recently, I have treated two patients with similar presentation following sleeve gastrectomy and hiatal hernia repair. GERD and dysphagia workup in these cases typically starts with upper endoscopy and UGI. The UGI is quite informative as it shows kinking of the distal esophagus. Distal esophagus passage from intra-thoracic to intra-abdominal location across the hiatal opening should be smooth with no angulation of kinking. Kinking occurs secondary to poor esophageal mobilization during hiatal hernia repair and aggressive posterior closure of hiatal opening. Consequently, the esophagus takes a 90-degree angle turn at the hiatal opening that leads to post-operative dysphagia and poor acid reflux control. In some cases, I have seen an S shaped distal esophagus on UGI whereby the posterior hiatal closure pushed the esophagus up and the fundoplication pushed it back down leading to severe esophageal outflow obstruction and dysphagia.
The solution to this problem is redo hiatal hernia surgery with proper distal esophageal mobilization and adequate posterior crural approximation. This area is highly dynamic as it constantly stretches and contracts to push food into the stomach. Hiatal hernia repair when properly performed respects the physiologic properties of the gastro-esophageal junction. Consequently, hiatal hernia repair should not be associated with esophageal angulation and outflow obstruction.
Of note, in sleeve gastrectomy cases, narrowing at the incisura angularis leads to proximal stomach dilation. The back pressure created from distal gastric obstruction may also lead to distal esophagus kinking independent of hiatal hernia repair. These cases of severe acid reflux disease require to redo hiatal hernia repair and sleeve to gastric bypass conversion to bypass functional obstruction at the incisura angularis.

#### Esophageal Outflow Obstruction and GERD
This particular patient I have just treated is quite interesting and worth sharing. The patient is young man who has been suffering with acid reflux for the past 15 years. He is currently in his early thirties and his GERD related symptoms are poorly controlled with high dose Dexilant. He has heartburn and food regurgitation on a daily basis. He avoids most food items in order to prevent a heartburn attack. He reports no dysphagia or food impaction. An upper endoscopy showed distal esophagitis but no hiatal hernia. His DeMeester score on ambulatory pH testing was high and he had positive symptom correlation to heartburn and food regurgitation. In preparation for Nissen fundoplication surgery, I performed an esophageal manometry. He had elevated intra-bolus pressure and slightly elevated residual lower esophageal sphincter (LES) pressure with incomplete relaxation. These findings indicate asymptomatic esophageal outflow obstruction in the setting of severe GERD. Of note, LES length was shorter than normal.
Esophageal outflow obstruction is sometimes encountered in large hiatal hernia cases. The obstruction is attributed to distortion of the GEJ anatomy by the hernia. In our case, however, the patient did not have any hernia. Instead, I found extensive adhesions surrounding the distal esophagus and “trapping” the LES in a fixed position just at the diaphragmatic level. Indeed, the intra-abdominal esophagus prior to dissection measured less than 2 cm. In my opinion, severe gastric content reflux has led to significant scarring around the distal esophagus and possibly leading to failure of the LES to completely relax. A non-relaxing LES did not prevent, however, reflux from occurring. Contrary to what LINX™ device proponent would like you to believe, LES augmentation is not a solution for GERD. GERD is not simply the result of a weak LES. It is rather a complex pathophysiological condition that results from abnormal esophago-gastric motility. Common sense interpretation limits our understanding of GERD to LES weakness or transient LES relaxation. However, LES weakness is secondary to an underlying complex motility problem that is currently only addressed by a floppy and short Nissen fundoplication. A floppy and short Nissen fundoplication does not really reinforce the LES. Any attempt at reinforcing the LES is likely to lead to postoperative dysphagia and esophageal dysmotility in the long run. In fact, in this particular patient who already has elevated LES pressure, any LES reinforcement would most likely lead to post-operative dysphagia.
Our patient had a great outcome from his laparoscopic fundoplication. I performed a short and floppy Nissen fundoplication that resulted in no dysphagia after surgery and in complete resolution of all GERD related symptoms. Can you imagine treating this patient with a LINX™ device?
It would be interesting to repeat esophageal manometry 3 to 6 months after surgery to check for the resolution of the incomplete LES relaxation and elevated residual pressure.

#### Facts about Caffeine
Many of us start our day with a steaming brew of coffee. In fact, according to researchers at Johns Hopkins University, it is estimated 80%-90% of people in America are regular coffee drinkers. Those suffering from heartburn know too well, caffeine is a major trigger of heartburn. With caffeine being so addictive it can be difficult to substitute it, or not drink it at all.

Seeing as caffeine is a major heartburn trigger, let’s look at some interesting facts on coffee from the National Coffee Association USA, 2014:

Daily consumption of espresso-based beverages on the rise, from 13% to 18%.
34% of Americans consume gourmet coffee beverages daily, up by 3%.
Daily coffee consumptions remain strong at 61%.
The highest amount of coffee brewers are aged between 25-39, at 42%, compared to only 24% of 60 and over.
61% of Americans drink more coffee than soft drinks.

What is caffeine and how does it work?
Caffeine comes from the coffee bean, kola nut, tea leaf and cacao pod. Once you consume caffeine, whether it’s a cup of coffee or a soda, it enters your bloodstream via the stomach and small intestine. You can feel the effect within 15 minutes. You are probably wondering how your cup of coffee wakes you up in the morning. According to the Harvard Medical School, caffeine blocks the actions of the brain chemical adenosine. This is the chemical that is linked to sleep. Low doses of coffee now and then can have positive effects, such as happiness and an energetic boost. A regular coffee drinker may not feel those effects after a while, but need a morning boost to overcome sleepiness.
Is there such a thing as too much caffeine?
The FDA recommends 400mg of caffeine a day, which is around 4 or 5 cups of coffee. This is a safe amount, with no dangerous side effects. However, the effects of caffeine can vary from person to person, as each individual is different. Some may be more sensitive to caffeine, whereas others may have a higher tolerance. In huge doses, caffeine is extremely lethal. The University of Washington suggest 10g of caffeine is fatal, the equivalent to 80-100 cups of coffee.

Are there any health benefits to caffeine?
Caffeine is a popular ingredient used to boost performance and increase energy. A study in JAMA Internal Medicine revealed consuming coffee is linked to lower rates in depression in women. The more caffeine consumed, the more effective it was found to be. Furthermore, a 2015 study found those who consumed 4 cups of coffee a day had a 20% lower risk of developing malignant melanoma, compared to those who drank less coffee.
Is caffeine bad for my health?
Caffeine can increase blood pressure, which in the long run stiffens the arteries. People with type 2 diabetes are also at risk, as ongoing research has found daily caffeine consumption can make it hard to keep blood sugar levels under control. Caffeine can also cause difficulty sleeping, heartburn and anxiety. Large amounts of caffeine can cause jitters, leading to headaches and dizziness, and can even make the heart beat faster.

If you suffer from caffeine withdrawals to avoid your daily heartburn, make an appointment today at Houston Heartburn to learn more about the steps you can take.

#### Facts on Citrus Foods
Another heartburn trigger; citric foods. Fruits such as oranges and lemons can cause heartburn, due to the citric content. Let’s look at some fun facts (capayvalleyfarmshop.com) on this heartburn triggering food:

The Huffington Post says lemons have many beauty benefits, which include removing acne and blackheads, whitening teeth, strengthening fingernails and even soothing chapped lips.
Citrus fruits are also high in antioxidants, which are believed to slow the aging process.
The vitamins, fiber and minerals in oranges a have important health benefits.
Vitamin C prevents the build up of free radicals, which have been linked to cancer and heart disease. Vitamin A, which oranges are high in, helps protect the eyes. And potassium helps keep a heart healthy and beating regularly.
The Meyer Lemon, which is a characterized by a school bus yellow peel and a sweeter less tart flavor, originated in China and is believed to be the product of crossing a mandarin orange with a lemon.
The technical name for a citrus peel is called a pericarp. It is divided into 3 parts: the exocarp, which is more commonly know as zest; the mesocarp, which is the white, spongy pith; and the endocarp, which is the pithy left over that clings to the fruit after you remove the peel.
Historically, rations of oranges were given to British soldiers on long ocean voyages to prevent scurvy. Scurvy is caused by vitamin C deficiency, so the high vitamin C content in oranges made them perfect for preventing the disease.

Contact Houston Heartburn today if you feel citrus fruits are triggering your heartburn.

#### Facts on Spicy Foods
Continuing our blogging on facts of heartburn triggers, this week we will be looking at spicy foods. For those suffering from heartburn, you may know depending on your taste buds, that spicy foods can trigger heartburn. Here are some facts about spicy foods you may not have known, from fillyourplate.com and kickassfacts.com:

There are 140 varieties of chili peppers grown in Mexico alone.
One of the most common reactions to numbingly hot, fiery food is to sweat which is referred to as gustatory perspiration.
The heat produced by spices or foods is measured in Scoville Heat Units (SHU).
Many hot and Spicy foods have medicinal and antimicrobial properties.
Garlic, chilies, onions, allspice, and oregano have all been proven to kill bacteria making food safer to consume.
Chili peppers can help you lose weight by boosting your metabolism and curbing your cravings for fatty and sugary foods.
Red peppers are unusually rich in vitamin C, and that paprika made from them retains more vitamin C by weight than even lemon juice. Paprika is also high in other antioxidants.
Trinidad Moruga Scorpion chili, the world’s hottest chili pepper can burn its way through protective latex gloves.
Mustard and wasabi aren’t spicy until crushed. Only when the plant’s cells are damaged can two otherwise harmless components mix and produce allyl isothiocyanate, the compound responsible for the familiar pungent taste.
The reason spicy food gets spicier after freezing and reheating is because capsaicin is stored in fats, which don’t evaporate during reheating like the water in a food, so there is a higher percentage of the spice than in the food before, causing it to be spicier.

Contact Houston Heartburn today, if you are suffering from heartburn. Whether it’s spicy foods or not, Dr. Darido can help you.

#### Functional Heartburn and Heartburn Pills
Louise from Houston asked us this interesting question: When pH, motility and gastric emptying tests come back negative, yet there is still heartburn and only partial response to a PPI, what does one do?  especially if one’s eGFR is in the 40’s.  Do you save the esophagus (in the hope that NERD won’t become GERD) or do you stop the heartburn pills to protect kidney function?
Fundoplication or LINX™? Horror stories abound on the internet!
Dear Louise,
Thank you for your interesting question. You touch upon a number of acid reflux related issues and controversies. I will try my best to clarify my answer for you. First, acid reflux diagnosis is the very first important step in acid reflux treatment. At Houston Heartburn and reflux Center, we utilize a number of diagnostic modalities to help diagnose and stage acid reflux. The diagnosis of acid reflux may not be straightforward all the time. This is where experience, training and expertise are helpful to differentiate GERD from NERD or heartburn from functional heartburn… If a solid acid reflux diagnosis is not made, heartburn patient treatment is incomplete, patient satisfaction is low and therapeutic outcomes are poor. You had a number of studies performed. An experienced acid reflux specialist will put all these study results together and meticulously go over your symptoms and history to come up with a conclusion.
Heartburn pills like proton pump inhibitors are associated with renal insufficiency when used over prolonged periods of time. I have a number of patients, at Houston Heartburn and Reflux Center, with renal problems secondary to years of PPI intake. Therefore, I am very cautious prescribing PPIs especially in the setting of renal insufficiency. I always to patients that if PPIs are helping you, Nissen fundoplication and hiatal hernia repair will help you more. Nissen fundoplication outcomes far surpass any other acid reflux treatment modality like LINX™. Properly performed hiatal hernia repair and Nissen fundoplication are safe, effective and durable. Our safety and efficacy record at Houston heartburn and Reflux Center is the ultimate proof.
Non erosive reflux esophagitis, NERD, represents less than 5% of all patients I evaluate at Houston Heartburn and Reflux Center. NERD patients have typical GERD symptoms but normal upper endoscopy. Distal esophageal mucosa shows no inflammation or erosions. NERD patients with a positive ambulatory pH or impedance study are offered Nissen fundoplication and hiatal hernia repair especially when they show partial response to heartburn pills. NERD patients with negative ambulatory pH or impedance testing and no response to heartburn pills are not likely to benefit from Nissen fundoplication and hiatal hernia repair. These patients are advised to stop proton pump inhibitor intake to avoid unnecessary side effects like renal failure. Esophageal neuromodulators like tricyclic anti-depressants and selective serotonin reuptake inhibitors are offered. Studies are needed in this field to determine the most effective drug regimen. Anti-reflux surgery, however, for NERD patients with negative ambulatory pH or impedance testing is not likely to help.

#### Fundoplication Surgery for Heartburn treatment
Jason from North Houston sent us this question: TIF vs. Toupet fundoplication: how is that decided??  Thanks so much.
Dear Jason,
I am not sure in what context you are asking this question. Comparing TIF to fundoplication surgery for acid reflux is like comparing oranges to apples. TIF, short for transoral incisionless fundoplication, is not actually a fundoplication. Fundoplication entails mobilizing the upper part of the stomach, gastric fundus, then wrapping the fundus around the distal esophagus to re-create the anti-reflux barrier. This can only be achieved using laparoscopic or open surgery. TIF is an endoscopic procedure that does not allow an acid reflux surgeon to mobilize the gastric fundus. Furthermore, TIF procedure does not include hiatal hernia repair and distal esophageal dissection. These two steps are crucial aspects of anti-reflux surgery. Hiatal hernia repair and distal esophageal mobilization restore normal anatomy and bring down the most distal esophagus and upper stomach from the chest into the abdominal cavity.
TIF procedure is limited to placating limited amount of gastric tissue around the distal esophagus. It is presumed that this simple technique restores the anti-reflux barrier and reliably stops heartburn.
Toupet or Nissen fundoplication, on the other hand, entails hiatal hernia repair, distal esophageal mobilization, complete gastric fundus mobilization to wrap around distal esophagus.
Nissen fundoplication is the preferred procedure at Houston heartburn and Reflux Center because of its high success rate and very low complication rate. Toupet fundoplication is primarily offered in cases of a gastric fundus too small to loosely wrap around the entire esophageal circumference. Consequently, the gastric fundus is partially wrapped around the posterior esophagus to prevent narrowing of distal esophagus.
The short answer to your question “TIF vs. Toupet fundoplication: how is that decided?” is simple. A properly performed Toupet fundoplication is a more reliable and durable solution for acid reflux when compared to TIF.

#### Fundoplication, Hiatal Hernia Repair and Esophageal Dysmotility
Natalie from Houston sent us this question: Do you recommend fundoplication in a patient with severe esophageal dysmotility and a paraesophageal hiatal hernia? Or is repairing the hernia the best that can be done?
Dear Natalie,
Your question is common and quite relevant. Why add a fundoplication to hiatal hernia repair especially in the setting of severe esophageal dysmotility? You are obviously concerned about post-fundoplication dysphagia (difficulty swallowing food).
Let me start by debunking a common myth about hiatal hernias. It is commonly thought that a hiatal hernia causes acid reflux. In reality, acid reflux causes a hiatal hernia to develop. The esophagus is made of two layers of muscle (longitudinal and circular muscles) that are spirally arranged around the mucosa (the inner lining of the esophagus). Chronic acid reflux causes the esophageal muscles to contract upward away from acid. This upward movement of the esophagus slowly drags the stomach through the hiatal opening. As a result, a hiatal hernia develops and continues to grow in size as long as acid reflux is not stopped. From this perspective, Natalie, a hiatal hernia is a consequence of untreated acid reflux rather than the cause. Of course, a hiatal hernia displaces the lower esophageal sphincter and weakens the anti-reflux barrier thus contributing to acid reflux. However, the root cause of acid reflux is not just hiatal hernia. Indeed, the etiology of acid reflux is multifactorial and remains poorly understood. By the way, as the esophagus retracts into the mediastinum in response to acid reflux, esophageal motility weakens. Most acid reflux patients have esophageal dysmotility. Esophageal dysmotility contributes to acid reflux by preventing effective acid clearance from the esophagus. Hence, both hiatal hernia and esophageal dysmotility are caused by acid reflux and both contribute to acid reflux creating a viscous circle that feeds on itself. For this reason, acid reflux is a chronic and progressive disease. GERD symptoms get worse and hiatal hernia size increases with time.
The purpose of hiatal hernia repair is to restore normal anatomy. A number of surgeons commonly attribute hiatal hernia repair to simply closing the hiatal opening. Such an approach, however, is not sufficient. In reality, the primary purpose of hiatal hernia repair is to bring down the distal esophagus and lower esophageal sphincter from the mediastinum into their original intra-abdominal position. Closing the hiatal opening without dissecting and mobilizing the distal esophagus is a useless operation. Restoring anatomy, however, does not recreate the missing anti-reflux barrier that led to hiatal hernia formation in the first place. Herein comes the role of fundoplication. Wrapping the gastric fundus (upper part of stomach) around the distal esophagus reliably stops acid reflux. The fundoplication cannot be performed unless the distal 4 cm of esophagus is present in the abdomen. For this reason, proper hiatal hernia repair i.e. distal esophageal mobilization, must be achieved to be able to perform a durable and reliable Nissen fundoplication. A poorly performed hiatal hernia invariably results in slipped Nissen fundoplication. The mechanism of action of Nissen fundoplication is multifactorial and is not well understood. Nissen fundoplication does not mechanically reinforce the lower esophageal sphincter like LINX™ device. Indeed, we currently perform a floppy and short fundoplication to prevent post-operative dysphagia. Even in the setting of severe esophageal dysmotility, a floppy and short fundoplication is associated with very low dysphagia rate. At Houston Heartburn and Reflux Center, our post-fundoplication dysphagia rate is zero.
In summary, fundoplication surgery in addition to hiatal hernia repair are both needed to restore the anti-reflux barrier. When properly performed, hiatal hernia surgery with Nissen fundoplication offer the most reliable cure for acid reflux.

#### Gaining a Better Understanding of Acid Reflux in 2015
Every year, research provides patients and doctors with a more comprehensive understanding of a variety of medical issues.  We often find ourselves paying close attention to new findings in some of the most serious and debilitating conditions like Alzheimer’s and cancer.  However, there is also continuous research dedicated to heartburn and acid reflux.  After all, the more serious it gets, the greater chance it can lead to esophageal cancer.
Here are some of the more recent reports that have been shared this year:
New device to help monitor conditions like GERD
The University of Colorado and EnteroTrack, LLC have initiated a license agreement centered around a device that effectively monitors the inflammation of the gastrointestinal tract. This agreement will allow EnteroTrack to develop and market a capsule that will provide an easier and more cost-effective way to gather esophageal analysis.  The idea behind this non-evasive device came from the difficulties surrounding the challenges of pinpointing inflammation, often resulting in patients having to undergo an endoscopy.

Popular heartburn medications could lead to a higher risk of heart attack
Stanford Researchers participated in a data mining study that appeared to link an increase in heart attack probability with those who take common PPI drugs like Prilosec.  This research pulled specific information from 16 million clinical records of about 3 million people in the U.S., and they concluded that people with gastrointestinal reflux disease (and took PPIs) were 16-21 percent more likely to have a heart attack than others.
Antacids may increase the probability of bone fractures
The Forsyth Institute has published new findings about the link between antacid medication and bone structure.  The findings point to stomach acids in the gastrointestinal tract that help absorb and distribute calcium in bones in the body.  PPI drugs obviously reduce such acids, which could slow down and perhaps even cease the absorption of calcium.
Genomic testing helps detect esophageal cancer risk
The Journal of Molecular Diagnostics has recommended a specific test that utilizes next-generation sequencing (NGS) to improve early cancer detection in patients with Barrett’s esophagus.  They point out that BE patients are strongly encouraged to seek regular cancer screenings, but those examinations often miss the warning signs for cancers.
Data confirms the effectiveness of the TIF Procedure (over PPI usage)
The very first random, blinded, sham-and placebo-controlled study of the Transoral Incisionless Fundoplication (TIF) procedure produced some significant results.  The results are featured in the official journal of the American Gastroenterological Association Institute and compare results from two sets of patients – one that underwent the TIF procedure, plus placebo medication, and another group that had sham surgery and took ongoing doses of PPIs.  More than half of the TIF patients said their regurgitation issues had ceased.
We’re very aware of the benefits of the TIF Procedure, and studies like these reinforce our own data.  If we can provide you with relief from heartburn/acid reflux disease, contact Houston Heartburn today.

#### Gallbladder, Digestive or Acid Reflux Issues?
Jeff from Houston sent us this question: “I have had acid reflux for around 2 year’s now. I am not over weight 6’0 190 lbs. and I eat quite well, most of the time!
Nov 30th I had a serious Gallbladder attack, they say, after all kinds of tests!
Now they want to remove my Gallbladder.
My retired nurse Lady Partner says that she is not sure if I truly have a bad gallbladder or just a case of upper digestive acid reflux problems!
My question is-Should I go ahead and have my Gallbladder removed and hope for the best…… Or do I go get another opinion to see if maybe it’s NOT my gallbladder and maybe it’s something else.” Thank you.
Dear Jeff,
In general, you should never “go ahead and have surgery done and hope for the best”. Proper diagnosis guides effective treatment. Symptomatic gallstones and acid reflux disease may have some common symptoms. However, gallstone disease and GERD are two separate problems that can be easily differentiated using proper testing.
A gallstone attack is typically characterized by severe right upper quadrant abdominal pain following food intake. Pain radiates to the shoulder and is associated with nausea and vomiting. An acid reflux attack is typically characterized by burning pain behind the breastbone that radiates up towards the throat. Nausea and vomiting are much less common with acid reflux. Food regurgitation, bloating and repetitive belching as well as nighttime symptoms are prevalent.
Symptoms guide testing. For gallstone related symptoms a gallbladder ultrasound is typically ordered. Not all patients with gallstones, however, need their gallbladder removed. Indeed, most patients with gallstones are asymptomatic. Removing a normal gallbladder or one with asymptomatic gallstones does not resolve the problem and may exacerbate pre-existing acid reflux.
If you suffer from heartburn, food regurgitation… upper endoscopy with ambulatory pH testing is a reliable test to confirm and stage reflux. Endoscopy allows the acid reflux specialist to check for hiatal hernia, distal esophagitis, ulcer formation, Barrett’s esophagus and esophagus cancer. Ambulatory pH testing measures the amount of acid reflux into the esophagus over a period of 4 days. Concomitantly, Symptom correlation can be measured to further help elucidate the GERD related symptoms.
In conclusion, do not jump on any kind of surgery without making sure surgery is going to help resolve your symptoms. Experienced acid reflux specialists in Houston can help you differentiate gallstone disease from GERD and help you make informed decisions regarding best and safest treatment options for your condition.

#### Gastric Diverticulum and Heartburn Treatment
53-year-old male presents for evaluation of severe acid reflux related symptoms poorly responsive to medical treatment. His symptoms include heartburn and food regurgitation. Upper endoscopy revealed large hiatal hernia, distal esophagitis, and a posterior gastric fundus diverticulum measuring around 5 by 5 cm. The gastric fundus diverticulum mucosa showed no ulceration or inflammation. Patient denied history of anemia, hematemesis or melena.
After thorough acid reflux evaluation and complete GERD staging decision was made to proceed with laparoscopic hiatal hernia repair and Nissen fundoplication. Laparoscopic hiatal hernia repair and Nissen fundoplication surgery are currently the most reliable treatment for heartburn in Houston. Other procedures like transoral endoscopic fundoplication and LINX™ surgery are less effective in alleviating heartburn, food regurgitation and other GERD related symptoms. Nissen fundoplication, at Houston Heartburn and Reflux Center, is close to 99.9% effective in stopping acid reflux.
During surgery, the gastric fundus diverticulum was surrounded with dense adhesions that were carefully dissected to completely mobilize the posterior gastric fundus in preparation for a short and floppy Nissen fundoplication. Patient had no contraindications for Nissen fundoplication on esophageal manometry. Esophageal manometry is a test performed prior to anti-reflux surgery to evaluate esophageal contractions and lower esophageal sphincter pressure. Esophageal manometry is an important part of GERD treatment. GERD management depends on accurate testing to confirm and stage acid reflux prior to surgical intervention.
The mobilized gastric fundus was then passed through the retro-esophageal window and rocked back and forth to make sure there is adequate mobilization. The diverticulum was found to be part of the right aspect of the fundoplication and if left unresected it may cause gastric inlet obstruction. Gastric diverticulae are rare and may be associated with bleeding, malignancy, and perforation. Large gastric diverticulae may cause dyspepsia and epigastric pain. A gastric fundus diverticulum is not likely to cause heartburn or contribute to acid reflux. The current patient had an asymptomatic diverticulum discovered incidentally on upper endoscopy while evaluating his acid reflux disease. Since the diverticulum was involving the fundoplication and may cause obstruction decision was made to resect it. Resection was performed with a linear mechanical stapler that was applied at the diverticulum base. A short and floppy Nissen fundoplication was then easily constructed around the distal esophagus.

#### Gastroparesis after LINX™ Removal Surgery
Indications to remove LINX™ device for acid reflux are numerous:

Erosion
Dysphagia
Recurrent hiatal hernia
Recurrent acid reflux
Poor heartburn control
Chest pain

Surgery for LINX™ device removal is performed through tiny incisions. Most of the time the same incisions used to place LINX™ device are used to remove it. As a foreign body, LINX™ device triggers scar tissue formation around the lower esophageal sphincter and both posterior and anterior vagus nerves. Scar tissue dissection to free LINX™ device and remove may result in vagus nerve injury. Vagus nerve injury is associated with gastroparesis development.
Gastroparesis or delayed gastric emptying is a debilitating disease. Gastroparesis patients have a lazy or paralyzed stomach that does not empty food. Symptoms associated with gastroparesis including nausea, vomiting, pain, early satiety and bloating. Gastroparesis exacerbates acid reflux leading to increased heartburn, food regurgitation, and sore throat.
Typically, LINX™ device removal is coupled by hiatal hernia repair and Nissen fundoplication to control acid reflux disease. If you had LINX™ device removal and conversion to Nissen fundoplication and you currently suffer from gastroparesis we may be able to help you.
At Houston Heartburn and Reflux Center, we do not offer LINX™ surgery for acid reflux disease. However, we have developed a simple and safe solution to get rid of post-LINX™ device removal gastroparesis without disrupting the Nissen fundoplication. A small stomach resection along the lateral aspect of the stomach is performed to promote gastric emptying. The resection is limited to the area between the gastric antrum and fundoplication resulting in 30% of the stomach removed. The surgery is minimally invasive and associated with overnight hospital stay and fast recovery.
Our preliminary results have been excellent with complete symptom resolution and normalization of gastric emptying on post-operative testing. The advantages of such an approach are numerous including low complication rate, preserving the fundoplication, and avoiding complicated revision surgeries like Nissen fundoplication to gastric bypass conversion. If you suffer from medically refractory gastroparesis, we may able to help you.

#### Gastroparesis and Pyloroplasty
I read with great interest the publication in the current issue Surgical Endoscopy by Lee Swanstrom titled “Laparoscopic pyloroplasty is a safe and effective first-line surgical therapy for refractory gastroparesis”. The study includes 177 patients collected from a prospective foregut surgery database. 133 of those patients (75%) underwent a concurrent fundoplication for GERD related issues. Gastroparesis was defined by abnormal gastric emptying study, endoscopic visualization of retained food in the stomach or clinical symptoms suspicious of vagal nerve injury following complex re-operative foregut surgery. Postoperatively only 70 patients (39%) underwent a gastric emptying study and two thirds of those patients had normalization of their emptying study results. The authors report that 11% of the pyloroplasy patients underwent further treatment for failure of symptoms to improve. They conclude that laparoscopic pyloroplasty is an effective first line treatment for gastroparesis. The use of pyloroplasty does not preclude future surgical treatments for delayed gastric emptying and most patients do not go on to require additional treatments for gastroparesis.
This study is misleading. There is no way to make any conclusions about pyloroplasty effect on gastrorparesis when 75% of patients had a concurrent fundoplication. Indeed, gastric fundus surgery in the form of antrum preserving longitudinal gastrectomy is the most effective treatment for delayed gastric emptying. In this series, the concomitant fundoplication must have had a considerable effect on gastric emptying improvement and this cannot be dismissed. Nissen fundoplication improves gastric emptying and causes dumping symptoms in certain cases.
Additional limitations are noted and further weaken this study. Less than half of the patients underwent postoperative gastric emptying testing to document improvement and the authors do not mention the number of patients who underwent preoperative testing. Relying on symptom analysis alone, especially in a patient population that suffers from GERD related symptoms, does not reliably demonstrate gastroparesis resolution. There are too many assumptions in this study and a number of unfounded conclusions. The role of pyloroplasty in treatment of gastroparesis remains limited and unsupported by studies and by logical reasoning. Gastroparesis pathophysiology is poorly understood. However, knowledge from bariatric surgery has allowed us to appreciate the function of gastric fundus in controlling gastric emptying. In our practice, gastric fundus resection rather than pyloroplasty is the first line surgical treatment of delayed gastric emptying. We have published a case of severe gastroparesis with dilated stomach and have shown that gastric volume reduction mainly at the level of gastric fundus improves gastric emptying. The pylorus does not control gastric motility. Rather gastric fundus and post-pyloric signals emanating from the proximal intestine control stomach motility and emptying.
In conclusion, gastric emptying remains a complex physiological process that is poorly understood. Gastric emptying is related to a number of medical problems like obesity and diabetes that have reached epidemic levels in our society. Understanding gastro-intestinal motility is crucial to advancing our treatment approach to gastroparesis, obesity, diabetes and acid reflux disease. Passive drainage procedures like gastro-jejunostomy and pyloroplasty have little impact on gastric emptying physiology. Please leave the pylorus alone and concentrate on understanding gastric fundus role in gastric motility.

#### Gastroparesis Following Nissen Fundoplication and Hiatal Hernia Repair
Nissen fundoplication with hiatal hernia repair is the most reliable and most effective treatment of GERD or acid reflux disease. The procedure is also very safe with less than 1% complication rate. Gastroparesis or delayed gastric emptying is a poorly understood medical disorder. Gastroparesis results from abnormal gastro-duodenal motility resulting in nausea, vomiting, bloating, epigastric pain and early satiety. Gastroparesis can also contribute to acid reflux disease. GERD is a multi-factorial problem and is closely related to gastric motility. Indeed, gastric fundus compliance, relaxation, food accommodation and luminal pressure affects transient lower esophageal sphincter relaxation, TLESR. TLESR is believed to be the main cause of acid reflux. It is not surprising for gastroparesis patients to suffer from heartburn and other GERD related symptoms. In fact, both GERD and gastroparesis may represent different aspects of the same problem related to esophago-gastro-intestinal dysmotility.
Many GERD patients undergoing Nissen fundoplication and hiatal hernia repair surgery may also have undiagnosed gastroparesis. Around 40% of GERD patients suffer from delayed gastric emptying. Nissen fundoplication increases gastric emptying and is sometimes associated with dumping especially in children. Wrapping the fundus around the esophagus decreases gastric compliance possibly leading to increased gastric emptying. The same mechanism of action may also be at play in the case of sleeve gastrectomy. By resecting the gastric fundus, gastric compliance decreases and emptying increases. Consequently, Nissen surgery improves gastric emptying and it contributes to gastroparesis symptom resolution.
In a minority of patients, Nissen surgery is associated with post-operative gastroparesis symptom development. These patients develop nausea, bloating, and pain in the first few days after Nissen surgery. It is unclear whether the surgery itself causes de novo gastroparesis or if it exacerbates an already existing problem with gastric emptying. It has always been assumed that vagal nerve injury results in gastric stasis and failure of the pylorus to relax. Pyloromyotomy has also been advocated in vagotomy cases. Swanstrom et al published a study in 2009 in Archives of Surgery titled “Outcomes of Nissen Fundoplication in Patients with Gastroesophageal Reflux Disease and Delayed Gastric Emptying”. He recommends the addition of pyloroplasty to Nissen fundoplication in cases of delayed gastric emptying. In my experience, pyloromyotomy, like other drainage procedures, has minimal effect on gastric emptying. Gastric emptying is a highly coordinated myo-electrical process. Many feedback signals, in addition to the vagus nerve, modulate this activity. It is unlikely that post-operative gastroparesis is the sole result of vagal nerve injury.
In 2004, a study published by Masclee et al, in the Annals of Surgery showed that laparoscopic fundoplication increases gastric emptying independent of vagal nerve function. The authors nicely showed that 10% of fundoplication patients developed vagal nerve dysfunction post-operatively without affecting gastric emptying or the efficacy of fundoplication in controlling acid reflux. The etiology of gastric stasis is following Nissen surgery remains unclear. There are no established treatment guidelines for gastroparesis. Medications, gastric pacing and drainage procedures are not effective solutions. Subtotal gastrectomy and gastric bypass are associated with poor outcomes. Longitudinal gastrectomy with or without duodeno-jejunostomy seems to be very effective in curing gastroparesis. I have developed this technique several years ago and I have had the chance to apply it on 4 patients so far. Last year, a young man with gastroparesis following fundoplication surgery at an outside institution presented to my office. I performed a longitudinal gastrectomy while preserving the fundoplication and antrum. His symptoms improved immediately. A post-operative UGI study on day one after surgery showed normal gastric emptying. The patient is 8-month post-op now and still doing great.
In summary, gastroparesis and gastric emptying remain poorly understood. However, a tailored longitudinal gastrectomy, even in the presence of a fundoplication, may be an effective and durable solution for gastroparesis. Additional studies are needed to establish this approach as the standard of care treatment for gastroparesis.

#### Gastroparesis following Nissen Fundoplication Surgery
Nelson from Houston emailed us this question:
“I have been diagnosed with gastroparesis years after Nissen fundoplication surgery for GERD. Would any of these surgical procedures help me at this point. I barely leave the house for fear of needing a bathroom in an emergency”.
Dear Nelson,
I am not sure which surgical procedure you are referring to for treatment of gastroparesis. However, a number of surgical options like pyloroplasty and a tailored longitudinal gastrectomy along the greater curvature may be offered in the setting of Nissen fundoplication. Pyloroplasty is minimally invasive and can be performed endoscopically nowadays. Per-oral endoscopic pyloromyotomy has been described in a number of studies for treatment of gastroparesis. The procedure is safe, but its efficacy is limited. Gastroparesis is complex gastric motility disorder and gastric drainage procedure like pyloroplasty and gastro-jejunostomy have a low success rate. A tailored longitudinal gastrectomy that preserves the gastric antrum (gastric pump) seems to promote gastric emptying and reverse gastroparesis symptoms even in the setting of Nissen or Toupet fundoplication. I have tried this approach on a limited number of patients with severe gastroparesis refractory to medical treatment. Surgery outcome was great with normalization of gastric emptying and complete resolution of nausea, bloating, vomiting and abdominal pain.
Gastroparesis developing years after Nissen fundoplication is most likely not related to fundoplication surgery itself. Diabetes, viral infections, autoimmune diseases… may cause gastroparesis. the majority of cases are however idiopathic. Thorough evaluation by a Houston acid reflux specialist who has special interest in gastroparesis is recommended prior to any surgical intervention in this particular case.

#### Gastroparesis from an Acid Reflux Specialist Perspective
Gastroparesis is a chronic motility disorder affecting the stomach and duodenum and characterized by delayed gastric emptying in the absence of mechanical obstruction. Patients with gastroparesis complain of bloating, nausea, vomiting, pain and heartburn. Gastroparesis may cause acid reflux since gastric emptying is impaired. Furthermore, many patients with acid reflux disease reports belching, bloating, pain, nausea and food regurgitation; these symptoms are commonly associated with gastroparesis. The underlying pathophysiology connecting gastroparesis and acid reflux disease remains poorly understood. It is important, however, to maintain a high index of suspicion for a potential gastrointestinal motility disorder when evaluating patients for acid reflux disease.
At Houston Heartburn and Reflux Center, patients presenting for acid reflux evaluation may undergo an esophageal manometry study to check for esophageal dysmotility and a gastric emptying study to check for delayed gastric emptying. Both esophageal dysmotility and delayed gastric emptying contribute to acid reflux disease.
If gastroparesis is diagnosed in the setting of acid reflux disease patients are counseled prior to proceeding with treatment. Gastroparesis is a chronic and difficult disease to manage and treat. There are no medications effective enough to restore gastric motility. Surgical options are limited with poor outcomes reported with subtotal gastrectomy. Traditionally, a gastric drainage procedure is added to gastroparesis patients undergoing Nissen fundoplication surgery for treatment of acid reflux disease. Typically a pyloroplasty is performed with acceptable outcomes. Gastric Bypass surgery has been recently proposed, in one study from the Cleveland Clinic, as a good option for gastroparesis in the morbidly obese patient. Gastric bypass surgery is an excellent treatment for acid reflux too. However, the remnant stomach may cause symptoms of bloating and pain since gastric secretion tends to accumulate in the paralyzed stomach.
A better alternative is a procedure I developed few years ago called longitudinal gastrectomy with a duodeno-jejunostomy. Resecting the gastric fundus seems to increase gastric emptying and draining the duodenum with a duodeno-jejunostomy promotes duodenal emptying. Preserving the antrum is important during longitudinal gastrectomy as it represents the gastric pump and promotes emptying. I published the first longitudinal gastrectomy and duodeno-jejunostomy as a case report in the journal of Surgery For Obesity And Related Diseases. I performed a second one on a young patient with idiopathic gastroparesis. Both patients did very well and were followed for up to one year after surgery.
Gastrointestinal motility affects many functions in the body and contributes to many diseases like acid reflux, diabetes and obesity. Gastric motility patterns are highly coordinated and still poorly understood. Future research will shed more light on the effect of gastric motility on acid reflux disease.

#### Gastroparesis in the Setting of Pancreatitis
Brenda from Houston sent us this question: “I recently had an ERCP with stenting since the doctors were suspecting that I had stones in my bile duct. The day after I have a gallbladder surgery. Immediately after, I developed post ERCP pancreatitis. Now, almost 6 weeks after, the pancreas has resolved but I was left with a chronic nausea and sudden pains. My GI performed a gastric emptying study and it came back abnormal. Now, I am showing symptoms of gastroparesis. My doctor is confident that this can be changed by diet modification which I have done and that this is only temporary, but the nausea is there all the time, I get bloated and I get full easily. Medications are losing their effect. Is it common to exhibit signs of gastroparesis after gallbladder surgery and does it actually correct with time? What options do I have?”
Dear Brenda,
Gastroparesis and gallbladder surgery are not related. Gastroparesis, gallbladder disease and pancreatitis, on the other hand, share a number of symptoms including abdominal pain, nausea and vomiting. If ERCP did not show common bile duct stones, your symptoms were most likely secondary to pre-existing gastroparesis. If ERCP was positive for stones, pancreatitis may cause gastroparesis that is typically transient in nature and tend to improve with time. Complicated pancreatitis with pseudocyst formation may result in gastric outlet obstruction. In this situation, pseudocyst drainage is indicated to alleviate symptoms.
First step management for gastroparesis relies on dietary changes (small frequent meals), along with pro-motility and anti-emetic medications. There are a number of pro-motility medications available on the market. If you fail medical treatment and lifestyle changes, a number of procedures may be considered for treatment of gastroparesis. We have discussed these treatment options in a number of previous blogs.

#### Gastroparesis in the Setting of Previous Pyloromyotomy
Sam from Houston sent us this question: “I am 54-year-old now, and I have suffered with delayed gastric emptying for the past 20 years. I have bloating, nausea and pain almost every day. I had a pylorus muscle surgery when I was an infant. I recently had pylorus Botox injection, but my condition did not change. My GI doc suggested a new procedure called G-POEM, but I don’t think it is going to help me. Please advise”.
Dear Sam,
You are right, G-POEM or endoscopic pyloromyotomy is not likely to promote gastric emptying to alleviate your symptoms. After all, you had a pyloroplasty as an infant most likely for pylorus hypertrophy and you failed a trial of Botox injection. Consequently, endoscopic or laparoscopic pyloromyotomy is not indicated in your case. In general, I am not a big fan of cutting pylorus muscle for gastroparesis.  The pyloric muscle in most gastroparesis patients is widely open. From a pathophysiology point of view, any procedure aiming at mechanically decompressing the stomach does not address the problem of gastroparesis. Gastroparesis or delayed gastric emptying is characterized by the lack of coordinating gastric contractions to empty gastric content in the absence of mechanical obstruction.
On the other hand, an antrum preserving longitudinal partial gastrectomy along the Magenstrasse emptying pathway results in normalization of gastric emptying. Around 40 patients in my practice at Houston Heartburn and Reflux Center have received this surgical approach with 100% success rate.  Gastroparesis patients experienced full resolution of nausea, bloating, vomiting, epigastric pain and constipation. Surgery is performed through tiny incisions. It is associated with fast recovery and low complication rate.
Today, we still don’t have a treatment guideline for medically refractory gastroparesis. Studies are needed to establish the best treatment approach to gastroparesis. I predict an antrum preserving longitudinal gastrectomy along the Magenstrasse emptying pathway will become the standard of care for gastroparesis patients in the near future.

#### Gastroparesis Severity Score
The gastroparesis cardinal symptom index, GCSI, is a calculated score to assess gastroparesis symptom severity. Several studies have confirmed its validity and reliability in assessing symptom severity and response to treatment.
GCSI is a composite score of nine symptoms grouped into three categories: nausea/vomiting, postprandial fullness, and bloating.

Nausea
Retching
Vomiting
Stomach fullness
Early satiety
Feeling excessively full after meals
Loss of appetite
Bloating
Visibly larger belly

Each symptom is reported according to a severity scale ranging from 0 to 5:

No symptom
Very mild
Mild
Moderate
Severe
Very severe

GCSI score is calculated as an average score of all 3 symptom categories. It is useful to evaluate gastroparesis treatment effectiveness. At Houston heartburn and reflux Center, we offer laparoscopic antrum preserving longitudinal gastrectomy for medically refractory gastroparesis. The procedure is associated with 100% percent symptom resolution including nausea, vomiting and bloating. Meal size after antrum preserving longitudinal gastrectomy is small because stomach volume is reduced. Patients, however, tolerate multiple small meals a day without any discomfort. Consequently, patients can stop TPN, and tube feeding and regain body weight.

#### Gastroparesis vs GERD: When You Have A Hammer In Your Hand, Everything Around You Starts Looking Like A Nail
The patient is a 34-year-old male with epigastric pain and belching following food intake. He rarely had heartburn, sore throat, chronic cough, or food regurgitation. He also denied vomiting. He responded poorly to PPI therapy. His workup included a negative pH Bravo study, and upper endoscopy showing no distal esophagitis or irregular Z line. He had a widened hiatal opening but no obvious axial displacement on the EGD pictures he shared with me. His treating physician decided to perform a TIF procedure (Transoral Incionsless Fundoplication) for presumed acid reflux disease that is poorly controlled with PPIs.
Following TIF, the patient epigastric pain persisted and he started developing severe postprandial bloating. A gastric emptying study showed delayed gastric emptying suggestive of gastroparesis. He was then started on Erythromycin and Reglan with minimal symptom improvement. An upper endoscopy with pyloric sphincter Botox injection was then performed but with no symptom relief. He presented to my office for a second opinion. The patient has occasional heartburn but the bloating and epigastric pain are the main complaints.
Gastroparesis and acid reflux disease may have overlapping symptoms. Gastroparesis may also contribute to acid reflux disease especially in the presence of a hiatal hernia. Both GERD and gastroparesis can be present at the same time further complicating the treatment approach. It is crucial however not to mistaken a gastroparesis case for acid reflux. The differentiation starts with history taking. As in this case, the patient symptoms were more suggestive of gastroparesis than acid reflux. The lack of response to PPI and the negative pH bravo study further supports gastroparesis. All patients with more bloating and epigastric pain related symptoms compared to heartburn and food regurgitation have gastroparesis until proven otherwise. All patients with recurrent vomiting are less likely to have acid reflux disease and other diagnostic testing should be considered.
The treatment of gastroparesis is quite challenging. Traditional medications are not effective most of the time and are associated with side effects like tardive dyskinesia. Newer medications are being tested. A ghrelin agonist is being developed by Pfizer and is already in stage 2 trials. The treatment however of gastroparesis like that of obesity and diabetes is multifactorial and one medication controlling one pathway is unlikely to work. Our understanding of gastric emptying remains limited and further research in this field is needed to better treat this vexing problem. I used a longitudinal gastrectomy with duodeno-jejunostomy for treatment of severe refractory gastroparesis in two patients and it worked very well. Resecting the gastric fundus promotes gastric emptying and may be of therapeutic value in gastroparesis cases. Similarly, a Nissen fundoplication increases gastric emptying and when combined with a pyloroplasty, it may be a good option for patients with severe acid reflux disease and delayed gastric emptying. I personally prefer the use of gastric fundus resection to promote gastric emptying and resolve acid reflux. Obviously, a prospective randomized study is desperately needed to answer these questions and develop clear guidelines for treatment of a growing problem like gastroparesis.

#### Gastroparesis, Hiatal Hernia, Heartburn and Gastric Pacemaker
Mary from Houston sent us this question: “I have severe acid reflux. I take Nexium and another PPI twice a day. I wake up in middle of the night burning like crazy and choking from the acid coming up. I sleep with my bed elevated. I will burn for a couple of hours. I’m have constant postnasal and cough drip which is from the reflux. I have Gastroparesis and have a stimulator. I also have a hiatal hernia that has gotten bigger. My doctors will not do anything with the hiatal hernia or reflux because of the gastroparesis. I need help. I do watch what I eat but it doesn’t matter. Thank You”.
Dear Mary,
Hiatal hernia repair is particularly indicated in the setting of gastroparesis. Delayed gastric emptying promotes stomach content backflow into the esophagus leading to longer and more severe reflux episode. Consequently, you are more likely to have cough and chocking especially at night, when you go to sleep and lay flat on your back.
Hiatal hernia repair by itself, however, is not enough to re-create the anti-reflux barrier. A Nissen fundoplication must be added to hiatal hernia repair to stop acid reflux. Doctors are reluctant, however, to add a Nissen fundoplication in the setting of gastroparesis because you cannot vomit after Nissen fundoplication. Therefore, your gastroparesis symptoms like nausea, vomiting, bloating and abdominal pain may get worse after Nissen fundoplication in the setting of gastroparesis.
To circumvent the problem, a pyloromyotomy has traditionally been performed in conjunction with hiatal hernia repair and Nissen fundoplication to decompress the stomach in case of gastroparesis. Pyloromyotomy may help especially that fundoplication promotes gastric emptying. However, at Houston Heartburn and Reflux Center, we have developed an effective procedure for gastroparesis than entails resecting the lateral side of the stomach while preserving the gastric antrum. We call the procedure and antrum preserving longitudinal gastrectomy. We have had great success in approximately 100 gastroparesis patients so far. In case of concomitant Nissen fundoplication, the stomach is resected from just above the antrum level to just below the wrap.
We believe that this approach is superior to pyloromyotomy in terms of promoting gastric emptying as opposed to simply cutting open the stomach outlet. By the same token, antrum preserving longitudinal gastrectomy avoids bile reflux from duodenum into stomach. Bile gastritis is a commonly encountered with gastroparesis and following pyloromyotomy.
Gastric pacemaker, or stimulator as you call it, does not improve gastric emptying. A gastric pacemaker may, theoretically, worsen acid reflux. This may be your case. I recommend thorough evaluation of your condition prior to any surgical intervention. The co-existence of GERD and gastroparesis complicates management. At Houston Heartburn and Reflux Center, we specialize in both conditions and we make sure we offer our patients the best possible solutions to alleviate these debilitating symptoms and improve quality of life.

#### Gastroparesis, PPIs, and Heartburn
Jane from Austin sent us this question: “I have been taking Pantoprazole since March of this year for acid reflux; however, I see no improvement. Instead, I got recently diagnosed with gastroparesis. I strongly suspect that PPI is causing this as I have no risk factors such as diabetes.
I am MD and teach medical and nursing students. What are your thoughts about this? Thank you”
Dear Jane,
You most likely have idiopathic (unknown cause) Gastroparesis. 80% of all gastroparesis cases are of unknown cause. PPIs or proton pump inhibitors may exacerbate gastroparesis, but they are not likely to cause gastroparesis. Other causes for gastroparesis include diabetes, auto-immune disease, viral infection, and stomach surgery.
One of the earliest symptoms of gastroparesis is heartburn. Heartburn may present prior to nausea and vomiting. For this reason, most patients with gastroparesis are started and maintained on PPIs. Indeed, gastroparesis may cause acid reflux even in the absence of a hiatal hernia. Treatment, however, does not depend on PPIs in this case.
At Houston Heartburn and Reflux Center, we offer Antrum Preserving Longitudinal Gastrectomy, APLG, to restore gastric emptying, (houstonheartburn.com/best-treatment-for-gastroparesis). This outpatient procedure is safe, minimally invasive, and reliable. We believe APLG is a more effective treatment solution for gastroparesis than gastric bypass, pyloromyotomy, and gastric pacing. Heartburn and acid reflux resolve following effective gastroparesis treatment.

#### GERD – Fast Facts
Nearly 95% of heartburn sufferers associate it with a particular food.
The majority of people report symptoms at night, with only 20% occurring during the day.
Those suffering from weekly heartburn have been experiencing symptoms for more than five years.
Roughly 7 million people in the United States experience symptoms of GERD.
1/3 of Americans suffer from heartburn at least once a month, with nearly 10% experiencing it daily.
Infants can also experience heartburn, but tend to grow out of it.
6 million prescriptions are written annually for heartburn medications.
It’s estimated by the American College of Gastroenterology that the symptoms of GERD result in almost $2 billion in lost productivity each week of the year.
5-7% of the world’s population complains of heartburn on a daily basis.

If you fall under one of these alarming statistics (provided by healthline.com and helpingheartburn.com), contact Houston Heartburn today!

#### GERD after Sleeve Gastrectomy
Question of the week from Goldy: I am 4 months out of Gastric Sleeve surgery. While the weight loss results are wonderful, I’m constantly struggling with acid reflux. It affects every aspect of my daily life and is quite terrible. Omeprazole helped, but my doctor took me off it due to the long-term side effects. H2 blockers and antacids have not been helpful at all. The symptoms are becoming more unbearable each day. What would you advise I do?
Dear Goldy,
Thank you for your interest in Houston Heartburn and Reflux Center. Your question is quite relevant. Acid reflux following gastric sleeve surgery is debilitating and poorly responsive to medications like Omeprazole. Post sleeve gastrectomy acid reflux occurs for two reasons:
1- A concomitant hiatal hernia was not repaired during sleeve gastrectomy
2- Gastric sleeve lumen was narrowed at the incisura angularis, the junction between upper two thirds and lower one third of the stomach
A properly performed gastric sleeve surgery and hiatal hernia repair are an excellent solution for GERD. Unfortunately, most bariatric surgeons elect to skip hiatal hernia repair with sleeve gastrectomy. As a result, the upper part of the sleeve is in the chest exposed to negative intra-thoracic pressure. This results in severe acid and bile reflux poorly responsive to medical treatment. The majority of patients have associated bile gastritis that further exacerbates symptoms of epigastric pain, bloating and nausea.
A number of bariatric surgeons continue to use very small calibrating bougie size especially at the level of the incisura angularis. A narrowed gastric sleeve lumen at this location causes severe GERD. With time, persistent GERD results in the development of hiatal hernia further exacerbating acid reflux related symptoms.
What can you do?
GERD post sleeve gastrectomy can be fixed. If a hiatal hernia is present, laparoscopic hiatal hernia repair can be performed. If narrowing of the incisura is found, then conversion of sleeve to gastric bypass is indicated. In both cases, GERD symptom resolution occurs immediately following surgery. Both surgeries are associated with low morbidity and mortality rates. I caution you against LINX™ device placement for management of post sleeve gastrectomy acid reflux. There is no role for LINX™ in this setting especially if the incisura angularis is narrowed. Furthermore, there are no studies to support LINX™ effectiveness post sleeve gastrectomy GERD.

#### GERD Surgery in Houston: When and Where?
GERD surgery in the form of laparoscopic hiatal hernia repair and Nissen fundoplication is the most reliable treatment for severe acid reflux disease, but only in the hands of the expert. Expert acid reflux surgeons at Houston heartburn and reflux Center dedicate their practice to the diagnosis and treatment of acid reflux disease. The end result is high patient satisfaction; the hallmark of a center of excellence for heartburn management.
Heartburn and acid reflux surgery requires advanced skills, and deep knowledge of GERD pathophysiology. Hiatal hernia repair and Nissen fundoplication are considered physiologic procedures. The stomach is manipulated to achieve a desired outcome: stop reflux. The surgeon does not resect or bypass the stomach. Rather, the stomach is gently plicated without torsion or tension around the lower esophageal sphincter to re-establish the anti-reflux barrier. The components of this newly created anti-reflux barrier are many. A common mistake is to assume that the fundoplication works as a high-pressure area around the lower esophageal sphincter. The fundoplication is not a stricture and should not mechanically restrict the distal esophagus. Indeed, we perform a short and floppy fundoplication to create the least amount of resistance to esophageal emptying. The end result is high acid reflux control and very low postoperative dysphagia rate.
A competent acid reflux surgeon understands these nuances not only in the operating room but also during acid reflux work up prior to fundoplication surgery. For this reason, at Houston heartburn and reflux center, workup, diagnosis and treatment are all concentrated in one place under the supervision of one expert acid reflux specialist. Acid reflux workup and patient selection are important determinants of acid reflux treatment outcome. One cannot expect excellent Nissen fundoplication outcomes if heartburn diagnosis and treatment are separated.
In summary, GERD management is best performed in dedicated centers for heartburn and acid reflux diagnosis and treatment. Nissen fundoplication and hiatal hernia procedure is an excellent solution for heartburn but only in the hands of competent acid reflux specialists.

#### GERD-Friendly Holiday Meal Guide
Holiday meals often bring on heartburn, bloating, and discomfort—especially from Thanksgiving through December, when many of us enjoy rich and heavy foods. If you struggle with GERD, certain holiday favorites may trigger acid reflux. Here are some simple substitutions and habits that can help you enjoy the season with fewer symptoms.

Tips for a GERD-Friendly Holiday

 	 Drink mocktails: Alcohol can worsen reflux. Choose non-alcoholic wine, beer, or festive mocktails instead.
 	 Choose low-fat options

 	Pick baked instead of deep-fried meats and vegetables. For example, baked turkey or roasted cauliflower is better than fried versions.
 	Skip the gravy.
 	Choose baked potatoes with a drizzle of olive oil instead of mashed potatoes loaded with butter.
 	Avoid topping your pumpkin pie with ice cream or whipped cream.


 	 Avoid acidic foods

 	Swap cranberry sauce for applesauce.
 	Replace citrus- or vinegar-based dressings with Greek yogurt dressings or ginger- and sesame-oil dressings.


 	 Limit spicy foods

 	Highly spiced cuisines like Mexican or Indian dishes may increase heartburn.
 	Avoid adding hot sauces to your plate.
 	Stay away from onions, garlic, and jalapeños, which commonly trigger symptoms.


 	 Avoid certain herbs: Mint is known to relax the lower esophageal sphincter and can worsen reflux.
 	 Avoid coffee: Choose herbal teas, chicory root coffee alternatives, or mushroom-based coffee substitutes. Avoid mint and peppermint teas.
 	 Eat small portions: Large meals stretch the stomach and weaken the anti-reflux barrier, leading to significant symptoms.
 	 Take a walk after eating: A gentle walk can improve digestion. Avoid lying down for at least 3–4 hours after your meal.

Key Points

 	Opt for baked, low-fat foods and avoid acidic, spicy, or mint-based items.
 	Alcohol and coffee are common triggers—consider reflux-friendly alternatives.
 	Small, mindful portions and light activity after meals can significantly reduce symptoms.
 	Simple swaps can make holiday meals enjoyable without worsening GERD.

If you have GERD and you think it is affecting your quality of life give us a call at 832-945-8717 to discuss safe and reliable solutions to cure your acid reflux and allow you to enjoy food again.

#### GERD: An Intriguing Disease On the Rise
Recently, Dr. Darido, MD, became a Contributing Editor in the MD News magazine. His first article is based upon the increasing rise of GERD. Darido mentions, “today, around one-third of all Americans experience a GERD-related symptom at least once weekly. Esophageal adenocarcinoma, a complication of GERD, is the fastest growing cancer in the U.S. Abdominal girth and excess weight contribute to GERD.”
There have been many studies Darido goes on to mention, on the link between BMI and GERD, and that “obesity may promote the development of GERD.” The question Darido proposes is, if obesity has an association with GERD, “what would be the underlying mechanisms?”
Based on studies, the association between obesity and GERD comes from the relation of increased intra-abdominal pressure secondary to abdominal fat accumulation. Darido goes on to mention how this process works, “Intra-gastric pressure increases, promoting a backflow of gastric content into the esophagus. Several studies have shown that GERD patients’ increasing BMI is independently associated with increased intra-gastric pressure.” As simple as this sounds, this is only the basis of complex problem. There are three components making up the gastroesophageal junction (GEJ), which is the foundation of GERD pathogenesis. The diaphragmatic crura is made up of:

Lower esophageal sphincter
The surrounding crural diaphragm: the angle of the Hiss – where the intra-abdominal esophagus joins the stomach).
Phrenoesophageal membrane (PEM)

Together these three components work together to prevent acid reflux. Dr. Darido goes on to discuss bariatric surgery as an option for weight loss to help ease acid reflux. However, a recent study showed “resolution of symptomatic GERD following sleeve gastrectomy in morbidly obese patients.” Could this be another option?
The future will bring new treatments and procedures, as GERD continues to rise. Read the full article here.

#### H Pylori vs GERD
H Pylori, Heartburn and Acid Reflux
Key Points Discussed:

H. pylori is common and often causes no symptoms.
Some patients develop gastritis, ulcers, and stomach cancer.
Most H. pylori acquisition happens in childhood, but disease manifests more often after age 40.
Declining H. pylori rates coincide with increases in GERD and related diseases.
Studies give mixed results on whether eradication of H. pylori worsens GERD.
The mechanism connecting H. pylori to GERD is still ambiguous.
In advanced GERD, H. pylori eradication has little effect on symptoms.

Helicobacter pylori (H. pylori) is a bacterium that colonizes the lining of the stomach. H. pylori bacteria produce its own antacids to be able to survive the harsh acidic environment of the stomach. H. pylori affect up to 30 % of the Houston population. Acquisition of H. pylori generally occurs in young children within the family environment. However, the risk of developing H. pylori related diseases increases over the age of 40.
Most individuals who have H. pylori will never manifest any symptom related to H. pylori infection. Some, however, develop gastritis (inflammation of stomach) and experience symptoms like abdominal pain and discomfort, bloating and burping as well as nausea and vomiting. Others may develop ulceration of stomach lining that results in bleeding and severe pain. H. pylori is also a risk factor for gastric cancer development.
The prevalence of H. pylori infection has declined in the United States and worldwide, which has led to a reduction in peptic ulcer disease and gastric cancer. Concomitant with this gradual decline, there has been an alarming increase in asthma, obesity, as well as GERD, Barrett’s esophagus and esophageal cancer. Some studies in the literature indicate that H. pylori eradication worsens esophagitis and GERD related symptoms, while others do not show any change in GERD symptom severity and disease progression after H. pylori is eliminated.
At Houston Heartburn and Reflux Center, we have not observed worsening GERD following H. pylori eradication. Most patients who present to our center are stage 3 and 4 GERD, so it is possible that at this stage, eliminating H. pylori has minimal impact on GERD severity. Nonetheless, the role of H. pylori in GERD pathogenies remains ambiguous. GERD is a complex multifactorial disease; H. pylori, and potentially other gut microbiota, as well as numerous gastrointestinal neurohormonal signals may influence acid reflux development and progression.

Reference
Key Finding

Bor et al. (2017)
Prevalence of GERD in high H. pylori regions.

Mungan & Pınarbaşı Şimşek (2017)
Discusses the GERD-H. pylori relationship.

Xue et al. (2015)
RCT on H. pylori eradication and reflux esophagitis therapy.

Zhao et al. (2020)
Meta-analysis on the effect of H. pylori eradication in GERD patients.

Chung et al. (2011)
Shows inverse correlation between H. pylori serology and risk/severity of reflux esophagitis in an endemic area.

#### Heartburn 101
You’re at your favorite Mexican restaurant in town with your family, sitting outside on the patio, taking in the scenery. You’re sipping a margarita while eating chips as you dip them into a homemade, fiery salsa. Your waiter serves you your entree —a chimichanga smothered in chili and nacho cheese with a side of jalapenos. You dig in, savoring every single, delicious morsel. You’re in heaven as you devour every bit of it, leaving your plate impeccably clean. You’re overcome with a great sense of satisfaction as you get your check and pay for the meal. Unfortunately, you might also be paying for your meal later.
That’s because a couple of hours later when you’re at home sitting on the couch, you start feeling an uncomfortable, burning sensation in the middle of your chest and in your throat. While it has nothing to do with your heart, heartburn mimics a heart attack. Luckily, it’s not life threatening, but rather an uncomfortable, common condition affecting more than 40% of all Americans at least once a month.
Now, if you have frequent heartburn, it may be a sign of a more serious problem called gastroesophaegeal reflux disease (GERD) — a chronic condition of irritating stomach acids that back up into the esophagus, causing irritation and damage to the lining of the esophagus.
Heartburn and Your Digestive System
In order to understand heartburn, you need to understand how your digestive system works. It all begins with your mouth, where food is chewed and mixed with saliva. From there, food travels to the esophagus and moves food to the stomach. The esophagus and stomach are connected by the lower esophageal sphincter (LES), which works like a valve by opening to allow food to pass to the stomach and closing to keep food and digestive juices from flowing back into the esophagus. However, if the sphincter relaxes when it shouldn’t or becomes weak, stomach acid can flow backward into the esophagus, causing the burning sensation we know as heartburn.

Heartburn Triggers
Food isn’t the only cause for heartburn. There are a variety of factors that both contribute and exacerbate heartburn and the weakening of LES.
 

Acidic foods and fried, fatty foods
Alcohol
Coffee
Cigarettes
Medical conditions (diabetes, asthma)
Overweight
Some medications

More factors
Some people have abnormal muscle or nerve function in the stomach that affects the stomach’s muscles to contract in a normal fashion, so food is in the stomach longer, increasing the chance of acid seeping back into the esophagus.
Hiatal hernia is a condition where there is an opening in the diaphragm, the muscular wall below the lungs that separates the chest cavity from the abdominal cavity, permitting the upper stomach to protrude through the hole into the chest, impairing the LES’s ability to prevent reflux.
Treatments
Fortunately, there are ways to eliminate or minimize your heartburn. For starters, you want to make lifestyle changes and modify your diet. You should definitely seek out a medical professional, who can make an evaluation and suggest treatment options.
Now that you know more about heartburn, you know it’s not something you have to live or suffer with. Contact Houston Heartburn so you can eat, drink, and enjoy!
 
 
 
 
 
 

#### Heartburn and Anxiety
Relating heartburn and anxiety may not be such an obvious choice; however, it can be common. In moments of stress and panic attacks, symptoms of what seem like heartburn can occur. Hyperventilating during a panic attack can mimic heartburn due to chest pain. If you are prone to panic attacks from stress, heartburn symptoms or suffering from heartburn are more likely to trigger these attacks. Stress takes its toll on your body in multiple ways. It can affect your body’s hormone level and how well your body works. As a result of this stress, many people have a lower esophageal sphincter, which doesn’t work correctly. This will result in acid flowing up from the stomach to the throat, causing heartburn.

Three common causes of heartburn resulting from anxiety include:
Changes in Digestion: stress and anxiety can slow down and cause poor digestion, which can create a build up of acid in the stomach.
Stomach Pressure: the more pressure on the stomach, the higher the likelihood of acid being pushed through the esophagus and causing heartburn. One of the symptoms of anxiety is muscle tension; therefore, we can see the relationship between stress and heartburn, and excess tension from anxiety in the stomach causing acid reflux.
Excess Stomach Acid: stress can increase the amount of stomach acid. Not only will this cause heartburn, but may also cause a loss of appetite.

While medication may help, it is always a good idea to try to prevent heartburn and stress from occurring in the first place. Take a look at the following tips to reduce your stress levels, preventing stress related heartburn:
Exercise: can decrease stress levels due to the production of endorphins, the “feel-good” chemicals. Endorphins also help with digestion!
Healthy diet: eating a balanced meal is crucial. Eating lots of fresh fruit and vegetables provides your body with the nutrients needed to function well under pressure.
Getting enough sleep: 7-8 hours of sleep is needed to reduce stress levels; studies have shown those who are sleep deprived have higher levels of stress.
Cutting down on caffeine and alcohol: not only are these heartburn triggers, but studies have shown the response to stress is much higher when consuming these substances.
Suffering from stress and anxiety can be a difficult issue to deal with. The many add-on effects of stress, including heartburn, can be tough. Make an appointment with Dr. Darido today, to see how you can manage your heartburn.

#### Heartburn and Pregnancy
Along with the glow of being pregnant comes weight gain, back pain, constant trips to the bathroom, itchy skin, fatigue, sweating and sleeplessness. If that weren’t enough, add heartburn to the list. Yes, that fiery sensation known as heartburn, where the lower esophageal sphincter (LES), a muscle responsible for keeping stomach contents in their place, begins to relax or leak, allowing stomach acids to flow upward into the esophagus.
Many women experience heartburn for the first time during pregnancy because hormones relax the muscles in your digestive tract, including the valve in the esophagus. This allows stomach acids to more easily seep back up the esophagus, especially when you’re lying down. These certain hormones appear to weaken the LES, and the increasingly crowded abdomen encourages reflux. Heartburn can be worse in your second and third trimesters, when your growing uterus presses on your stomach — sometimes pushing food back up into the esophagus.
Even if you do experience heartburn during your pregnancy, there are things you can do to lessen or even eliminate it all together. Here are some tips on what to do:
Eat less, more often
Overeating exacerbates heartburn, so try eating five or six small meals a day instead of eating three large meals. That helps your body digest food better. When you’re pregnant, there’s less room for your stomach to expand, so smaller meals can stave off heartburn.
Eliminate Trigger Foods
Identify foods that give you heartburn and then eliminate them from your diet, which helps. Typical culprits are acidic foods, like citrus fruits and tomatoes, greasy or fried foods, spicy foods, chocolate, coffee and carbonated beverages and alcohol. Hopefully, you’ve already eliminated that last one.
Fluids, fluids, fluids
Liquids are less likely to cause problems than solids since they go through the stomach more quickly. Soups, smoothies, yogurt, milkshakes, protein shakes and puddings are all good choices. Liquids with plenty of protein, such as milk and drinkable yogurt, are great options, too.
Sleep Smart
Don’t eat anything for at least three hours before bedtime. Plus, elevate the head of your bed by placing books under the legs and always try sleeping on your left side.
For most women during pregnancy, heartburn is temporary and mild. However, severe heartburn can be the sign of a more serious problem. Talk to your health care provider if it becomes severe and you notice unusual symptoms.
If heartburn is common to you even when you are not pregnant, contact Houston Heartburn for relief.
 

#### Heartburn and the Challenges You Face While Eating Out
As convenient as eating out can be, it’s always stuck in the back of your mind – heartburn. What can I eat? Will there be anything for me to eat? You may even find yourself avoiding social situations, just to stay clear of your heartburn worries, and eat a tomato-free, spicy- free meal at home instead.
You shouldn’t let heartburn stop you from doing what you love to do, and especially being social. We will look at the best ways to tackle going out to eat, while avoiding heartburn, too!
Remember and know your heartburn trigger foods: each food affects each person differently. Avoiding heartburn while you eat out will be much easier if you know what gives you heartburn and what doesn’t. Common trigger foods include fried foods, tomato based foods, spicy foods, alcohol, soda, chocolate and citrus fruits. Keep a journal to track which foods work for you, and which don’t.
Make changes to suit you: most restaurants are open to making slight changes to suit your needs. For example, ordering pasta with a different sauce, such as pesto, rather than a tomato based sauce, will allow you to eat what you like without the heartburn kicking in.
Try to avoid alcohol: choose a different drink, such as ice tea, if you find alcohol triggers your heartburn. If you want to indulge, don’t gulp down your whole drink. Slowly sip your drink instead.
Eat smaller portions: the portions at restaurants tend to be rather big. Eating your whole meal or stuffing yourself until you are overfull may trigger heartburn. Order smaller or half size portions, or even a kid’s meal. Sharing food with your friends is also a good way to prevent overeating. You can also take your leftovers home if it is too much to eat at once.
Eat slowly: take time to enjoy your food and eat at a slower pace to prevent eating too much and too fast. Converse with friends and take your time. Stop eating when you feel comfortable and not too full.
Don’t eat too late: if you are out at the movies or at a show, it can quickly become really late to eat dinner. Try eating early, maybe before the movies, to allow your food to digest and prevent heartburn. You should aim to eat at least 3 hours before you sleep. If it does happen to get late, stick with lighter foods and drinks, such as salads and water.
Dress in comfortable clothes: you may not realize, but what you wear can have an impact on your heartburn. Tight clothes, especially around your stomach, are bad news for heartburn, as this can increase pressure on your stomach and push what’s inside your stomach up into the esophagus.
Follow these simple tips for a heartburn-free night out with friends and family. Contact the specialists at Houston Heartburn today if you are unable to control your heartburn.

#### Heartburn at Night: Food and Drinks to Avoid
The next time you get a late-night snack craving, it’s important to remember that while you may satisfy an appetite, you might also create an uncomfortable night of sleep.  Sure, there are some foods or drinks that might help you rest, but there are others that will cause you to take heartburn and acid reflux to bed with you.
Here some late night culinary companions that you should avoid:
Milk
While it’s widely believed that milk can help relieve heartburn, it can actually cause it or make it worse.  The cool feeling you get from drinking it might be nice, but as the calcium hits your stomach, it will produce more acid.
Chocolate
If your sweet-tooth is talking to you at night, it’s a good idea to avoid chocolate.  It contains a combination of ingredients like caffeine, cocoa, and fat – all of which can contribute to heartburn and acid reflux.
Wine
While wine and alcohol are popular choices to help you relax, it’s counter-productive if it makes any sleeping an uncomfortable experience.  Alcohol can be a contributor to heartburn and acid reflux.
Pizza
Leftovers are a popular choice for a late night snack – especially cold pizza.  However, any tomato-based products are foods that are likely to give you heartburn.  They are known for producing plenty of gastric acid. Plus, it’s only going to make things worse if that pizza includes other heartburn-inducing ingredients like onions and garlic.
While these are a handful of foods that can make it a rough night, it’s important to understand that consuming anything before sleep is likely to cause problems.  The moment you lie flat, it becomes harder for your stomach to keep acid down.
If you find that acid reflux and heartburn are giving you continuous problems at night, it might be best to seek some professional medical assistance.  Dr. Elias Darido and his staff at Houston Heartburn are always ready to help.
 
 

#### Heartburn during Pregnancy
Rona in Sugarland Texas sent us this question: “I have had a Nissen fundoplication & hiatus hernia repair.  I am 25 weeks pregnant and have got heartburn. Does it mean my fundoplication has come undone? Thank you.”
Dear Rona,
Nissen fundoplication reliably and effectively eliminates acid reflux and heartburn. Therefore, heartburn or food regurgitation in the setting of Nissen fundoplication and hiatal hernia repair may indicate wrap failure. Pregnancy increases intra-abdominal pressure. In the setting of a partially undone or poorly performed Nissen fundoplication, heartburn and acid reflux may occur.
Upper endoscopy and ambulatory pH testing are recommended to check for acid reflux, evaluate the integrity of Nissen fundoplication and rule out a recurrent hiatal hernia. Obviously, the workup for acid reflux and potential revision surgery are postponed till after delivery. Lifestyle changes including head of bed elevation and avoiding trigger foods like spices and tomato sauce may help alleviate symptoms. Eating small meals and avoiding excessive weight gain also help reduce acid reflux severity and frequency. Antacids like Tums and Maalox control severe attacks of heartburn. Additional medications to reduce stomach acidity may be prescribed by your obstetrician.

#### Heartburn Medications after Nissen Fundoplication
Sandy from Houston sent us this question: “I had partial Nissen 6 months ago. Just had an upper endoscope and my surgeon told me there was irritation in lining and I should take proton pump inhibitors again. I don’t feel that is correct route”.
Dear Sandy,
Properly performed Nissen or Toupet (partial) fundoplication is associated with a very high success rate. Nissen fundoplication eliminates any form of reflux from the stomach into the esophagus. 6 months after surgery esophageal lining irritation should have healed and your acid reflux symptoms completely resolved. One of the benefits of Nissen fundoplication is the cessation of all forms of antacid medications including proton pump inhibitors. Lifelong PPI use is associated with serious side effects. Resuming PPIs after Nissen or Toupet fundoplication is not the “correct route” as you mentioned.
You need to be evaluated by a competent acid reflux specialist to properly diagnose your particular condition and tailor the treatment accordingly. If the surgery was not properly performed it needs to be redone. Revision Nissen fundoplication surgery is slightly more complicated than primary surgery but still quite effective at alleviating your acid reflux symptoms. I am not sure why you had a partial fundoplication instead of 360 fundoplication. A number of surgeons don’t feel comfortable performing a Nissen or 360-degree fundoplication for fear of post-operative dysphagia. However, at Houston Heartburn and Reflux Center our post-Nissen fundoplication dysphagia rate is less than 1 in 1000. Your partial fundoplication can easily be converted to Nissen fundoplication and give you lifelong relief from heartburn and acid reflux.

#### Heartburn Moment of the Super Bowl
While enjoying the game today between the New England Patriots and Los Angeles Rams you may develop heartburn. There are plenty of reasons for a heartburn attack during Super Bowl: Greasy and spicy food, alcoholic drinks, maybe smoking and definitely strong emotional reactions to the game.
Stress and anxiety by themselves do not cause acid reflux. However, if you suffer from acid reflux, a stressful situation exacerbates the sensation of heartburn and other acid reflux related symptoms. On the other hand, trigger foods like tomato sauce, hot salsa, pizza… relax the lower esophageal sphincter and contribute to severe acid reflux episodes.
Loading up on proton pump inhibitors prior to Super Bowl and munching on Tums and Rolaids during the game is not a solution for severe acid reflux. Rather, Houston Heartburn and Reflux Center recommends prevention, thorough evaluation and effective treatment to reliably stop acid reflux. Proton pump inhibitors mask heartburn but don’t stop acid reflux. Consequently, as you are indulging in heartburn trigger food items, thinking acid reflux is under control, reflux is occurring and damaging your esophagus and health.
If you suffer from recurrent heartburn, don’t hesitate to contact a competent acid reflux specialist in your area to get evaluated and properly treated. Don’t go through another Super Bowl loaded on Nexium, Prilosec, Zantac … Don’t simply mask your heartburn. Treat your acid reflux to stop heartburn and start enjoying life again.

#### Heartburn on Vacation
The crashing sounds of the waves, the warm sun beaming down on your skin, no alarm clocks waking you up in the morning…absolute bliss! Vacation, the best time of the year by far. Until the uninvited guest shows up and ruins the whole day and night. Heartburn.

It’s enough having to deal with acid reflux at home, day to day, but suffering from heartburn while away on vacation is not something you want to do. Whether you are traveling far away or on a one day business trip, being away from home and your normal comforts can be difficult when dealing with heartburn.

While preparing for your trip, keep in mind your heartburn relief remedies, as well as ways you can prevent an onset. Here are a few tips on ‘packing for heartburn relief.’

Loose clothing that won’t restrict your belly area
Heartburn medications, prescribed or over-the-counter antacids
Fruit flavored gum or candy. Avoid mint flavored gum, as mint is a common heartburn trigger food
Healthy snacks for when you are unable to find a meal that won’t aggravate your stomach. Foods such as granola bars, whole-grain crackers, and non-citrus fruits are all good options
Carry a refillable water bottle at all times to avoid the temptation of drinking a soda or coffee – both heartburn triggers
Ask you hotel for extra pillows to prop your head up while you sleep, or pack extra bedding

When you’re on vacation, you’re carefree and have no schedule. However, to avoid heartburn, there are a few things you must remember to do:

Don’t overeat. It is very tempting to over indulge on vacation. Nevertheless, keep portion sizes small and eat slowly to avoid acid reflux.
Eat early. Eating dinner right before bed will cause heartburn. Eating earlier will allow your food to digest. Have an early dinner and spend the evening strolling along the beach or enjoying the hotel facilities.
Choose healthy foods. It’s convenient to grab some fast food, as it’s quick and easy, while traveling. The grease and fat, however, will cause heartburn and is not the healthiest option to pick. Go for a salad, fresh fruits and vegetables, and grilled protein, such as chicken or fish, rather than fried foods.
Don’t rely on coffee. You may be under stress and on a time crunch before you travel, trying to get your packing done last minute. The easy option is to get a quick fix of energy from a cup of coffee. Even waking up on vacation in a new environment can throw you off. Coffee is a known heartburn trigger in many people, so try different ways to boost your energy. Get plenty of sleep and exercise. Exploring your new surroundings in the morning is a great way to become energized and to feel refreshed.
Don’t down too many cocktails. Ending the day with a scrumptious cocktail, after a beach day or a long business meeting, could be the perfect way to relax. However, alcohol triggers major heartburn. Try to limit the number of cocktails you drink and possibly try the local non-alcoholic beverages instead.

It may sound more work than it should be, preparing for your long-awaited vacation. However, with just a few simple tips and steps, you can enjoy a heartburn-free vacation this summer! If you suffer from more intense bouts of heartburn, schedule an appointment with Dr. Darido to see the steps you can take to ease your pain.

#### Heartburn Pills Raise Risk of Liver Cancer
Heartburn pills like proton pump inhibitors, PPIs, are associated with a number of serious side effects including renal disease, early dementia and heart problems. A recent study shows that the use of heartburn pills like Prilosec and Zegerid increases the risk of primary liver cancer by 80%. The incidence of primary liver cancer has recently increased in the US. Liver cancer is the fifth leading cancer in men and the ninth in women and is associated with very low 5-year survival rate.
The mechanism of action behind this association remains unknown. Chronic acid suppression leads to increased gastrin blood levels. Gastrin is known to stimulate liver tumor growth. Furthermore, chronic acid suppression promotes intestinal bacterial overgrowth. Intestinal bacteria and any potential carcinogenic substances they may secrete may cross the gut barrier and end up in the liver. In a study published by Llorente et al demonstrated this phenomenon in mouse models and humans in a study published in 2017 in Nature Communications.  The authors showed that chronic acid suppression in acid reflux patients increase liver inflammation by promoting intestinal bacterial overgrowth and increased translocation of microbial products from intestinal lumen to liver.
Irrespective of mechanism of action, gastric acid plays an important role in normal gastrointestinal physiology. Acid reflux is not associated with increased gastric acid secretion. The root cause of acid reflux is a faulty anti-reflux barrier. Heartburn pills do not address the underlying pathophysiology of acid reflux and chronic heartburn pill use for severe acid reflux disease can no longer be considered an effective and safe solution.
If you suffer from acid reflux disease contact our reflux specialists at Houston heartburn and let them alleviate your symptoms for good.
 

#### Heartburn Pills: The Good, Bad, and Ugly
Heartburn pills or Proton Pump Inhibitors also known as PPIs, are powerful stomach acid suppressors commonly used by thousands of acid reflux patients in Houston. A number of heartburn pills like Nexium, Prilosec, and Prevacid are readily available over the counter. PPIs are also commonly prescribed by most Houston gastroenterologists and primary care physicians for first line treatment of heartburn and acid reflux. In Houston, acid reflux and heartburn patients spend millions of dollars every year on heartburn pills. Many cannot start their day without taking a PPI and other cannot go to bed before taking one. For acid reflux patients, life is very difficult without one or two, daily heartburn pill.
Stomach acid, however, plays an important role in normal food digestion and absorption. Furthermore, stomach acid production and secretion are normal in acid reflux and heartburn patients. Heartburn is not the result of acid over-production. Rather, heartburn occurs secondary to acid reflux into the food pipe due to a weak acid reflux barrier. Heartburn, a recurrent and debilitating burning pain behind the breast bone responds very well to PPI treatment. Similarly, esophageal inflammation, and ulceration secondary to acid reflux resolve with PPI therapy. PPIs, however, do not address the underlying cause of acid reflux disease. Heartburn pills do not restore the anti-reflux barrier to stop acid reflux. In order to mask heartburn, acid reflux patients have to take an escalating number of heartburn pills every day, for the rest of their lives.
Long-term PPI intake damages different organs of the body at the same time resulting in serious side effects. Dementia, heart disease, renal failure, osteoporosis, pneumonia, C diff colitis, vitamin and mineral deficiency, and delayed gastric emptying. While short term use of PPIs alleviates a heartburn attack and heal an ulcer, long term PPI use is bad for your health.
Furthermore, heartburn pills neither stop the progression of acid reflux disease nor reduce the likelihood of Barrett’s esophagus progressing to esophageal cancer. Indeed, studies have shown that acid reflux patients with Barrett’s esophagus who take PPIs are more likely to get cancer.  PPIs don’t stop reflux but simply mask symptoms. This is the ugly truth about heartburn pills; Acid reflux patients on PPIs have the illusion that reflux is under control. They take a pill and eat whatever they like as the TV commercial implies. At Houston Heartburn and Reflux Center, we educate and caution our patients against such an approach to GERD treatment. We advocate proper diagnosis to confirm GERD stage prior to treatment. We evaluate symptom control and carefully examine lifestyle patterns that contribute to acid reflux. We recommend smoking cessation and alcohol intake reduction. We encourage weight loss and healthy eating. We try to wean PPI use and when possible replace them with less harmful medications like histamine receptor blockers. Most importantly we explain to our patients that PPIs don’t cure acid reflux disease. The only cure for severe acid reflux is hiatal hernia repair and Nissen fundoplication. Indeed, Nissen fundoplication surgery when properly performed is the safest, and most reliable solution for GERD.

#### Heartburn Treatment after Sleeve Gastrectomy
Cherie from Houston sent us this question: Can some type of Fundoplication be done if I’ve had a Sleeve Procedure?  It’s been 3 years and symptoms of my acid reflux are worse.
Recent UGI showed almost continuous episodes of spontaneous gastroesophageal reflux. Looking for options other than gastric bypass. Thank you.
Dear Cherie,
Nissen fundoplication or any other type of partial fundoplication relies on the presence of gastric fundus (upper part of the stomach) to wrap around the lower esophageal sphincter. Gastric fundus is resected during sleeve gastrectomy. Therefore, by definition, a fundoplication cannot be performed after sleeve resection. A number of post-sleeve gastrectomy acid reflux cases have presented to Houston Heartburn and reflux Center over the past few years. Some of these patients had a perfectly done gastric sleeve in the presence of a large hiatal hernia that was not fixed during initial sleeve gastrectomy. Consequently, we were able to stop acid reflux by fixing the hiatal hernia only. This is only possible if the sleeve is properly resected and contoured; there is no narrowing or twisting of gastric sleeve lumen and the gastric fundus is properly resected. If the sleeve is narrowed at the incisura angularis during initial resection, hiatal hernia repair by itself is not likely to stop acid reflux and conversion to gastric bypass is indicated to stop acid reflux.
If gastric fundus is incompletely resected during initial surgery, then hiatal hernia repair with re-sleeve to properly contour the lumen are indicated to resolve heartburn and other acid reflux related symptoms. One may consider in this case, a partial fundoplication instead of gastric fundus resection if there is enough gastric fundus to wrap or if gastric fundus tissue is thin or stretched and one is concerned about staple line leak if resection is performed. We don’t have studies to corroborate such an approach and surgery outcome in terms of acid reflux control remains unknown.
Few reports in the literature describe the use of LINX™ device to stop acid reflux after sleeve gastrectomy. The use of LINX™ surgery in the case of sleeve gastrectomy is not FDA approved and has not been properly evaluated. However, the same principle applies regarding a twisted or narrowed sleeve lumen in which case LINX™ surgery for GERD is not likely to be effective in stopping heartburn.
My recommendation for you is to get thoroughly evaluated by a competent acid reflux specialist with knowledge in bariatric surgery prior to committing to any revision surgery. In some cases, you may be able to save your gastric sleeve and stop heartburn at the same time.

#### Heartburn Treatment Options in Houston
Question of the week from Grace in Houston: I have been on heartburn medications for 19 years since my gallbladder surgery in 2000. What else can help control my GERD?
Dear Grace,
Heartburn pills are neither the most effective nor the only treatment option for GERD. Indeed, heartburn pills only mask symptoms of acid reflux rather than stopping reflux. In addition, long-term use of certain heartburn pills is associated with serious side effects.
Consequently, if you have been taken heartburn medications for the past 19 years of your life you ought to be evaluated by a reflux specialist. Effective acid reflux treatment starts with proper GERD diagnosis and staging. Treatment is subsequently tailored to your GERD stage. “One pill does not fit all” is a principle we strongly believe in at Houston Heartburn and Reflux Center.
Stage 3 and 4 GERD patients are better served with anti-reflux surgery that restores the anti-reflux barrier. Once you restore an effective barrier against acid reflux, you eliminate GERD symptoms, improve your quality of life and stop your dependency on heartburn medications. Most importantly you will stop acid reflux disease progression and significantly decrease your chances of developing esophageal cancer.
Hiatal hernia repair with Nissen fundoplication is the most reliable acid reflux surgery. When properly performed the procedure has very high effectiveness and safety rate.

#### Heartburn, Acid Reflux and Gastroparesis Treatment in San Antonio, TX
Juan from San Antonio, TX sent us this question: “I have had a long history of acid reflux, including Barrett’s esophagus.
However, each year my symptoms have gotten a little worse. Finally, I had a pH Bravo test while off PPIs that demonstrated clear reflux. All my prior EGD’s have been unremarkable.
I do have mild gastroparesis and occasionally get nausea and feel sick after eating solid foods.
Is fundoplication surgery helpful to me? What are my best options to get rid of reflux symptoms?”
Dear Juan,
Properly performed Nissen fundoplication and hiatal hernia repair is the most reliable treatment for stage 4 acid reflux. You have stage 4 acid reflux because you have developed Barrett’s esophagus. Barrett’s esophagus is the result of longstanding severe acid reflux disease. PPIs do not cure acid reflux. PPIs only mask symptoms while acid reflux continues to progress over time.
Concomitant gastroparesis or delayed gastric emptying exacerbates acid and bile reflux. Interestingly, Nissen fundoplication promotes gastric emptying and in cases of mild gastroparesis, Nissen fundoplication cures both acid reflux and gastroparesis. For moderate or severe gastroparesis, I add an antrum preserving longitudinal gastrectomy that stops below the level of the wrap to promote gastric emptying.

#### Heartburn, Acid Reflux and Nissen Fundoplication Revision
Heartburn, Acid Reflux and Nissen Fundoplication Revision
Janice from the Houston Galleria area sent us this question: I had a fundoplication because of so much acid. It worked for a few years. About 7 years ago, I was told that it had come undone. I want to have a gastric sleeve because of medical problems and being obese. Will it be possible?
Dear Janice,
Conversion of loose or failed Nissen fundoplication to sleeve gastrectomy along with redo hiatal hernia repair is possible and safe. Obesity, especially central or visceral obesity, is associated with increased intra-abdominal pressure and increased risk of metabolic disorders such as diabetes, sleep apnea and hypertension. Increased intra-abdominal pressure along with overeating and stretching of the stomach weakens the fundoplication and may lead with time to fundoplication failure. Revision surgery consists of unwrapping the fundoplication and resecting the gastric fundus along the rest of the greater curvature to create the gastric sleeve. I cannot over stress the importance of hiatal hernia repair in this situation to reliably stop acid reflux. A sleeve gastrectomy in the presence of a normal lower esophageal sphincter resting pressure is as good as Nissen fundoplication in stopping acid reflux. If the lower esophageal sphincter pressure is low, then conversion to gastric bypass may be a better acid reflux procedure. Pre-operative esophageal manometry to study esophagus motility and sphincter pressure is an important test prior to choosing the right surgical revision. Weight loss following failed Nissen to sleeve conversion further contributes to acid reflux control as well eliminating other obesity related comorbidities.

#### Heartburn, Esophageal Spasm, and Functional Dyspepsia
Lee from Cypress, TX sent us this question: “Hi I’ve been having upper stomach issues for over 6 years now. I’ve had endoscopy and a 24-hour camera up my nose and barium meal which showed I’ve got esophageal spasm. My doctor put me on pill which numbs the spasm but I’m still struggling with upper bloating and pain as soon as I eat anything.   I’ve noticed I’ve been like this since I was put on a PPI 40mg and notice since then I’m constantly choking on acid at night.  I also have pain under my right rib cage and back every time I get this bloat to which my doctor says is normal with functional dyspepsia.  What could this be could it be delayed stomach emptying due to the PPI?   How can I come off them as when I’ve tried before I get terrible gastritis?   Really could do with some help please”.
Dear Lee,
Choking on acid at night is a strong indicator of severe acid reflux disease. Gastroparesis or delayed gastric emptying may contribute to acid reflux disease and exacerbate acid reflux especially at night. Proton pump inhibitors, PPIs, may delay gastric emptying and cause bloating, and pain after eating. Esophageal spasm causes severe pain behind the breastbone that is not necessarily related to food intake.
Proper diagnosis of GERD related symptoms is crucial to guide effective therapy. Upper endoscopy and ambulatory esophageal pH testing are commonly offered at Houston and Heartburn Reflux Center before starting acid reflux treatment. If both tests are negative, then we start investigating other issues like gastroparesis. A 4-hour gastric emptying study is recommended when delayed gastric emptying is suspected. Esophageal spasm is diagnosed using esophageal manometry. Esophageal motility disorders are rare and typically associated with substernal chest pain and difficulty swallowing food. It is unlikely for you to suffer from esophageal spasm, GERD and gastroparesis at the same time. I recommend you consult with a competent acid reflux specialist to help elucidate your problem and alleviate your symptoms.

#### Heartburn, Smoking and Barrett’s Esophagus
Mike from Houston sent us a question this past week: “I was diagnosed with Barrett’s esophagus in 2010. I stopped smoking and have lost around 40 pounds. I was started on Nexium 40 mg daily. I have had regular upper endoscopies since 2010 and they have consistently showed a regressing Barrett’s segment. My last scope was last week, and it showed a small residual patch of Barrett’s esophagus measuring less than 1 by 1 cm. Is it possible for Barrett’s to get better with time?
Dear Mike,
Obesity, and smoking in the setting of acid reflux are major risk factors for Barrett’s esophagus. Studies have shown that Barrett’s mucosa does regress back to normal after reliably stopping acid reflux following Nissen fundoplication. This is particularly true for short segment Barrett’s esophagus. Weight loss is associated with decreased acid reflux and decreased inflammation. In combination with smoking cessation, weight loss may prevent Barrett’s esophagus progression to cancer and promote Barrett’s esophagus regression. At Houston heartburn and reflux center, 90% of acid reflux patients who are cigarette smokers have evidence of Barrett’s esophagus on upper endoscopy. The incidence of Barrett’s esophagus in non-smokers at Houston heartburn and reflux center is around 10%. Cigarette smoking greatly exacerbates esophageal injury in GERD patients and smoking cessation is highly advised.
Heartburn medications like proton pump inhibitors, on the other hand, don’t stop reflux and simply mask symptoms. There is no evidence to suggest that proton pump inhibitors cause Barrett mucosa to regress to normal. The evidence is controversial on the effect of heartburn medications like proton pump inhibitors on the progression of Barrett’s esophagus to cancer. A number of GERD patients presenting to Houston heartburn and reflux center show progression of acid reflux despite years of PPI treatment including development of Barrett’s esophagus. One concern with chronic acid suppression secondary to PPI use is the increased bile salt accumulation in esophageal squamous cells. This leads to cellular damage, increased incidence of Barrett’s esophagus and increased progression to cancer.
In summary, weight loss and smoking cessation cannot be overemphasized in acid reflux patients. Obesity and smoking are major risk factors for Barrett’s esophagus development in GERD patients. Smoking cessation and weight loss decrease inflammation and reflux. Nissen fundoplication is superior to heartburn medications in reliably stopping reflux and preventing the progression of Barrett’s esophagus to cancer.

#### Heartburn: A Warning Sign for Barrett’s Esophagus
May 16 is Barrett’s Esophagus Awareness Day, a time to raise awareness about a potentially serious complication of chronic acid reflux. While heartburn may seem minor, persistent symptoms can be a warning sign of Barrett’s esophagus, a condition that increases the risk of esophageal cancer if left untreated.
What Happens in Barrett’s Esophagus?
Barrett’s esophagus occurs when the lining of the distal esophagus (food pipe) changes from normal squamous (flat) cells to columnar (raised) cells like those lining the stomach. The conversion of one cell type into another is called metaplasia.
Metaplasia occurs in response to injury and inflammation. In the case of Barrett’s esophagus, uncontrolled long-term GERD causes injury and inflammation.
Obesity and smoking in the setting of GERD further increase the risk of Barrett’s esophagus development.
Is Metaplasia Good or Bad?
The metaplastic tissue, Barrett’s esophagus, is more resistant to damage from the injurious agent, GERD. In other words, metaplasia is a protective response to tissue injury.
However, Barrett’s esophagus may progress to cancer in some cases. The 5-year survival rate for esophageal cancer is low. Hence, early detection and prevention are crucial.
When to Get Checked
If you experience any of the following acid reflux symptoms, get evaluated by a competent acid reflux specialist:

Heartburn

Food regurgitation

Excessive burping and bloating

Cough

Constant throat clearing

Don’t mask your symptoms with Tums and Pepcid year after year, until it is too late. It is much easier to treat acid reflux and Barrett’s esophagus than to treat esophageal cancer.
How Is Barrett’s Esophagus Diagnosed?
Barrett’s esophagus is suspected on upper endoscopy. Diagnosis is confirmed by examining a sample of esophagus lining under the microscope.
Once the diagnosis is confirmed several measures can be taken to minimize the risk of Barrett’s esophagus progressing to esophageal cancer.
What Are the Treatment Options?
PPIs, proton pump inhibitors, have no effect on extent of Barrett’s esophagus. Several studies, on the other hand, have reported regression or elimination of Barrett’s esophagus after antireflux surgery.
At Houston Heartburn and Reflux Center, we have documented cases of complete Barrett’s mucosa regression following hiatal hernia repair and Nissen fundoplication.
Effective Treatment Starts Here at Houston Heartburn and Reflux Center
A properly performed hiatal hernia repair and Nissen fundoplication is the most reliable cure for GERD. If you are struggling with acid reflux, don’t wait until it is too late.
Call 832-945-8717 and get evaluated by a competent acid reflux specialist.

#### Heller Myotomy Versus Peroral Endoscopic Myotomy (POEM)
“Laparoscopic Heller Myotomy Versus Peroral Endoscopic Myotomy (POEM) for Achalasia: A Systematic Review and Meta-analysis” is a new article published by Patti el al in the Annals of Surgery. The authors conducted a Medline literature search for achalasia treatment. 53 Heller myotomy studies included 5834 patients were compared to 21 POEM studies that covered 1958 patients. The two main outcomes examined were improvement of dysphagia and postoperative GERD. Mean follow-up time was 41 months for Heller myotomy and 16 months for POEM. At 12 and 24 months after intervention for achalasia treatment dysphagia improved in more than 90% of patients in both groups. However, patients undergoing POEM were significantly more likely to develop symptomatic GERD (gastroesophageal reflux disease).
The study is quite relevant to our practice at Houston Heartburn and Reflux Center as it gives us more evidence based information about the long-term outcome of POEM. Most importantly however, this study highlights the phenomenon of rapid early adoption of endoscopic techniques despite several significant limitations. I remember attending SAGES conference few months ago here in Houston and several authorities in the field of laparoscopic foregut surgery were confirming that POEM is currently the gold standard treatment for achalasia. The assumption was that as long as the phreno-esophageal membrane is not disturbed the incidence of post-POEM GERD should remain low. This article disproves this assumption and highlights the importance of an anti-reflux procedure following lower esophageal sphincter myotomy to prevent acid reflux. Indeed, GERD is a multifactorial disease and esophageal dysmotility is a contributing factor. In the case of achalasia, the addition of lower esophageal sphincter myotomy significantly increases the risk of acid reflux. Accordingly, an anti-reflux barrier in the form of fundoplication is particularly needed in achalasia cases following lower esophageal sphincter myotomy.
There is no doubt that POEM and other forms of natural orifice transluminal endoscopic surgery (NOTES) are quite appealing to both patient and surgeon. However, such approaches are limited by their own nature and in some cases like achalasia treatment half the surgery is not possible to complete using POEM. Consequently, achalasia patients undergoing POEM are at higher risk of GERD and this meta-analysis proves it.

#### Here's To Heartburn
When you think about the causes of heartburn, what immediately comes to mind? Hot, spicy food and fried, fatty food, right? You’re extra careful avoiding those foods like it’s poison to avoid getting heartburn. Well, ever thought that burning sensation you actually feel could be from what you’re drinking?
That’s right. It’s pretty funny, people are so cautious with what they eat, but never give what they’re drinking a second thought. If you never thought about it, let us be the first to tell you that coffee, alcohol, acidic juices, and other caffeinated beverages can play a role in heartburn. You see, there’s a ring of muscle called the lower esophageal sphincter (LES) located between the stomach and the esophagus. It’s supposed to close except when food is passing into the esophagus.
The problem is, when you drink alcohol, the sphincter muscle relaxes, creating an opening and allowing stomach acid to come back up into the esophagus. That’s called acid reflux — the burning sensation you feel. It’s also pretty much the same thing when you drink caffeine. Plus, with caffeinated sodas, like colas, acid increases in your stomach coupled with bloating, which leads to heartburn.
Of course, not everyone gets acid reflux after drinking alcohol or caffeine. Some people are predisposed or may have a weak sphincter muscle to begin with. Other factors, like being overweight, also increase your chances for heartburn.
It’s also been recommended to avoid acidic and citrus juices, like orange and tomato juice. In fact, milkshakes and whole milk, which aren’t acidic at all, have been known to give people heartburn. That’s because fat can exacerbate heartburn by staying in the stomach longer. The more fat you drink, the fuller your stomach is, increasing your chances for reflux.

What can you drink?
We’ve covered what you shouldn’t drink, now here are drink recommendations to prevent heartburn. For starters, noncarbonated and decaf beverages, herbal teas, skim milk and apple juice. Lastly, water is extremely important and beneficial because it helps minimize stomach acid.
Herbal teas
Other than spearmint or peppermint, herbal teas are great for acid reflux because they improve digestion and help soothe stomach issues, like gas and nausea. Some people suggest chamomile, licorice, slippery elm, and marshmallow herbal teas to soothe GERD symptoms. Licorice, in particular, has been proven effective against GERD by increasing the mucus coating of the esophageal lining, helping calm the effects of stomach acid.

Goat’s Milk or Skim Milk
Regular cow’s milk has a considerable amount of fat, so it’s hard to digest, which may worsen reflux. Skim milk or goat’s milk, both lower in fat, are better choices.
You should still keep an eye on what you eat when it comes to heartburn. However, while you’re doing that, you might also what to rethink what you drink because what’s in your glass could effect what’s in your stomach. If you have chronic acid reflux, come speak to Dr. Darido at Houston Heartburn.
 
 

#### Hiatal Hernia Repair Improves Quality of Life
I read with great interest the new study “Patient-Centered Outcomes after Laparoscopic Paraesophageal Hernia Repair” by Ujiki et al published in the current issue of JACS (Journal of the American College of Surgeons). 314 patients who underwent laparoscopic hiatal hernia repair were prospectively followed between 2009 and 2016. 188 had adequate follow up and were included in the analysis. Most common presenting symptoms were heartburn and food regurgitation. 82% of patients had type 3 hiatal hernia, 14% had type 4 hiatal hernia and the rest had type 2 hiatal hernia. 90% of all crural repair repairs were reinforced with prosthetic mesh. Absorbable mesh was mostly used except in 6 cases permanent mesh was chosen. Permanent mesh is not recommended around the hiatus for fear of esophageal erosion. The authors used a permanent mesh in select cases where the crura were weak and attenuated and a large defect was present to bridge. Nissen fundoplication was performed in 140 patients. The rest underwent Toupet or Dor fundoplication. Mean operative time was 2.3 hours. 5 intraoperative complications occurred including 4 esophageal perforations and one gastric perforation. All were detected and repaired intraoperatively.
Median length of hospital stay was 48 hours. Median number of postoperative days on narcotics for pain control was 3 days. Resumption of daily living activities occurred at a median of 6 days. The mean age of this patient sample is 69. The overall morbidity rate was 7% (infection (1), pneumonia (4), dehydration (2), dyspnea (1), esophageal perforation requiring reoperation (4), esophageal obstruction requiring reoperation (1). Mortality rate was 0.5%.
Reflux symptom index, GERD health related quality of life, Dysphagia, physical functioning/health, emotional well-being, energy and fatigue, social functioning, pain and general health scores all showed significant improvement 2 years after surgery.
The study validates the safety and effectiveness of laparoscopic hiatal hernia repair in treating GERD. In an elderly patient population, the recovery was swift, pain was minimal, and complication rate was low. The benefits of laparoscopic hiatal hernia repair are numerous. In addition to reliably eliminating heartburn and food regurgitation, quality of life greatly improves. Acid reflux is a chronic and progressive disease that slowly and insidiously erodes patient quality of life and energy levels. Laparoscopic hiatal hernia repair is described by most patient as a life changing surgery. At Houston Heartburn and Reflux Center, we advocate early hiatal hernia repair to stop disease progression. We believe that hiatal hernia causes acid reflux and acid reflux causes hiatal hernia to develop and grow. As gastric content refluxes into the esophagus, esophageal muscles retract cephalad favoring the development of hiatal hernia and the progression of type 1 to type 3 paraesophageal hernia. Along this progression, the right and left crura weakens and the esophagus contracts and shortens. As a result, hiatal hernia repair success rate decreases while recurrence and surgery complication rate increases.
Of note, I used hiatal and paraesophageal hernia interchangeably in this blog to avoid reader confusion. Technically speaking, a hiatal hernia is type 1 paraesophageal hernia also known as a sliding hernia.

#### Hiatal Hernia Repair in the Setting of Gastroparesis
Lina from Baytown sent us this question: “Hi I am 49-year-old Hispanic women with a long medical history. Systemic Lupus, history of a stroke at 32, kidney failure at 27 and Barrett’s Esophagus among others. I am considering hiatal hernia repair. My GI has advised me against it because I have gastroparesis. The GERD has become unbearable. I have suffered and treated it to over 20yrs. The GI said I should try for a second opinion for the surgery. I’m currently on a lot of meds including immunosuppressants for the Lupus. I take Dexilant for my stomach and when that alone doesn’t work, I take 2-8 tablets of Gaviscon. What are the results for hiatal hernia repair with someone who also suffers from gastroparesis?”
Dear Lina,
Gastroparesis is a heterogeneous disorder that remain poorly understood. Gastroparesis that develop in the setting of severe and longstanding acid reflux disease is different from idiopathic gastroparesis or diabetes related gastroparesis. In my mind, gastroparesis in your situation represents end stage acid reflux disease. I have treated few patients with acid reflux, hiatal hernia and gastroparesis. I performed hiatal hernia repair, Nissen fundoplication and partial longitudinal gastrectomy along the greater curvature of the stomach to promote gastric emptying. All patients did well and had complete resolution of all symptoms related to acid reflux and gastroparesis.
I understand your GI doctor concern. Dexilant, however, like many other proton pump inhibitors may cause delayed gastric emptying and may exacerbate your gastroparesis symptoms. Of course, you cannot stop PPIs because your GERD symptoms will increase. PPIs have several side effects when taking for prolonged periods of time. PPIs do not stop acid reflux and when you have stage 3 or 4 acid reflux surgery is a better solution.
My advice for you is to get evaluated by a competent acid reflux specialist in Houston to get the best treatment possible. You have multiple medical issues and you need to have the right surgery that best suits your condition.

#### Hiatal Hernia Repair with or without Mesh
I read with great interest the recent publication in JAMA surgery (Journal of the American Medical Association) titled “Hiatal Hernia Repair with Tension-Free Mesh or Crural Sutures Alone in Anti-reflux Surgery”. This is a double blinded randomized clinical trial with a 13 year follow up. The study was performed in a single center in Sweden. A total of 159 acid reflux patients were recruited and follow-up data obtained from 103 patients (71% response rate, 53 patients had hiatal hernia repair with an absorbable mesh reinforcement, and 50 patients had hiatal hernia repair with no mesh placement). The primary outcome was recurrent hiatal hernia after more than 10 years. Secondary outcomes included difficulty swallowing, PPI consumption, and reoperation rates.
The authors find that reinforcement with nonabsorbable mesh in acid reflux patients with hiatal hernia undergoing anti-reflux surgery for treatment of GERD does not reduce the risk of hiatal hernia recurrence 13 years postoperatively. Hiatal hernia recurrence rates at 13 years were 38% for mesh and 31% for sutures alone. This difference was not statistically significant. However, dysphagia scores for solid food were slightly higher in the mesh group. The authors conclude that routine use of tension-free mesh closure in laparoscopic hiatal hernia repair for GERD is not supported by this study.
At Houston Heartburn and Reflux Center we do not routinely use mesh reinforcement for tension free hiatal hernia repair. We always use pledgeted sutures to close the hiatal hernia posterior to esophagus under no tension. We make sure our hiatal closure is not too tight to avoid narrowing the hiatal opening to prevent post-operative dysphagia. Our dysphagia rate after hiatal hernia repair (with or without mesh) and Nissen fundoplication is zero.  We reinforce the repair with absorbable mesh when we notice weakness, attenuation and loss of tone and muscle mass in the right crus compared to left crus. Right and left crura are two muscular bands on either side of the hiatal hernia that anchors the breathing muscle to the vertebral column. In GERD patients, right crus is particularly weakened by acid reflux compared to left crus. The mesh we use is U- shaped and we make sure mesh does not get in contact with esophagus. The purpose of mesh reinforcement is to increase scar tissue formation to strengthen the hiatal closure potentially leading to decreased recurrence rate. Excessive scar tissue, however, may alter lower esophagus wall compliance and pressure leading to difficulty swallowing. We avoid this problem by keeping at least 5 mm gap between edge of mesh and esophagus. We also fixate the mesh in place using biologic glue thus preventing potential mesh displacement and impingement on esophagus.
In summary, we do not advocate the routine use of mesh for hiatal hernia repair. A biologic mesh does not add strength and durability to a hiatal hernia repair if the diaphragmatic crura are strong enough to hold pledgeted sutures. However, when the right crus is “paper thin” we recommend mesh reinforcement. Furthermore, the gastro-esophageal junction, GEJ, is a dynamic area that is constantly contracting and relaxing. Foreign body induced scar tissue formation around the GEJ may result in difficulty swallowing. This has been the case with every foreign body placed in this area including LINX™ which consists of movable magnetic beads. For this reason, we do not encircle esophagus with mesh, we make sure mesh is not placed in direct contact with esophagus, and we only use absorbable mesh. Absorbable mesh dissolves in 3 months after placement. If difficulty swallowing develops (an unlikely event) after we place a biologic mesh, endoscopic balloon dilation is quite effective at breaking down scar tissue around GEJ and alleviating symptoms.
Finally, we strongly recommend, at Houston Heartburn and Reflux Center, early surgical intervention in GERD patients. Right crus muscle weakens, and esophagus shortens as GERD progresses. The longer you wait before surgery, the more tissue damage you sustain potentially leading to higher risk of hiatal hernia recurrence.
Early hiatal hernia with Nissen fundoplication, by a competent acid reflux specialist, is the best approach to avoid hiatal hernia recurrence.

#### Hiatal Hernia Repair Without Fundoplication
I read with great interest the recent study “Fundoplication at the time of paraesophageal hernia repair does not decrease the rate of hernia recurrence or postoperative reflux” published in Surgical Endoscopy Journal. The authors retrospectively examined the outcome of 1155 patients who underwent paraesophageal hernia, PEH, repair at a single institution from 2010 till 2023. 53% of patients underwent paraesophageal hernia repair with concomitant Nissen fundoplication. the remaining patients had a paraesophageal hernia repair only. The authors found no difference in the rate of reoperation and postoperative GERD between both groups. The fundoplication group had a higher rate of dysphagia. The study concludes: “While there are definite indications for fundoplication at the time of PEH repair (i.e., type 1 hernia), these data do not support the routine use of fundoplication during PEH repair with a normal gastroesophageal flap valve intraoperatively”.
These findings underscore an important perspective on the management of hiatal hernia and the role of Nissen fundoplication, particularly in the context of different types of hiatal hernias and their relationship to gastroesophageal reflux disease (GERD).
Nissen fundoplication is the most reliable solution for GERD. However, not all hiatal hernias are associated with GERD. Indeed, paraesophageal or hiatal hernias are anatomically classified into 4 types depending on the location of the lower esophageal sphincter relatively to gastric fundus and hiatal opening. Only type 1 hiatal hernia also known as sliding hiatal hernia is strongly associated with GERD. Type 1 hiatal hernia repair by itself does not restore the antireflux barrier. Therefore, adding a Nissen fundoplication is crucial in this type of hiatal hernia to stop GERD. On the other hand, type 2, 3 and 4 PEH are typically not associated with GERD. Hence, the addition of a fundoplication in this case, which is common practice, is unnecessary. I agree with the authors’ conclusions.
Instead of a fundoplication, anchoring the stomach in the abdomen may help reduce the hiatal hernia recurrence rate which, for type 2,3 and 4 PEH, approaches 50% at 5 years. After all, the primary concern for type 2,3 and 4 hiatal hernias is the risk of gastric volvulus (stomach twisting on itself in the chest), and strangulation (loss of blood supply). From this perspective, an anchoring procedure like the Hill repair seems to be a better alternative than a Nissen fundoplication. A modified version of the Hill repair, (since there is no need to reconstruct the angle of His for acid reflux control), can be adopted to fixate the posterior aspect of the gastroesophageal junction to the pre-aortic fascia. Adding a gastric tube may help vent the stomach in the postoperative period as well as anchor the anterior stomach wall.
In conclusion, this study reinforces the tailored approach needed in hiatal hernia repair surgery, where the choice of procedure depends largely on the type of hiatal hernia, associated symptoms, and the specific pathology involved. The pathophysiology of type 1 PEH is closely linked to GERD, and it is dramatically different from that of type 2,3 and 4 PEHs. At Houston Heartburn and Reflux Center, we mainly treat type 1 or sliding hiatal hernias for GERD management. Our Nissen fundoplication dysphagia rate is zero and our long-term recurrence rate is less than 1%. We believe that GERD causes a sliding hiatal hernia to develop, and a sliding hiatal hernia exacerbates GERD. For this reason, hiatal hernia by itself is not enough for GERD control. To restore the antireflux barrier, a Nissen fundoplication must always be added for type 1 PEH repair.

#### Hiatal hernia Repair, Nissen Fundoplication and the Hypercontractile Esophagus
C.M. is a 71-year-old patient with worsening GERD related symptoms of 30-year duration. After years of proton pump inhibitor therapy, she has stopped responding to medical treatment and decided to seek more effective GERD treatment options. An upper endoscopy with ambulatory pH testing showed a hiatal hernia and confirmed the diagnosis of GERD. Esophageal manometry revealed a hypercontractile esophagus without esophageal outflow obstruction. Of note, patient reported a history of dysphagia to solid food like rice and bread. She underwent esophageal balloon dilation around 5 years prior to presentation and her dysphagia related symptoms resolved. She also has primary hypertension and is on several anti-hypertensive medications including calcium channel blockers. She has no chest pain and her main complaint upon presentation was heartburn with occasional food regurgitation.
She was offered hiatal hernia repair with Nissen fundoplication. Patient agreed to proceed and underwent the procedure with no complications. Her GERD related symptoms immediately resolved. Two months after surgery she was tolerating regular diet with no dysphagia, regurgitation, or chest pain.
The incidence of hypercontractile esophagus (also called nutcracker esophagus) in GERD patients presenting for hiatal hernia repair and Nissen fundoplication is low. The presence of hypertensive esophageal contractions and normal peristalsis is, however, not a contraindication for Nissen fundoplication. The success rate of Nissen fundoplication in cases of hypertensive esophageal contractions remains high even in the presence of elevated lower esophageal sphincter resting pressure. It should be noted that diffuse esophageal spasm is different from hypercontractile esophagus and is characterized by uncoordinated and simultaneous contractions. Patients with diffuse esophageal spasm typically present with chest pain and around 20% of patients report heartburn. Calcium channel blockers, hydralazine and sublingual nitroglycerine are often used to relax the esophagus and alleviate symptoms. In certain cases, a long myotomy with partial fundoplication may be offered especially when patients do not respond to medications. Due to poor esophageal motility, Nissen fundoplication has been traditionally contraindicated in these cases.
Last, I would like to mention that there may be a causal relationship between esophageal motility disorder and GERD. Pelligrini et al report in the study I reference at the end of this blog that elevated contraction amplitude in nutcracker esophagus cases decreased after Nissen fundoplication. Whether GERD contributes to altered esophageal motility patterns remains to be determined.
Reference:
Outcomes of laparoscopic Nissen fundoplication in patients with the “hypercontractile esophagus”. Barreca M , Oelschlager BK, Pellegrini CA.
Arch Surg. 2002 Jun;137(6):724-8, discussion 729.

#### Hiatal Hernia Repair: When and Why?
Kim from Houston sent us this question: “Would you do hiatal hernia repair on a 2 cm hiatal hernia causing possible extreme symptoms?”
Dear Kim,
Hiatal hernias come in different sizes and forms. Hiatal hernia size, however, does not always correlate with acid reflux symptoms. You may have a large hiatal hernia with no acid reflux, and you may have a small hiatal hernia with severe acid reflux symptoms. Consequently, acid reflux treatment does not and should not depend on hiatal hernia size. This is a common misconception I frequently encounter among patients and gastroenterologists in Houston.
Indeed, the pathophysiology of acid reflux is far more complex than hiatal hernia size. There is no doubt in my mind that acid reflux causes a hiatal hernia to develop. In return, hiatal hernia exacerbates acid reflux. This vicious circle of acid reflux leading to hiatal hernia formation and hiatal hernia exacerbating acid reflux is central to GERD pathophysiology and disease progression with time. This is the reason why acid reflux is described as a chronic and progressive disease. Acid reflux does not get better by itself with time. Symptoms start mild and intermittent and over time, they become severe and more frequent. The only way to break that cycle is to restore the anti-reflux barrier and stop acid reflux.
The most effective and reliable solution to restoring the anti-reflux barrier is hiatal hernia repair and Nissen fundoplication. Hiatal hernia repair by itself does not stop acid reflux; Hiatal hernia is more of a consequence of acid reflux and not a cause. Stomach and distal esophagus are reduced back into the abdominal cavity. Now the upper part of the stomach can be used to perform a floppy and short fundoplication around distal esophagus. It is the Nissen fundoplication that reverses GERD pathophysiology to stop acid reflux.
The exact mechanism by which Nissen fundoplication reverses GERD pathophysiology is not well understood. Dr Nissen discovered the procedure by serendipity more than 50 years ago. It has been assumed that the fundoplication creates a mechanical one-way valve around the lower esophageal sphincter. This assumption however is naïve. Nissen fundoplication induces neuromuscular and biomechanical changes in the gastro-esophageal junction. These changes extend beyond the gastroesophageal junction to alter gastric emptying patterns and gastrointestinal neuro-hormonal signaling.
In conclusion, no matter how small your hiatal hernia is, if you have severe acid reflux symptoms hiatal hernia repair and Nissen fundoplication surgery are indicated.

#### High Dose Proton Pump Inhibitors, Are They Any Good?
Lindsey from Houston sent us this question: “I am on 40 mg of pantoprazole 2 times a day. I am not getting heartburn, but I am getting a lot of fluid in my throat and a cough with it.  I get a tickle on the left side of my throat and start to cough, and then I choke until I cough up the fluid.  I tried to find a diet for acid reflux online, but it is impossible.  Could you please help me with any of this?”
Dear Lindsey,
High dose proton pump inhibitors (PPIs) like 40 mg of Protonix, Nexium, or Dexilant taken twice daily are rarely indicated. Several studies in the literature have demonstrated comparable efficacy of standard and high dose PPI in terms of heartburn control. Furthermore, PPIs neutralize stomach acid but do not stop gastric content reflux into esophagus. Consequently, as you have eloquently described in your question, acid reflux patients on PPIs, continue to experience food regurgitation and throat irritation in the absence of heartburn. Weakly acidic or non-acid fluid escapes the stomach across a weak anti-reflux barrier. At the throat level, it causes cough, globus, throat clearing, hoarseness, and voice fatigue. In some cases, patients report choking at night. In addition, aspiration pneumonia and asthma may develop. Increasing PPI dosage or changing PPI brand name is common among gastroenterologists. However, these measures are not associated with improved acid reflux symptom control.
By the same token, diet does not stop acid reflux, nor does it cause acid reflux. There is no such thing as an anti-reflux diet. There is no available diet that can restore an anti-reflux barrier and stop chocking episodes at night. Of course, we recommend a reflux friendly diet to avoid exacerbating acid reflux episodes. However, you can still have acid reflux on an empty stomach. As long as your anti-reflux barrier weak, reflux will continue unabated.
Laparoscopic Nissen fundoplication restores the anti-reflux barrier with very high reliability. The minimally invasive procedure is safe, effective, and durable. Following Nissen fundoplication, you can eat a regular diet and sleep without choking. Reflux from stomach into esophagus or throat is completely inhibited. Throat related symptoms will greatly improve, and you no longer need to take PPIs.

#### Hoarse voice, chronic cough, pneumonia and GERD
Erik from Houston sent us this question: “About 18 months ago I began waking in the morning wheezing and coughing. That progressed from occasionally to daily and worsened. I had an EGD and colonoscopy last summer and was told I have Barrett’s esophagus.  I was prescribed Omeprazole 40mg daily.  I now sleep at an incline, I have no alcohol, tomatoes, fried food, spicy food, I eat smaller portions of food and have nothing but water after 4pm, yet I am currently suffering with pneumonitis, hoarse voice and chronic cough in spite of my lifestyle changes. There has to be a better option. Can you offer me any recommendations for the short term, until the COVID emergency is over?”
Dear Erik,
You are doing all the right things to help control acid reflux. Unfortunately, you suffer from stage 4 GERD and lifestyle changes are no longer enough to control acid reflux. The presence of Barrett’s esophagus indicates severe acid reflux. Laparoscopic hiatal hernia repair and Nissen fundoplication is the best solution for severe acid reflux and stage 4 GERD. A properly performed Nissen fundoplication
Due to Corona virus pandemic, all elective surgeries have been put on hold in Houston. Obviously, if the risk of aspiration pneumonia is high, one may consider your situation to be more urgent than elective. I recommend you continue avoiding heartburn trigger foods, avoid overeating, as well as eating late at night. Sleeping at an incline helps alleviate nighttime symptoms. If you are a smoker, I recommend you stop smoking. Losing weight also helps decrease GERD symptom severity.
You may double your Omeprazole dose for now. Consider getting in touch with your acid reflux specialist to review your symptoms and response to medical therapy and potentially plan for hiatal hernia repair and Nissen fundoplication.

#### Houston Acid Reflux Specialist Replies to Your Question: Does Eggnog make my Heartburn worse?
Eggnog is a rich beverage that is commonly served around Christmas time. Regular heartburn sufferers know the importance of avoiding certain food items to prevent an acid reflux attack. Eggnog is prepared using heavy cream and egg yolks. Eggnog high fat content makes it an important heartburn trigger beverage especially when alcohol is added. Houston reflux specialists recommend consuming Eggnog in moderation to enjoy a heartburn free holiday. Alcohol and fatty foods weaken the lower esophageal sphincter. A loose lower esophageal sphincter allows acid that is normally present in the stomach to splash up into the esophagus. Acid in the esophagus is quite annoying. It causes pain, prevents from sleeping and functioning and may lead to cancer if left untreated. Similar to Eggnog, peppermint, chocolate, tomato sauce, garlic and onions are some of the food items that tend to precipitate an acid reflux episode. Avoiding these items is your first step towards taking control of your acid reflux disease.
For more information on how to control your acid reflux disease check our website houstonheartburn.com or if you need to contact our reflux specialist call us at 832-945-8717. Houston Heartburn and Reflux center offers many effective and minimally invasive solutions for GERD.

#### Houston Heartburn Advocates Social Distancing
The novel coronavirus, COVID-19, (short for coronavirus disease 2019), continues to spread in Houston and Texas. Coronavirus infection has reached a pandemic level and President Trump has declared a national emergency to fight the outbreak.
The health and safety of our Houston community is our highest priority, and Houston Heartburn and Reflux Center urges all Houstonians to avoid crowding and follow basic rules to limit the spread of the virus. Coronavirus spreads mainly by droplets similar to flu. Keep a safe distance from anyone who is sick and avoid handshakes and hugs. Do not touch your eyes, nose, mouth and face and properly wash your hands. Eat healthy and increase your vitamin intake especially vitamin C. Exercise enhances your immune system. It is much safer to avoid the Gym for now. Try to exercise at home or go a brisk walk or run in your neighborhood (weather is great nowadays in Houston).
Cough, sore throat and hoarseness are common acid reflux symptoms. A number of acid reflux patients develop asthma like symptoms from chronic airway micro aspiration. A viral infection like coronavirus exacerbates theses symptoms. Acid reflux patients may be at higher risk of coronavirus infection complications. If you suffer from acid reflux, we recommend a reflux friendly diet, avoid over-eating and eating late at night. We also recommend elevating the head of the bed to minimize the frequency and amount of gastric refluxate reaching the throat, larynx, and lungs.
We pray for a fast resolution of the coronavirus pandemic. During these trying times, we cannot overemphasize the importance of social distancing to limit the spread of the coronavirus. It is hard but is it currently our best defense.

#### Houston, we have a heartburn problem
You have just finished a wonderful Italian dinner accompanied by nice red wine and followed by a delicious dessert – and now here you are sensing that all is not quite well. You feel a burning pain in your stomach that is moving up your chest. You know it is going to be a long night.
We all know the story all too well. In fact, thousands of Houstonians suffer from heartburn several times a week. Most of us think that heartburn is just the result of what we eat and antacid pills cure the problem – right? WRONG!!!s
Those recurring heartburn pains are a signal from your body that something is wrong – very wrong! Acid in the stomach is very normal. Every time you eat, millions of tiny cells in the stomach secrete acid to help digest food. Acid belongs in the stomach. A competent lower esophageal sphincter relaxes after each swallow allowing food to get in the stomach. The sphincter then closes to prevent acid from backing up into the esophagus.
Unfortunately, for some, the lower esophageal sphincter does not function properly. The sphincter is damaged and acid escapes the stomach into the esophagus causing pain. When in pain, most Houstonians do what most people always do… pop a pill. The drug industry sells over $ 14 billion in medications to “cure” heartburn. Everyone that watches television has seen Larry the Cable guy promoting the “purple pill”. But do antacid pills, like the purple pill cure Gastro-esophageal reflux disease?
The answer is NO. Antacid pills relieve symptoms by neutralizing stomach acid. They are useful for the occasional heartburn but not chronic heartburn. In chronic heartburn, the lower esophageal sphincter is damaged. Pills don’t repair the weakened lower esophageal sphincter. As a result, stomach content continues to reflux into the esophagus causing more damage as years pass by. If you suffer from heartburn and reflux on a weekly basis get help from a reflux specialist.
At Houston Heartburn and Reflux Center, proper diagnosis and effective treatment is our priority. First, we offer you a comprehensive workup to confirm the diagnosis of acid reflux. If you don’t have acid reflux you don’t need to take all these anti-reflux medications. Second, if you have acid reflux, we stage your disease. Accordingly, we tailor a treatment plan that eliminates your symptoms, cure your acid reflux, and prevent future complications with the least side effects possible.

#### How do I select a heartburn and reflux doctor in Houston, TX?
Gastro-esophageal reflux disease, GERD, is a chronic and serious condition. If you are looking for a GERD or Heartburn doctor in Houston, TX please consider the following:

Is the doctor board certified? Only select a surgeon who is certified by the American Board of Surgery.
Is the doctor trained in the field of heartburn and acid reflux? Only select a surgeon who is fellowship trained in minimally invasive foregut surgery (the field of gastro-esophageal reflux disease).
How often does the physician treat GERD patients? Only choose dedicated physicians to the treatment of GERD. These highly specialized experts practice in Heartburn Reflux centers that use state of the art diagnostic and therapeutic modalities for GERD management. Ask your surgeon about the number of anti-reflux surgeries he has performed. Your surgeon should have done over 100 procedures in his or her career.
What do other patients say? Ask your doctor to provide contact information for 2 or 3 patients who have the procedure performed by him. Call these people and discuss their experience.
Does your doctor take his time to explain to you the diagnosis, prognosis or disease progression, treatment options, alternatives and procedure risk factors? Choose a compassionate physician who treats you as a member of his own family.

If you are not satisfied with your physician or surgeon you should look further. Don’t be rushed into a something you are not convinced of especially when it comes to GERD treatment.

#### How Do I Strengthen My Acid Reflux Barrier?
Grace from Houston sent us this question: “Hi, I have reflux at night, and I am on a mixture of zinc, digestive enzymes, and slippery elm. This helped and I just was on zinc. But just recently it has flared up again, but with heartburn as well. I had reintroduced coffee and small amount of dark chocolate. I saw you have said food doesn’t cause reflux. How do I strengthen the weak anti-reflux barrier, is this the sphincter and what if I have low stomach acid? I really appreciate your help, thank you.”
Dear Grace,
The most reliable approach to strengthening acid reflux barrier is hiatal hernia repair and Nissen fundoplication. Laparoscopic hiatal hernia repair and Nissen fundoplication safely and effectively restores the anti-reflux barrier, leading to immediate cessation of acid reflux from stomach into esophagus. Following Hiatal hernia repair and Nissen fundoplication you can enjoy a regular diet including coffee and dark chocolate.
There are no medications or natural supplements that can strengthen or restore the anti-reflux barrier. Zinc, digestive enzymes, and an endless number of folk remedies do not address the complex underlying pathophysiology of acid reflux.
By the same token, prescribed medications for acid reflux like proton pump inhibitors, PPIs, do not strengthen the anti-reflux barrier. These medications reduce stomach acid secretion. However, PPIs do not stop gastric content reflux into esophagus and throat. PPIs are therefore a Band-Aid for acid reflux. PPIs reduce GERD symptom severity without curing acid reflux.
Furthermore, certain exercises, stretching techniques and chiropractic adjustments do not strengthen or restore the anti-reflux barrier. Hiatal hernia repair can only be achieved through surgery. There is no musculoskeletal maneuver that can reverse a hiatal hernia or strengthen the anti-reflux valve.
Finally, diet and certain social habits like smoking and alcohol consumption affect the strength of the lower esophageal sphincter. We do recommend weight loss, smoking cessation and reduced alcohol consumption. A reflux friendly diet can help lessen the severity and frequency of acid reflux symptoms in early stages of the disease. However, as GERD progresses and acid reflux barrier weakens, dietary changes become less effective at controlling acid reflux.

#### How Do We Evaluate Dysphagia at Houston Heartburn and Reflux Center?
Bruce from Houston sent us this question: “I was diagnosed with dysphagia.
Last week my GI did an endoscopy and this week I have an esophageal manometry test.
I’ve been suffering for a month with a tight throat, pain in my throat and chest, pain in my eyes and ears. Liquid mucous is burped up often daily. I must sleep upright, or my throat closes up with pain. I changed my diet to veggies, soups, coconut milk puddings, sometimes plain chicken, quinoa with coconut milk, oatmeal. I also stopped eating bread and cut down on sugar and coffee. No alcohol. I do smoke about 8 cigarettes a day.
Do you have any suggestions for any medical testing, supplements or my diet? Thank you”
Dear Bruce,
Dysphagia or difficulty swallowing food is a common symptom for acid reflux patients. It often indicates advanced disease and stage 3 or 4 GERD. Recurrent and long-term acid reflux damages esophageal motility. Esophageal motility is a coordinated process that propels solid or liquid food through your food pipe into stomach. Weak and poorly coordinated esophagus contractions result in slow and incomplete food bolus movement. Acid reflux patients often report food getting stuck in the esophagus. Heartburn patients develop the habit of sipping on water after each bite of steak or bread to facilitate swallowing. Esophageal motility is best evaluated using manometry. Manometry is an outpatient test that does not require sedation. It takes about 30 minutes to complete. The test measures with high accuracy esophageal contractions and pressure in lower esophageal sphincter. Pressure in lower esophageal sphincter may be elevated in acid reflux patients due to excess scar tissue formation around distal esophagus. Scar tissue develops secondary to chronic inflammation due to acid reflux. Scarring may occur within the esophageal wall (less common these days due to PPI use) or around esophageal wall. Failure of lower esophageal sphincter to relax with each swallow results in esophageal outflow obstruction and dysphagia.
Other causes for dysphagia include achalasia, Schatzki’s ring, large hiatal hernia, and esophageal cancer. Acid reflux is a risk for esophageal cancer. Esophageal cancer starts developing along the lining of distal esophagus. As cancer grows, it partially obstructs esophageal lumen resulting in dysphagia. Upper endoscopy is an important test performed under sedation to visualize the inside of esophagus. The scope is inserted through the mouth and into the esophagus. Inflamed areas, polyps, lesions and ulcers are biopsied and sent for pathological examination.
Severe acid reflux disease causing dysphagia is not treated with diet or supplements. Diet does not cause acid reflux. Rather a weak anti-reflux barrier allows acid in the stomach to escape into the esophagus. Stomach content is always acidic whether you eat or not. In order to stop acid reflux, the anti-reflux barrier must be resorted. For stage 3 and 4 acid reflux disease, Houston Heartburn and Reflux Center specialists recommend hiatal hernia repair and Nissen fundoplication. Nissen fundoplication, when properly performed, is currently the most effective and most reliable treatment for GERD.

#### How Does Nissen Fundoplication Work to Stop Acid Reflux?
Gastro-esophageal reflux disease (GERD) is a complex disease. A variety of malfunctioning systems contribute to GERD. Esophageal motility, lower esophageal sphincter tone, hiatal hernia, gastric fundus relaxation as well as gastric emptying are some of these systems that contribute to reflux.
Nissen Fundoplication is the gold standard surgery for treatment of acid reflux. At Houston Heartburn and Reflux Center, Nissen Fundoplication is associated with 100% success rate.
The reliability of Nissen fundoplication results from the fact that it works on several mechanisms to stop acid reflux:

Nissen Fundoplication stops acid reflux by strengthening the weakened lower esophageal sphincter. In fact, the upper part of the stomach called gastric fundus is mobilized during a Nissen Fundoplication surgery and wrapped around the lower esophageal sphincter. In this fashion, the gastric fundus creates pressure around the lower esophagus. This high-pressure area prevents acid from backing up into the esophagus.
Nissen fundoplication reduces the frequency of transient lower esophagus sphincter in response to gastric distention
Nissen Fundoplication works is believed to involve moving the acid bubble away from the gastro-esophageal area. Wrapping the gastric fundus around the esophagus changes gastric motility in such a way that acid no longer lingers at the junction between the esophagus and stomach. Thus, acid reflux is less likely to occur.

We continue to explore and better understand Nissen fundoplication mechanism of action. A surgery discovered almost 70 years ago by Dr Nissen. Nissen fundoplication surgery has helped thousands of acid reflux patients in Houston and worldwide.
At Houston Heartburn and Acid Reflux center, it is our privilege to take care of you. We are eager to share with you the latest treatment options for acid reflux disease. We are conveniently located on 610 freeway in the Galleria area in Houston. Please give us a call at 832-945-8717 for more information.
Reference:
“Nature of antireflux barrier formed by Nissen fundoplication surgery” by: Robert Lee , Ravinder K Mittal , Kenneth J Chang , Ninh T Nguyen. Sci Rep. 2025 Sep 30;15(1):34047.

#### How Heartburn Treatment Makes for a Great Reality Television Show
Nothing says romance like heartburn.  Okay, maybe it doesn’t warm the heart the same way love does, but just humor us for a minute.  It’s rare we can learn anything valuable from reality television, but that’s about to change right now.
Imagine if you will, a dating show like The Bachelorette in which a group of guys attempt to win the heart of the woman at the center of the series.  As you know, producers of these shows find ways to throw curveballs or unveil twists that shock contestants and audiences alike.  That’s what’s going to happen on our fake reality show that we’re creating just for this blog post.
Here’s the scenario:
The four remaining men are going to try one last time to sweep our lady (named Jennifer) off her feet.  She is waiting in a beautiful garden, surrounded by colorful flowers and free-flowing trees.  A quaint little dirt path will lead her suitors through the garden and right to the scenic spot she stands.
Little do they know when they talk to Jennifer this time, she will smile, take them by the hand, gaze into their eyes, take a deep breath, and say, “I have heartburn.”
They probably weren’t expecting that.
If they are going to win her over, they have to tell her how they think she should cure her problem.  Here are some answers that just might win her over:
Offering to cook her new things to eat
Food choices can definitely contribute to heartburn and acid reflux.  The size of meal portions can also be a significant factor.  So, our first contestant suggests cooking some smaller meals that won’t cause her problems.
When it comes to breakfast, they might want to leave out tomato or citrus juices to go with breakfast.  He will also suggest less soda and alcohol during lunch and dinner.  These meals likely won’t include spaghetti with marinara sauce, macaroni and cheese, oil based salad dressings, buffalo wings, ground beef or sour cream.  In fact, according to a recent study, a high-fiber diet could reduce her chances of acid reflux by 20 percent.
Make sure there’s more than “just dinner” to their dates
It would be beneficial to have more to do on an outing than just eat and fall asleep.  That’s because the moment she lies down, it becomes a lot easier for food to work its way up to her esophagus (LES muscles), instead of staying at the bottom of her stomach.  Also, offering her gum instead of peppermints will provide a valuable after-dinner choice that won’t contribute to acid reflux.
Go on adventurous dates and get exercise
Our third contestant could impress her with his smarts by telling her that the International Journal of Epidemiology found a strong link between the symptoms of GERD and weight gain.  He’s just very careful in how he words this and makes it more about adventurous dates (like hiking and rollerblading) than her current weight.
Take an interest in long term health
Our last contestant might just be the one.  After all, he takes an interest in Jennifer’s long-term health so that their relationship can be long, happy, and healthy.  He suggests visiting specialists at a heartburn and acid reflux center to find out if her condition might need more than just a simple remedy.
Fortunately you don’t need to be featured on a reality show to learn more about treating heartburn and acid reflux – you just had to read this blog.  You can also visit a place like Houston Heartburn & Reflux Center to learn even more about the severity of your ailments.

#### How Long Does Acid Reflux Last?
Mia from Houston sent us this question: “I just had my gallbladder removed a few days ago. I went to the ER for what turned out to be acid reflux and ended in my gallbladder removed. My question is what do I eat and how long will the acid reflux last? I am open to whatever. I haven’t really eaten in forever. Thank you”
Dear Mia,
Acid reflux is a chronic and progressive disease. Acid reflux lasts all your life, and it tends to worsen as you age. Acid reflux symptoms like heartburn, cough and food regurgitation increase in both severity and frequency over time.
A reflux friendly diet helps alleviates some of the symptoms of acid reflux disease especially in early stages of GERD. However, stomach always secretes acid independent of what you eat. Indeed, acid production is normal part of normal physiology. Consequently, patients with a weak anti-reflux barrier experience acid reflux whether they eat or not. The root cause for acid reflux disease is not what you eat. It is a weak anti-reflux barrier. The weaker your anti-reflux barrier is, the more symptoms you have.
The most reliable solution to restore the anti-reflux barrier is hiatal hernia repair and Nissen fundoplication. A properly performed fundoplication surgery and hiatal hernia repair are 100% effective in stopping acid reflux. Gallbladder disease may co-exist with GERD. Removing the gallbladder eliminates gallbladder related symptoms only. Your acid reflux will continue, and it may even get worse after gallbladder surgery.
I recommend you get evaluated by a competent reflux specialist. We are accepting new patients for 2023 at our Houston Heartburn and Reflux Center. Please give us a call at 832-945-8717.

#### How Long Does LINX™ Surgery Last?
Steve from Austin, TX sent us this question: “I had the LINX™ procedure about 5 years ago. I’m a singer. The first 4 years everything was awesome. Now suddenly I literally can’t go one night without reflux no matter what. I’ve tried everything recently with zero results. I’m wondering if something happened with the LINX™”.
Dear Steve,
Like any mechanical device, LINX™ device may break down over time. A simple X-ray study can detect device failure. LINX™ device may also migrate up into the chest or erode into the esophagus leading to recurrent acid reflux symptoms like heartburn, hoarseness, sore throat, and voice fatigue.
Revision surgery is indicated to correct the problem. Evaluation prior to surgery consists of upper endoscopy, esophageal manometry, and UGI contrast study. LINX™ device is dissected and removed followed by conversion to a floppy and short Nissen fundoplication.

#### How Successful Is Heartburn Surgery in The Setting of Gastroparesis?
Spence from Cypress, Texas sent us this question: “Hello. I’m a 31-year-old male with a hiatal hernia and gastroparesis. I’ve dealt with severe heartburn since my teen years and in the last 7 or 8 years it’s run my life. I have vomiting episodes that last upwards of a day sometimes. I’m on Dexilant and famotidine and even with those, if I don’t sleep perfectly elevated up, I’ll wake up with stomach acid choking me in my lungs and it also in my sinuses behind my eyes. My insurance isn’t the best, so I’ve been going through the motions for years now, months or even up to a year in between tests/visits. My day-to-day life is full of uncomfortable feelings and a ton of fear. Fear that an episode will start and ruin the day of my family. Now I have a final endoscopy scheduled for August and I should hopefully be scheduled for the Nissen procedure shortly after. Now to the issue, my wife fears the procedure and I can see no other alternative because living the way I am now, is not an option for the rest of my life. I can’t even bend over for more than 10 seconds after eating without everything flowing right back up. Anyways, like I said I’m 31 and hopefully should have no problems recovering, but my wife thinks this isn’t an all-out fix and she thinks my gastroparesis won’t get better. I can’t see another way of me having a normal healthy life without it, so my question is, does it seem like this procedure is the best course of action for someone like me? Thanks for your time and I look forward to hearing back. Have a great day”.
Dear Spence,
Severe acid reflux disease is quite debilitating. Concomitant gastroparesis makes day-to-day life unbearable as you explain in your question. Fortunately, we have safe and effective solutions for both GERD and gastroparesis. Concomitant GERD and gastroparesis are rare. It is sometimes hard to differentiate if gastroparesis started first and resulted in GERD and hiatal hernia development, or if gastroparesis developed at a later stage, and GERD was the primary problem. In either case, thorough evaluation, and comprehensive testing by an EXPERT acid reflux specialist is crucial to tailor the best solution for your condition.
Heartburn surgery or anti-reflux surgery restores the anti-reflux barrier in order to stop acid reflux. The most reliable surgery to recreate the anti-reflux barrier and stop heartburn is Nissen fundoplication and hiatal hernia repair. Nissen fundoplication is performed by wrapping the upper part of the stomach around the distal esophagus. The wrap, by itself, enhances gastric emptying and mild gastroparesis tend to resolve after Nissen fundoplication.
For moderate gastroparesis, a pyloroplasty is added to Nissen fundoplication to enhance gastric emptying. An alternative to pyloroplasty is a limited antrum preserving longitudinal gastrectomy that extends up to fundoplication level. I personally prefer partial gastrectomy over pyloroplasty because it makes more physiologic sense. Partial gastrectomy promotes gastric emptying. When added to fundoplication, an antrum preserving partial gastrectomy effectively and safely enhances gastric emptying.
For severe gastroparesis, hiatal hernia repair and an antrum preserving longitudinal gastrectomy including gastric fundus are recommended. In this case, it is felt that acid reflux is a consequence of gastroparesis rather than a co-existing or primary disease. By restoring normal gastric emptying, acid reflux symptoms resolve. Of course, any size hiatal hernia must be corrected at the same time as partial gastrectomy to stop acid reflux. Most severe gastroparesis cases are associated with a dilated stomach. Gastric fundus is usually quite large. Fundoplication is this setting is not likely to promote gastric emptying and less likely to stop acid reflux.

#### How Successful Is Nissen Fundoplication?
Thomas from Cypress sent us this question: “I had Nissen fundoplication surgery 2 years ago and after about 6 months I developed heartburn and reflux again and now 2 years later it’s so bad I’ve had to have a heart cath to check my stents in my heart and they are perfectly fine and heart DR believes my pain is coming from Nissen surgery. But the DR who performed the surgery does not seem to want to do anything about it. What should I do? I can’t keep living like this with this pain in my chest?”. Thank you Dr. Darido.
Dear Thomas,
At Houston Heartburn and Reflux Center, we do one thing and one thing only, but we do it right. We do it right because a properly performed Nissen Fundoplication is associated with 100% success rate. Our Nissen fundoplication patients are very happy with surgery outcome. They have complete resolution of acid reflux related symptoms including chest pain.
Chest pain after Nissen fundoplication may be related to recurrent acid reflux disease 6 months after a failed Nissen fundoplication. An expert acid reflux surgeon can help you figure out the cause of your symptoms. Your acid reflux specialist is likely to order upper endoscopy with ambulatory pH testing to check wrap anatomy, rule out recurrent hiatal hernia and recurrent acid reflux are indicated.
If there is evidence of wrap failure, slippage and/or recurrent hiatal hernia, revision surgery is indicated. Revision surgery performed by an expert acid reflux surgeon is associated with good outcome. Additional tests like gastric emptying study and esophageal manometry may be ordered prior to redo Nissen fundoplication and hiatal hernia repair.

#### How to Control Your Heartburn with Portion Control
When you feel heartburn coming on, you may think “not this again” or “what did I eat to cause this?” However it may not be entirely what you are eating, but how and how much you are eating. According to health-treatment.com, overeating is one of the top triggers for heartburn, which is where the concept of portion control comes into play.
Portion control is centered on understanding a portion size of food, and how many calories a serving of food contains. The Lower Esophageal Sphincter (LES) can become damaged over time due to overeating. The LES’s primary function is to keep stomach contents in the stomach. When the LES functions normally and is healthy, it stops acids moving from the stomach into the throat. However, when we overeat, the LES weakens. The larger the meal, the more the stomach stretches, causing excess pressure on the LES. This makes it harder for the LES to function correctly, possibly resulting in acid reflux.

Eating five meals a day, rather than the standard three meals a day, will help to ease your heartburn. This method will help you overcome your hunger pangs between meals and to control the amount of food you eat. Here are some ways to adjust your portion control:
Eat slowly: many of us eat too quickly, or without even thinking. You are more likely to enjoy your food if you savor each bite. Putting your silverware down between each bite is another good idea to slow yourself down. Your stomach will have enough time to send messages to your brain, telling it you are full.
Eat at home to begin with: you have more control with your portions if you initially eat at home. It can be difficult to understand a portion size at a restaurant or at a friend’s house, and how many calories are in your meal.
Eat first thing in the morning: this will help with your energy levels and will keep your blood sugar levels more stable.
Try not to focus only on your meal: making conversation with others at the dining table will make you more relaxed, slowing down your eating.
Schedule your eating: tracking when you eat is very important to avoid unnecessary snacking and overeating at the end of the day. When you switch to eating five meals a day, eat every three hours.

Portion control will help you to feel better, not only about how much you eat, but also your health. You may see less heartburn and even lose weight too!
If you have been watching your portion size, when you eat, what you eat, but nothing is letting up, come see Dr. Darido at Houston Heartburn. Schedule an appointment today.

#### How to Make a Heartburn-Free Sandwich
A quick and easy meal, the sandwich! Eaten for lunch or even dinner, the sandwich can come in various varieties and yummy flavors. What might be an easy meal for some may be heartburn hell for others. Popular ingredients in sandwiches, such as tomatoes, and fatty foods, such as bacon, are common causes of heartburn. As it is National Sandwich Day today, we will be celebrating by laying out the fundamentals of making a ‘heartburn-free sandwich.’

BREAD: whole grain bread that is low in fat is a good option. Try to go for a slice of bread with only 2g or less of fat in it.
FILLERS: try to stick to meats lower in fat, such as chicken, turkey, ham or roast beef. Buy meats that haven’t gone through a lot of processing. For example, avoid smoked or cured meats, as these can often trigger heartburn; the meat is often spiced or glazed with honey or sugar.
SPREADS: choose a low fat mayonnaise. Mustards tend to have a kick, which can be problematic for heartburn sufferers. Go for sweeter mustard, such as honey mustard, instead. Another spread, an unusual option but a flavorful one, is a creamy low-fat dressing. Substituting this for the fatter spreads is a good way of incorporating flavor into your sandwich.
TOPPINGS: try one topping at a time to see which one really triggers your heartburn. Lettuce, spinach, and other greens are good options. Tomato, a popular sandwich topper, is known to be a heartburn trigger. Some may be able to tolerate a slice, but not tomato ketchup. Trial and error is the true way to find out what topping triggers your heartburn.
Try out this easy way to make a ‘heartburn-free’ sandwich and see how you get on. If you are still suffering from heartburn, contact Houston Heartburn today and take control of your heartburn.

#### Hurricane Harvey: Together We Heal
We have witnessed unprecedented flooding and destruction over the past few days. Harvey, a storm of epic proportions, has affected the lives of nearly 5 million Houstonian. In two days, over 50 inches of water were unloaded over the greater Houston area. Many families had to evacuate their houses leaving everything behind.
Our thoughts are with our patients and our teams affected by the flooding. Houston, however, will recover very soon. I have witnessed firsthand the resilience, compassion, and courage of Houstonians. There is still much work to be done but we will get through this together.
We are planning to reopen our offices this coming week. We appreciate your patience and ask you to please bear with us as our phone lines may be busy and some of our team members may not be working.
Warm Regards,
Elias Darido, MD

#### I Have a Lap Band: Should I Be Taking Antacid Medications?
Almost all Lap Band patients who present to my office for heartburn evaluation have already been started on proton pump inhibitors, PPIs. Primary care physicians in Houston and all over Texas recommend PPIs for heartburn. Irrespective of etiology, severity, or presentation, PPI treatment is, unfortunately, first line therapy. These powerful antacid medications have many side effects including renal failure, osteoporosis, magnesium deficiency, and altered gut microbiome. Thorough evaluation and GERD staging are crucial prior to committing patients to lifelong PPI treatment. Patients with stage 1 GERD don’t need PPIs. Patient with stage 3 or stage 4 GERD need surgery. Lap Band patients in particular do not benefit from any PPI treatment. The cause of heartburn, food regurgitation and chronic cough in Lap Band patients is directly related to the band itself. Any sensible treatment needs to address the band first.
When Lap Band patients present to Houston Weight Loss Surgery Center or Houston Heartburn and Reflux center for GERD related symptom evaluation, the subcutaneous port is accessed and all fluid aspirated. An upper gastro-intestinal (UGI) contrast study is performed. If the UGI shows a dilated gastric pouch, a hiatal hernia, tertiary esophageal contractions, or esophageal dilation then the band should remained completely decompressed for at least 6 months. Meanwhile, the patient is closely monitored for GERD related symptoms. Most patients will promptly improve with fluid removal from the band. Those patients may have their bands readjusted especially if they have a normal UGI study. Patients who do not improve with band decompression usually have a hiatal hernia and significant esophageal dysmotility. An esophageal manometry is highly recommended to evaluate the degree of dysmotility and the lower esophageal sphincter. If there is evidence of weak peristalsis, low contractile amplitudes and weak lower esophageal sphincter a Roux en Y gastric bypass and hiatal hernia repair are offered. Gastric bypass surgery isolates most of the stomach from the esophagus preventing reflux and decreasing the risk of aspiration. Roux limb anatomy creates a low-pressure system promoting esophageal emptying and further safeguarding against potential aspiration. It should be mentioned that patients with normal esophageal motility and a hiatal hernia might be offered the traditional Nissen fundoplication surgery for GERD symptom control. However, most Lap Band patients gain significant amount of weight following band removal and gastric bypass is preferred over Nissen fundoplication in order to promote weight loss. Indeed, excess weight is a major contributor to GERD and Nissen surgery in morbidly obese patients is associated with lower efficacy and durability.
Overall, patient satisfaction rates are very high following Lap band removal and conversion to Gastric Bypass. I caution against converting a Lap Band to gastric sleeve in the setting of esophageal dysmotility. Gastric sleeve is assumed to be a high-pressure system. Therefore, it may exacerbate acid reflux and esophageal emptying.

#### Incomplete Symptom Resolution Following Heller Myotomy for Achalasia
Sherry sent us this question last week: “I have achalasia and has suffered with it for over 19 years. four years ago I had a Heller myotomy which was unsuccessful. I still cannot swallow and I have the worst heartburn. Like your patient above I am 50 years old and a BMI of 35 making me very obese and would be interested in getting a gastric bypass and Heller myotomy for achalasia treatment. Looking forward to hearing from you soon”.
Dear Sherry,
Esophageal motility is a highly-coordinated neuro-muscular process that propels food and the occasional gastric content reflux into the stomach. Achalasia occurs when these contractions are absent or uncoordinated. Patients typically present with worsening dysphagia and heartburn. Heller myotomy is a palliative procedure that opens the lower esophageal sphincter to facilitate food passage from the esophagus into the stomach. Heller myotomy does not reverse esophageal dysmotility but rather prevents the development of a large and dilated esophagus also called megaesophagus. A large and dilated esophagus may require complete resection to alleviate symptoms. Therefore, we recommend early intervention with achalasia patients to prevent the development of megaesophagus.
An early Heller myotomy with Toupet fundoplication has a very good success rate in terms of alleviating dysphagia and heartburn. Failure to improve following Heller myotomy may be secondary to several reasons:
1- Incomplete myotomy
2- Un-resected esophageal diverticulum
3- Gastroparesis
4- Tight or twisted fundoplication
5- Herniated or slipped fundoplication
6- Megaesophagus
A complete and thorough work up must be completed before any redo Heller myotomy. If the cause of failure is not accurately pinpointed revision surgery is not likely to help you. At Houston Heartburn and Reflux Center, we recommend upper endoscopy, esophageal manometry, upper gastrointestinal contrast study, and gastric emptying study prior to revision Heller myotomy. Treatment is tailored according to workup findings. At Houston heartburn and reflux Center, incomplete myotomy is probably the most common reason for incomplete dysphagia resolution following Heller surgery. The myotomy must be properly extended cephalad and at least 3 cm below the gastro-esophageal junction to completely open the gastric inlet. Endoscopic dilation as well as POEM (Per-Oral Endoscopic Myotomy) are additional tools that may be used for treatment of failed Heller myotomy. POEM is particularly useful in type 3 achalasia allowing the surgeon to perform a long esophageal myotomy that is otherwise difficult to achieve using laparoscopy. POEM however in the setting of morbid obesity may result in severe postoperative GERD. Adding Roux-en-Y gastric bypass surgery for achalasia patients in addition to esophageal myotomy has the advantage of alleviating excess weight and GERD related symptoms.

#### Is GERD a Curable Disease?
Darnell from Houston sent us this question: “is advanced GERD curable? And if so, how. Will KETO work or help with those with this situation or will it intensify the Gerd situation… Thank you!!”
Dear Darnell,
Advanced acid reflux or GERD is treated and cured with surgery. Nissen fundoplication and hiatal hernia repair is a minimally invasive procedure with almost 100% effectiveness in stopping acid reflux. Nissen fundoplication surgery, when properly performed, is safe and durable. It re-establishes the anti-reflux barrier, and it stops acid in the stomach from refluxing back into esophagus.
Diet has limited efficacy in alleviating symptoms in advanced stage acid reflux. Indeed, stomach content is always acidic irrespective of what diet you consume. In the setting of a weak anti-reflux barrier, Keto diet is not likely to help control your symptoms when you have stage 3 or 4 GERD. Keto diet neither reduces stomach acid secretion nor does it strengthen the anti-reflux barrier.
It is a common misconception to consider diet as both cause and treatment option for severe acid reflux. Certain food items exacerbate acid reflux symptoms in stage one and two GERD. At this early stage of acid reflux, trigger food items, like coffee, chocolate, mint, and spicy food, may precipitate a heartburn attack. Avoiding coffee, tomato sauce… in early-stage acid reflux disease, reduces the frequency and severity of GERD symptoms. Avoiding coffee or going on a keto diet in stage 4 GERD is less likely to be effective.
Acid reflux disease or GERD is a chronic and progressive disease. Understanding disease pathophysiology and natural progression is crucial to offer a tailored and effective treatment that suits each patient particular condition.

#### Is It a Sluggish Gallbladder or GERD?
Maya from Houston sent us this question:
“I am a 45-year-old woman in overall good health. I am overweight but not obese and I live a very active lifestyle. After many years of regular bouts of intense acid reflux (started in my 20s when I was thinner than I am now) my doctor put me on a daily dose 20mg of Omeprazole when I was pregnant with my second child.  It was a game changer allowing me to eat/drink almost anything with no discomfort.
After 5 years on it, I woke up one day in excruciating pain ultimately going to the ER unsure of what was happening.  Looking at my symptoms and location of pain (upper right quadrant) there was thought that it was my gallbladder, but no stones were detected, and I was sent on my way. 
I went to my gastroenterologist, and they ordered a HIDA scan which showed that I had a very low functioning gallbladder, and they diagnosed me with biliary dyskinesia and recommended I surgically remove my gallbladder.
I did not act on this right away and ended up in the ER again in excruciating pain about 10 months later.  The pain subsided after a few hours, and I was sent home.  No treatment or next steps.
I had an upper endoscopy, and they were able to see that I have a very small hiatal hernia, but they felt that it was so small it wasn’t worth operating on.  They did say that I should still plan to get my gallbladder removed but they also said that it was no guarantee I would not still get these painful attacks. 
It’s been 9 months now since my last attack.  I currently take 40mg of Omeprazole per doctor’s prescription.
I am very conflicted about scheduling the surgery, is it necessary?  Is the Omeprazole the reason for my low functioning gallbladder?  Will my acid reflux be even worse after removal?  Should I explore the hernia again and see if surgery makes sense for that?  I just don’t know which thing to tackle first. Thank you.”
Dear Maya,
Biliary dyskinesia (often described as a “sluggish” or “lazy” gallbladder) and gastroesophageal reflux disease (GERD) can produce overlapping symptoms, including pain beneath the breastbone, nausea, bloating, and digestive discomfort. Because of this overlap, distinguishing between the two conditions can be challenging—but it is certainly possible with careful clinical evaluation.
In your case, there is clear evidence of longstanding GERD. Pregnancy is known to worsen reflux symptoms, and during your second pregnancy you were appropriately started on proton pump inhibitor (PPI) therapy to control acid reflux. Your positive response to PPIs further supports the diagnosis of GERD.
Approximately five years later, you developed sudden right upper abdominal pain, a symptom more typically associated with gallbladder disease. You also had several well-known risk factors for gallbladder dysfunction, including female sex, a history of multiple pregnancies, increasing age, and being overweight.
There is some evidence suggesting that chronic PPI use may reduce gallbladder ejection fraction and potentially contribute to biliary dyskinesia or gallstone formation. While the exact mechanism is not fully understood and the association is not definitively established, this raises the reasonable consideration of discontinuing PPIs to assess whether gallbladder function improves.
In your situation, however, your PPI dose was increased to adequately control reflux symptoms, underscoring the severity and persistence of your GERD. Additionally, the finding of a small hiatal hernia on endoscopy does not rule out significant GERD and does not exclude you from being a candidate for anti-reflux surgery.
In my opinion, it is important to complete your GERD evaluation with esophageal manometry and ambulatory pH testing.
Esophageal manometry assesses how well the lower esophageal sphincter (LES) functions, while pH testing measures the amount of acid exposure in the esophagus over time. Together, these studies confirm the diagnosis of GERD and help determine its severity.
If testing confirms significant acid reflux, hiatal hernia repair with Nissen fundoplication is recommended to restore the natural anti-reflux barrier and reliably control reflux. When properly performed, this operation has a very high success rate and often allows patients to discontinue proton pump inhibitors (PPIs).
During anti-reflux surgery, gallbladder removal can be performed safely at the same time if needed. However, in your case, there is a reasonable option to first monitor your biliary dyskinesia–related symptoms after anti-reflux surgery, especially once you are off PPIs.
If your right-sided abdominal pain resolves after surgery and stopping acid-suppressing medications, gallbladder surgery may not be necessary. In this situation, chronic PPI use and prolonged acid suppression may have contributed to biliary symptoms.
If, however, abdominal pain persists or recurs, a second, separate operation to remove the gallbladder would then be appropriate.

#### Is It Gallbladder Disease, Heartburn or Acid Reflux?
Patrick from Pasadena sent us this question:
Dr Darido,
The answers in your blog are so informative and in detail. I am a 28-year-old living in Pasadena, TX. For the last 1 year I used to experience excessive gas, bloating and flatulence every morning but never had any heart burn or acid reflux even after having a heavy spicy meal or binge drinking night. But Since March,2020 I started experiencing severe heart burn, with some episodes of unable to swallow food. The symptoms keep changing. Sometimes it’s the feeling as if the food is struck in my throat and chest, pain in my back and shoulders and sometimes its lot of belching. But one consistent symptom every single day I notice is constant throat clearing, burping, flatulence and bloating. I have been extremely strict with my diet (no fatty, spicy, tomatoes, onions and what not). In this process I lost 35 lbs. in 10 weeks. I used to weigh 155 lbs. before (not obese). They have performed an endoscopy and ruled out hiatal hernia or ulcers. They found mild chronic gastritis in the reports.
Currently I am on 40mg Omeprazole in the mornings and 20 mg Famotidine in the evenings
Recently in an ultrasound they even found echogenic sludge and multiple small gallstones in Gallbladder. I strongly believe this is because I lost 35lbs in such short time. Now the doctors here are recommending me to get my gallbladder out. So far, I haven’t experienced any gallstone pain or episode with the exception of very minimal dull pain in right upper abdomen which is sensitive to touch.  I am extremely scared that Gallbladder surgery would only worsen my Gastritis and GERD symptoms.
Can you please advise if I should get my gallbladder out or should I wait till my GERD is cured? Also, can I use Urso to treat my gallstones meanwhile or while that aggravate the GERD symptoms too? I know stress can only elevate GERD, but this whole gallstone diagnosis is making me lose my sleep and making things worse. Would really appreciate your advice.
Thank you,
Dear Patrick,
Thank you for your question. Your situation and presenting symptoms are quite common. Unfortunately, many acid reflux patients undergo unnecessary gallbladder surgery every year in Houston. You have typical acid reflux symptoms and zero gallbladder related symptoms. I wouldn’t even order a gallbladder ultrasound. 30% of the population in Houston and Pasadena have gallstones and sludge in their gallbladder; If they are asymptomatic, gallbladder surgery is not indicated. Gallbladder related symptoms may overlap with acid reflux symptoms like bloating, maldigestion, and abdominal pain. Sore throat, difficulty swallowing, heartburn and food regurgitation are classic acid reflux symptoms and highly indicative of GERD.
You had an upper endoscopy that did not show acid reflux, yet you are being treated with high dose antacids. Unfortunately, we encounter many patients like you at Houston Heartburn and Reflux Center with severe acid reflux symptoms and presumably negative endoscopies. We invariably repeat the upper endoscopy with ambulatory pH testing and find clear evidence of hiatal hernia and acid reflux.
My recommendation for you is to get evaluated by a competent acid reflux specialist in Houston before you commit to any surgery. Unnecessary gallbladder surgery may exacerbate your acid reflux symptoms. Ursodiol decreases the chance of gallstone formation especially when losing lot of weight. I don’t think it is helpful for you at this point. Stress and anxiety exacerbate GERD symptoms but do not cause acid reflux to develop.

#### Is It GERD or Gastroparesis?
Gastroparesis and GERD (gastroesophageal reflux disease) are two gastrointestinal problems with overlapping symptoms but different treatments. In the case of gastroparesis or delayed gastric emptying, stomach contractions that propel food down into intestines are lost. Undigested food and stomach secretions accumulate in stomach for days and weeks. This results in nausea, bloating, vomiting, and in many cases, heartburn. Heartburn, a burning sensation behind the breastbone, is indeed very common in gastroparesis cases. Food stasis and increased gastric pressure favor gastric content reflux into esophagus resulting in heartburn.
Heartburn, however, is a classic GERD symptom. In GERD patients a weak anti-reflux barrier allows frequent gastric content reflux into esophagus. In addition to heartburn, GERD patients suffer from food regurgitation, bloating, excessive burping, sore throat, cough, and globus. Nausea, vomiting, and early satiety are not common GERD symptoms.
Careful history taking and symptom analysis along with comprehensive testing by expert acid reflux specialists allows for accurate diagnosis. Upper endoscopy shows hiatal hernia formation in GERD patients and stomach solid food residue in gastroparesis patients. Ambulatory pH testing shows multiple acid reflux events in GERD cases and less numerous but long reflux events in gastroparesis cases. Furthermore, stomach is typically dilated and elongated in gastroparesis. This finding is best appreciated on radiography studies.  Ultimately, the diagnostic test for gastroparesis is a gastric emptying study that shows delayed gastric emptying.
The gold standard treatment for GERD is a properly performed Nissen fundoplication and hiatal hernia repair. Procedure effectively re-establishes the anti-reflux barrier resulting in complete cessation of gastric content reflux into esophagus including vomiting. Nissen fundoplication prevents stomach from venting upward in case of gastroparesis. For this reason, it is contraindicated in the setting of gastroparesis. Gastroparesis patients who mistakenly undergo Nissen fundoplication surgery are likely to experience worsening bloating, nausea, and dry heaving.
Nissen fundoplication takedown is indicated in this case to allow gastroparesis patient to vomit and decompress stomach upwards into esophagus. At Houston Heartburn and Reflux Center, we offer a concomitant antrum preserving longitudinal gastrectomy to promote gastric emptying. We have had great success with this approach. About 50 patients with medically refractory gastroparesis have undergone antrum preserving longitudinal gastrectomy. 70% of the stomach is resected through tiny incisions. Surgery is outpatient and it is associated with fast recovery and very low complication rate. Patients report immediate resolution of nausea, vomiting, bloating and abdominal pain. Repeat gastric emptying study after surgery shows normalization of gastric emptying rate.
To summarize, it is important to differentiate GERD from gastroparesis because treatment is different. Nissen fundoplication is contraindicated in gastroparesis cases. Antrum preserving longitudinal gastrectomy seems like an excellent solution for medically refractory gastroparesis patients.

#### Is Keto Diet a Good Option for GERD Patients?
Jane, a GERD patient who happens to be a nutritionist and ketogenic diet advocate, presented to my office for evaluation of GERD related symptoms of several year duration. She is frustrated with her GERD symptom progression and severity over the past few years despite maintain a healthy lifestyle for the past 30 years.  She has a strong family history of GERD and unlike her patients, a ketogenic diet did not help alleviate her acid reflux related symptoms. She reports that she has helped many of her patients control their acid reflux symptoms by adopting a very low carbohydrate, high fat diet, known as ketogenic or keto diet. Keto diet, however, did not eliminate her GERD symptoms. She is otherwise healthy and fit. She exercises daily and maintains a normal body weight. Given the popularity of keto diet, I have encountered a number of GERD patients like Jane and her patients reporting acid reflux symptom improvement on ketogenic diet. Such observations are unexpected. We advise our GERD patients to avoid fatty food to decrease the incidence of heartburn. So why and how does a ketogenic diet help alleviate heartburn?
The relationship between diet and GERD is well recognized but not well studied. For instance, spicy food, alcohol, and chocolate exacerbates acid reflux, but the underlying mechanism is not known. A heavy meal rich in fat is more likely to cause heartburn than a light meal consistent of lean meat and fresh vegetables. Fat like smoking, alcohol, chocolate and mint… is believed to decrease the lower esophageal sphincter pressure favoring acid reflux. GERD, however, is a multifactorial problem. GERD pathophysiology is not limited to lower esophageal sphincter pressure and relaxation. GERD is in fact a gastroduodenal motility disorder that favors reflux of gastric content into the esophagus. Ingested food alters gastrointestinal motility in a number of ways that we still don’t understand. In the case of GERD, certain ingested foods alter gastric motility in such a way to favor reflux. Along those lines, we have noticed that a low carbohydrate diet in obese patients reduces heartburn events. A study published in 2006 in the journal of Digestive Diseases and sciences, by Shaheen NJ et al, demonstrates that a very low carbohydrate diet in obese patients with GERD significantly reduces distal esophageal acid exposure. The authors enrolled 8 patients. Each participant underwent a 24-hour pH impedance study prior then 6 days after starting a diet containing less than 20 grams of carbohydrates per day. Both the DeMeester score and percent total time with pH less than 4 significantly decreased. All patients reported improvements in heartburn, chest pressure, excessive burping and other GERD related symptoms. The study is too small to draw any major conclusion, but the results do suggest decreased acid reflux on low carbohydrate diet in obese patients prior to any significant weight loss. 80% of obese individuals suffer from GERD. A high intra-abdominal pressure causes gastric lumen content to reflux back into the esophagus. Furthermore, obese patients suffer from abnormal carbohydrate digestion, absorption and metabolism. Post-prandial hormones secreted by the gastro-intestinal tract like GLP-1 and PYY are diminished in obese patients. This results in elevated post-prandial blood glucose and insulin levels. Dysfunctional gastric emptying along the Magenstrasse pathway results in decreased post-prandial GLP-1 and PYY secretion. It is also possible that disrupted Magenstrasse emptying results in acid reflux. Indeed, Nissen fundoplication, the most reliable treatment for acid reflux, increases postprandial GLP-1 and PYY secretion. Nissen fundoplication increases gastric emptying and possibly restores a dysfunctional Magenstrasse emptying pathway.
Along those lines, a very low carbohydrate and high fat diet, like ketogenic diet, may be of great benefit to obese GERD patients. Keto diet may be particularly effective in reducing heartburn in overweight and insulin resistant individuals (the majority of adult US population). GERD is also a chronic and progressive disease. Patients with stage 3 and 4 GERD are less likely to benefit from just diet and lifestyle changes. Advanced GERD is associated with abnormal anatomy (hiatal hernia), esophageal dysmotility (detected on manometry) and significant gastric emptying issues (still poorly misunderstood and cannot be measured). Nissen fundoplication with hiatal hernia repair address these issues and provide a reliable and durable cure for advanced acid reflux disease.

#### Is Nissen Fundoplication Covered by My Insurance?
John from Houston sent us this question: “I was suggested to get a Nissen Fundoplication after a Gastroenterologist saw I disqualified for TIF procedure. I am worried about Nissen fundoplication potential side effects. I used to be a highly active person. Epigastric pain every day. Does insurance cover expenses? Thank you.”
Dear John,
TIF and LINX™ procedures are not always covered by insurance because they are not effective and reliable treatment options for GERD. Nissen fundoplication, on the other hand, is always covered by insurance. A properly performed Nissen fundoplication has a very high success and safety rate. Indeed, a properly performed Nissen fundoplication is first line treatment for acid reflux disease. Nissen fundoplication side effects, when surgery is performed by expert hands, are rare. Side effects like difficulty swallowing and bloating after surgery are very rarely encountered at Houston Heartburn and Reflux Center.
Consequently, a properly performed Nissen fundoplication improves quality of life. Unlike TIF and LINX™ surgery, Nissen fundoplication effectively and reliably restores your anti-reflux barrier. As a result, you no longer need to avoid certain foods or take acid reflux medications like Proton Pump Inhibitors. Nissen fundoplication surgery stops all acid reflux related symptoms, and when properly performed, it will give you back your normal active life.

#### Is Nissen Fundoplication the Best We Can Do?
I came across this article titled “Is Nissen Fundoplication the Best We Can Do?” and published in 2021 in the official newspaper of AGA (American Gastroenterology association). The author, a gastroenterologist, argues that “a safer standardized reversible surgical option” or “a less invasive endoscopic approach” have greater appeal than the standard Nissen fundoplication. He concludes that our current surgical options are “good but not perfect” and “we should not settle on the current state of GERD management”.
Interestingly, the author quotes a study by Spechler et al published in 2019 in the New England journal of Medicine that showed Nissen fundoplication was superior to medical management in patients who did not respond to proton pump inhibitors (PPIs). Thus, a mechanical solution to reflux disease, as the author describes Nissen fundoplication, may only be needed for some patients.
As an acid reflux surgeon and specialist in Houston, I find it difficult to try or even consider a novel or alternative procedure for acid reflux management besides Nissen fundoplication surgery. I have so far performed more than a 1000 consecutive Nissen fundoplications with 100% success rate and 0% complication rate. At Houston Heartburn and Reflux Center, our long-term hiatal hernia repair and Nissen fundoplication durability is very high. Equally, our patient satisfaction rate with surgery outcome, acid reflux symptom control and quality of life after surgery is very high.
At Houston Heartburn and Reflux Center, a properly performed Nissen fundoplication and hiatal hernia repair, is the perfect treatment for acid reflux disease. I simply cannot offer a better solution for GERD. For this reason, I do not recommend novel anti-reflux procedures especially when a foreign body must be implanted like RefluxStop™ or LINX™. Nissen fundoplication alters the geometry of the stomach to achieve a multifaceted physiologic effect that stops acid reflux.
Nissen fundoplication is indeed, more than a simple mechanical barrier to reflux. It is crucial for gastroenterologists in Houston to understand this concept to properly advise their GERD patients. 

#### Is Ozempic Exacerbating Your Heartburn?
Mary from Houston sent us this question: “My PCP started on Ozempic 3 months ago for my type 2 diabetes. My blood sugar control has improved but my heartburn has gotten worse. I can no longer control my acid reflux symptoms with daily Protonix. I wake up at night with food regurgitation despite elevating the head of my bed. My PCP has recently double my Protonix dose, but I don’t think it is helping me a lot”. Thank you.
Dear Mary,
GLP-1 agonists like Ozempic, Wegovy, Mounjaro and Zepbound are commonly used now for treatment of diabetes and obesity. GLP-1, (glucagon like peptide-1), agonists delay gastric emptying. The most common side effect of delayed gastric emptying is nausea. Around 20% of patient on Ozempic experience nausea. Vomiting and abdominal pain occur in 10% of patients taking Ozempic. Furthermore, delayed gastric emptying favors acid reflux. Consequently, patients who are already on proton pump inhibitors for acid reflux control, may experience worsening heartburn and food regurgitation after starting Ozempic.
The spectrum of acid reflux disease is wide. GERD patients are divided into 4 stages. Stage 2 GERD patients have frequent or constant symptoms that are well controlled with medications like proton pump inhibitors. Stage 3 GERD patients experience breakthrough symptoms despite daily acid suppressant treatment. In your case, Mary, the addition of Ozempic to control your blood sugar upgraded your GERD from stage 2 to stage 3.
Surgical therapy in the form of a properly performed hiatal hernia repair and Nissen fundoplication is indicated for stage 3 GERD patients. Once the anti-reflux barrier is restored, patient can safely resume Ozempic treatment without struggling with any GERD related symptom like heartburn and food regurgitation. Another option for diabetic or overweight patients with concomitant acid reflux is to undergo a bariatric procedure in addition to hiatal hernia repair. This approach is both safe and reliable to control blood sugar, lose excess weight, as well as eliminate GERD related symptoms and the need to continue Ozempic for life.

#### Is Thanksgiving Synonymous with Heartburn for You?
Thanksgiving meal is the ultimate challenge for acid reflux patients. It is big, heavy and rich in an endless array of heartburn trigger foods. If you have a hiatal hernia and weak lower esophageal sphincter you are not likely to survive Thanksgiving without a major heartburn attack. What can you do?
First, eat a small meal. Easier said than done especially on Thanksgiving Day. However, large meals stretch the stomach and weaken the anti-reflux valve leading to acid and gastric content reflux into the esophagus. Make an effort to eat multiple small portions throughout the day instead of one large meal at night to avoid heartburn and food regurgitation.
Second, avoid fat rich meals like gravy. Look for alternatives and fill up on white turkey meat, green beans, carrots, corn and multigrain bread.
Third, avoid spicy food items. Spicy food item like hot Tamales are particularly common on Thanksgiving in Houston, TX.
Fourth, cut down on alcohol and coffee consumption on November 22. Both coffee and alcohol relax the lower esophageal sphincter. In the setting of a Thanksgiving dinner, you are most likely to develop heartburn if you drink coffee and consume alcoholic beverages.
Last but not least, get evaluated by a reflux and heartburn specialist in Houston. There is no need for you to live like this year after year. There are many safe and effective solutions for acid reflux. Get treated so that next year you may celebrate Thanksgiving with family and friends without heartburn on the menu.

#### Is Your Job Giving You Heartburn?
Houston ranks among America’s most stressful cities. Endless working hours and long daily commutes are major contributors to stress; Houstonians are paying a huge price with their health. Chronically stressed people are more likely to suffer from obesity, diabetes, hypertension and heart disease. But does stress cause acid reflux disease?
Many patients report stress as a trigger for heartburn. More than half of the patients that report to Houston Heartburn & Reflux Center attribute recurrent heartburn to a hectic lifestyle. The reality is that stress in and by itself does not cause acid reflux. The lower esophageal sphincter is a ring of muscles acting as a barrier against acid reflux. Stress does not affect the competency of the lower esophageal sphincter; hence, stress does not cause reflux. However, chronic stress can exacerbate the intensity and duration of an already existing acid reflux problem. Indeed, stress increases stomach acid production, as well as the sensitivity of the esophagus to pain. As a result, acid reflux, if already present, is felt more intensely with stress.
If you suffer from acid reflux disease and chronic stress, do not simply mask your symptoms by taking proton pump inhibitors. Rather, seek curative solutions for both issues. First, get evaluated by a reflux specialist to stage your acid reflux disease. According to your acid reflux stage, the appropriate treatment plan is offered. Second, work on developing stress coping techniques to face your daily challenges. Do not resort to smoking, heavy drinking or drug use as a means to alleviate stress. This will only exacerbate your reflux problem. Do not overeat to comfort yourself. Obesity is a significant contributor to acid reflux disease. Take care of your body by adopting a daily exercise routine. Exercise is one of the best solutions for fighting stress. Spend some time in nature, meditate, and get in touch with your inner self.
At Houston Heartburn & Reflux Center, we comprehensively target the causes of acid reflux rather than the symptoms. If stress is contributing to your acid reflux disease, we have solutions for you.

#### Is Your Lap Band Causing You Heartburn?
Adjustable gastric banding or lap band surgery is a weight loss procedure that is rarely performed nowadays. A few years ago, however, lap band surgery was quite common. The concept of adjustable gastric banding revolves around creating stomach restriction, forcing the patient to eat less. The band is progressively tightened around the stomach by injecting fluid inside its lumen. Unfortunately, most patients were over-restricted in hopeless attempts to make them loose weight. Over-restriction resulted in near obstruction of the esophagus. Food passage into the stomach was hindered. Patients developed heartburn, food regurgitation, nocturnal cough, and vomiting.
If you have a lap band and suffer from heartburn, food regurgitation, nocturnal cough, or vomiting you may be over-restricted. Band over-restriction, if left unattended, leads to irreversible damage to your esophagus. You may develop esophageal dilation and difficulty swallowing. The esophageal lining may herniate through its muscular wall, creating a blind pouch we call diverticulum. Food accumulates in the diverticulum, causing pain, regurgitation, and nocturnal cough. Nocturnal cough results from food material backing up into your upper airway and lungs when you lay on your back. This is a dangerous condition as it puts at risk for aspiration pneumonia. Aspiration pneumonia is lung infection, developing from stomach content entering your lungs.
If you have a lap band, you need to follow up with your doctor on a regular basis for adjustments. If your band is causing you heartburn, Houston Heartburn and Reflux Center offers the most comprehensive heartburn evaluation and care in the greater Houston area. Contact us to alleviate your symptoms.
 

#### Is Your Sleeve Surgery Causing Acid Reflux?
Most overweight individuals complain of heartburn. Excess fat accumulation inside the belly contributes to increased pressure on the stomach, leading to acid reflux. Furthermore, overweight individuals tend to overeat. Overeating stretches and weakens the lower esophageal sphincter, LES, allowing acid to reflux back up into the esophagus. Delayed gastric emptying and a dilated gastric fundus (upper part of the stomach) also may contribute to the increased incidence of heartburn in this patient population.
At Houston Heartburn and Acid Reflux Center, we always treat the cause of acid reflux to eliminate the symptom of heartburn. For a patient with a body mass index (BMI) higher than 35 and suffering from acid reflux, the best treatment is weight loss surgery. Bariatric surgery allows for long-term effective weight loss, leading to alleviation of most acid reflux symptoms. Sleeve gastrectomy is currently the most commonly performed weight loss procedure around the world. During sleeve surgery, 85% of the stomach is resected, ending up with a banana-shaped stomach. As you lose weight following sleeve surgery, heartburn tends to resolve. A recent study published in the Annals of Surgery by Dr. Morino showed that heartburn resolves after sleeve gastrectomy in the majority of patients who suffered from gastro-esophageal reflux disease (GERD) prior to surgery. The study also showed that new onset acid reflux after sleeve gastrectomy is rare. Interestingly, the study demonstrated that sleeve surgery increases the pressure of the lower esophageal sphincter, LES, hence strengthening the acid reflux barrier. This is an additional anti-reflux property for the sleeve that is independent of weight loss.
If you have persistent heartburn after sleeve surgery, Houston Heartburn and Reflux Center offers thorough evaluation for bariatric patients. Our acid reflux and bariatric surgery expert, Dr. Darido, has adopted a comprehensive approach for sleeve patients suffering from acid reflux. A missed hiatal hernia, a retained gastric fundus, or narrowing in the gastric sleeve are the most common causes for persistent acid reflux after sleeve surgery. Dr. Darido offers simple solutions to help you get rid of acid reflux and enjoy weight loss. If you are a sleeve patient and suffers from acid reflux, please contact us today.

#### Is Your Weight Causing Heartburn?
There can be many factors associated with your heartburn – trigger foods, health conditions; however, a factor you may not be considering could be one of the riskiest of them all. Is your weight causing your heartburn?
If you are overweight, your chances of suffering from heartburn are increased. This is thought to be because of the extra pressure put onto the stomach by the excess weight around the abdomen area. This causes hiatal hernia to develop, which causes acid to be pushed back into the throat instead of staying in the stomach.

Obesity is related to three esophageal disorders:

Heartburn
Barrett’s Esophagus: constant acid flowing into the throat can cause long term damage. Precancerous changes can occur to the esophagus, known as Barrett’s esophagus.
Esophageal Adenocarcinoma: throat cancer

Losing weight and eating healthy are a great combination to attack your heartburn. A 2012 study showed participants take part in a weight loss program to see the effects of losing weight and heartburn. Women saw improvements in their heartburn symptoms when they lost 5% – 10% of weight, compared to men who saw improvements after losing 10% of their body weight.
The Nurse’s Health Study saw researchers analyze 10,000 women and found the symptoms of heartburn increase by a large amount when there was a weight gain of 10-20 pounds. However, at the same time, if a woman were to lose weight, it would decrease her risk of heartburn by 40%.
Losing weight can lead to less heartburn symptoms. This means there is less acid in the stomach, which may result in buying less over-the-counter or prescribed medication.
Heartburn used to be a common problem in the elderly; however, now younger Americans are suffering from this condition. It is believed to be an increase in acids in the American diet. Fast food is a popular choice for the younger generation due to its convenience and cheapness. The greasy, fatty food is a perfect recipe for heartburn.
 
If you are suffering from heartburn or similar symptoms, overweight or not, make an appointment today with Dr. Darido.

#### Jackhammer Esophagus
Miguel from South Houston asked us this question: “Can or is Hypercontractile esophagus a cause for Dyspnea/shortness of breath? I have Jackhammer esophagus.  I had fundoplication surgery 2 months ago and started eating solid food 2 weeks ago. I have a degree of dysphagia post-op which i never had before, but I am still manifesting breathing irritation/limitations which I need to get resolved. My surgeon said the surgery would correct this problem, but it has not been the case. I don’t have medical professionals in my community that know or can address this condition, hence my reaching out to you.  Thank you”.
Dear Miguel,
Jackhammer esophagus or hypercontractile esophagus, also known as nutcracker esophagus, is a rare motility disorders characterized by intense esophageal spasm. The spasm can be severe causing patients to think they are having a heart attack. A number of medical conditions may result in dyspnea and shortness of breath including esophageal spasm. Other symptoms of hypercontractile esophagus include heartburn, food regurgitation and difficulty swallowing. The etiology and underlying cause of jackhammer esophagus are not well understood. Acid reflux may trigger esophageal spasms development. If you are diagnosed with a jackhammer esophagus in the setting of acid reflux, acid reflux control is recommended as it may be causing esophageal spasm. Nissen fundoplication surgery is the most reliable solution for GERD. Jackhammer esophagus, however, may not resolve following Nissen fundoplication. A number of medications are used to manage a hypercontractile esophagus like tricyclic antidepressants and smooth muscle relaxants like calcium channel blockers and Viagra. However, there is no consensus regarding the most effective medical treatment. Your acid reflux specialist may try more than one medication before settling on the most suitable medical regimen to your condition. Esophageal dilation and Botox injection may be used in select cases. Esophageal myotomy preferably in the form of POEM (Per Oral Endoscopic Myotomy) is indicated in severe cases refractory to medical therapy. Post-operative dysphagia may be secondary to a tight Nissen fundoplication or hypercontractile esophagus. I typically recommend waiting 3 months prior to balloon dilating the wrap if needed. You need to be evaluated by an acid reflux specialist with interest in esophageal motility disorders to benefit from the best treatment suitable to your condition.

#### Laparoscopic vs Open GERD Surgery
I read with great interest the newly published article titled “Comparative Analysis of Perioperative Outcomes and Costs Between Laparoscopic and Open Anti-reflux Surgery” in the journal of the American College of Surgeons by Patti el al. This is a retrospective study based on the National Inpatient Sample for the period between 2000 and 2013. A total of 75544 patients were included with 58% undergoing laparoscopic fundoplication and 42% receiving an open acid reflux surgery. As expected the rate of minimally invasive procedures for acid reflux has increased over time.
The study has shown that laparoscopic fundoplication is associated with lower postoperative morbidity and mortality rate, shorter length of hospital stay, and lower cost than open fundoplication. Interestingly, the number of fundoplications for GERD treatment has decreased from 2000 till 2013 despite an increase in GERD prevalence. The authors attribute this decrease to patients’ and gastroenterologists’ concerns about acid reflux surgery outcome including efficacy and durability. While this assumption makes sense, I think that the widespread use of proton pump inhibitors, and the trivialization of GERD as a complex medical disease have diverted both patients and physicians from properly addressing acid reflux disease. Over the past 15 years GERD has become a nuisance that patients had to live with one way or the other. Only after hiatal hernia repair and Nissen fundoplication, patients realize the full effect of GERD on their health and lifestyle.
Furthermore, despite an increase in laparoscopic acid reflux procedures, 15% of fundoplications are still performed using an open approach. This may be due to older surgeons who have not embraced laparoscopy. Other factors may be related to difficult revision acid reflux surgeries or complicated cases due to previous abdominal surgery.
In conclusion, laparoscopic fundoplication is currently the standard of care for treatment of GERD. Nissen fundoplication has stood the test of time and is currently the most effective and most reliable treatment of GERD.

#### Laryngopharyngeal Reflux (LPR) - A Patient's Review
Below is a patient experience with Nissen fundoplication for LPR treatment
The outstanding reviews on this page were so helpful in my discernment, and I hope my experience can be useful too! The short story is that my surgery for LPR was a complete success, and I’m most grateful to Dr. Darido and his high standard of excellence.
My LPR symptoms became debilitating a year and a half ago when I got pregnant for the first time. When I contacted Dr. Darido postpartum, I was down to fasting after 3:30pm and only six foods that I could tolerate. If I deviated from this diet even a little bit, I would experience debilitating lung pain, ear pain, congestion, throat pain, throat mucus, and laryngitis. I could not bend over or lay flat.
I was diagnosed with asthma when I was very little, but I’ve since learned that LPR was the true reason for my respiratory issues all these years. Unfortunately, I wasn’t aware of LPR’s existence until after I gave birth. I vomited constantly during pregnancy and went through tissue boxes like crazy because of congestion and throat mucus. I didn’t understand my symptoms and neither did my doctors, including two ENTs. I’m lucky that both baby and I are okay.
Not the case with Dr. Darido’s practice. Brenda and Valerie were wonderful and helped me see Dr. Darido, who was very knowledgeable about my condition, as quickly as possible. When I came in for testing in September 2024, he found a large hiatal hernia, saw that my LES was very damaged, and diagnosed me with LPR. I went in for surgery soon after, and the pain was gone as soon as I woke up! Dr. Darido even gave me his cell phone number and responded right away when I had questions during recovery.
I’m fully confident that I made the right choice in choosing Dr. Darido as my surgeon. As he said, and as my experience confirms, my Nissen wrap was executed flawlessly. Dr. Darido is in a league of his own, and I will take care of my wrap to ensure it lasts a lifetime!
God bless you Dr. Darido! I can get back to my life and give my best to my family and baby girl because of you, and my family and friends are so happy to finally see me well and eating again! If that wasn’t enough, my husband and I look forward to me being much healthier and safer in the next pregnancy, if we are ever blessed again in that way! I desperately needed help and am most grateful to have found a surgeon I could trust. I can’t imagine my life without Dr. Darido and will recommend him to everyone I know suffering from acid reflux pain. I have even recommended him to my own family – that’s how much I trust him! Thank you again for everything! God bless you!!!
Read review on Google

#### Late Complications of LINX™ Device for Heartburn Treatment
Barbara from Cypress sent us this question: “I have chest pain, sore throat, a little food coming up in my throat. I’m miserable. What can my doctor do? I had the LINX™ surgery for 4 years ago”
Dear Barbara,
Several LINX™ device related late complications have been reported in the literature. These include LINX™ erosion, LINX™ migration into the chest with or without recurrent hiatal hernia and pseudo-achalasia. Evaluation starts with upper endoscopy with possible pH bravo capsule placement to measure esophageal acid exposure. UGI contrast study may be added along with esophageal manometry to study esophageal motility and lower esophageal sphincter pressure.
Once your acid reflux specialist has completed this work up, a treatment plan can be tailored to suit your condition. LINX™ erosion necessitates LINX™ device removal. LINX™ migration along with recurrent hiatal hernia repair is typically treated with redo hiatal hernia repair and preferably LINX™ device removal and conversion to Nissen fundoplication. Pseudo-achalasia requires LINX™ device removal, lysis of adhesions and partial fundoplication.
There is no need to be miserable. Contact Houston acid reflux specialists and get your problem resolved today.

#### Life Is Too Short to Live with Heartburn
Dr Harris from Humble sent us this question: “What is the durability of Nissen fundoplication in Your Experience? In literature is written that after 10 years Nissen loses efficacy I am a family doctor affected by LES incontinence since 1993. Thank you.”
Dear Dr. Harris,
Heartburn puts a damper on enjoying life to the fullest. It’s essential to address it and find ways to manage or alleviate it so you can focus on the things that truly matter to you. Lower esophageal Sphincter (LES) pressure is an important component of the antireflux barrier. LES pressure is measured using manometry. Esophageal manometry is a simple outpatient test that we offer at Houston Heartburn and Reflux Center. A low pressure LES on manometry indicates a weak antireflux barrier that results in severe acid reflux symptoms. The most reliable solution for a weak LES is Nissen fundoplication. A properly performed hiatal hernia repair and Nissen fundoplication restores the antireflux barrier and prevents any backflow of gastric content into esophagus.
The durability of Nissen fundoplication greatly depends on surgical technique, and health of tissues that are sewn together to construct the wrap and close the hiatal hernia. Acid reflux causes inflammation and tissue destruction around the gastroesophageal junction. Reconstructing the acid reflux barrier with weak tissues is not likely to last very long. Similarly, age and smoking further weaken the repair and decrease durability. The most frequently cited paper for long-term follow up of Nissen fundoplication patients was published in in 2001 by Spechler et al in JAMA (Journal of the American Medical Association). Of the original 247 patients that participated in the study, 239 were found. 79 patients were confirmed dead mostly from heart disease. Among the 160 survivors, 129 participated in the follow up (91 in the medical group and 38 in the surgical treatment group). Of note, the subjects included in the study had advanced GERD with esophageal ulcers, stricture, and or Barrett’s esophagus. Average age at the time of surgery was 58 and 50% of subjects were smokers.
The authors concluded that after a mean follow up duration of 10 years, 23 out of 37 Nissen fundoplication patients reported use of proton pump inhibitors. Hence, there is no advantage of Nissen fundoplication over medical therapy. Although the study is underpowered for any meaningful conclusion, it has been adopted by many gastroenterologists and primary care physicians in Houston as a treatment guideline for GERD.
Our experience at Houston Heartburn and Reflux Center is different. With over 1000 consecutive Nissen fundoplications over the past 10 years we have achieved 100% success rate in eliminating GERD related symptoms and improving quality of life. At the same time, our complication rate is zero. Our postoperative dysphagia rate is zero, and our patient satisfaction rate is very high. So far, we have not had any patient presenting back to Houston Heartburn and reflux Center with recurrent GERD or failed Nissen fundoplication. Our experience strongly supports early surgical intervention not only to prevent the development of GERD complications like Barrett’s esophagus, esophageal stricture and ulcers, but also to enjoy a reflux and heartburn free life.

#### Lifestyle Changes To Keep Heartburn At Bay
Men’s Fitness Magazine recently ranked Houston as among one of the fattest cities in the United States. 34 % of Houstonians are overweight and the rates are rapidly rising for both adults and children. Overweight individuals have 3 times the likelihood of frequent GERD symptoms compared with those of normal weight. Studies have shown that the frequency of reflux symptoms is directly related to body mass index, BMI. The higher the BMI, which is your weight relative to your height, the more likely a person is to experience heartburn more than once a week. When tested for GERD by reflux experts, using a pH study, 70% of obese individuals (BMI more than 30) tested positive for acid reflux.

Overweight individuals (BMI between 25 and 30) who suffer from GERD will greatly benefit from lifestyle changes that result in weight loss. Portion control is the first key step in alleviating reflux symptoms. We tend to overeat and by doing so we distend our stomach and put too much pressure on the lower esophageal sphincter. The lower esophageal sphincter is a barrier between the esophagus and the stomach that prevents acid back up into the esophagus. Try smaller, more frequent meals to prevent stomach distention and preserve the lower esophageal sphincter function. Second, try to exercise on a daily basis to shed some of the extra weight you are carrying in the abdomen. Belly fat puts lot of pressure on the lower esophageal sphincter leading to acid reflux. Third, avoid eating greasy and fried food items. Food rich in fat delays emptying of your stomach content and increases the incidence of acid reflux. Make healthy choices that have a lower likelihood of triggering acid reflux such as fresh fruits, vegetables, lean meats, fish, and skinless poultry. Fourth, avoid carbonated beverages that contribute to stomach distention and add inches to your waist.
Obese GERD individuals (BMI above 30) are a sub group of patients were lifestyle changes tend not to be very effective in alleviating acid reflux. In this particular patient population, the decision often comes down to whether they are willing to undergo bariatric or weight loss surgery. Weight loss surgery has proved itself to be a long-term tool for obese patients to loose excess body weight and help control a number of concomitant health problems like diabetes, high blood pressure and GERD. I strongly recommend weight loss surgery as an effective and durable modality for patients suffering from GERD whose BMI is above 30.

#### LINX™ Acid Reflux Surgery Revision in Houston
Magnetic sphincter augmentation surgery consists of placing a bracelet of magnetic beads around the lower esophageal sphincter. The magnetic bracelet increases resistance around the lower esophageal sphincter. LINX™ device keeps the sphincter closed at gastric pressures less than 20 mm of Hg. Acid reflux occurs at a sphincter pressure around 10 mm of Hg.  Swallowing pressure is typically higher than 20 mm of Hg in a healthy esophagus. Therefore, LINX™ device allows forward food passage from esophagus into stomach while preventing backward acid reflux from stomach into esophagus. Such an approach to a complex problem like GERD is obviously very simplistic and naïve. Suffice to stay that a distal esophageal stricture creates a high-pressure area around the lower esophageal sphincter, yet it does not prevent acid reflux. Many patients presenting for acid reflux evaluation have esophageal outflow obstruction on manometry with elevated basal and relaxing lower esophageal sphincter pressure and still suffer from severe acid reflux. Decreased esophageal wall compliance around the lower esophageal sphincter has been proposed as a contributing factor to acid reflux but it is definitely not the only factor.
More interestingly, however, is the short and long-term impact of LINX™ device on esophageal motility. The lower esophageal sphincter pressure decreases in response to a swallow to facilitate food bolus passage into stomach. In the presence of LINX™, esophagus must overcome a pressure barrier of around 25 mm of Hg, with each swallow, to push a food bolus across LINX™ device into the stomach. Swallowing pressures are typically strong enough to do the job, but what happens in the long run? Does LINX™ device weaken esophageal motility leading to achalasia like symptom development?
Food impaction, difficulty swallowing food, chest and epigastric pain and pooling of solid food and liquids above the lower esophageal sphincter are well described LINX™ complications. A poorly sized LINX™, weak esophageal motility, and scar tissue formation are obvious causes for such symptoms to develop shortly after LINX™ implantation. However, a number of patients present one or two years after LINX™ surgery with contrast pooling on barium swallow necessitating LINX™ device removal. Such patients raise the concern of slow esophageal motility deterioration over time. Future studies are needed to better understand this issue.
The gastro-esophageal junction, GEJ, area is a complex physiologic and anatomic structure that constitutes the anti-reflux barrier. Competency of the GEJ depends on a complex interplay of myogenic, neurogenic and mechanical properties of that area. Nissen fundoplication surgery remains the most effective solution for a weak anti-reflux barrier. Its mechanism of action remains unknown. However, Nissen fundoplication does not work by creating a high pressure or increased resistance area around the Lower esophageal sphincter. Indeed, the most effective Nissen fundoplication is a short and floppy fundoplication that does not cause any stricture or LINX™ like effect around the GEJ. Failed LINX™ device is best revised to a fundoplication procedure to best help your GERD patient.

#### LINX™ Device for Heartburn Treatment in Houston
“Objective Evidence of Reflux Control After Magnetic Sphincter Augmentation: One Year Results From a Post Approval Study”, is a new multicenter, prospective, study recently published in the Annals of Surgery journal. 200 patients with objective evidence of acid reflux were treated with LINX™ device surgery between 2013 and 2015. At one year after surgery, only 74% of patients had normal esophageal acid exposure. LINX™ device removal rate at one year was 1%. One LINX™ device erosion was reported. The authors conclude that LINX™ device is both safe and effective for treatment of GERD.
Our results at Houston Heartburn Center are much better. On one hand we have a 100% patient satisfaction and 0% surgery failure rate. Since 2015, our redo surgery rate is less than one per one thousand hiatal hernia repair and Nissen fundoplication. Since we don’t use LINX™ device, our erosion and device failure rate are zero. Most importantly, however, is safety and effectiveness of Nissen fundoplication. Our mortality rate is zero and our 30-day complication rate is less than 1%. Nissen fundoplication when properly performed completely eliminates acid reflux. LINX™ device in this study eliminates acid reflux in only 74% of cases. Nissen fundoplication does not impair esophageal motility. LINX™ device is a barrier against esophageal contractions and is contraindicated in patients with weak esophageal peristalsis.
The superiority of a properly performed Nissen fundoplication in controlling GERD is closely associated with its mechanism of action. Nissen fundoplication does not simply augment the lower esophageal sphincter as LINX™ device is assumed to do. Acid reflux is a complex esophago-gastric motility disorder. GERD pathogenesis is not limited to a weak LES. Meticulous hiatal hernia repair restores normal gastro-esophageal junction anatomy and Nissen fundoplication restores a competent reflux barrier without impeding esophageal motility and food emptying from esophagus into stomach. For these reasons, we are hesitant at Houston Heartburn Center to offer LINX™ device for treatment of stage 3 or stage 4 acid reflux disease.

#### LINX™ Device Placement after Sleeve Gastrectomy
Pamela from Cypress sent us this question: “I had a sleeve gastrectomy in 2015 and have had horrible heartburn/reflux since.  I recently had a surgical consult for a hiatal hernia and was told that a repair wasn’t possible with a sleeve.  He recommended to research the LINX™ or revision to a Roux-en-Y. I’m not excited about either of these options.  Would it be possible to get more information about fixing a hiatal hernia with a sleeve? The heartburn is very painful and it’s a daily occurrence, I’ve become insanely frustrated and I’m not sure what my next step should be! I’m located in Cypress, but I’m having trouble finding a good solution in my area. Thank you so much for any info/advice you could provide.”

Dear Pamela,

Hiatal hernia repair after sleeve gastrectomy is feasible and indicated to alleviate heartburn and acid reflux. Gastric sleeve has low wall compliance. Consequently, when the gastric sleeve herniates into the chest, negative intra-thoracic pressure is easily transmitted inside sleeve lumen. Negative pressure exacerbates not only acid but also bile reflux back into esophagus. This results in “horrible” heartburn and reflux as you explain.

Hiatal hernia repair after sleeve gastrectomy restores normal anatomy and reverses the effect of negative chest pressure on gastric sleeve lumen. This results in immediate acid reflux resolution. Gastric sleeve surgery, like Nissen Fundoplication, improves gastric emptying and moves the postprandial acid bubble away from distal esophagus. Therefore, in the absence of functional sleeve lumen obstruction, hiatal hernia repair by itself is enough to stop acid reflux in the setting of sleeve gastrectomy. Obviously, if gastric sleeve lumen is narrowed, conversion to gastric bypass along with hiatal hernia repair is needed to stop GERD.

A recent study was published in Obesity Surgery journal to evaluate the efficacy and safety of LINX™ surgery following sleeve gastrectomy. A total of 30 patients were enrolled in the study. Patient underwent upper endoscopy and contrast studies prior to LINX™ surgery. At one year after LINX™ implantation 6 out of 27 patients showed normalization of esophagus acid exposure. However, 80% of patients reported improvement in acid reflux symptoms and decrease in proton pump inhibitor. Of note, 90% of patients underwent a concomitant hiatal hernia repair. In a subsequent study published in Diseases of the Esophagus, the same author recommends carefully selecting sleeve gastrectomy patients with GERD for LINX™ surgery by using esophageal manometry to measure lower esophagus sphincter pressure and motility as well as contrast studies and upper endoscopy to evaluate gastric sleeve morphology. If gastric sleeve morphology is abnormal or if esophagus diameter is more than 3 cm, sleeve to gastric bypass conversion is recommended. Abnormal gastric sleeve morphology in this paper is defined as narrowed sleeve lumen at the incisura angularis, dilated or retained gastric fundus, tubular sleeve shape with most of the antrum resected. If sleeve morphology is normal and lower esophageal sphincter pressure is low in the setting of normal esophageal motility then magnetic sphincter augmentation is indicated to help control acid reflux. If sleeve morphology and lower esophageal sphincter pressure are normal and there is no hiatal hernia the author recommends Stretta. Follow up studies on GERD patients treated according to this algorithm are currently not available.

In conclusion, if you suffer from acid reflux after sleeve gastrectomy, get evaluated by an experienced acid reflux specialist. A properly performed hiatal hernia repair is enough to control heartburn and acid reflux in most cases. If gastric sleeve functional obstruction is present, LINX™ placement is not recommended and conversion to gastric bypass is indicated. If lower esophagus sphincter pressure is low but esophagus motility is normal, and sleeve morphology is normal, magnetic sphincter augmentation, in addition to hiatal hernia repair, may help you. At his point, Houston Heartburn and Reflux Center does not offer magnetic sphincter augmentation surgery.

 

#### LINX™ for Acid Reflux: Side Effects and Esophageal Wall Compliance
Jacqueline from Cypress Sent us this question: I have a lot of the long-term side effects from my LINX™ procedure and all my tests have come back normal. One of my new side effects is when the food gets stuck and I try to force it through with liquid I feel like I am going to pass out every time. My question is: “have you heard of this with any other patients and if so, what seems to be the problem?” Thank you for your time and answering my question.
Dear Jacqueline,
At Houston heartburn and reflux Center, I don’t perform LINX™ surgery for several reasons. However, I offer LINX™ revision surgery. the main indication for LINX™ revision surgery at Houston Heartburn and Reflux Center is dysphagia or difficulty swallowing. At Houston Heartburn and Reflux Center our post Nissen fundoplication dysphagia rate is zero. We perform a floppy and short Nissen fundoplication that does not hinder esophageal motility and food passage from esophagus into stomach. We have achieved zero dysphagia rate with tailored, floppy Nissen fundoplication even in the setting of poor esophageal motility secondary to severe acid reflux.
LINX™ device mechanism of action is quite different from Nissen fundoplication. LINX™ device creates a pressure zone around distal esophagus. Esophageal contractions must overcome this barrier to facilitate food passage from esophagus into stomach. Furthermore, LINX™ device creates scar tissue formation around distal esophagus. Scar tissue decreases esophagus wall compliance. Decreased compliance causes dysphagia or difficulty swallowing despite normal sphincter relaxation and intact esophageal contractions on manometry. Esophageal wall compliance is measured using Endoflip.
Given your presentation, I recommend a thorough evaluation by a competent acid reflux specialist. Testing for dysphagia includes upper endoscopy, UGI contrast study, manometry and Endoflip. Treatment starts with endoscopic balloon dilation to break down scar tissue formation. If this approach fails LINX™ device removal and conversion to Nissen fundoplication are recommended.

#### LINX™ for Heartburn and Difficulty Swallowing
Jeremy from Houston sent us this question: “I am a 68-year-old male pretty healthy and had the LINX™ procedure 6 months ago. I never had many of the problems people were complaining about on Facebook. Acid reflux at night completely gone but I do struggle getting food past the LINX™ device into my stomach. The Surgeon said it would gradually get better and it is. I just ate thin crust pizza no problem but a hamburger with bread, I really have to watch out for bread and have chocolate milk on hand”.
Dear Jeremy,
Dysphagia or difficulty swallowing is a common complication associated with LINX™ device. Early dysphagia after LINX™ placement is very common due to swelling of tissues. Most patients slowly improve and are able to tolerate regular diet. LINX™ patients with persistent dysphagia require endoscopic balloon dilation to breakdown scar tissue formation and try opening up esophagus lumen. If balloon dilations fail to alleviate dysphagia symptoms, LINX™ device removal is recommended.
I agree with your surgeon, Jeremy, dysphagia gradually gets better after LINX™ surgery for two reasons. Swelling goes down with time, but most importantly esophageal contractions recover and improve after stopping acid reflux. It is hard, however, to predict the degree of improvement. Some damage to esophageal motility is irreversible even after repairing the hiatal hernia and stopping acid reflux. It is helpful to repeat esophageal manometry one year after LINX™ surgery and check for contractile strength. If esophageal contractions remain weak one year after surgery, LINX™ device may need to be removed and replaced with a fundoplication.
The advantages of Nissen fundoplication over LINX™ surgery for acid reflux management are numerous. Nissen fundoplication is much more effective than LINX™ device in terms of controlling heartburn because it does not simply rely on lower esophageal sphincter augmentation. Consequently, a properly performed Nissen fundoplication is loosely constructed around the lower esophageal sphincter so as not to cause dysphagia. Indeed, our post-Nissen fundoplication dysphagia rate at Houston Heartburn and Reflux Center is less than 1%.

#### LINX™ for Heartburn: A Dysphagia Problem
Rick sent us this question: Good Afternoon Dr. Darido … I am about 9 weeks out from placement of the Linx device and repair of a hiatal hernia.
I currently am experiencing dysphagia as well as regurgitation of the contents of the esophagus.
I have discussed my problems with the surgeon who placed the device.  After a number of conversations with the surgeon I decided to take my complications to my Primary Care Provider, an Internist.
I appreciate you help.  At this point I am hoping to have the device removed and be relieved of my problems.
Thank you for your time …
Dear Rick,
I am sorry that you are going through these problems after LINX™ surgery for acid reflux disease. I am also surprised you are not able to get answers from your surgeon regarding your current situation. Your surgeon, not the internist or primary care physician, is qualified to deal with surgery outcome and offer solutions for potential surgery complications. You may be frustrated with LINX™ surgery outcome because you may have had different expectations regarding LINX™ surgery. LINX™ surgery is being promoted as a less invasive and superior treatment option for acid reflux when compared to Nissen fundoplication. In my opinion, LINX™ surgery is neither safer, nor less invasive than a properly performed Nissen fundoplication.
In general, dysphagia is not uncommon after LINX™ device placement and patients are encouraged to consume regular diet to stretch the distal esophagus and prevent scar tissue formation. Sometimes, your surgeon may need to perform balloon dilation to improve swallowing. In certain cases, LINX™ device must be removed or replaced with a larger size. In addition, LINX™ device placement is contraindicated for patients with weak esophageal motility. Did you have esophageal manometry testing prior to LINX™ surgery to evaluate esophageal contractions?
Current studies utilizing Endoflip technique to measure compliance of distal esophagus at the time of LINX™ placement are underway in Houston to help decrease post LINX™ dysphagia rate. So far, there are no published guidelines regarding intra-operative Endoflip use.

#### LINX™ Removal without Nissen Fundoplication
Liam from Dallas, TX sent us this question: “I am 57 years-old, and in excellent shape. I had LINX™ surgery performed in May 2021. I am having significant problems with swallowing now.
I am scheduled to see my surgeon next week. I am scared that my swallowing problems are permanent, but his surgical assistant told me that “dysphagia” in some patients require Dilation. I just cannot understand why the LES would cause problems with “swallowing.” I hope it does, and that this is not something more serious. Please tell me that swallowing problems (in my throat area) are associated with LINX™. Also, can I just get it removed without the fundoplication? I just want this thing out. I would do anything to be normal again. Thank you so much for any advice. Liam”
Dear Liam,
Late onset dysphagia (difficulty swallowing) after LINX™ placement requires further investigation and testing prior to endoscopic balloon dilation. Barium swallow is first performed to rule out LINX™ erosion, LINX™ migration into chest and recurrent hiatal hernia. At Houston Heartburn and Reflux Center, we perform a concomitant esophageal manometry to rule out loss of esophagus contractions and ineffective esophageal motility as a cause for dysphagia. LINX™ removal and subsequent or concomitant conversion to fundoplication surgery are indicated if any of the above conditions are confirmed.
LINX™ removal alone without fundoplication surgery puts you at risk for recurrent acid reflux disease. Hiatal hernia repair by itself following LINX™ removal is not enough prevent acid reflux. Nissen or Toupet fundoplication is needed to recreate the anti-acid reflux barrier and stop GERD.
A properly performed Nissen fundoplication and hiatal hernia repair is currently the most reliable treatment for acid reflux disease. The procedure is safe, and it is associated with less than 1% complication rate. At Houston Heartburn and Reflux Center, our dysphagia rate following Nissen fundoplication and hiatal hernia repair is zero.

#### LINX™ Revision Surgery: Nissen or Toupet Fundoplication
Linda from Houston, Texas sent us this question: “A LINX™ device was placed 6 Months ago. Pain, bloat, and dysphasia are still present. There is occasional food regurgitation.
Some have recommended Nissen fundoplication while others recommended Partial fundoplication and the Toupet procedure
What is your experience and recommendations”.
Dear Linda,
Patients who present to Houston Heartburn and Reflux Center, requesting LINX™ device removal and revision surgery are thoroughly evaluated. Upper endoscopy, manometry and contrast studies are routinely ordered prior to surgery. Gastric emptying study is added if symptoms of gastroparesis are present. Most patients with failed LINX™ surgery undergo LINX™ device removal, redo hiatal hernia repair and Nissen fundoplication. We prefer Nissen over Toupet fundoplication for two reasons. First, and most important, we know how to properly perform a short and floppy Nissen fundoplication that reliably stops acid reflux without resulting in dysphagia, bloating and discomfort. Second, Nissen fundoplication is more durable than a Toupet fundoplication because we suture stomach to stomach as opposed to stomach to esophagus. Stomach wall is thick and holds sutures better than esophagus.
Patients with very weak esophageal motility or with small gastric fundus are better served with a partial posterior fundoplication also called Toupet fundoplication. Less than 5% of all fundoplications performed at Houston heartburn and Reflux Center are partial fundoplications.

#### LINX™ Surgery and Pregnancy
“Grace from Houston sent us this question: “Has the LINX™ procedure had any studies regarding pregnancy. I will be undergoing this procedure, but I am planning to become pregnant a few months after. With my first child my GERD became much worse and had continued after the pregnancy so much that I was not able to eat anything at times and PPIs didn’t help. It seems it would be unlikely to have a 2nd pregnancy without some intervention due to the importance of being able to eat and consume additional calories. Any information would be helpful. Thank you”
Dear Grace,
I am not aware of studies evaluating the efficacy, safety and durability of LINX™ device during and following pregnancy. Patients who undergo LINX™ surgery can vomit following LINX™ device placement. LINX™ may therefore be advantageous during pregnancy. LINX™, however, has limited efficacy in stopping acid reflux and controlling symptoms, particularly in cases of severe GERD. A more reliable solution for severe acid reflux is Nissen fundoplication. A properly performed Nissen fundoplication along with hiatal hernia repair in patients with confirmed acid reflux disease has more than 99% success rate and less than 1% complication rate.
For more information on Nissen fundoplication and pregnancy, please check this blog:
https://houstonheartburn.com/nissen-fundoplication-before-or-after-pregnancy

#### LINX™ Surgery and Vagus Nerve Irritation
Linda from Houston sent us this question: “I have suffered from acid reflux all my life. I have had multiple endoscopies and gastric emptying studies. I regurgitate food multiple times per week. Hiatal hernia repair and LINX™ surgery were recommended by my surgeon. I underwent the procedure this past July. Immediately following surgery, I had diarrhea. A month later I started developing nausea, vomiting, and sweating. I feel tired and lethargic. I was started on Amitriptyline for vagus nerve irritation and Welchol for diarrhea. Both medications control my symptoms, but I cannot stop them for one single day. I have been on Amitriptyline for several months now and I am concerned about side effects. I don’t think my symptoms will resolve without removing LINX™. Thank you.”
Dear Linda,
LINX™ device is surgically placed between posterior vagus nerve and esophagus around the lower esophageal sphincter. As a foreign body, LINX™ device results in scar tissue formation. Patients react differently to foreign body placement. It is highly likely that you have over-reacted to LINX™ device placement, and your vagus nerve got entrapped in scar tissue. Scar tissue built up around vagus nerve may cause nerve irritation. Subsequently, nausea, vomiting, sweating and diarrhea may develop. It is also possible that your vagus nerve was partially injured during surgery. Vagus injury has been reported to cause diarrhea immediately after surgery. As your vagus nerve was healing, excessive scar tissue might have developed in the setting of a foreign body like LINX™ device. Consequently, nerve irritation develops resulting in nausea, vomiting, and sweating. The fact that you are responding to Amitriptyline, a neuromodulator, further confirms a nerve related problem.
Additional vagus nerve irritation symptoms include but are not limited to:

Chronic Pain: Including epigastric pain where the LINX™ device is present
Cardiovascular: Palpitations, changes in heart rate and blood pressure
Respiratory: Hoarseness, wheezing, loss of voice, difficulty breathing, and coughing
Neurological: Headaches, dizziness, tunnel vision, ringing in the ears, tingling
Psychological: Anxiety, mood changes, fatigue, difficulty concentrating and brain fog.

I recommend a gastric emptying study to rule out gastroparesis and a barium study to evaluate LINX™ position and anatomy. Assuming both studies are within normal, I recommend LINX™ device removal and conversion to Toupet or Nissen fundoplication. Foreign body removal is associated with reduction in scar tissue formation and likely resolution of vagus nerve irritation.

#### LINX™ Surgery Complications and Efficacy: A New Study
A new retrospective study of 553 acid reflux patients undergoing LINX™ surgery at a single institution was recently published in the journal of the American College of Surgeons. The lead author of the study is a paid consultant to Johnson & Johnson, the company that currently sells LINX™ device.
At a mean follow up of around 10 months after surgery, 76% of patients had normalization of esophageal acid exposure (approximately 50% of patients were re-tested after surgery) and 84% reported at least 50% improvement in GERD related symptoms. 18% of patients required one dilation and 13% required more than one dilation for bothersome dysphagia. 7% required device removal. The authors conclude that LINX™ surgery is associated with “excellent clinical and objective outcomes”. They further add that LINX™ surgery “rapid, reproducible and less invasive tool to effectively treat GERD and improve patient quality of life”.
At Houston Heartburn and Reflux Center, our Nissen fundoplication outcomes are a far superior to those reported in this study. Our post-Nissen fundoplication dysphagia rate is zero. Our patient satisfaction rate is very high. All of our heartburn patients stop antacid medications after surgery. Our complication rate is zero. LINX™ device is no match to a properly performed Nissen fundoplication. Indeed, the only indication for LINX™ surgery in my book, is a surgeon’s inability to properly perform Nissen fundoplication and hiatal hernia surgery.
LINX™ mechanism of action does not address the complexity of GERD pathophysiology. The naïve concept of lower esophageal sphincter augmentation is only a small fraction of the solution. Properly performed Nissen fundoplication recreates an effective anti-reflux barrier without hampering esophageal motility. Nissen fundoplication creates no barrier against swallowing, food bolus passage and lower esophageal sphincter relaxation. Hence, a properly performed Nissen fundoplication is associated with zero dysphagia rate. Indeed, the hallmark of a flawlessly executed Nissen fundoplication is the absence of post-operative dysphagia.

#### LINX™ Surgery effect on esophageal motility and compliance
Sam from Houston sent us this question: “I am a 53-year-old male. A Linx device was installed 18 months ago, and I believe is failing, leaving me with tremendous difficultly sleeping, as I must be upright, with a persistent dry cough when I’m not standing straight up and with breathing difficulties after eating. My chest X-ray was clear. There are signs my esophagus has lost some motility on contrast study. Do I need to have the Linx removed before conceding other actions, like Laparoscopic Nissen Fundoplication surgery? Can you remove the Linx, or do I need the physician who installed it to do that?”
Dear Sam,
Nighttime dry cough and difficulty swallowing are classic symptoms of impaired esophageal emptying. Esophagus motility consists of well-coordinated contractile waves that push food down through lower esophageal sphincter and into stomach. When a contraction starts at the upper esophagus in response to swallowing a food bolus, lower esophagus sphincter immediately relaxes to allow for unhampered food propagation down the esophagus. Lower esophagus sphincter function has two components. Active muscle fiber tension measured by manometry, and a passive stiffness or compliance of esophagus wall and surrounding structures measured by Endoflip. LINX™ device placement around the lower esophagus sphincter alters both components. Several published studies have demonstrated increased lower esophagus sphincter resting and residual pressure using manometry testing. Concomitantly, as a foreign body, LINX™ device induces scar tissue formation around lower esophagus sphincter leading to increased stiffness or decreased compliance. The degree of compliance change varies from patient to patient. In most acid reflux cases, there is increased compliance (decreased stiffness). Decreased compliance of the esophago-gastric junction is desirable to some extent to reduce acid reflux. However, if compliance continues to decrease due to excessive scar tissue formation, esophageal emptying may be hampered. I am not aware of any published studies using Endoflip to evaluate esophageal compliance changes following magnetic sphincter augmentation.
A healthy esophagus adapts to increased resistance at the gastro-esophageal junction by increasing peristaltic vigor. If esophageal muscular contractions fail to adapt to LINX™ device, patient starts to experience dysphagia or difficulty swallowing. Pooling of saliva and gastric secretion in distal esophagus due to poor esophageal clearance causes retrograde fluid movement into the larynx and trachea especially at night. This leads to nighttime cough, aspiration, wheezing, shortness of breath, and adult-onset asthma.
Balloon dilation can be initially tried to break down scar tissue formation and increase lower esophagus wall compliance. However, studies have shown that late onset dysphagia rarely responds to such an approach. This is particularly true if repeat esophageal manometry shows deterioration in esophageal peristalsis compared to pre-op study. At this point, LINX™ device removal is strongly indicated. A Nissen or Toupet fundoplication with redo hiatal hernia repair can be performed at the same time to restore the anti-reflux barrier. Rarely, severe scar tissue formation prevents a concomitant fundoplication and hiatal hernia repair. In this case, LINX™ is removed, and patient is given 3 to 6 months before re-operation to allow for scar tissue to melt away.

#### Long term Dysphagia after LINX™ Surgery
Janet from Dallas sent us this question: “I had my GERD surgery done 4 years ago. It was the LINX™ procedure. My heartburn went away. Over the past one year I have been having difficulty swallowing my meals. I have lost around 20 pounds and I am currently on liquid diet only. My gastroenterologist recommended endoscopy with balloon dilation. I had this done 2 weeks ago but my swallowing did not improve. He then did a manometry test that showed increased LES pressure. I was told the sphincter is not relaxing due to LINX™ device placement and scar tissue formation. It’s hard to live like this”.
Dear Janet,
I agree with your gastroenterologist’s diagnosis. You have developed dysphagia, difficulty swallowing, secondary to esophageal outflow obstruction 4 years after magnetic sphincter augmentation, LINX™, surgery. LINX™ device causes scar tissue to form around distal esophagus and lower esophageal sphincter (LES). Scarring stiffens esophageal wall leading to decreased esophagus wall compliance. It also limits the ability of lower esophagus sphincter to relax in response to a swallow. Esophageal manometry measures esophagus contraction and sphincter pressure. Manometry is quite useful in evaluating cases of dysphagia or difficulty swallowing.
A recent study titled: “The Impact of Magnetic Sphincter Augmentation (MSA) on Esophagogastric Junction (EGJ) and Esophageal Body Physiology and Manometric Characteristics” was published in the Annals of surgery journal. Using manometry testing at baseline and one year after LINX™ surgery, the authors demonstrate increased outflow resistance at the lower esophageal sphincter. However, esophageal contraction amplitude also increased. This compensation for increased outflow resistance increased intra-bolus pressure and prevented a decrease in bolus clearance. In this study, 4 patients (4%) required device removal secondary to persistent dysphagia or chest pain not relived by up to 3 endoscopic dilations. The small number of events prevented a detailed analysis on factors associated with the risk of device removal. However, there was a trend toward higher lower esophagus sphincter pressure on manometry for these patients. The authors conclude that “it is likely that the compensatory response in esophageal contractility after MSA may have not been sufficient in these patients to facilitate bolus transit across the augmented lower esophagus sphincter”.
We currently don’t have enough data to predict lower esophageal sphincter function years after magnetic sphincter augmentation. In a recent article published in 2023 in the European Surgery Journal, Bonavina et al state: “The mechanism of action and the long-term physiologic effects of MSA on esophageal motility and wall compliance are not completely understood due to the relative paucity of objective high-resolution manometry (HRM) and functional luminal imaging probe (FLIP) data available in the literature”. The article title is: Real world evidence with magnetic sphincter augmentation for GERD: a scoping review.
For now, treatment for patient with dysphagia or chest pain who do not respond to balloon dilation, relies on device removal. LINX™ removal will allow scar tissue to gradually melt away. Repeat manometry one year after surgery is recommended to document resolution of esophageal outflow obstruction and recovery of LES function. A properly performed Nissen fundoplication, at this point, will protect you against acid reflux without hampering food swallowing.

#### Long-Term Consequences of Untreated Acid Reflux
A small amount of acid reflux into the esophagus is normal. We have all experienced the occasional heartburn indigestion. However, for those who suffer from reflux symptoms on a daily or basis, the situation is different. Chronic acid reflux is a serious progressive disease that if left unattended will lead to serious complications.
First, patients with chronic acid reflux have a diminished quality of life. Acid reflux symptoms are not pleasant to experience. Imagine splashing your eyes with lemon juice several times a week. This is what happens when stomach acid backs up into the esophagus. Patients wake up in the middle of the night with burning pain in their chest radiating up to their throat. They are unable to function next day because they haven’t rested well the night before. Occasionally, pain is so severe that it mimics a heart attack. Heartburn sufferers cannot eat properly for fear of acid reflux symptom recurrence. Over time, patients become dependent on escalating doses of tums and antacid medications. Antacids medications have with significant side effects when taken over long periods of time.
Second, recurrent acid reflux events burn the delicate esophageal lining. The inner lining of the esophagus does not tolerate. As a result, the lining becomes inflamed. Inflammation of the esophagus also called esophagitis leads to ulceration, bleeding and stricture formation. A stricture is a narrowing in the esophageal lumen. A stricture results in difficulty swallowing food as well vomiting and bad odor breath.
Third, untreated acid reflux may lead to esophageal cancer. Esophageal cancer is rising in incidence in Houston. 15 % of patients with acid reflux develop changes in the esophagus that predispose them for cancer. Early diagnosis and control of acid reflux prevents cancer.
In summary, acid reflux is not simply a nuisance. Acid reflux is a disease that if left untreated, can lead to serious health issues.

#### Long-Term effect of Nissen Fundoplication on Barrett’s Esophagus
Knight BC et al has recently published in the Annals of Surgery an interesting study on the regression of Barrett’s esophagus following laparoscopic Nissen fundoplication surgery for GERD. Since 1991, the authors followed prospectively 50 GERD patients with Barrett’s esophagus who underwent laparoscopic fundoplication. the average post-operative follow up was 12 years. All patients underwent repeat upper endoscopy with biopsies and ambulatory pH testing using the BRAVO system. 41% of patients had complete histologic regression of Barrett’s esophagus, and 64% showed endoscopic reduction in the length of Barrett’s esophagus. In both groups, esophageal acid exposure was significantly lower than patients with no improvement in their Barrett’s esophagus histology or segment length. 92% of patients reported excellent or good surgery outcome.
This study demonstrates the effectiveness, safety and durability of Nissen fundoplication in GERD patients with Barrett’s esophagus. Barrett’s esophagus represents advanced GERD. Barrett’s mucosa ablation and continued PPI use do not address the underlying cause. When properly performed by acid reflux specialists and experts in the field of laparoscopic foregut surgery, Nissen fundoplication remains the most reliable solution for GERD and Barrett’s esophagus.

#### Long-Term Poorly Understood LINX™ Complications
“I’ve had the LINX™ implant for about 5 years now and recently began having sever pain after a large meal. Any ideas?”
Had LINX™ for GERD put in Dec 2017….problems taking a deep breath, especially after meals. Cleared by pulmonary Dr……..Does this improve or is removal necessary. FYI: still sleep elevated, but meds now PRN
A number of LINX™ patients report to Houston Heartburn and Reflux Center with unforeseen LINX™ related complaints several years after the procedure. The two most common complaints include pain and dysphagia. LINX™ device erosion comes first to our mind and is first rule out with a proper evaluation. Evaluation typically includes upper endoscopy, manometry and contrast study. Most LINX™ patients, however, have no abnormalities on the work-up to explain either symptom of pain or dysphagia. Manometry in particular shows good motility with normal basal and relaxing lower esophageal sphincter pressure. There is no stricture of distal esophagus to esophagus to explain dysphagia and contrast study shows normal contrast emptying from esophagus into stomach.
There are no studies in the literature explaining the etiology of dysphagia and pain years after LINX™ placement and in the setting of normal upper endoscopy and manometry. Few studies have shown pain resolution after LINX™ removal. The etiology of pain may be related to vagal nerve compression by LINX™ magnets. Scar tissue formation and nerve entrapment may also irritate the vagal nerve and cause pain. Dysphagia may result from decreased compliance of the gastroesophageal junction area. Patients do not typically respond to balloon dilation and do not improve after LINX™ removal.
As of now, we don’t have a good explanation for these long-term complications of LINX™ procedure for treatment of heartburn and acid reflux. Studies are needed to better elucidate the problem. Nissen fundoplication, in expert hands, remains a much safer and more effective alternative to LINX™ for the management of GERD.

#### Manometry and Heartburn Treatment in Houston
Proper acid reflux diagnosis is the first step towards heartburn treatment in Houston. High resolution esophageal manometry is an important for acid reflux diagnosis at Houston Heartburn and Reflux Center. The test employs a catheter dotted with closely placed pressure sensors to measure esophageal motility, contractile pressure, and lower esophagus sphincter pressure. Esophageal contractile function plays a central role in acid reflux pathophysiology. Weak esophagus contractions contribute to acid reflux and chronic acid reflux weakens esophageal contractions. It is a vicious circle that contributes to worsening esophageal injury, GERD related symptoms and dysphagia. Dysphagia is commonly associated with acid reflux. Dysphagia is the feeling of food getting stuck in the esophagus. More than 70% of heartburn patients presenting to Houston Heartburn and Reflux Center for evaluation of acid reflux disease have dysphagia. Obstruction to flow or inability to adequately propel a food bolus into the stomach results in dysphagia. Mechanical obstruction is caused by stricture, tumor, Schatzki’s ring, eosinophilic esophagitis, hiatal hernia and distorted anatomy of gastro-esophageal junction. Incomplete lower esophageal sphincter relaxation in response to a swallow can also create obstruction to flow and result in dysphagia. LINX™ device, scar tissue around the sphincter, lap band and achalasia are some of the causes of poor lower esophageal sphincter relaxation.
Furthermore, a number of esophageal motility disorders like achalasia may initially present with heartburn in the absence of dysphagia. High resolution esophageal manometry is currently the most sensitive test to evaluate esophageal motility in the setting of heartburn evaluation. Manometry can differentiate the different types of achalasia as well as other hypercontractile and spastic disorders affecting the esophagus. Whether esophageal contractions are absent, rapid or vigorous, high resolution manometry is an important tool for acid reflux specialists. Proper testing is the first step towards heartburn treatment. At Houston Heartburn and Reflux Center we offer state of the art acid reflux testing including high resolution esophageal manometry. If you suffer from acid reflux, heartburn, dysphagia or GERD give us a call at 832-945-8717.

#### Medium Size Hiatal Hernia: Now What?
Anna from Houston sent us these questions:

I was diagnosed during an EGD/Upper Endoscopy with a “medium-sized” hiatal hernia, and I was wondering if I should have it repaired?
What causes hernias to get worse or bigger over time?
Is it best to closely monitor it and do surgery to repair it earlier rather than later, in order to prevent further complications or emergency medical attention?
Do “medium to larger hernias” need to be repaired?
What happens if you don’t repair a hiatal hernia?

Dear Anna,
The diaphragm or breathing muscle has a central opening, hiatus, through which the esophagus or food pipe goes through. Weakness in the lining covering this opening results in a hiatal hernia formation and upward movement of stomach into chest. There are different kinds of hiatal hernias. Prognosis and treatment depend on cause, anatomy, size, and associated symptoms.
At Houston Heartburn and Reflux Center, we divide hiatal hernias into two categories: sliding and paraesophageal hernias.
Sliding hiatal hernias are the most common (95% of all hiatal hernias). Sliding hiatal hernia is closely associated with acid reflux disease. Most patients with GERD have a sliding hiatal hernia. Sliding hiatal hernia repair and a concomitant Nissen fundoplication are indicated to control acid reflux disease. If left unrepaired, a symptomatic sliding hiatal hernia tends to get bigger with time resulting in a progressively weaker acid reflux barrier and worsening acid reflux symptoms. Acid reflux is the main cause of hiatal hernia development and growth. In the absence of acid reflux, there is no indication to repair an asymptomatic sliding hiatal hernia as it poses no risk of complications.
Paraesophageal hernias, on the other hand, are a completely different animal. Here, acid reflux does not play a role in the development of a paraesophageal hernia. Age, collagen synthesis genetic abnormalities, and an abnormally curved spine are some of the contributing factors to paraesophageal hernia development. Most patients have minimal symptoms that do not affect their quality of life. Some patients, however, report difficulty swallowing, pain, heartburn, nausea, vomiting and shortness of breath. Furthermore, ulcers may develop in the herniated stomach leading to blood loss and anemia. Finally, the herniated stomach may twist on itself leading to gastric volvulus and strangulation. Patients present with acute onset severe pain and inability to vomit. This is a surgical emergency requiring immediate medical attention and intervention.
Symptomatic paraesophageal hernias must be repaired. There is room to closely monitor an asymptomatic patient with a paraesophageal hernia. However, if surgical expertise is available and patient is a good surgical candidate with no contraindications for general anesthesia, elective repair is recommended.

#### Mid Afternoon Snacks for Heartburn Sufferers
We all know the all too familiar feeling of a sudden craving or hunger pang in the afternoon, even after we’ve eaten our lunch. Some may go for the candy bowl, which you will find out wasn’t the best of ideas come 5pm! For those with heartburn, however, it is trickier. The last thing you want is heartburn during the day at work.
The mid afternoon snack is similar to the mid morning snack; keeping something in your stomach to prevent triggering a flare up. Let’s take a look at some heartburn friendly mid afternoon snacks:

Slice a small piece of fruit and dip into some non-fat yogurt, a healthy, refreshing snack to keep you going until the end of your work day.
Jell-O. As Jell-O is artificially flavored, the citrus may not affect your heartburn flare up. There are also sugar free versions, helping you eliminate calories.
Ready-made fat free puddings also come in a fat free, sugar-free option. This will satisfy your sweet tooth while keeping up your energy.
Vegetables, such as carrots and cucumbers, dipped in low-fat yogurt.
If you had a sandwich for lunch, you could save half of it and eat the rest as your mid afternoon snack.

If you find yourself suffering from heartburn, whether it’s when you wake up, after lunch or at night time, make an appointment with Houston Heartburn today and start to take control of you heartburn now.

#### Most Frequent Nissen Fundoplication Question: Am I Able to Vomit After Surgery?
The one question that every single acid reflux patient asks me prior to Nissen fundoplication surgery is: Will I be able to vomit after surgery?
The short answer is no. You cannot vomit after Nissen fundoplication because the Nissen wrap creates a one-way valve: food can enter the stomach, but acid, bile and food cannot back up into esophagus.
What Exactly Happens if You Cannot Vomit?
If you get food poisoning or develop a viral gastroenteritis in the setting of Nissen fundoplication, you may experience nausea and dry heaving, but vomiting will not happen. Stomach squeezes the food down through the pylorus (stomach outlet) and into intestines. You may develop diarrhea, but you will not experience worse nausea and dry heaving because you have a Nissen fundoplication.
At Houston Heartburn and Reflux Center, GERD patients preparing for hiatal hernia repair and Nissen fundoplication, understand that the inability to vomit after surgery is not a complication. Rather, it is an expected outcome of successful anti-reflux surgery.
If you have acid reflux disease and you are contemplating Nissen fundoplication to stop acid reflux and improve your quality of life, give us a call at 832-945-8717.

#### My Gastroparesis Is Worse after TIF
Maggie from Cypress, TX sent us this question: “I had the TIF surgery on Jan. 11. I have mild gastroparesis and have not been able to have a bowel movement in almost 2 weeks. I have taken stool softeners and Motegrity the past week. I also fill up very fast and not sure the procedure has made my gastroparesis worse or if it just takes time to recover. Please advise what your thoughts are. Thank you.”
Dear Maggie,
TIF or Transoral Incisionless Fundoplication is a less reliable treatment for GERD than Nissen fundoplication. Indeed, TIF is not even a fundoplication and the name is a misnomer. TIF procedure consists of “bunching” up a small amount of stomach tissue around the lower esophageal sphincter. Gastric fundus is not mobilized during TIF to create an anti-reflux barrier as is the case with a Nissen fundoplication. Furthermore, TIF does not promote gastric emptying like Nissen fundoplication. Consequently, if mild delay in gastric emptying is present in a primary GERD case, Nissen fundoplication will address both the weak anti-reflux barrier and the sluggish gastric emptying. TIF barely improves the anti-reflux barrier, and it does not alter gastric emptying.
Heartburn is a common symptom in gastroparesis patients. Indeed, heartburn may be the first presenting symptom in gastroparesis before nausea and vomiting develop. Careful history taking, and comprehensive testing help the experienced acid reflux specialist differentiate GERD from gastroparesis. GERD is characterized by a weak anti-reflux barrier. A hiatal hernia is typically present. Ambulatory pH testing shows multiple reflux events secondary to transient lower esophageal sphincter relaxation. Distal esophagitis is commonly seen. GERD patients report heartburn, food regurgitation, globus and excessive burping as the main symptoms affecting quality of life. On the other hand, post-prandial (after eating) nausea, vomiting and abdominal pain are the main symptoms reported by gastroparesis patients. Constipation and weight loss are also common. Furthermore, a hiatal hernia is small or absent on upper endoscopy. Solid food residue may or may not be present in stomach. pH Bravo study shows very few acid reflux events in the case of gastroparesis.
My recommendations for you is to get evaluated by an experienced acid reflux specialist. If you have GERD as a primary disease, then TIF to Nissen fundoplication conversion is indicated. If gastroparesis is the primary disease, an antrum preserving longitudinal gastrectomy is our first line of treatment to promote gastric emptying.

#### My PCP Told Me I Have GERD; Now What?
70% of GERD patients do not seek medical attention. They self-diagnose and often self-medicate. Antacid medications like proton pump inhibitors are sold nowadays over the counter. At Houston Heartburn and Reflux Center, we encounter patients who have been taking such medications for the past 10 to 15 years of their life. Most of these patients never had an upper endoscopy to check for acid reflux.
Here is the problem:
Patients who complain of heartburn do not necessarily have GERD. Heartburn is a symptom; GERD is a disease. Physicians don’t treat symptoms. Physicians manage an underlying disease to control symptoms. Without proper testing (upper endoscopy and Bravo or impedance pH measurement) one cannot rule in or rule out acid reflux.  Furthermore, upper endoscopy allows physicians to evaluate the severity of acid reflux. The 4 stages of GERD are determined based on the extent of damage to the esophageal lining. GERD treatment is tailored according to stage. Stage one patients benefit from lifestyle changes and the occasional use of Tums. Stage 3 patients will benefit from a laparoscopic Nissen Fundoplication. A nissen fundoplication, in this case, reliably stops acid reflux. This in turns eliminates symptoms and prevents disease progression.
At Houston Heartburn and Reflux Surgery Center, we highly encourage anyone suspected of having GERD, based on symptoms, to request a referral to a GERD expert. Dr. Darido has the expertise to confirm a GERD diagnosis (or help you explore the underlying cause of your symptoms); determines if your disease has progressed to esophagitis, Barrett’s esophagus, or esophageal cancer; and provides you with all the available treatment options for your consideration.  Houston Heartburn and Reflux Center’s mission is to educate and empower patients to take control of their disease. Educated patients can make smart decisions about their health, lifestyle, and quality of life.

#### National GERD Awareness Week: Why Does It Matter?
November 18 – 24 is GERD awareness week. 30% of the population in Houston suffer from recurrent GERD related symptoms like heartburn and food regurgitation. GERD is a common disease with serious consequences that range from esophageal dysmotility to cancer. Unfortunately, most GERD patients in Houston are self-medicating their disease without proper diagnosis and staging.
If you suffer from heartburn, chest pain, food regurgitation, cough, hoarseness, difficulty swallowing food, bloating and excessive burping you need help from a reflux specialist. Experts in the field of acid reflux disease, at Houston Heartburn and Reflux Center, can help you. The diagnosis of GERD depends on accurate and comprehensive testing that may include upper endoscopy and esophageal ambulatory pH testing. Testing allows your reflux specialist to stage your disease and tailor the most suitable treatment to your condition. Do not stop asking questions until your acid reflux symptoms are under control. A common scenario we encounter at Houston Heartburn and Reflux Center is highlighted by this question from Taylor in northern Houston: “I have stomach acid traveling back into my food pipe & causing hoarseness & coughing. PPIs have failed. My endoscopy done recently is ok. Which treatment can benefit me?”
Upper endoscopy is not “OK”, most of the time, when we repeat it at Houston Heartburn and Reflux Center. It is unlikely for GERD patients to experience a number of worsening GERD related symptoms like heartburn and food regurgitation and have a normal endoscopy. It is not acceptable to limit GERD patient treatment to one or two PPIs a day and hope they get better. Houston Heartburn and Reflux Center is an advocate of GERD awareness week. We wholeheartedly support patient education about GERD symptoms and treatment options. Unless you understand GERD, you cannot make the best decisions to alleviate your symptoms and improve your quality of life. Fortunately, GERD can be cured with effective and safe solutions. If you suffer from heartburn or any other GERD related symptoms, start asking questions. There is no need to suffer. Call Houston heartburn and Reflux Center, for a comprehensive GERD evaluation, at 832-945-8717.

#### National Refreshment Day – Which Drinks Will Ease Your Heartburn Today?
July 23rd is celebrated as National Refreshment day, held annually on every fourth Thursday in July. With summer well into play, celebrate this day with a cold and, of course, refreshing beverage.
This may be easier said than done if you suffer from acid reflux, where certain drinks such as alcohol and soda can actually trigger acid build up. Not the ideal way to celebrate!
Heartburn friendly drinks
Herbal teas: good at soothing the stomach, especially if you suffer from gas or nausea, and improve digestion. Teas such as chamomile, licorice and marshmallow are all good at soothing heartburn. According to Harvard Medical School reports, licorice is a very effective ingredient in soothing heartburn as it increases the mucus coating of the throat, helping calm the effects of stomach acid.

Non-citrus juices: alcohol and tomato based juices, as well as orange, pineapple and tangerine juices are out of the question; however, there are other juices that one can drink. Apple, aloe or carrot juices are tasty and will soothe any chances of heartburn.

Goat/Skim milk: regular fat milk, or full fat milk, has a high amount of fat, which is difficult for the body to digest. Full fat milk is known to relax the lower esophageal sphincter, which increases the chances of acid reflux. Opting for the lowest-fat milk possible is a good way to still enjoy this beverage, while preventing heartburn.

Water: the easiest of drinks to help acid reflux. Drinking 8 glasses a day is recommended. Drinking alkaline water is also a good idea to reduce acid levels in the stomach.

Sticking to these four key drinks will help prevent heartburn and allow you to celebrate National Refreshment Day, too! If you still find yourself suffering from heartburn, even though you watch what you eat and drink, Dr. Darido can help. Make an appointment today!

#### Natural Ways To Help Heartburn
Acid reflux or GERD (gastroesophageal reflux disease), aka heartburn, affects 50 percent of Americans. One in 10 Americans suffer from heartburn symptoms at least once a week. Heartburn happens when you eat something that didn’t agree with you, while GERD is when food and acid travels back up into your esophagus, causing trouble more than twice a week.

Fortunately, heartburn isn’t a hopeless situation. If you’re one of the many people suffering, before you reach for OTC antacids or prescription drugs, you might want to try some natural ways. These aren’t FDA approved, so check with your doctor before trying any. Here are 15 natural remedies that might bring you relief:

Lose weight – losing 10 percent of your body weight can improve acid reflux symptoms.

Anti-reflux diet – unfortunately, that means reducing some of your favorite things, like chocolate, alcohol, caffeine, nicotine, spicy and fatty foods.

Raw almonds –an alkaline-producing food that’s a good source of calcium can balance your pH.

Aloe Vera juice – drinking two unprocessed ounces daily can reduce inflammation in the stomach.

Cup of warm water and fresh lemon juice – start your day by drinking on an empty stomach and 15 minutes before eating anything else. It naturally reduces acid levels and is a great digestive aid.

Baking soda – a tablespoon in half a cup of water can neutralize stomach acid.

Red Delicious apple – can calm your stomach after eating unfriendly meals.

Saccharomyces boulardii – a supplement with a probiotic strain specifically for the small intestine, helping optimize absorption of key vitamins to aid in digestion.

Slippery elm – a supplement in a capsule, powder or lozenge form that helps coat and protect the stomach.

Chamomile tea – may help reduce acid reflux symptoms.

Gum – chewing after meals can help reduce acid.

Sleep on your left side – offers relief as opposed to right side or stomach sleepers.

Licorice – stomach-healing properties by increasing the mucus coating of the esophageal lining, helping calm the effects of stomach acid.

Melatonin – a supplement that can help protect the digestive tract.

Apple cider vinegar – 1-2 teaspoons daily mixed with honey in tea. People think all acid reflux and indigestion is caused by an overproduction of acid, but the opposite may be true. Too little acid to adequately digest food could be the problem, so this works well to help stimulate acid.

Again, after talking to your doctor, why not try one or a few of these? Who knows? Maybe the answer to your problem might not be in your medicine cabinet, but rather your pantry or refrigerator. If you continue to experience acid reflux after trying some of these natural remedies, visit us at Houston Heartburn.
 
 

#### New GERD Surgery: BICORN Procedure
A 40-year-old patient from Houston, Texas presented to Houston Heartburn and Reflux Center with persistent acid reflux related symptoms following a novel anti-reflux procedure. Patient has been struggling with severe acid reflux related symptoms like heartburn and food regurgitation for many years. He had poor symptom control with daily Dexilant and strict dietary habits. He underwent a new procedure for acid reflux called Bicorn, in Germany. Procedure was performed through tiny incisions and recovery was fast. Surgery consisted of standard hiatal hernia repair, but instead of a Nissen fundoplication, the angle of His was reconstructed using couple of sutures. The angle of His is an angulation present on the left side of esophagus as it joins the stomach. This angulation contributes to the anti-reflux barrier. As acid reflux develops, and hiatal hernia starts to form, the angle of His gets progressively obliterated. Phrenoesophageal membrane and right diaphragm crus are also part of the anti-reflux barrier anatomy. The phrenoesophageal membrane anchors lower esophagus sphincter to breathing muscle. The right crus creates a tunnel like hiatal opening that separates the intra-abdominal esophagus from the chest cavity. Both structures are stretched and thinned out as acid reflux progresses and hiatal hernia grows.
Restoring the angle of His, surgically (BICORN procedure) or endoscopically (TIF, GERD-X), short of doing a Nissen fundoplication is not enough to stop acid reflux. The anti-reflux barrier is not just an anatomical structure. Rather, it is a complex physiologic barrier that relies on esophageal motility, lower esophagus sphincter function and gastric motility. Lower esophagus sphincter function is probably the most important factor in preventing acid reflux. Transient lower esophageal sphincter relaxation, TLESR, as opposed to basal lower esophagus sphincter pressure, is the most common mechanism for reflux in both normal and GERD patients. Neither TLESR events are increased, nor is basal lower esophagus sphincter pressure decreased in acid reflux patients. Rather, GERD patient TLESR events are more likely associated with acid reflux leading to increased esophageal acid exposure. TLESR events are controlled by electric impulses generated in various parts of the stomach and possibly esophagus. TLESR dysregulation leading to GERD is not fully understood. However, any procedure or medication that reverses TLESR dysregulation is most likely to control GERD.
Several studies have shown that Nissen fundoplication surgery reduces TLESR events as well as the likelihood of acid reflux during TLESR leading to effective acid reflux control. BICORN procedure and hiatal hernia repair by itself without a wrap do not alter the physiology of the anti-reflux barrier leading to poor acid reflux control.
A properly performed hiatal hernia repair and Nissen fundoplication is currently the only anti-reflux procedure that addresses both anatomy and physiology of anti-reflux barrier. It is crucial, however, to find an expert acid reflux specialist to manage your acid reflux disease. Not all Nissen fundoplication surgeries are created equal. 
If you struggle with acid reflux give us a call at 832-945-8717

#### New Year, New Resolution: Take control of Your Heartburn
Year after year 30% of all Houstonians struggle with recurrent heartburn, food regurgitation, persistent dry cough and constant bloating. These are some of the symptoms that indicate GERD also known as acid reflux. Acid reflux is a chronic medical problem that affects many aspects of your life. Left untreated, acid reflux symptoms will continue to slowly get worse, insidiously deteriorating your quality of life. “I cannot believe how I have lived with heartburn all this time”, our patients at Houston Heartburn and Reflux Center report after Nissen fundoplication surgery. For most GERD patients, acid reflux becomes part of their daily life. They wake up with a sour mouth taste, they end their lunch with burning chest pain, and they have difficulty sleeping at night due to constant cough and food regurgitation.
Fortunately, GERD is treatable and even curable. Let 2019 be the year you get rid of acid reflux and regain your normal life. Start with lifestyle changes. Quit smoking, lose weight, reduce alcohol intake, avoid large meals and eating late at night. If these simple lifestyle changes do not help you check our reflux specialists at Houston heartburn and Reflux Center. Get evaluated by expert acid reflux doctors to stage and confirm your acid reflux problem. Constantly quenching the burn in your throat and esophagus with Tums, Rolaids, Zantac, Nexium, Prilosec…is not a solution for acid reflux. These medications simply reduce stomach acid secretion. They do not stop acid reflux. Stomach acid secretion, however, is part of normal digestion whether you have GERD or not. Medications like proton pump inhibitors simply mask acid reflux symptoms giving you the illusion that reflux is under control. If you are in the habit of popping Nexium and Prilosec in the morning, and indulging in large meals that trigger acid reflux, you are doing yourself a disservice. You are masking an important signal from your stomach alerting you about a serious problem.
For 2019, Houston Heartburn and Reflux Center invites you to stop self-medicating acid reflux. Get the help you need to overcome GERD and start enjoying your life again. You deserve it!!

#### Nighttime Heartburn is Keeping Houston Awake
Of the nearly one million Houstonians who suffer from acid reflux, more than 50 percent report experiencing having heartburn at night several times a week. A bitter taste in the mouth, a hoarse voice, sore throat, fatigue…if you wake up in the morning with some of these symptoms you may be suffering from nighttime acid reflux.
Nighttime acid reflux can be more severe than daytime reflux. When you are in an upright position, gravity helps the esophagus clear the refluxed material back to the stomach. When you are laying down acid tends to stay longer in the esophagus causing more damage. As a result, nighttime heartburn sufferers are nearly 11 times more likely to develop cancer of the esophagus according to a study published in the New England Journal of Medicine.
In addition to health risks, like cancer, respiratory infections, and esophageal inflammation, 75 percent of nighttime heartburn patients report sleep deprivation. They are either unable to sleep or wake up during sleep with burning pain in the chest. Many Houston area residents are unable to work effectively the next day because of nighttime heartburn.
Houston Heartburn and Reflux Center offers the following recommendations to alleviate nighttime heartburn:

Eat early and light: have dinner at least 3 hours before going to bed. Avoid large meals and avoid snacking close to bedtime

Avoid drinks that can trigger reflux like coffee, tea, alcohol, and carbonated beverages

Avoid foods that can trigger reflux like tomato sauce, pepper, mint, mustard, chocolate, greasy food like French fries and cheeseburgers

Keep a food diary of you eat for dinner. Try to avoid those foods that trigger heartburn

Raise the head of your bed by 6 to 8 inches to reduce acid backflow into your esophagus

Avoid heavy exercise before bedtime

Watch your weight. Trimming down your waist may help with acid indigestion

Quit smoking

Wear loose pajamas

If your symptoms don’t improve please call Houston Heartburn and Reflux Center and request a consultation. Don’t ignore your symptoms. There may be a sign of severe acid reflux disease.

#### Nissen Conversion to Toupet Fundoplication
Diane from Corpus Christi sent us this question: “I had a redo lap Nissen fundoplication via Toupet procedure for GERD surgery done 20 years ago.  I’m 8 months post op, still having epigastric pain/burping…had severe constipation in the beginning and had to push to have a bowel movement. Could the wrap have slipped?
Dear Diane,
Straining due to constipation or coughing increases intra-abdominal pressure. Increased intra-abdominal pressure in the early post-operative period may result in hiatal hernia recurrence. In this this case, the wrap does not slip but rather moves up into the chest along with the esophagus. By the same token, a poorly constructed Nissen or Toupet fundoplication may slip independent of increased intra-abdominal pressure. Another cause for recurrent acid reflux symptoms after revision surgery include the development of gastroparesis secondary to vagal nerve injury. Vagal nerve injury may also result in constipation.
Whatever is the underlying cause, you need to consult with your acid reflux surgeon. A thorough evaluation including upper endoscopy provides important information on the repair. Wrap slippage and recurrent hiatal hernia are easily diagnosed. Gastroparesis may require a gastric emptying study to confirm.
Once a diagnosis is made, a tailored solution is offered. Gastroparesis is difficult to treat but we have developed an effective procedure at Houston Heartburn and Reflux Center that promotes gastric emptying. If you suffer from gastroparesis, please give us a call at 832-945-8717. We may be able to help you.

#### Nissen Fundoplication and Dysphagia
“Clinical Significance of Esophageal Outflow resistance Imposed by a Nissen Fundoplication”, is a new study published by Demeester el al in the journal of the American College of Surgeons, JACS. Using esophageal manometry, the authors measured intrabolus pressure in normal subjects and in acid reflux patients undergoing Nissen fundoplication before and after surgery. They showed that Nissen fundoplication significantly increases intrabolus pressure. The authors concluded that Nissen fundoplication should be constructed in such a way as to avoid an intrabolus pressure higher than 20 mmHg. As long as patients have a distal esophageal contraction amplitude higher than 20 mmHg, they are at minimal risk for postoperative dysphagia.
Indeed, at Houston heartburn and reflux Center, dysphagia after Nissen fundoplication is rare. Advanced surgical technique, comprehensive pre-operative evaluation, and extensive experience in the field of acid reflux management allow us to maintain a very low dysphagia rate. Esophageal manometry is an important test performed prior to Nissen fundoplication. Manometry evaluates peristaltic vigor and lower esophageal sphincter relaxation pressure. At Houston heartburn and Reflux Center, our cutoff point for distal esophageal contraction amplitude is 25 mmHg. Patients with values lower than 25 mmHg are more likely to undergo a partial fundoplication like Toupet fundoplication to avoid postoperative dysphagia. We agree with the authors that a loose and floppy Nissen fundoplication must be constructed to decrease outflow resistance. Patients with normal manometry but small gastric fundus end up with a partial fundoplication to avoid a tight Nissen fundoplication and associated dysphagia.
To summarize, in expert hands, properly selected acid reflux patients undergoing Nissen fundoplication are at very low risk for postoperative dysphagia.

#### Nissen Fundoplication and Eosinophilic Esophagitis
Liam from Houston sent us this question: “I was diagnosed with Both eosinophilic esophagitis (biopsies) and GERD (lax LES). Motility test showed motility as fine.
EOE is being treated with steroids and might switch to a biologic. Count is now down to zero.
Question is should I go for Nissen Fundoplication, which might reduce motility given my EOE, or go with the endoscopic procedure (TIF) which has a lesser risk of motility issues but less long-term data on effectiveness? Thank you”.
Dear Liam,
The gold standard treatment for acid reflux disease is a properly performed Nissen fundoplication. At Houston Heartburn and Reflux Center we don’t consider TIF a reliable treatment option for GERD. TIF success rate and durability are low. TIF or transoral incisionless fundoplication is not even a fundoplication. “Bunching up” a bit of stomach tissue around the lower esophageal sphincter is not a fundoplication by any stretch of the imagination. Furthermore, TIF does not address the complex pathophysiology of GERD. Hence, very few patients benefit from a TIF procedure.
A properly performed floppy and short Nissen fundoplication along a hiatal hernia repair is associated with a very low dysphagia rate. Indeed, dysphagia or difficulty swallowing is expected to improve after a properly performed Nissen fundoplication. For chronic acid reflux damages esophageal motility. Stopping acid reflux ameliorates esophageal contractions and swallowing. By the same token, a poorly performed Nissen fundoplication may damage esophageal motility leading to worsening dysphagia.
Acid reflux may cause or worsen eosinophilic esophagitis by increasing inflammation in esophageal lining. For GERD increases permeability of esophageal mucosa. Food allergens can easily penetrate esophagus wall and illicit an allergic reaction. Conversely, eosinophilic esophagitis weakens the anti-reflux barrier leading to development or worsening of GERD. Chronic inflammation reduces lower esophageal sphincter pressure favoring reflux. Furthermore, it weakens esophageal motility allowing refluxed acid to linger longer within the esophagus.
Eosinophilic esophagitis may occur by itself independent of any measurable acid reflux. However, in cases of concomitant acid reflux and eosinophilic esophagitis, stopping acid reflux is crucial to reduce inflammation and control symptoms. The most effective solution to control acid reflux reliably and safely, in the setting of eosinophilic esophagitis, is a properly performed Nissen fundoplication.

#### Nissen Fundoplication and Esophageal Cancer
Carol from Katy, TX sent us this question: “Does Nissen Fundoplication surgery keep esophagitis from progressing to Barrett’s and does the surgery keep Barrett’s esophagus from progressing to esophageal cancer?  Thank you!”
Dear Carol,
Properly performed hiatal hernia repair and Nissen fundoplication reliably stops acid reflux. Consequently, esophagitis and ulceration due to acid reflux resolves completely after Nissen fundoplication. Barrett’s mucosa also regresses back to normal esophageal mucosa after Nissen fundoplication. Barrett’s mucosa regression is a stepwise and gradual process. Barrett’s mucosa regresses first to gastric cardia type mucosa then to squamous cell lining over a period of several years after Nissen fundoplication.
Regression rate varies from patient to patient depending on the severity of each case. Studies have shown that short segment Barrett’s esophagus (length of Barrett’s mucosa is less than 3 centimeters) is more likely to regress back to normal than long segment Barrett’s esophagus.
It is important to know that Nissen fundoplication, unlike proton pump inhibitors, PPIs, completely stops both bile and acid reflux. Bile acids are carcinogenic, and they contribute to esophageal mucosa metaplasia (Barrett’s esophagus) and dysplasia (progression of Barrett’s esophagus to esophagus cancer).
Therefore, Nissen fundoplication surgery, when properly performed at Houston Heartburn and Reflux Center, is the best treatment for GERD patients with Barrett’s esophagus.

#### Nissen Fundoplication and Gallbladder Function
MJ from Houston sent us this question:” Hi, my daughter had laparoscopic partial Nissen fundoplication for hiatal hernia repair three years ago.  She has had constant stomach air and now her gallbladder is not functioning (HIDA Scan 0%).  She is 20 and a college runner.  Is the gallbladder issue related to her Nissen fundoplication surgery?  Thanks”
Dear MJ,
Several small studies in the literature suggest that gallbladder ejection fraction decreases after cutting the hepatic branch of the vagus nerve. The hepatic branch of the vagus nerve is a small nerve that runs along the medial aspect of the upper stomach. It innervates the gallbladder among other structures, and it promotes gallbladder contraction. Hepatic branch of vagus nerve is commonly sacrificed during hiatal hernia repair and Nissen fundoplication, in order to mobilize the upper stomach. Accordingly, gallbladder contractions may decrease, and stone formation may be promoted.
However, gallbladder contractions and overall function are mediated by numerous other factors and signals. Hence, it is not clear to what extent does cutting the hepatic branch of vagus nerve contribute to gallbladder dysfunction.
Indeed, a study published by my colleagues at the university of North Carolina showed improvement in gallbladder ejection fraction after Nissen fundoplication. The study also showed no effect of cutting the hepatic branch of vagus nerve on gallbladder ejection fraction. The authors believe that chronic proton pump inhibitor use like Nexium and Omeprazole contribute to gallbladder stone formation and biliary dyskinesia. Nissen fundoplication stops acid reflux and allow GERD patients to stop PPIs leading to improvement in gallbladder function.
Finally, constant air is not a sign of biliary dyskinesia and is not an indication for gallbladder surgery even in the setting of positive HIDA scan. I caution my patients against unindicated gallbladder surgery in the setting of atypical symptoms like bloating. Unless patient is suffering from right upper quadrant pain, worse with fatty food consumption and associated symptoms like nausea and vomiting, gallbladder resection should be avoided. There are many other causes for gas and bloating. A careful workup prior to any surgical intervention, including the commonly performed laparoscopic cholecystectomy, is always warranted.

#### Nissen Fundoplication and Gastroparesis
Kelley from Houston sent us this question: “What if you have gastroparesis? Is a Nissen fundoplication contraindicated? Thank you.”
Dear Kelley,
In theory, Nissen fundoplication is contraindicated in the setting of gastroparesis. Nissen fundoplication re-establishes the anti-reflux barrier. Nissen fundoplication stops any gastric content reflux into esophagus. Gastroparesis patients depends on upward decompression of gastric content into esophagus for stomach propulsive contractions are weak. Consequently, Nissen fundoplication in the setting of gastroparesis may result in worsening bloating, pain, nausea, and dry heaving.
Nissen fundoplication, however, promotes gastric emptying. In a case of mild gastroparesis, Nissen fundoplication may cure both GERD and delayed gastric emptying. Traditionally a pyloroplasty has been added to Nissen fundoplication if gastroparesis is present. The pylorus muscle or gastric outlet valve is cut to facilitate gastric drainage. Such an approach, however, has limited success rate especially in a case of severe gastroparesis.
A more effective solution to promote gastric emptying is an antrum preserving longitudinal gastrectomy. I developed this procedure several years ago and I have had great success with at least 50 gastroparesis patients. After repairing the hiatal hernia and completing the fundoplication, gastric body is longitudinally resected along the Magenstrasse line. Resection stops just below the fundoplication level. The combination of fundoplication and gastric resection addresses both acid reflux and delayed gastric emptying. Promoting gastric emptying increases the durability and efficacy of Nissen fundoplication.
Please note that gastroparesis can result in heartburn and acid reflux. Indeed, most gastroparesis patients have heartburn. Care must be taken to differentiate GERD from gastroparesis as the primary problem. If gastroparesis is the primary problem, treatment consists of antrum preserving longitudinal gastrectomy without fundoplication. The dilated gastric fundus, often associated with gastroparesis, is included in the longitudinal resection to promote gastric emptying. If a hiatal hernia is present a concomitant hiatal hernia repair is performed to prevent acid reflux after surgery.

#### Nissen Fundoplication Durability
Praveen from Houston Asked us this question this past week: I’m 32-year-old and I have been suffering from GERD for almost 2 years now. I am considering the Nissen fundoplication to control my acid reflux. I don’t want to have multiple major surgeries, especially when they are so operator dependent and if not done properly can be disastrous. How long does a properly performed Nissen last?
Dear Praveen,
Your question is quite relevant. It is one of the most common questions I get asked at Houston Heartburn and reflux Center. There is a general misconception among gastroenterologists and primary care physicians that Nissen fundoplication acid control effects do not last, and patients end up with recurrent acid reflux symptoms. In reality, properly performed Nissen fundoplication in patients your age group are likely to enjoy the rest of their life free of acid reflux disease. A properly performed Nissen fundoplication surgery is key, and you are absolutely right: Nissen fundoplication surgery is operator dependent. Indeed, the whole process of GERD management starting with initial diagnosis is operator dependent. For this reason, at Houston Heartburn and Reflux Center, I personally perform GERD work up and accurately select patients for Nissen fundoplication. A comprehensive GERD work-up, accurate patient selection and PROPERLY performed Nissen fundoplication invariably result in effective and durable outcomes.
Comprehensive GERD work-up starts with a detailed initial consultation. During this initial encounter, an experienced acid reflux specialist goes over patient symptoms, exacerbating factors and response to medications. Subsequently, a number of tests like upper endoscopy, ambulatory pH testing, esophageal manometry and UGI contrast are ordered to rule in or rule out GERD diagnosis, hiatal hernia, Barrett’s esophagus, peptic ulcer disease, esophageal stricture, esophageal diverticula, achalasia, gastroparesis… Once the diagnosis of GERD is made, a tailored treatment plan is formulated that best suits patient particular condition.
If Nissen fundoplication is indicated, surgery must be meticulously performed by an expert acid reflux surgeon to yield good outcome. Fundoplication surgery requires experience and mastery of advanced surgical skills. When properly done GERD patients enjoy durable and reliable acid reflux symptom resolution.

#### Nissen Fundoplication for Acid Reflux treatment
Nissen fundoplication surgery, when properly performed, sets the bar quite high in terms of our expectations for new treatment modalities for acid reflux disease. Heartburn patients with objective evidence of acid reflux who undergo Nissen fundoplication and hiatal hernia surgery at Houston heartburn and Reflux Center are happy patients. They enjoy complete acid reflux symptom resolution, for many years after surgery and at a very low complication rate. Stretta, EndoStim, LINX™, and Esophyx are neither safer nor more effective than Nissen fundoplication. Most importantly, none of these devices and modalities address the multifactorial pathophysiology of acid reflux disease like Nissen fundoplication and hiatal hernia repair. Last but not least, a prospective randomized trial comparing a novel acid reflux treatment modality to Nissen fundoplication
Consequently, one cannot but wonder about the indications to perform Linx, TIF or Stretta procedure. Endoscopic acid reflux procedures are scarless and therefore more attractive to patients. There are, however, no high-quality studies that demonstrate better or equivalent efficacy, durability and safety when compared to Nissen fundoplication. Stretta for example is an endoscopic procedure for treatment of acid reflux disease approved by the FDA in 2000. The device is developed with the purpose of increasing the competency of the lower esophageal sphincter. In reality, all it does is increased scarring around that area. Prospective randomized studies showed no improvement in the lower esophageal sphincter function and no decrease in acid reflux. Potential serious complications associated with Stretta include gastroparesis and necrotizing pancreatitis. A number of acid reflux specialist still recommend Stretta procedure. They claim that Stretta doesn’t burn any bridge and if doesn’t work a Nissen fundoplication can still be performed.
At Houston Heartburn and Reflux Center, we recommend the best to our patients. The best modality for acid reflux treatment, today, is a properly performed Nissen fundoplication. If an acid reflux surgeon does not know how to perform a proper Nissen fundoplication, would LINX™, TIF and Stretta be indicated? I will answer this question in next week blog.

#### Nissen Fundoplication Improves Quality of Life
“Laparoscopic Nissen fundoplication improves disease specific quality of life in patients with GERD and functional esophageal outflow obstruction” is a recently published study in Surgical Endoscopy. The authors demonstrate that functional esophageal outflow obstruction noted on manometry in acid reflux patients is not a contraindication for Nissen fundoplication. 211 acid reflux patients underwent Nissen fundoplication between 2009 and 2017. 7% of 211 patients had functional esophageal outflow obstruction on manometry. There was no difference in baseline dysphagia scores and at one year follow up post Nissen fundoplication in both groups. Both groups showed similar improvement in acid reflux symptom control and disease specific quality of life.
Functional esophageal outflow obstruction is diagnosed using esophageal manometry. It is characterized by an elevated integrated relaxation pressure, IRP, greater than 15 mmHg in the setting of preserved esophageal peristalsis. Functional esophageal outflow obstruction is not associated with a structural or anatomic abnormality like a stricture, tumor or eosinophilic esophagitis. In the setting of GERD, we have noted, at Houston heartburn and Reflux Center, increased adhesions around the distal esophagus and lower esophageal sphincter in patients with esophageal outflow obstruction. Concomitantly, most GERD patients with esophageal outflow obstruction and increased adhesions around distal esophagus have small hiatal hernias. We believe that these peri-esophageal adhesions are secondary to severe acid reflux. Furthermore, excessive scar tissue formation around the distal esophagus prevents hiatal hernias from growing over time and contributes to esophageal outflow obstruction. It is possible that inflammation and adhesion formation prevent lower esophageal sphincter from properly relaxing. Hiatal hernia dissection and distal esophageal mobilization followed by floppy Nissen fundoplication reliably stops acid reflux. Such approach releases the adhesions contributing to outflow obstruction and stops acid reflux, the underlying cause of adhesion formation in this case. Consequently, we agree with the authors that the best treatment for functional esophageal outflow obstruction in GERD patients is laparoscopic Nissen fundoplication and hiatal hernia repair.

#### Nissen Fundoplication Surgery in Canada
Caleb sent us this question from Toronto, Canada: “I had Nissen Fundoplication surgery in September, and I have chest pain before and since then. I questioned my surgeon about this, and he said to restart my Protonix two times a day. GERD has reappeared in my throat also. Possibly unrelated I have black stools. Any help is appreciated.”

Dear Caleb,

Nissen fundoplication surgery is the most reliable treatment for GERD. Success rate is very high reaching 100% in centers of excellence like Houston Heartburn and reflux Center. Heartburn, chest pain, and sore throat are excepted to completely resolve following a properly performed hiatal hernia repair and Nissen fundoplication surgery. Surgery restores the anti-reflux barrier allowing patients to stop proton pump inhibitors or PPIs like Protonix.

If any acid reflux related symptom persists or recurs after Nissen fundoplication evaluation is warranted. The gold standard diagnostic test for acid reflux is upper endoscopy with ambulatory pH testing off PPIs. Upper endoscopy allows your acid reflux specialist to evaluate anatomy of gastroesophageal junction, check for hiatal hernia and integrity of wrap. Ambulatory pH testing measures acid reflux into esophagus. An intact Nissen fundoplication is invariably associated with negative ambulatory pH testing.

If there is evidence of recurrent hiatal hernia, slipped Nissen fundoplication or undone wrap, revision surgery is indicated. At Houston Heartburn and Reflux Center, we do not recommend blindly resuming Protonix after Nissen fundoplication for chest pain, sore throat or any other GERD related symptom.

#### Nissen Fundoplication Surgery in Houston
Terry from Woodlands, TX, sent us this question: “I had the Nissen fundoplication done 11 years ago & had difficulty swallowing immediately & shortness of breath among abdominal pain & discomfort, gas/bloating & have to have esophagus stretched two to four times every year. Wondering if I should have Nissen fundoplication undone then have the LINX™ procedure-very unhappy these past 11 years. Thank you.”
Dear Terry,
A properly performed Nissen fundoplication for the right acid reflux patient is not associated with difficulty swallowing, shortness of breath, bloating and abdominal pain. Rather, a properly performed Nissen Fundoplication and hiatal hernia repair is the most reliable treatment for acid reflux. Nissen fundoplication has a very success rate. It improves quality of life. At Houston Heartburn and Reflux Center, we have a very high patient satisfaction rate following Nissen fundoplication surgery.
Nissen fundoplication is a technically demanding surgery. GERD is a complicated disease. For this reason, we have dedicated our practice to acid reflux management. We do one thing and one thing only, but we do it right. We don’t offer LINX™ surgery because it is an inferior procedure to a properly performed Nissen fundoplication. Unfortunately, patients with poorly performed Nissen fundoplication blame the surgery rather than the surgeon for poor outcome. Not all Nissen fundoplications are created equal.
My advice for you is to get evaluated by a competent acid reflux specialist. The fact that you need esophagus stretching 2 to 4 times a year is a clear indication that your fundoplication was not properly performed. That does not translate into LINX™ surgery is a better option for you than Nissen fundoplication.

#### Nissen Fundoplication Versus PPIs for Barrett’s Esophagus
I read with great interest the article titled: “Antireflux Surgery Versus Antireflux Medication and Risk of Esophageal Adenocarcinoma in Patients With Barrett’s Esophagus” recently published in the journal Gastroenterology. A cohort of almost 34000 patients with Barrett’s esophagus were followed for 32 years. Only 542 patients (1.6%) underwent Nissen fundoplication surgery. The remaining patients were treated with anti-reflux medications. 14 patients in the surgery group developed cancer. 437 patients in the medical group developed cancer. The authors concluded, using statistical analysis, that the risk of developing esophageal cancer did not decrease after anti-reflux surgery compared with antireflux medications. It was not only higher but cumulative: the risk increased over the years. Patients should therefore continue to be surveilled.
I agree with the surveillance recommendation for Barrett’s esophagus after Nissen fundoplication. However, should we conclude that Nissen fundoplication does not halt the metaplasia-dysplasia-adenocarcinoma sequence in patients with Barrett’s esophagus? Should we deny our patients with Barrett’s esophagus the most reliable procedure that stops both acid and bile reflux and put them on PPIs (no evidence for cancer prevention) for the rest of their lives? After all isn’t acid and bile reflux the most important risk factors for Barrett’s mucosa development and progression to cancer.
The reality is that not all Nissen fundoplications are created equal. A poorly performed Nissen fundoplication does not stop acid and bile reflux.  A poorly performed Nissen fundoplication does not help anyone with Barrett’s esophagus. Similarly, a flawless Nissen fundoplication performed in the setting of severe longstanding GERD and long segment Barrett’s esophagus may be too late to prevent a focus of undetected low grade dysplasia from progressing to high grade dysplasia and cancer. The above study design does not control for these two very important variables. The authors rather assume that there should be no difference in length of Barrett’s segment between the two groups. If significantly more patients were offered surgery, one may accept such an assumption. However, less than 2% of the total study cohort had Nissen fundoplication surgery. In a clinical setting, patients with the most advanced disease tend to be offered surgery. Patients whose GERD has been progressing over many years and whose symptoms are no longer controlled by PPI therapy are more likely to undergo antireflux surgery. After all, inadequate symptom relief, is the most common indication for Nissen fundoplication. GERD symptom severity correlates with length of Barrett’s esophagus, likelihood of dysplasia and progression to cancer. Patients with more advanced Barrett’s esophagus are more likely to develop cancer especially after a poorly performed Nissen fundoplication. How many ineffective (poorly performed) Nissen fundoplications have been offered to patients in this study? Were these antireflux surgeries performed by expert hands?
Given the low number of Nissen fundoplication surgeries (542 over several years), it is safe to assume that the surgeons performing theses surgeries have limited expertise in anti-reflux surgery. Ineffective Nissen fundoplication exposes Barrett’s mucosa to progression to high grade dysplasia and adenocarcinoma. We all agree on this.
To summarize, not all Nissen fundoplication procedures are created equal. Patient selection and surgeon expertise play a huge part in determining the quality of Nissen fundoplication surgery. Unfortunately, this is not always taken into consideration in published studies leading to selection bias, and misleading results. This study was published in the journal Gastroenterology. A foregut surgeon and gastroenterologist commented on this study in the journal editorial. “These data argue strongly against antireflux surgery having any preventative benefit for the development of esophageal adenocarcinoma in patients with Barrett’s, so that outcome should not be used as a selling argument for antireflux surgery”. This a hardly the case at Houston Heartburn and Reflux Center. Our Nissen fundoplications result in high, short term and long-term success rate. Our patients are properly selected and worked up prior to surgery. We offer a solid post Nissen fundoplication surveillance program for Barrett’s esophagus. For all these reasons, we continue to recommend Nissen fundoplication, a properly performed Nissen fundoplication, as the most reliable treatment for GERD and the best cancer prevention option for Barrett’s esophagus. https://houstonheartburn.com/long-term-effect-of-nissen-fundoplication-on-barretts-esophagus.

#### Nissen Fundoplication vs Nexium
The LOTUS study, a randomized clinical trial, was published in 2011 in JAMA (Journal of the American Medical Association). The study compared laparoscopic Nissen fundoplication and hiatal hernia repair to daily high dose Nexium (up to 40 mg twice daily) for treatment of GERD.
266 patients were randomized to receive medical treatment with Nexium, and 248 patients were randomized to Laparoscopic hiatal hernia repair and Nissen fundoplication. The primary outcome measure of this trial was the time to treatment failure, which was defined as inadequate symptom control after dose adjustment in the Nexium group and the need for acid suppression in the anti-reflux surgery group.
Follow-up included a clinic visit every 6 months after randomization. Upper endoscopy was scheduled at 1, 3, and 5 years, and distal esophageal acid exposure was assessed at baseline, 6 months, and 5 years respectively.
Key findings
Both Nissen fundoplication and Nexium normalized distal esophagus acid exposure leading to excellent heartburn and epigastric pain control. However, food regurgitation was better controlled in the surgical group.
Higher rates of dysphagia, bloating and flatulence were noted in the surgical group.
Treatment failure occurred in 33/180 surgical vs 19/192 medical patients at 5 years.
Laparoscopic hiatal hernia repair and Nissen fundoplication was associated with 3% surgical morbidity but no mortality.
Study Limitations

Patients enrolled in the study are limited to PPI responders. Non responders, patients with refractory GERD to medical treatment, were excluded.
Surgical technique was not standardized among participating surgeons.

Conclusion
So, what does the LOTUS trial mean to you as a GERD patient in Houston?
Escalating doses of Nexium reliably control some acid reflux symptoms like heartburn but not food regurgitation. Furthermore, GERD is a progressive disease, and symptoms get worse over time despite high dose Nexium.
On the other hand, Nissen fundoplication is superior in terms of complete acid reflux symptom control. This is not surprising since Nissen fundoplication, unlike Nexium, eliminates acid reflux by restoring the anti-reflux barrier. Nexium does not alter the anti-reflux barrier. Nexium simply decreases acid secretion by the stomach. Thus, you will continue to reflux with Nexium but the refluxate is less acidic.
Key to Nissen fundoplication success, however, is finding a competent acid reflux surgeon who can perform flawless surgery. A properly performed Nissen fundoplication, for the right patient, has 0% dysphagia rate (difficulty swallowing after surgery) and 100% success rate.
The durability of Nissen fundoplication not only depends on surgical technique, but also on patient tissue quality. In other words, GERD is a progressive disease because of progressive tissue damage by acid reflux to the gastroesophageal junction.
The lower esophageal sphincter gets shorter and less competent as acid reflux disease progresses. Esophageal motility also is progressively weaker.
The fibromuscular tissues of the hiatus (the opening in the breathing muscle) lose strength and tone leading to a larger hiatal hernia. All these tissues are needed are needed to reconstruct the acid reflux barrier because of damage from constant acid reflux.
So, if you are on escalating doses of Nexium, it is time to think about acid reflux surgery before it is too late. At Houston heartburn and Reflux Center, we recommend early surgical intervention as opposed to chronic and escalating doses of Nexium. Early intervention allows for solid reflux barrier reconstruction thus leading to durable repair.
If you suffer from acid reflux and you are currently dependent on daily Nexium to fully or partially control your acid reflux symptoms give us a call at 832-945-8717 to learn about safe and reliable acid reflux treatment options.

#### Nissen Fundoplication, Dysphagia and Gastroparesis
Angela from Houston sent us this question: “My 33-year-old daughter had a fundoplication when she was 4 months old due to severe reflux that was inhibiting her ability to gain weight. Ever since her surgery, she has suffered with retching. She’s been diagnosed with Barrett’s and gastroparesis and has constant abdominal pain and excessive flatulence. Within the past several years, she has developed serious dysphagia. She’s had the fundoplication stretched several times and had Botox injected the last time (about 6 months ago) but the dysphagia has returned. What options do you feel are available to relieve these symptoms?”
Vagal nerve injury after Nissen fundoplication may result in gastroparesis. Retching, bloating and abdominal pain are classic symptoms of gastroparesis. Constant retching may disrupt the Nissen fundoplication and result in a recurrent hiatal hernia. Barrett’s esophagus and dysphagia may consequently develop. Other causes for late onset dysphagia after Nissen fundoplication may include pseudo-achalasia secondary to a tight wrap or new onset esophageal dysmotility disorder not related to fundoplication surgery.
These symptoms are quite debilitating. Therefore, at Houston Heartburn and Reflux center we strive to perform the most perfect Nissen fundoplication from the very beginning to avoid these issues. The good news is that several treatment options are available to effectively address most of these problems.
The first step to resolving any issue after Nissen fundoplication is proper evaluation and diagnosis by expert acid reflux specialist. For gastroparesis after Nissen fundoplication I have developed an effective minimally procedure that restores gastric motility and eliminates gastroparesis related symptoms. The procedure consists of antrum preserving longitudinal gastrectomy that ends below the fundoplication level. For late onset dysphagia, balloon dilation typically does not work and redo Nissen fundoplication is most often needed. The presence of Barrett’s esophagus indicates poor acid reflux control. Revision Nissen fundoplication and redo hiatal hernia are indicated in this case.

#### Nissen Fundoplication: Before or After Pregnancy?
Emma from Houston sent us this question: “I was recently diagnosed with a small hiatal hernia due to having heartburn since July that would not go away. My husband and I are trying to have a baby so my question is should I have a baby first or have surgery to fix my hiatal hernia and reflux? How long after surgery would I have to wait to become pregnant? Thank you”
Dear Emma,
Women of childbearing age with stage 3 and 4 GERD presenting at Houston Heartburn and Acid Reflux Center commonly face the same dilemma you are having; On one hand, they want to control severe acid reflux, stop proton pump inhibitors, and improve quality of life, especially during pregnancy. Pregnancy exacerbates heartburn and food regurgitation. On the other hand, they worry about morning sickness and the inability to vomit during pregnancy following Nissen fundoplication. In addition, during pregnancy and delivery, increased intrabdominal volume and pressure may cause a recurrent hiatal hernia or slipped Nissen fundoplication leading to recurrent acid reflux. Excessive weight gain during pregnancy may further increase the risk of wrap failure.
There are few studies in the literature that address the effect of pregnancy on Nissen fundoplication. The published studies I had reviewed showed no adverse outcome of pregnancy on Nissen fundoplication. In other words, most Nissen fundoplication patients undergo pregnancy with good acid reflux control and continue to be symptom free after delivery.
The Nissen fundoplication patients I have personally followed at Houston Heartburn and reflux Center reported no issues with pregnancy. During morning sickness episodes, patients experienced dry heaving without vomiting. They did not have heartburn and they did not have to take antacids or PPIs during pregnancy.
I advise patients with severe acid reflux disease to undergo Nissen fundoplication and hiatal hernia repair prior to pregnancy if they have a body mass index, BMI between 20 and 25. I caution overweight and obese patients about the increased risk of wrap failure and hiatal hernia recurrence with increased intra-abdominal pressure during pregnancy. I also emphasize the importance of avoiding excessive weight gain during pregnancy to minimize the risk of Nissen fundoplication failure.

#### Nissen Fundoplication: Where You Go First Matters
Patrick from Katy sent us this question: “I have been on medication for acid reflux for about 10 years and just last year it seems to have gotten worse. My doctor suggested surgery, so he referred me to a general surgeon who sent me for endoscopy test and pH study. After testing he told me that my esophagus is a little weak but working and that the normal acid level is 73 while mine is 78. He went ahead and schedule surgery. I had 360 Nissen fundoplication surgery on the June 29th but I had difficulty swallowing after surgery. He arranged for redo on July 18th and conversion to 270 partial fundoplication. Since surgery, I have been having constant burning in my throat, even finding hard to swallow especially cold liquid but the pain is increasing every day, even to the point that I am have pain that goes from my throat to my head. My doctor thinks the wrap is still tight, but when I talked to the surgical doctor, he told me there is nothing he can do for me and the wrap is not tight. I went to see a GI doctor and she said I have ineffective esophageal motility and that I should not have had the surgery. I have visited ER more than twice as the pain increases. Please help I don’t know what to do.
Dear Patrick,
Proper diagnosis and patient selection in addition to flawless surgical technique are key components of successful and safe acid reflux surgery. GERD is a complicated disease. An experienced acid reflux specialist who understands GERD pathophysiology is more equipped than a general gastroenterologist to interpret acid reflux testing results to recommend the most suitable solution to your acid reflux problem. An expert and skilled acid reflux surgeon is more equipped than a general surgeon to deliver a flawless Nissen fundoplication.
At Houston Heartburn and Reflux Center, our acid reflux specialists offer state-of-the-art A to Z management of acid reflux disease. Properly performed Nissen fundoplication remains the most reliable treatment for acid reflux disease. Difficulty swallowing after Nissen fundoplication indicates a technical problem. I recommend evaluation by an expert acid reflux specialist to figure out the cause of your symptoms and offer the most suitable and permanent solution.

#### Nissen vs Toupet Fundoplication for Heartburn Treatment
Rick from Houston sent us this question: My acid reflux doctor gave me the option of partial, 270 degree also known as Toupet fundoplication or complete, 360 degree wrap, also known as Nissen fundoplication. My doctor explained that Nissen fundoplication is sometimes a little difficult with certain foods to go down, but the Toupet fundoplication may allow some acid reflux to occur. What do you recommend?
Dear Rick,
Thank you for your question. Both 270 and 360 degree wraps or Toupet and Nissen fundoplication procedures are equally effective in treating acid reflux and eliminating GERD related symptoms. The key to Toupet or Nissen fundoplication reliability and effectiveness is good surgical technique. Both surgeries have to be flawlessly performed to restore the acid reflux barrier and achieve excellent outcome.
At Houston Heartburn and Reflux Center, we mostly perform Nissen fundoplication and our post-operative dysphagia rate is less than 1%. Dysphagia means difficulty swallowing food. A short and floppy 360 degree wrap, when properly performed, is associated with a very low dysphagia rate. We reserve Toupet fundoplication for severe esophageal dysmotility including cases like achalasia detected on pre-operative esophageal manometry study. Scleroderma patients and patients with years of poorly controlled acid reflux disease have poor esophageal contractions and are better served with a Toupet rather than Nissen fundoplication. Again, both 270 and 360 degree have the same efficacy in terms of controlling acid reflux. In rare situations, a small gastric fundus can sometimes prevent us from performing a floppy 360 degree wrap and in this case, a partial 270 degree wrap is indicated.
By the same token, patients with a large gastric fundus don’t do well with a partial wrap. A 270 degree wrap is a floppy and redundant posterior gastric fundus may not control acid reflux as expected. In this particular situation, we prefer to offer a two stitch (as opposed to the traditional 3 stitch) Nissen fundoplication. Such approach allows for better acid reflux control as it offers the patient a more suitable anti-reflux barrier with a very low dysphagia rate.
The take home message is summarized by the following: Not all acid reflux patients are created equal. An expert acid reflux specialist will tailor the fundoplication to the particular patient situation to achieve best possible outcome.

#### Obesity and GERD: Weight loss surgery options
GERD remains an intriguing disease with several important unanswered questions about its rising incidence, precipitating factors, underlying pathophysiology and relationship to the obesity epidemic. Today, around one-third of all Americans experience a GERD-related symptom at least once weekly.
Esophageal adenocarcinoma, a complication of GERD, is the fastest-rising cancer in the U.S. Abdominal girth and excess weight contribute to GERD. Several studies demonstrate a strong, almost linear association between BMI and GERD. Obesity may promote the development of GERD. If true, what would be the underlying mechanism?
The link between obesity and GERD seems to be related to increased intra-abdominal pressure secondary to abdominal fat accumulation. Intra-gastric pressure increases, promoting a backflow of gastric content into the esophagus. Several studies have shown that GERD patients’ increasing BMI is independently associated with increased intra-gastric pressure. While logical, these findings are a simplistic interpretation of a complex problem.
GERD is a result of a weak LES
GERD pathogenesis is centered on the gastroesophageal junction (GEJ). This complex and dynamic structure is comprised of the lower esophageal sphincter — the surrounding crural diaphragm — the angle of Hiss (angle where the intra-abdominal esophagus joins the stomach) — and the phrenoesophageal membrane (PEM). The diaphragmatic crura prevent strain-induced reflux events, while the angle of Hiss configuration prevents increased gastric pressure-induced reflux events. The PEM is composed of elastin intertwined with thick bundles of collagen. Elastin contributes to its elasticity and flexibility, while collagen confers strength. This delicate balance between flexibility and strength allows the remaining components of the GEJ to work in synchrony and with clocklike precision: relaxing, contracting and contorting to gastric pressure variations with upward esophageal movements to prevent reflux. Secondary to obesity, a persistent elevated intra-abdominal pressure may challenge the delicate PEM (the Achilles heel of the anti-reflux barrier). A weak and lax PEM causes anatomic changes in the structure of the GEJ that evolve into functional failure of multiple acid reflux defense mechanisms like low sphincter pressure, transient lower esophageal sphincter relaxation, prolonged acid clearance, and changes in the post-prandial acid pocket position. The end result is the development of an overt hiatal hernia: the only independent predictor for GERD.
Weight loss surgery options rather than acid suppression
Interestingly, increased gastric acid secretion is not a contributing factor in the GERD pathogenesis — quite a paradox in that acid suppression has been the mainstay of GERD therapy for the past 50 years. Particularly in the obese patient population, GERD treatment should mainly rely on weight loss rather than acid suppressive therapy. The most effective weight loss therapy for obese patients is bariatric surgery. Roux-en-Y gastric bypass surgery is an established anti-reflux procedure. It diverts the acid-producing stomach away from the esophagus. The literature remains ambivalent on the effect of sleeve gastrectomy in resolving acid reflux disease. Is gastric fundus resection during sleeve gastrectomy equivalent to gastric fundus plication during a Nissen fundoplication surgery? A recent prospective study by Morino et al. showed resolution of symptomatic GERD following sleeve gastrectomy in morbidly obese patients. Will the sleeve gastrectomy have a role in GERD treatment in obese patients?
Additional studies are needed to answer these questions. As GERD continues to rise, new screening, diagnostic and treatment paradigms will emerge.

#### Overweight and Suffering from Heartburn? We Can Help
Heartburn and food regurgitation are difficult to control when you are overweight. The constant pressure over the stomach forces gastric juices to escape into the esophagus. Large meals consumed on a daily basis and especially at night stress the gastro-esophageal junction area and promote acid reflux. A large and dilated gastric fundus contributes to frequent transient lower esophageal sphincter relaxation episodes leading to increased gastric content reflux into the esophagus. If you are overweight and you suffer from acid reflux disease or GERD, Houston Weight Loss Surgery Center and Houston Heartburn and Reflux Center have a solution for you. As a specialist in both acid reflux disease and weight loss surgery, I have developed a unique protocol to address GERD in overweight individuals living in Houston and surrounding communities.
There is a strong relationship between GERD and obesity. One cannot address GERD while ignoring obesity and vise versa. Weight loss, healthy food choices, and small meals serve both the overweight and heartburn patient. Nissen fundoplication, gastric sleeve surgery and Rous en Y gastric bypass all have the gastric fundus in common. Whether the gastric fundus is wrapped, excised or bypassed the end result is the same: weight loss, decreased meal size, early satiety, and lower Ghrelin levels. In addition, there is decreased acid reflux. A properly constructed gastric sleeve (no narrowing at the incisura and no retained gastric fundus) effectively diverts gastric content and acid away from the esophagus. Nissen procedure and gastric bypass surgery have traditionally been the most reliable treatments for GERD. Nissen surgery creates an effective antacid barrier with excellent long-term results. Gastric bypass is equally effective with the added benefit of weight loss in the overweight patient. Both gastric sleeve and gastric bypass are great solutions for GERD and obesity. Patients who are more than 50 pounds overweight and who suffer from multiple obesity related comorbidities like type 2 diabetes should strongly consider weight loss surgery over Nissen fundoplication for treatment of GERD. Nissen procedure is associated with some weight loss but not enough when compared to gastric sleeve surgery or gastric bypass procedure. Neumayer et al published a study in 2005 in Surgical Endoscopy showing significant weight loss after Nissen fundoplication. He showed persistent weight loss of around 9 pounds at one year after Nissen procedure in a group of patients with an average starting BMI of 27.6. One would expect more weight loss with a higher starting BMI, however, Nissen fundoplication is not a bariatric procedure. Twenty to thirty pound weight loss is not enough in our obese patient population. Furthermore, hiatal hernia repair and complete circumferential distal esophageal dissection are quite challenging in the obese patient. Indeed, it is almost impossible to properly release the distal esophagus in the setting of a large liver and thick abdominal wall. Therefore, hiatal hernia repair, like any other hernia type, is best performed after weight loss is achieved. Our approach to hiatal hernia repair in the obese patient is different from most practices in Houston. I prefer not to violate the hiatus in an obese patient. I completely avoid an anterior crural approximation since it has no benefit. I also consider a posterior hiatal repair without esophageal dissection and mobilization to be associated with a high recurrence rate. For these reasons, I leave the hiatal hernia alone during gastric sleeve or gastric bypass procedure. One year later, I come back to fix it. Of course, for small hiatal hernias one can easily repair them concomitantly with the weight loss procedure. However, one may argue that there is no need to fix a small hiatal hernia in the setting of gastric sleeve surgery. I completely avoid repairing a small hiatal hernia in a gastric bypass case as it has no benefit whatsoever to the patient.

#### Pain Following LINX™ Surgery for Heartburn
Tim from Houston sent us this question:
“I’m wondering if (1) Dr Darido has first-hand experience with implantation of the LINX™ device to treat GERD and (2), if so, would its potential removal and follow-up application of Nissen Fundoplication subsequently prevent return of GERD?
It seems there are acid reflux patients experiencing delayed pains following LINX™ surgery and opting to have their device removed. Not sure of the location, duration, severity of their pains and nobody seems to know what the actual cause of the pain is, or if indeed it’s associated with this device. Best I can tell, my concurrent pains occur over the center of my chest where the device sits, near my gall bladder and appendix, in my right-side neck and lower jaw, behind my right eye and along my right-side temple. Suspect it’s all associated with a nerve pathway of some sort for it to be that extensive. I’m wondering what my options are, if Dr Darido is knowledgeable about this issue, and if having a balloon stretch might rid or alleviate these pains.”
Dear Tim,
At Houston Heartburn and Reflux Center, competent acid reflux specialists and Nissen fundoplication surgery experts have hard time recommending LINX™ surgery to their patients. Nissen fundoplication surgery, when properly performed, is safe, durable and very effective cure for acid reflux. For this reason, we see no indication for LINX™ surgery. Consequently, we don’t have any first-hand experience with implantation of the LINX™ device to treat GERD. LINX™ device removal may be complicated due to scar tissue formation and erosion of LINX™ device into esophageal musculature. Once removed, conversion to Nissen fundoplication will most likely stop all acid reflux related symptoms.
Substernal and epigastric pain of unknown etiology, following LINX™ device placement, has been described. Fortunately, it is not common. Pain typically does not radiate beyond esophagus anatomical location and is not associated with any other symptom. Our experience with LINX™ device removal for this particular presentation is limited. It is crucial to rule out prior to LINX™ device removal any other potential cause of substernal pain.

#### Persistent Gastroparesis Following LINX™ to Nissen Fundoplication Conversion
Karen from Houston sent us this question: “Hello, my name is Karen. I am a 21-year-old female who suffers from gastroparesis. The LINX™ device caused my gastroparesis. I got it removed and now have a Nissen fundoplication. But still suffer with GP. Is there hope for me besides medication? I’ve heard that the G-POEM procedure can cause dumping syndrome. So, I didn’t want to get that surgery. Is there a safer and better option than G-POEM?”

Dear Karen,

Injuring the vagus nerve during hiatal hernia repair or LINX™ surgery may result in delayed gastric emptying or gastroparesis. Conversion of LINX™ to Nissen fundoplication improves gastric emptying. However, Nissen fundoplication by itself may not be enough to normalize gastric emptying. The traditional recommendation is to add a pyloroplasty (cutting the pyloric muscle that controls stomach outlet) to improve stomach drainage. However, this approach is neither reliable nor effective. G-POEM is pyloroplasty performed through the mouth using endoscopy. Although many publications in the literature show promising results, G-POEM is as unreliable as laparoscopic pyloroplasty. The pylorus is not narrowed in gastroparesis and therefore, cutting open the pylorus to promote stomach drainage neither results in improved gastric emptying nor gastroparesis symptom resolution. Therefore, dumping or accelerated gastric emptying, is not likely to occur following G-POEM. Indeed, G-POEM increases the risk of bile reflux from duodenum into stomach. Bile accumulation in stomach causes bile gastritis (stomach inflammation) and esophagitis (esophagus inflammation).

At Houston Heartburn and Reflux Center, we have developed a novel treatment for gastroparesis: an antrum preserving longitudinal gastrectomy. The procedure is both safe and reliable. In cases of vagal nerve injury where a Nissen fundoplication has already been constructed, the resection stops just below the level of the wrap with no need to take down the fundoplication. We have achieved great outcomes with this procedure that normalizes gastric emptying and alleviates nausea and vomiting. Should you have any questions about gastroparesis management following anti-reflux surgery please give us a call at 832-945-8717.

#### Persistent Heartburn after Nissen Fundoplication
Paula from Houston sent us this question: “Just had Nissen fundoplication surgery still having heartburn surgeon gave me an upper endoscopy said I’m not having reflux its anxiety. I don’t know what to do”.
Dear Paula,
Heartburn is a symptom. Acid reflux is a disease. The gold standard diagnostic tool for acid reflux is ambulatory pH testing that measures esophageal acid exposure over a number of days. Heartburn is the most common symptom of acid reflux. However, patients may feel heartburn in the absence of acid reflux disease. You may have a hypersensitive esophagus. Stress and anxiety do not cause acid reflux to happen but increase esophageal sensitivity to acid reflux.
Nissen fundoplication patients who report persistent or new onset heartburn after surgery need to be evaluated with upper endoscopy and ambulatory pH testing. An acid reflux specialist uses upper endoscopy to evaluate the anatomy of the gastro-esophageal junction and rule out recurrent hiatal hernia or loose wrap. Furthermore, upper endoscopy visualizes distal esophageal lining to check for acid reflux induced inflammation or ulceration. The addition of ambulatory pH testing increases the sensitivity and specificity of testing and effectively rule in or out persistent or recurrent acid reflux disease after Nissen fundoplication.
By the same token, upper endoscopy and ambulatory pH testing are used prior to Nissen fundoplication surgery to confirm acid reflux disease. Patients who don’t have acid reflux disease will obviously not improve after Nissen fundoplication and continue to have whatever symptoms they suffered from prior to surgery.
To summarize, pre-operative acid reflux work-up and patient selection are important aspects of acid reflux treatment. Patients with confirmed acid reflux disease have a very high success rate with a properly performed Nissen fundoplication. Patients with persistent or recurrent acid reflux symptoms after Nissen fundoplication need to be evaluated by an acid reflux specialist. I am completely against the blind use of proton pump inhibitors after Nissen fundoplication without confirming recurrent acid reflux disease. Revision Nissen fundoplication surgery is offered to patients with a disrupted wrap, or recurrent hiatal hernia with good outcome.

#### POEM after Toupet Fundoplication for Achalasia
Peter from Houston sent us this question: “I currently have a Toupet fundoplication and the latest testing shows that I have achalasia not allowing food to enter the stomach. Can a POEM be performed to correct the achalasia without disturbing the fundoplication? Therefore, I would still have GERD protection and able to eat normal food”.
Dear Peter,
Either POEM or Heller myotomy can be performed after Toupet fundoplication for newly diagnosed achalasia. The advantages of POEM over traditional laparoscopic Heller myotomy are faster recovery and less pain. Additional benefits of POEM following Toupet fundoplication include avoiding possible scar tissue formation around gastroesophageal junction from previous surgery. You are right, preserving the Toupet fundoplication will prevent acid reflux after POEM.
I am not sure if you had undergone esophageal manometry prior to Toupet fundoplication. At Houston Heartburn and Reflux Center, esophageal manometry is performed prior to any fundoplication mainly to rule out achalasia. In certain cases, achalasia develops many years after fundoplication surgery, and this may be your case.
I should mention that tight approximation of hiatal opening during hiatal hernia surgery may lead to pseudoachalasia. Pseudoachalasia, like achalasia, is associated with progressive dysphagia, dilated esophagus and narrow esophageal outlet. Pseudoachalasia treatment entails enlarging the hiatal opening to alleviate esophageal outflow obstruction.
I recommend thorough pre-op evaluation by an acid reflux specialist including esophageal manometry, upper endoscopy and contrast study to properly diagnose the problem and choose the solution that best fits your particular condition.

#### Power Foods to Fight Acidity
You may find yourself suffering more from acid reflux in the summer months, which can be a natural occurrence. It may be more difficult eating when certain foods trigger your symptoms more in the scorching summer months. You now find yourself asking, is there any food which won’t give me heartburn? Fear not, here are six top foods that can help you fight your acidity this summer.
Green veggies: really effective in fighting off heartburn in the summer. Try to eat lots of greens, such as spinach, broccoli, green beans, and asparagus, throughout the summer to prevent your acidity levels increasing.

Ginger: great ingredient that has been used for many years to treat gastrointestinal problems. Ginger is a versatile ingredient, meaning it can be used raw, peeled, or cooked.

Salads: a great way to eat a healthy meal without feeling too heavy and can be digested quickly. However, make sure to eliminate tomatoes, onions, cheese and dressings high in fat.

Bananas: great at neutralizing the excess acid in your stomach, due to their PH value. However, make sure you test this ingredient first as bananas may not work for everyone.

Capsicum: alkalizing ingredient and has anti-bacterial properties that can help reduce your heartburn. An easy ingredient to add to salads or as a side dish of roasted vegetables.

Summer can be a very tempting time to overindulge in lots of treats, such as ice cream, hot dogs, and highly fatty foods, all which can trigger heartburn. Try to incorporate the mentioned ingredients into your diet this summer to avoid heartburn.
If your heartburn is consistent for a while and nothing has worked, make an appointment with Dr. Darido today.

#### PPI Use and Lupus erythematosus
Proton Pump Inhibitors, PPIs, have many serious side effects including early dementia, heart disease and kidney failure. Such adverse events are attributed to endothelial damage and vascular aging. Few weeks ago, a young GERD patient presented to my office with PPI induced subacute cutaneous lupus erythematosus, SCLE. A number of medications like ACE inhibitors, thiazides and others can result in SCLE. I was not aware that PPIs are included in this list. The FDA does not recognize SCLE as a PPI-associated adverse event. However, a study published in 2016 by Nitish Aggarwal, recommends PPI discontinuation if SCLE occurs. The author analyzed 120 SCLE cases and he confirmed an association with PPI use. PPI discontinuation resulted in SCLE resolution.
PPIs are not without side effects. Their adverse reactions are numerous and affects multiple organ system including the immune system. Indiscriminate use of PPIs by patients and physicians is to be discouraged. Self-medicating with OTC PPIs is unfortunately quite prevalent. The majority of GERD patients ignore the FDA warning on OTC PPI bottles limiting PPI use to less than 14 days. Indeed, once you start PPIs for acid reflux symptom control it is quite hard to stop them. Herein lies the danger of these medications. PPIs use cannot be limited to 14 days for GERD is a chronic and progressive disease. PPIs neither address GERD pathophysiology nor cure the disease. These medications simply mask GERD related symptoms.

#### PPIs, Diabetes and Gastroparesis
Kelly from Houston Sent us this question: “My husband has been using proton pump inhibitors for many years. He has just been diagnosed with Gastroparesis. Can taking proton pump inhibitors to cause an irreversible chronic condition in patients with diabetes?
Dear Kelly,
PPIs or proton pump inhibitors’ long-term use is associated with several side effects. PPIs may delay gastric emptying. However, it is not likely that PPIs cause permanent damage of gastric emptying resulting in gastroparesis.
In your husband’s case, diabetes is the most likely cause of gastroparesis. Stopping PPIs and improving blood sugar control may help improve gastric emptying. Adding pre-motility medications help symptom control in mild gastroparesis cases.
For severe, medically refractory gastroparesis, an antrum preserving longitudinal gastrectomy along the greater curvature is offered at Houston Heartburn and Reflux Center. Concomitant hiatal hernia repair is performed if a hiatal hernia is present. Such an approach allows your husband to stop acid reflux, restore gastric emptying and greatly improve blood sugar control. In a good number of cases, diabetes may completely resolve.

#### Pregnancy, In Vitro Fertilization & GERD
A new study focused on pregnancy has shown that women who give birth through in vitro fertilization are more likely to experience GERD than those who don’t.  While the direct cause is unknown, researchers do have some theories.
The results of the GERD study are published in the UEG Journal (United European Gastroenterology), in which 156 women who had a IVF-induced birth took a reflux-based questionnaire a year following pregnancy.  These were all women who had either one child or twins.  The same questions were given to a group of 111 women who had given birth naturally.
Out of that group, 13.5% of IVF participants reported experiencing GERD, as opposed to just 4.5% in women who went through natural child birth.  Among the possible causes for the presence of GERD, researchers pointed to psychological and medical factors.
They believed factors such as depression, stress and anxiety could play a role.  Often times, worries about a miscarriage can take a mental toll on a pregnant mother.  High level intakes of progesterone and estrogen were also believed to be potential factors.
The next step in the study will be to take these results and analyze prevention options, as well as possible treatments.   “There was no difference between women with singleton birth and those with twin birth in terms of developing subsequent reflux symptoms. Further long-term follow-up studies are required to determine whether therapy during pregnancy can prevent this risk,” the researchers said.
If you are experiencing symptoms of GERD, contact the specialists at Houston Heartburn.

#### Probiotics for GERD and Heartburn
The gut microbiome is composed of millions of microbes living in symbiosis and regulating a number of physiologic processes including gastrointestinal motility. GERD, a multifactorial gastrointestinal motility disorder, may partly result from gut microbiome dysbiosis. Manipulation of gut microbes through diet, prebiotics, probiotics and fecal transplantation is a promising therapeutic target to eliminate heartburn.
A number of small studies have been published in the literature showing a beneficial effect on reducing heartburn and other GERD related symptoms with probiotic supplement consumption. Probiotics are found in fermented food items like yogurt and sauerkraut as well as dietary supplements. In one study, infants who were given probiotic supplement for 30 days showed accelerated gastric emptying, and decreased food regurgitation. The underlying mechanism of theses beneficial effects remains to be elucidated. There are currently no treatment guidelines of GERD using probiotics. At Houston Heartburn and Reflux Center we encourage all our patients to adopt healthy eating habits including the consumption of fermented foods. However, we caution patients about treating severe GERD and advanced symptoms with food supplements and dietary manipulation. Stage 3 and 4 GERD necessitates management by an experienced acid reflux specialist. At Houston Heartburn and Reflux Center we offer a number of solutions for severe GERD that cure your acid reflux and improve your quality of life.

#### Properly Performed Nissen Fundoplication
Luke from Dallas sent us this question:
I am a 65-year-old man with revision of a Nissen fundoplication in 2018.
5’11 185 lbs.
Symptoms did not improve (even temporarily) following either procedure.
Barium swallow two days ago:
1. Moderate size paraesophageal hernia containing the proximal stomach.
2. Changes suggestive of prior gastric fundoplication with disrupted
wrap.
Since I have no significant weight problem is gastric bypass still the best option?
Dear Luke,
Properly performed Nissen fundoplication and hiatal hernia repair is the most reliable and effective treatment for acid reflux disease. Nissen fundoplication is safer, less invasive and more suitable for an acid reflux patient with normal BMI than gastric bypass surgery.
To answer your questions, one need to know whether your initial and redo Nissen fundoplication and hiatal hernia repairs were performed by expert acid reflux specialists. I have noticed that the esophagus is incompletely mobilized in most revisions I perform at Houston Heartburn and Reflux center for recurrent paraesophageal hernias. Incomplete esophageal mobilization is a common mistake in acid reflux surgery that leads to hiatal hernia recurrence, slipped Nissen fundoplication and poor acid reflux symptom control. If this is your case, third time revision is indicated and is typically associated with good outcome.
In rare cases of short esophagus, a gastric bypass may be indicated in lieu of an esophageal lengthening procedure and Nissen fundoplication also called Collis gastroplasty.
Of note, gastric bypass while effective at controlling acid reflux, does not restore the anti-reflux barrier like a Nissen fundoplication. Gastric bypass simply diverts gastric acid away from distal esophagus.
To summarize, we strive at Houston Heartburn and Reflux center to offer a properly performed Nissen fundoplication and hiatal hernia repair for the right patient from the get-go. Consequently, our revision rate for Nissen fundoplication and hiatal hernia repair that we perform is almost zero. It is crucial to choose an expert acid reflux surgeon to perform your Nissen fundoplication and hiatal hernia repair. Once again, a properly performed Nissen fundoplication and hiatal hernia repair is the best solution for acid reflux disease.
 Please let us know if you have any questions or comments regarding this blog article.
  

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#### Proton Pump Inhibitors Delay Gastric Emptying
“Effect of proton pump inhibitors on gastric emptying: A systemic review” is a study by Yasushi Kuyama el al demonstrating the effect of PPIs on gastric emptying. The authors showed a consistent delaying effect of PPIs on gastric emptying of solid meals but not liquids following a systemic literature review. The underlying mechanisms are not well understood. One possible explanation is based on the concept that gastric emptying of solids involves a process of peptic hydrolysis. PPIs impair the hydrolytic digestion by inhibiting acid-dependent peptic activity, thereby delaying the solid emptying. In contrast, liquid gastric emptying depends on volume and energy density of intra-gastric contents. According to Kuyama et al “PPIs variably modify the volume and the energy density by reducing gastric fluid secretion, thereby modifying the liquid emptying in an unpredictable manner”.
10 to 30 % of GERD patients suffer from delayed gastric emptying. Furthermore, delayed gastric emptying by itself contributes to acid reflux pathogenesis. It is believed that transient lower esophageal sphincter relaxation, TLESR, is one of the major causes of acid reflux. TLESR increases after eating. Gastric fundus distention, pharyngeal stimulation and gastrointestinal hormones may contribute to TLESR. Gastric distention increases with delayed gastric emptying. Furthermore, persistent delay in gastric emptying may lead to gastric fundus stretching and increased compliance. These factors increase the frequency of TLESR leading to increased gastric juice reflux into the esophagus. In the presence of bile reflux, PPI therapy may potentially exacerbate the esophageal exposure to bile leading to increased incidence of Barrett’s and esophageal adenocarcinoma.
PPIs are considered the gold standard treatment for acid reflux disease. However, PPIs do not address the underlying causes of acid reflux. Though PPI therapy is excellent at masking symptoms, it may exacerbate reflux by delaying gastric emptying. Chronic PPI therapy may irreversibly stretch the gastric fundus due to persistently delayed gastric emptying thus leading to worsening reflux over time. This may partly explain the progressive nature of acid reflux disease under PPI treatment.
Acid reflux disease is a complex disorder. PPI therapy, considered the gold standard GERD treatment, addresses symptom control only. Additional studies are needed to develop more effective pharmaceutical alternatives that target TLESR, gastric fundus tone, and esophageal acid clearance rather than gastric acid secretion.

#### Proton Pump Inhibitors Mortality Risk
An open access observational study has been recently published in BMJ about the risk of death among users of proton pump inhibitors, PPIs. The authors used administrative data from the US department of Veterans Affairs. A cohort of 349,312 patients were included. The analysis showed that over a median follow up of 5.71 years, PPI use was associated with an increased risk of death compared to histamine receptor blocker users. The analysis further showed a graded association between duration of exposure and risk of death. In addition, the association of increased mortality and PPI use was independent of an existing underlying gastrointestinal condition like acid reflux, achalasia, Barrett’s esophagus and esophageal adenocarcinoma.
This study further adds to the growing literature showing increased morbidity and mortality with PPI use. PPIs are available over the counter in Houston and all over the country. Ironically, the OTC PPI bottle does carry the FDA warning of not using the medication for more than 14 days. However, once GERD patients start self-medicating with PPIs, it is hard to stop. GERD is a chronic and progressive medical condition. PPIs heal erosive esophagitis and alleviate heartburn but PPIs do not stop reflux. PPIs do not address the underlying GERD pathophysiology and there is good evidence to suggest that PPIs do not prevent the development esophageal adenocarcinoma.
An increasing number of GERD patients are presenting to Houston Heartburn and Reflux Center who are concerned about PPI side effects. Houstonians and primary care physicians, unlike gastroenterologists, are no longer in favor of long-term PPI treatment of stage 3 and 4 GERD. It is a great time in the history of acid reflux disease management to re-affirm Nissen fundoplication as the most reliable treatment for GERD. A properly performed fundoplication is currently the only effective and safe solution for GERD. Nissen fundoplication addresses several components of GERD pathophysiology that are beyond simple lower esophageal sphincter, LES, reinforcement as LINX™ proponents advocate. GERD is a multifactorial problem and most patients with GERD have normal LES pressure. In my opinion GERD is a form of foregut motility disorder that favors acid and bile reflux. Nissen fundoplication promotes gastro-duodenal emptying thus contributing to the anti-reflux barrier. It may also prevent bile reflux by the same mechanism.
In short, in this day and age, GERD patients have an excellent and safe solution to their problem. You neither have to risk PPI side effects nor suffer from poor acid reflux symptom control. Give us a call and witness the care Houston Heartburn and reflux Center offers.

#### Question of the week regarding Barrett’s esophagus
Question of The Week
Lori from Houston has a question regarding Barrett’s esophagus:
“I have stage 4 GERD plus Barrett’s and would appreciate any additional info you can provide. I recently turned 60, and my dad and his sister both died of esophageal cancer and stomach cancer”.
Dear Lori,
Acid and bile reflux damage esophageal lining resulting in Barrett’s esophagus. About 10% of patients with GERD develop Barrett’s esophagus and 1% of patients with Barrett’s esophagus develop esophageal cancer. Esophageal cancer, the fastest rising cancer in the country, is a serious and potential fatal disease. Barrett’s esophagus and stage 4 GERD are strong indications for hiatal hernia repair and Nissen fundoplication surgery.
Proton pump inhibitors mask your acid reflux related symptoms but don’t stop reflux. At Houston Heartburn and reflux Center, we commonly encounter patients with Barrett’s esophagus despite taking proton pump inhibitors for many years. Nissen fundoplication surgery reliably and effectively stops gastric content reflux into the esophagus. As a result, Nissen fundoplication halts the progression of Barrett’s esophagus into cancer, and in certain cases Barrett’s mucosa regresses back to normal.

#### Question of The Week: Band to Sleeve Revision
Stacy wrote: “I converted a band to sleeve and have had horrible reflux I take PPIs, with minimal relief…it’s absolutely horrible. I converted because band slipped and kinked I traded one problem for another and paid for it all out of pocket. Help”
Dear Stacy,
Lap Band slippage is uncommon but when it happens, and lap band removal is needed to alleviate stomach obstruction, I don’t recommend a concomitant sleeve gastrectomy. Band slippage is invariably associated with severe inflammation and scar tissue formation around the gastro-esophageal junction. It is also associated with hiatal hernia formation and poor esophageal motility. I highly advise in such situations to remove the band and wait 3 to 6 months prior to any surgical intervention like sleeve gastrectomy and hiatal hernia repair.
Staging the conversion of Lap Band to Sleeve gastrectomy has many advantages. First, it allows the inflammation and Lap Band induced scar tissue around the Gastro-esophageal junction to resolve. Adhesions prevent proper gastric resection to create a well contoured gastric sleeve. A well contoured sleeve gastrectomy results in optimal weight loss and no acid reflux.
Second, waiting 3 to 6 months after slipped band removal allows the esophagus to recover. It gives your acid reflux specialist time to evaluate esophageal motility and the status of your anti-reflux barrier. A weak anti-reflux barrier must be addressed at the time of sleeve gastrectomy to prevent post sleeve surgery acid reflux.
PPIs in your case Stacy, have very limited efficacy. A poorly contoured gastric sleeve surgery with a large retained gastric fundus and hiatal hernia result in severe acid reflux. I recommend a comprehensive acid reflux work-up by an experienced acid reflux specialist. At Houston Heartburn and reflux Center we tailor the treatment to fit your particular situation. Such an approach results in complete acid reflux symptom resolution and high patient satisfaction rate. You don’t need to suffer; your problem can be reliably fixed.

#### Question of the Week: Can TIF procedure be done in cases of esophageal dysmotility due to scleroderma?
Scleroderma is a rare connective tissue disorder of unknown etiology. Scleroderma results in tightening of the skin due to increased synthesis of collagen. It can be localized or systemic. Systemic scleroderma affects internal organs like the esophagus. When the esophagus is affected by the disease, esophageal motility is lost resulting in dysphagia and GERD. GERD results from the inability of the esophagus to clear naturally occurring reflux. There is no cure for scleroderma and treatment is mainly focused on symptom relief.
Patients with early stage GERD, in the setting of scleroderma, may benefit from antacid medications like proton pump inhibitors. Prokinetic drugs have very limited effect on acid reflux symptom control. As scleroderma advances and esophageal dysmotility worsens, GERD symptoms like heartburn and food regurgitation become poorly controlled with proton pump inhibitors. For these advanced GERD stages, anti-reflux surgery is indicated. At Houston heartburn and reflux center we offer a partial posterior fundoplication also called Toupet fundoplication. The surgery is associated with excellent symptom control without worsening any pre-existing dysphagia. Toupet fundoplication like Nissen fundoplication prevents any backflow of gastric content into the esophagus. The exact mechanism of action of fundoplication is not well understood. It is likely that fundoplication reverses certain gastric motility patterns that are poorly understood resulting in reflux control.
TIF or transoral incisonless fundoplication is an endoscopic procedure presumably developed to reinforce the lower esophageal sphincter and mimic fundoplication surgery. The procedure has nothing to do with the gastric fundus itself and the nomenclature is misleading. Indeed, the gastric fundus is left untouched during TIF procedure. Rather, gastric cardia tissue is plicated around the distal esophagus hoping to restore the angle of His. Restoring the angle of His by itself is obviously not a fundoplication and consequently TIF is not a reliable GERD solution. At Houston Heartburn and reflux Center we offer reliable treatments for GERD. In my opinion, TIF is not one of them especially in the case of scleroderma and esophageal dysmotility.

#### Question of the Week: Do PPIs Cause Delayed Gastric Emptying?
Andy sent us this question: “I was put on omeprazole 40 MG Feb 9th for stomach issues I was having. I had an endoscopy Feb 12th that should a lot of inflammation from where the esophagus dumps into the stomach to the intestines. I was negative for H Pylori bacteria. I used a lot of NASAIDS so was told gastritis from that. A month later I did a food emptying test that was a little abnormal. Could the ppi cause the lazy stomach?”
Dear Andy,
PPIs may cause some delay in gastric emptying. It seems however that you have significant distal esophagitis indicating severe GERD. Up to 40% of GERD patients may have associated gastroparesis or delayed gastric emptying. Gastroparesis contributes to acid reflux disease and it further complicates the treatment approach. As you probably know PPIs only mask GERD related symptoms and are associated with several side effects when taken over long periods of time. If you suffer from severe acid reflux disease, medical treatment in the form of daily PPI intake may not be the optimal solution. Hiatal hernia repair and Nissen fundoplication surgery is the most reliable and most effective treatment for GERD. The surgery restores the anti-reflux barrier and when properly performed, it is associated with very high success rate as well as high safety profile.
I routinely add an antrum preserving longitudinal gastrectomy along the greater curvature to fundoplication surgery in case of concomitant gastroparesis. I have had great success alleviating delayed gastric emptying using this technique. Performing a Nissen fundoplication in the setting of moderate to severe gastroparesis results in significant post-operative patient discomfort. In certain instances, gastroparesis patients are mistakenly diagnosed with acid reflux and a fundoplication is offered. Recently, a patient presented to my office with severe abdominal pain, bloating, and dry heaving post Nissen fundoplication performed at an outside institution. I performed an upper endoscopy that showed an intact 360 degree wrap and extensive amount of solid food residue in the stomach. The patient was unable to vomit or belch due to the newly constructed fundoplication and because of gastroparesis her stomach was not emptying into the duodenum.
At Houston Heartburn and Reflux Center, we avoid such situations by carefully listening to patient symptoms and comprehensively evaluating the patient. I have developed a great procedure for gastroparesis. An antrum preserving longitudinal gastrectomy performed by itself or in conjunction with a fundoplication and hiatal hernia repair, if the patient suffers from a hiatal hernia and acid reflux, has resulted in complete symptom resolution. I have had success with 9 gastroparesis patients so far. I am carefully following these patients and hopefully I will be able to publish my experience in the near future.

#### Question of the week: GERD Treatment Options
Question of the week: GERD Treatment Options
I am 30 years old. I have had reflux for almost five years now. It used to be present mostly at night, so I used Zantac 150 mg every night for about 4 and a half years. Last year, I felt the feeling of dysphagia and I added Omeprazole 20 mg to my nightly dose. I don’t drink coffee, eat chocolates sparingly, I’m a vegetarian so don’t eat any meat, try to avoid overly spicy food, I use more than 2 pillows at night. I tried eliminating PPI and Zantac respectively from my routine, but the reflux and dysphagia returns. What do you think are my options regarding this issue?
Dear Patient,
Gastroesophageal reflux disease, GERD, is a chronic and progressive disease. GERD related symptoms tend to increase in intensity and frequency over time. GERD is the result of a weak anti-reflux barrier between the esophagus and the stomach. The first approach to GERD is to examine the anti-reflux barrier to confirm and stage the diagnosis. Your symptoms are progressing, and currently, they indicate stage 3 GERD. Your symptoms are no longer controlled with lifestyle changes. You avoid trigger foods like coffee, chocolate and spicy food, you elevate the head of your bed… You still, however, need Zantac and Omeprazole to take the edge off. Of note, these medications do not address the underlying GERD pathophysiology; Medications do not restore the anti-reflux barrier and therefore you will never be able to eliminate H2 receptor blockers and proton pump inhibitors unless you restore the anti-reflux barrier.
Currently, the only reliable approach to restoring the anti-reflux barrier is Nissen fundoplication with hiatal hernia surgery. The procedure is safe and effective. Prior to surgery, you complete a comprehensive GERD workup to confirm and stage your disease. This includes an upper endoscopy, ambulatory pH testing, esophageal manometry and UGI contrast study. Patients with stage 3 or 4 GERD are offered hiatal hernia repair and Nissen fundoplication to stop reflux. Patients with achalasia causing dysphagia and heartburn are offered laparoscopic Heller myotomy with Toupet fundoplication.

#### Question of the Week: Partial vs Full Fundoplication for GERD
John sent this question to Houston Heartburn this past week:
“I had a 190-200 partial fundoplication and small hiatal hernia repair on 12/11/17. I am still suffering with GERD related symptoms. How do I go about getting a revision into s 270 or 360 fundoplication?”
Dear John,
More than 95% of all fundoplications that I perform at Houston Heartburn and reflux Center are 360-degree fundoplication also known as Nissen fundoplication. A floppy and short 360-degree fundoplication is the gold standard approach to GERD treatment. When properly performed, a full wrap is associated with very high success and durability rate. Concomitantly, Nissen fundoplication is associated with a very low complication rate, including post-operative dysphagia, at less than 1%. Key to our success is proper diagnosis and patient selection, as well as meticulous surgical technique.
The partial fundoplication, a 270-degree posterior wrap also known as Toupet fundoplication is as effective as a Nissen fundoplication in controlling GERD symptoms. Toupet fundoplication is, however, believed to be less durable than a 360-degree fundoplication. I don’t think we have solid evidence for such an assumption and I personally believe that a Toupet fundoplication is as durable as a Nissen fundoplication. When I construct a Toupet fundoplication I place deep sutures into the esophageal wall to include esophageal mucosa. Esophagus mucosa is the toughest layer in the esophageal wall and if not incorporated in the suture the repair is considered weak. At Houston Heartburn and reflux Center, we use Toupet fundoplication when the gastric fundus is not large enough to construct a floppy 360-degree fundoplication. Other indications for Toupet fundoplication include GERD cases in the setting of very poor esophageal motility.
A 200-degree fundoplication also known as Dor fundoplication is rarely performed these days. This is an anterior fundoplication that some surgeons still use concomitant with a Heller myotomy for achalasia treatment. I prefer a Toupet fundoplication following Heller myotomy for several reasons. One the posterior partial wrap keeps the myotomy open. Second, gastric fundus is a posterior structure and is more amenable for a posterior rather than anterior plication.
If you had a Dor Fundoplication and you still have acid reflux, then revision to a Toupet or Nissen fundoplication can be performed by an experienced reflux specialist with good outcome. A good workup is needed prior to any revision surgery including upper endoscopy, ambulatory pH testing, esophageal manometry and gastric emptying study.
Healthy Regards,
Dr. Darido

#### Question of the Week: Revision Nissen Fundoplication - Options and Outcomes
Question of the week: I am a 67-year-old female. My GERD symptoms peaked in 2014 when I had a Nissen fundoplication in Cleveland Ohio. The procedure failed at the end of the first year or so and my symptoms have returned even greater than before the surgery. I have an appointment in Cleveland for testing, Upper GI scope, July 10th and then a consult with the surgeon on the same day. This surgeon says my only option is a Roux-en-Y procedure. Are there any other options. Thank you
Dear Joyce,
I am sorry your Nissen fundoplication has failed one year after surgery. This is quite unusual. The success and durability of Nissen fundoplication have been established by numerous published studies as well as our own data analysis at Houston Heartburn and Reflux center. Nissen fundoplication durability and effectiveness hinges on 3 crucial management guidelines:
1- Proper patient selection
2- Solid and comprehensive GERD workup
3- Flawless surgical technique.
If anyone one of these key factors is violated, Nissen fundoplication surgery is not likely to succeed. There are no shortcuts in acid reflux management. At Houston Heartburn and Reflux Center, we go far and beyond to make sure your Nissen fundoplication is nothing less than PERFECT. Only then you can expect high success rates and reliable outcomes.
The first step in evaluating your case, Joyce, is to obtain all previous records including operative report. Your file is then carefully reviewed and an extensive face to face consultation is conducted. We need to understand your symptoms, and what kind of pre-surgery testing you had undergone. We then order specific tests to your condition that may include upper endoscopy, ambulatory pH testing, and upper gastrointestinal contrast study. Revision Nissen fundoplication is offered if we demonstrate that one or more of the three GERD management guidelines have been violated. We typically find evidence of increased esophageal acid exposure in the setting of recurrent hiatal hernia and slipped Nissen fundoplication. A number of technical factors contribute to Hiatal hernia recurrence and gastric wrap break down or slippage. In the majority of cases, incomplete mobilization of distal esophagus and gastric fundus is found. Revision Nissen fundoplication surgery remedies these issues and results in very good outcomes. In these situations, there is no need to proceed with Roux-en-Y procedure unless the patient is morbidly obese (at least 100 pounds over ideal body weight). Obesity limits our ability to properly dissect and mobilize the esophagus, a key step in Nissen fundoplication surgery. Furthermore, weight loss is an integral part of acid reflux management. Consequently, a Roux-en-Y gastric bypass is indicated in obese patients with a failed Nissen fundoplication.
To summarize, Nissen fundoplication surgery has to be PERFECTLY executed to work. When properly performed, Nissen fundoplication is the most reliable treatment for acid reflux disease. Houston Heartburn and Reflux Center is dedicated to GERD management. Strict and clear GERD management guidelines along with compassionate patient care guaranty excellent Nissen fundoplication outcomes.

#### Question of the week: Severe Cough after Gastric Band Removal
Question of The Week: Gastric band removed. Have severe cough that has continued along with reflux, and shortness of breath. Who do I need to see about this? What type of doctor? Thank you.
Dear Leslie,
Lap Band weakens the anti-reflux barrier in so many different ways, especially when the band is over-filled resulting in excessive restriction. Lap Band over-restriction creates partial obstruction against normal esophageal contractions. This results in gastric pouch dilation, hiatal hernia formation and weak esophagus motility. All three conditions lead to severe acid reflux symptoms like heartburn, food regurgitation and cough. Cough results from gastric content reflux up to the throat level. Acid, bile and gastric enzymes irritate the vocal cords and laryngeal structures resulting in cough and hoarseness. If stomach content is drawn past the vocal cords and into the lungs, patients develop asthma related symptoms like wheezing, shortness of breath and dry chronic cough.
The best approach to your situation, Leslie, is to consult with an experienced acid reflux specialist. You need a comprehensive acid reflux workup that includes upper endoscopy, esophageal manometry and UGI contrast study. At Houston Heartburn and Reflux Center all three studies are done together under one roof and in less than one hour. Accurate information about your current anti-reflux barrier is crucial to tailor a treatment plan that best suits your particular condition.
Surgical options to reinforce the anti-reflux barrier include hiatal hernia repair with Nissen or Toupet fundoplication, sleeve gastrectomy or Roux-en-Y gastric bypass. Hiatal hernia repair restores the normal anatomy by reducing the stomach and lower esophageal sphincter into the abdominal cavity and away from the negative intra-thoracic pressure. Nissen fundoplication reliably restores the anti-reflux barrier and effectively eliminates GERD-related symptoms. Sleeve gastrectomy promotes gastric emptying and similar to gastric bypass, it diverts stomach acid away from the esophagus. Both gastric bypass and gastric sleeve surgery are effective weight loss procedures. Weight loss greatly contributes to acid reflux resolution. If you are overweight, a properly performed hiatal hernia surgery with concomitant sleeve gastrectomy or gastric bypass is indicated to control your acid reflux-related symptoms.

#### Quick Tips to Avoid Heartburn While Exercising
You don’t need to let heartburn stop you from what you love doing. The last thing you want is your heartburn to flare up while you work out. However, there are certain things you could do to prevent this from happening. Take a look at 6 easy ways you can prevent heartburn while you exercise.
Tip 1: a soothing snack before you work out can help, but it depends on what it is. Here you have to experiment on what really works for you. Clearly scoffing down a burger and fries isn’t the cleverest of ideas before you go for a run. A banana, yoghurt or a small bowl of whole – grain cereal can help stimulate you, and prevent heartburn.
Tip2: before you start a workout regime, take a look at your diet, but not only what you eat, but when. You may already be exercising and suffering from heartburn. Take a step back and look at your eating patterns. It is never a good idea to exercise on a full stomach or eat right before.
Tip 3: work out a plan of how long you can eat before you workout. You could find you can eat only an hour before and be fine while you exercise. The only way to know is to test it out each time. Start with 2/3 hours and whittle your way down to a shorter time period, if that works for you. However, remember tip 2, and watch what you eat before you exercise.
Tip 4: try adding baking soda to your water as a quick, temporary solution while you are working out. The baking soda can help wash away the acid in the stomach, however, can add more salt to your diet. Be sure to speak to your doctor if this would be a concern to you.
Tip 5: certain exercises may actually be causing your heartburn. It may be time to re think your workouts. Exercises which involve heavy impact on your stomach area may have to go, such as crunches and core work. Certain yoga positions such as downward dog may also cause heartburn, due to the position you are in. A good way is to test it out. If high impact workouts do trigger heartburn, try hiking instead, or even a cycle class. Both are great ways of getting some exercise, without worrying about heartburn.
Tip 6: you can also keep some antacids with you in case heartburn decides to ruin your run. An antacid with calcium is always the best choice, as the calcium helps to neutralize the acid.

If you are suffering from heartburn, not only when you exercise, but on a daily basis, contact Houston Heartburn today.

#### Recipes for Heartburn
It can be a tough time finding the right meals to eat to avoid heartburn. Keeping a journal of foods that trigger your heartburn is a good way to keep track; however, your options may be limited. From tomatoes, to citric foods, to coffee, there are many foods and drinks that trigger heartburn. To make it slightly easier, here are a few low-fat recipes from Health.com to allow you to avoid heartburn, yet still enjoy a healthy, tasty meal.
Muesli-Style Oatmeal
Ingredients
1 cup instant oatmeal
1 cup milk
2 tbsp. raisins (brought to a boil, drained)
½ banana, diced
½ golden apple, peeled, diced
Pinch of salt
2 tsp. sugar or honey
Directions

The evening before (or at least 2 hours before), mix the oatmeal, milk, raisins, salt, and sugar (or honey) together in a bowl.
Cover and place in the refrigerator.
Add fruit before serving.
If the mix is too thick, add milk.

 Black Bean and Cilantro Soup
Ingredients
8 oz. canned black beans
1 pint chicken stock
½ cup fresh cilantro
Salt to taste
1 tbsp. nonfat sour cream
Directions

Bring the chicken stock to a boil. Add the beans, cilantro, and salt.
Cook 30 minutes on low heat.
Blend with a hand blender to the desired consistency.
Season as needed.
Serve in a soup bowl and garnish with 1 tsp. nonfat sour cream and a sprig of cilantro.

Hummus
Ingredients
1 can (19 oz.) canned chickpeas (drained and washed twice)
1 cup chicken stock
2 tbsp. olive oil
¼ tsp. sesame oil
½ tsp. salt
Directions

Place the chickpeas in a food processor and add the chicken stock, olive oil, sesame oil, and salt.
Process until smooth.
Add chicken stock as needed.
Serve cold with toast points, oven-toasted corn chips, or small wedges of flatbread.

Carrot Salad
Ingredients
1 lb. carrots (peeled, trimmed, and grated)
¼ lb. mesclun greens
2 tbsp. raisins
2 tbsp. orange juice
1 tsp. dried oregano
2 tbsp. brown sugar
2 tsp. olive oil
¼ tsp. salt
Directions

In a bowl, mix the raisins, orange juice, oregano, brown sugar, olive oil, and salt. Let sit for about 5 minutes.
Pour the dressing over the carrots and mix thoroughly.
Season with additional salt as needed.
Serve over mesclun leaves.

Banana Ginger Energy Smoothie
Ingredients
½ cup ice
2 cups milk
2 bananas, ripe
1 cup yogurt
½ tsp. fresh ginger, peeled and grated fine
2 tbsp. brown sugar or honey (optional)
Directions

In a blender, add the ice, milk, yogurt, bananas, and ginger.
Blend until smooth.
Add sugar as needed.

These are quick and easy recipes to whip up at any time. The guideline to stick to in order to avoid heartburn is to eat lots of whole grains, vegetables and non-citrus fruits, and meals that are low in fat and acid.
If you suffer from ongoing heartburn, visit Dr. Darido to see what steps you can take to relieve your acid reflux.

#### Recurrent Heartburn after Nissen Fundoplication
Laparoscopic Nissen fundoplication is the most effective and reliable treatment for acid reflux disease. Nissen fundoplication durability is very high when workup and surgery are performed by expert reflux specialists. Therefore, most patients who present with recurrent or persistent heartburn after a properly performed Nissen fundoplication do not have recurrent reflux. Heartburn is a symptom; acid reflux is a disease. A symptom is a subjective complaint reported by patient; a disease is objectively confirmed by appropriate testing. You may feel heartburn in the absence of reflux. At Houston Heartburn and Reflux Center, we recommend repeat upper endoscopy with ambulatory pH testing to rule out recurrent reflux following laparoscopic Nissen fundoplication. I reviewed our patient data at Houston Heartburn and reflux Center over the past 3 years. 4 patients presented after Nissen fundoplication with recurrent heartburn. All 4 patients were found to have intact fundoplication, no recurrent hiatal hernia and negative pH bravo study for acid reflux on repeat upper endoscopy and ambulatory pH testing. Anxiety and stress seemed the precipitating factor in recurrent heartburn in 3 patients. One patient’s son attempted suicide. Following this unfortunate event, patient started feeling heartburn, sore throat, food regurgitation. Such symptoms are highly suggestive of recurrent GERD. The unexperienced physician may rush and wrongly start patient on proton pump inhibitors, PPIs. However, without proper testing, and in the absence of a confirmed diagnosis of recurrent GERD in the setting of a failed fundoplication, such approach is wrong. Interestingly, some patients may respond to PPI treatment for recurrent heartburn in the absence of recurrent reflux due to a placebo effect. Most of these patients will end up spending the rest of their lives taking a medication for the wrong indication. Long-term PPI use is associated with serious side effects including kidney and heart disease. Committing patients to PPI therapy without GERD diagnosis is best avoided.
The second cause for recurrent heartburn in the setting of absent reflux following Nissen fundoplication is heart disease. The fourth patient presented to Houston Heartburn and Reflux Center, one year after Nissen fundoplication with burning epigastric pain, bloating, maldigestion and the feeling of food regurgitation. He had shortness of breath at night and he was sleeping with the head of bed elevated. Work up showed a dilated heart on CXR and low ejection fraction on echocardiogram. He was diagnosed with congestive heart failure due to viral cardiomyopathy. Lasix rather than Protonix was the appropriate treatment. Heart disease and GERD have overlapping symptoms. Differentiating both diseases before or after laparoscopic Nissen fundoplication is crucial. We maintain a high index of suspicion for heart disease especially in high risk patients presenting for GERD evaluation. Risk factors for heart disease include smoking, hypertension, type 2 diabetes, obesity and hypercholesterolemia as well as a sedentary lifestyle.

#### Refluxstop™: A Novel Procedure for Acid Reflux
“A safety and effectiveness evaluation of Refluxstop™ in the treatment of acid reflux comparing large and small hiatal hernia groups: results from 99 patients in Switzerland with up to 4-years follow-up” is a recently published article in Hernia journal. Refluxstop™ is a novel surgical treatment for acid reflux disease. The procedure was developed in Europe, and it is currently not FDA approved for use in Houston, TX. It consists of hiatal hernia repair, partial fundoplication (around 100-degree wrap placed against the left of the esophagus), followed by gastric fundus invagination using a small silicon cube. The silicon cube weighs 9 grams and measures less than one by one inch in dimensions. The silicon cube is imbedded in the top part of the stomach fundus (the stomach dome), just lateral to the partial fundoplication. For the device to work, it must be positioned above the level of the lower esophageal sphincter. In other words, the fundus itself must be invaginated. If the device is placed lower than fundus level, the invagination will involve the gastric body, and the procedure will not control acid reflux.
The purpose of implanting Refluxstop™ according to the manufacturer is to stabilize the partial fundoplication. I am not sure how exactly a silicon cube stabilizes a partial fundoplication. I rather think that Refluxstop™ completes the partial 100-degree fundoplication, by further invaginating the remaining fundus wall, to look more like a Nissen fundoplication (at least from a physiologic point of view).
From this perspective, Refluxstop™ may be as effective as Nissen fundoplication in controlling acid reflux. (a prospective study is currently underway to compare Refluxstop™ to Nissen fundoplication). However, assuming Refluxstop™ is as reliable and durable as a Nissen fundoplication for treatment of GERD, then what is the advantage of Refluxstop™? After all, placing a foreign body near the gastroesophageal junction is always associated with risk of erosion. (Not to mention the increase cost of surgery). Refluxstop™ does not encircle the lower esophageal sphincter, therefore, the risk of postoperative dysphagia (difficulty swallowing) is low. However, unlike LINX ™ surgery, a properly performed Nissen fundoplication by expert acid reflux specialist has a negligible rate of postoperative dysphagia (difficulty swallowing). At Houston heartburn and reflux Center, our Nissen fundoplication dysphagia rate is zero. Hence, I see no advantage in performing a partial fundoplication, then using a foreign body to plicate whatever is left of the gastric fundus to achieve the same therapeutic effect of a Nissen fundoplication.
The second theoretical purpose of placing a silicon ball is to anchor the newly restored anti-reflux barrier below the diaphragm (breathing muscle). The authors of the above-mentioned article expand on this theoretical assumption by comparing small to large hiatal hernia repairs. Large hiatal hernia repair is associated with a higher recurrence rate compared to small hiatal hernia. At one year after surgery, the study showed equally significant improvement in GERD health related quality of life questionnaires in both small and large hiatal hernia repairs with Refluxstop™ implantation. The authors conclude that Refluxstop™ device creates a “mechanical stop” that prevents upward movement of the lower esophageal sphincter into the chest. In other words, as the positive abdominal pressure drives the gastroesophageal junction into the negative chest pressure through the hiatus, the silicon cube will come against the underside of the left side of the hiatus to prevent the lower esophageal sphincter from migrating into the chest through the hiatus.
This assumption, however, holds true, only if hiatal repair remains intact. For if the hiatal repair falls apart, the invaginated fundus and Refluxstop™ device along with the lower esophageal sphincter will slip back into chest. Since, Refluxstop™ does not alter hiatal hernia repair integrity and strength, the claim that Refluxstop™ decreases hiatal hernia recurrence remains to be confirmed

#### Revision Acid Reflux Surgery
Nissen fundoplication and hiatal hernia repair procedure, when properly performed, is the most reliable, effective and safest treatment for acid reflux disease. The advent of laparoscopy has allowed the reflux surgeon great visualization of the gastro-esophageal anatomy. Consequently, the distal esophagus became more accessible to full mobilization. Esophageal mobilization is a key step in reflux surgery commonly missed by the general surgeon. Chronic GERD results in slow and progressive retraction of the esophagus into the chest. The purpose of hiatal hernia surgery is to reverse this process to re-establish normal anatomy prior to performing the fundoplication. Incomplete esophageal dissection and mobilization is the most common cause of anti-reflux surgery failure resulting in wrap migration into the chest or slipped fundoplication. Incomplete gastric fundus mobilization results in dysphagia, and wrap failure. It is the second most common cause of anti-reflux surgery failure.
Failed Nissen fundoplication and hiatal hernia repair surgeries require surgical revision. Laparoscopic revision surgery is the first line treatment since it allows greater visualization than open trans-abdominal surgery. laparoscopic revision is also associated with lower morbidity. However, conversion to an open approach is sometimes necessary due to severe scar tissue formation, inflammation and loss of normal tissue planes. The success rate of revision anti-reflux surgery is lower than primary repair. It decreases with each revision. Indeed, we prefer to offer gastric bypass surgery after the second revision as it offers better acid reflux control than a traditional Nissen fundoplication.
Patients presenting for recurrent acid reflux or dysphagia following Nissen fundoplication undergo complete GERD workup including upper endoscopy, 24-hour pH impedance, manometry, UGI and a gastric emptying study. Patients with gastroparesis, intact wrap and no hiatal hernia are offered a fundoplication preserving longitudinal gastrectomy along the greater curvature. I have had great success with such approach and I am currently extending the application to morbidly obese patients. Patients who underwent Nissen fundoplication surgery years ago for GERD and are suffering now from excess weight can safely undergo gastric sleeve surgery without the need to take down the fundoplication. A wrapped fundus is equivalent to a resected fundus from a weight loss perspective. The key is to resect most of the redundant posterior gastric fundus. I preserve 80% of the antrum when performing gastric sleeve surgery to promote gastric emptying and avoid mutilating the stomach.
In summary, anti-reflux surgery is safe and effective when properly performed. Avoiding short cuts and paying attention to small details are crucial to avoid revision surgery.

#### Revision Hiatal Hernia Surgery
Hiatal hernia surgery requires complete phrenoesophageal membrane dissection and proper esophageal mobilization. The phrenoesophageal membrane and hernia sac must be dissected and completely resected to allow for circumferential esophageal mobilization. The esophagus must be dissected free of mediastinal adhesions until obtaining at least 3 cm of tension free intra-abdominal esophagus. The hiatus is then carefully closed with interrupted pledgeted sutures. An absorbable mesh is sometimes used to cover the repair for added reinforcement especially when the hiatal muscle is weak.
Studies have shown decreased early but not late recurrence rate with mesh placement. The key to preventing hiatal hernia recurrence and increasing its durability is first early intervention. The earlier the repair is performed in a patient life the better the outcome. Hiatal hernias increase in size with time due to chronic GERD. Reflux of acid and bile into the esophagus results in esophageal contraction and shortening. This causes the stomach to further herniate into the chest which in turn worsens GERD. This vicious cycle perpetuates the problem of GERD leading to a progressive disease that worsens with time. Esophageal shortening hinders adequate esophageal mobilization. Inadequate esophageal mobilization increases hiatal hernia recurrence rate. This is the most important factor in hiatal hernia repair. If the esophagus is brought under tension into the abdominal cavity the hiatal hernia will recur.
Most hiatal hernia revisions that we perform at Houston Heartburn and Reflux Center are associated with a poorly mobilized esophagus. Very rarely do I encounter a short esophagus following adequate mobilization. In such cases I prefer to perform a Roux-en-Y gastric bypass rather than a Collis gastroplasty. I am not a fan of the Collis gastroplasty. The idea of wrapping the gastric fundus around a tubular stomach makes no physiologic sense to me. Gastric bypass offers great protection against GERD and in revision cases I always add the possibility of gastric bypass to the surgical consent.
Reference:
Surg Endosc. 2017 Jan 11
Equal patient satisfaction, quality of life and objective recurrence rate after laparoscopic hiatal hernia repair with and without mesh.
Koetje JH, Oor JE, Roks DJ, Van Westreenen HL, Hazebroek EJ, Nieuwenhuijs VB.

#### Robotic Hiatal Hernia Repair and Nissen Fundoplication
Laparoscopic hiatal hernia repair is the most common surgical approach to repairing hiatal hernias during Nissen fundoplication. The laparoscopic approach is both safe and reliable. Small incisions result in short hospital stay and fast post-operative recovery with very little pain and discomfort. More than 1000 successful laparoscopic hiatal hernia repair and Nissen fundoplication have been performed at Houston Heartburn and reflux Center with very high patient satisfaction.
Robotic hiatal hernia repair is a relatively new approach to acid reflux disease. The surgeon uses a robot to perform the procedure through tiny incisions. This approach has increased in frequency over the past few years. However, multiple studies have shown no clinical benefit in outcomes of robotic hiatal hernia repair compared to laparoscopic hiatal hernia repair. Rather, robotic hiatal hernia repair has been associated with increased surgery cost and hospital length of stay.
From a technical point of view, the robotic approach offers improved flexibility in instrument control. Tactile feedback is however limited. The ability to feel tension on tissues during mediastinal dissection improves safety. Most importantly, appreciating tension on gastric fundus tissue during fundoplication construction is crucial to avoid a tight and twisted wrap. I perform a floppy Nissen fundoplication without a calibration tube in place. I use my intuition, clinical sense, and experience to construct the most optimal wrap that best suits the patient. There is an artistic component to fundoplication surgery that may be compromised by the robotic approach. Surgery after all is an art and this is particularly true in the case of hiatal hernia repair and Nissen fundoplication surgery.

#### Robotic Hiatal Hernia Repair for Severe Heartburn
Question of the week from Reginald in Houston: I had surgery for hiatal hernia in 2014. I re-experienced reflux after 15 months and began taking Omeprazole. This seemed to work. In the last 4 months other symptoms have begun and my surgeon had me go for and Upper G.I.  The surgeon says I have a slipped Nissen fundoplication. Next week I’m scheduled for a robotic surgery conversion from Nissen to Toupet fundoplication, possible gastropexy and redo hiatal hernia repair with possible mesh placement. How successful and durable is revision surgery?  Will heartburn reoccur?
Dear Reginald,
There is no difference in laparoscopic Nissen fundoplication and hiatal hernia surgery outcome when performed with or without a robotic platform. What determine heartburn surgery outcome are surgeon skills and experience as well as surgical technique. Slipped Nissen fundoplication shortly after primary repair is almost always secondary to poor esophageal mobilization. Slipped Nissen fundoplication is non-existent in my practice at Houston Heartburn and Reflux Center. I have performed more than 1000 Nissen fundoplications and hiatal hernia repairs.
I general, the success rate of Nissen fundoplication and hiatal hernia repair decreases after each revision. However, redo hiatal hernia and Nissen fundoplication surgery is particularly effective in the setting of poor prior esophageal mobilization. I rarely need to convert Nissen to Toupet fundoplication during revision surgery. I always prefer a full wrap over partial wrap because of better durability. However, I offer Toupet fundoplication if part of gastric fundus is resected during revision surgery and there isn’t enough gastric fundus tissue to perform a floppy Nissen fundoplication. In most cases, a Nissen or 360-degree wrap can be redone without any difficulty or problem. I almost never use gastropexy unless patient has had history of gastric volvulus. Gastropexy does very little in terms of preventing hiatal hernia and heartburn recurrence.
If revision surgery is properly performed, hiatal hernia repair and Nissen fundoplication are durable, and heartburn is not likely to recur.

#### Schatzki’s Ring: A Variant Form of GERD
Narrowing of the distal esophagus may be secondary to Schatzki’s ring. Shatzki’s ring is a mucosal and sub-mucosal shelf located at the squamo-columnar junction and commonly associated with a hiatal hernia. The diagnosis is typically made using a contrast upper gastro-intestinal study. The ring may be easily missed on upper endoscopy. The majority of patients have no symptoms but some patients present with solid food dysphagia, regurgitation, and occasional food impaction. Schatzki’s ring can cause nighttime acid reflux related symptoms. This is due to gastric juice pooling in the esophagus secondary to esophageal obstruction. Pooling occurs at night because gravity drives gastric content into the esophagus especially in the presence of a hiatal hernia. In the setting of a ring, LINX™ device, or tight gastric band, gastric juices tend to linger in the esophagus longer than usual causing GERD related symptoms. The most common nighttime symptom associated with this condition is cough. Gastric juices including acid and possibly bile reach the laryngo-pharyngeal area. Vocal cord irritation and inflammation results in cough and hoarseness. Some patients report waking up from their sleep choking and gasping for air. Others experience food regurgitation and wake up vomiting. I have had experience with several patients with symptomatic Schatzki’s ring. All successfully treated with endoscopic balloon dilation. All patients with Schatzki’s ring that I have so far encountered in my practice, have had an associated sliding hiatal hernia that seems to reduce following dilation.
The pathophysiology of esophageal rings remains poorly understood. Some think that Schatzki’s rings are a congenital malformation while others link ring formation to acid reflux. The fact that most patients with esophageal rings present when they are more than 40 years old points more towards an acquired condition. I think with acid reflux the Z line or squamo-columnar junction tends to move in a cephalad direction. As the Z line retracts faster than the underlying longitudinal esophageal muscle have time to shorten, a mucosal/submucosal ridge develops above the diaphragm. As a result, gastric mucosa herniates above the crus level forming a sliding hiatal hernia that is commonly associated with Schatzki’s ring. Both Schatzki’s ring and a concomitant sliding hiatal hernia may have the same etiology: GERD. In other words, hiatal hernia development in this model is most likely secondary to GERD. GERD after all, is a chronic and progressive multifactorial disease. The accumulation of various insults to the gastro-esophageal junction transforms physiological reflux into GERD, and culminates into the development of a Hiatal hernia. A hiatal hernia further exacerbates GERD and perpetuates the problem of reflux in a vicious circle that is only broken by hiatal hernia repair and Nissen fundoplication surgery.
In the case of Schatzki’s ring, balloon dilation stretches the mucosal and sub-mucosal shelf leading to reduction of the herniated gastric mucosa to its original position below the diaphragmatic crura. Both dysphagia and night time GERD related symptoms resolve. Several studies recommend the use of lifetime proton pump inhibitors like Nexium, Prevacid and Dexilant to prevent Schatzki’s ring recurrence. In my practice, I advise patients to use H2 receptors blockers instead of PPIs to avoid PPI related long-term side effects. In my opinion, ring recurrence can be easily re-dilated and is safer and cheaper than lifelong proton pump inhibitor therapy. The role of Nissen fundoplication and hiatal hernia surgery has not been evaluated in preventing Schatzki’s ring recurrences. However, if GERD were the underlying cause for Schatzki’s rings then Nissen surgery would be the most reliable and durable treatment.

#### Severe Acid Reflux Disease After Lap Band Removal
The case of the month is a 50-year-old female who had her adjustable gastric band removal a year ago for heartburn, food regurgitation and nighttime cough. The patient like so many other adjustable gastric band victims was over-restricted for so many years in hopeless attempts to promote weight loss. Pure mechanical restriction does not lead to weight loss but instead it causes esophageal dysmotility that leads to GERD. Long-term Lap Band over-restriction leads to irreversible esophageal damage. Esophageal function failure is characterized by heartburn, food regurgitation, difficulty swallowing food, recurrent vomiting and nighttime symptoms including cough. Patients may develop an aspiration pneumonia that requires hospitalization and intravenous antibiotics to treat.
The key to management of acid reflux in the setting of adjustable gastric banding is EARLY intervention and band decompression. An UGI series is recommended to evaluate the band position, gastric pouch above the band and esophageal diameter and peristalsis. Patients with tertiary contractions and esophageal dilation are unlikely to loose weight from band adjustment in the future. Band removal is recommended to these patients to prevent further esophageal damage and to prepare them for a metabolic procedure like gastric bypass surgery if they wish to loose weight. Gastric sleeve surgery is not recommended in the setting of esophageal dysmotility. Contrary to Roux en Y gastric bypass surgery, a gastric sleeve is a high-pressure system and it may exacerbate GERD related symptoms if esophageal motility is affected. I recommend staging the revision process. First, the band is removed and after 6 months an UGI and esophageal manometry are performed. If both manometry and UGI are normal then a gastric sleeve may be performed otherwise a gastric bypass is offered.
Back to our patient, her work up showed a dilated flaccid esophagus with minimal peristalsis. Contrast freely refluxed on UGI from the stomach into the esophagus when placed in the head down position. Esophageal manometry showed a weak lower esophageal sphincter, 50 % failed peristalsis, low distal contractile integral and distal wave amplitude. Any surgical intervention should achieve two aims: Alleviate dysphagia and stop reflux. Roux en Y gastric bypass surgery can do both. Gastric bypass has traditionally been used for GERD. The Roux en Y configuration is, in addition, a low-pressure system that promoted esophageal emptying. A study published in 2007 in the Annals of Thoracic Surgery showed that gastric bypass surgery is superior to esophageal resection and Nissen fundoplication for treatment of GERD in Scleroderma patients. It is associated with lower morbidity and mortality than esophageal resection. It causes less dysphagia than a Nissen and offers excellent GERD control.
I plan to perform a gastric bypass on my patient for treatment of both GERD and esophageal dysmotility related symptoms. Her symptoms will resolve and I hope with time she may recover some of her esophageal function.

#### Severe Acid Reflux Disease and Gastroparesis
Sandy from Houston sent us this question: “I have a hiatal hernia and have been taking Omeprazole 40mg each morning and 300mg Ranitidine at night. I now have a very bad case of gastroparesis. I don’t see my GP until mid-August but was wondering if my hiatal hernia was fixed and I could get off of these medications, could it reverse the gastroparesis?”
Dear Sandy,
Thank you for your interesting question. Gastroparesis or delayed gastric emptying contributes to acid reflux symptoms especially in the setting of a hiatal hernia. Fortunately, Nissen fundoplication improves gastric emptying. In cases of mild gastroparesis, hiatal hernia repair with Nissen fundoplication are enough to cure both acid reflux and gastroparesis. In cases of acid reflux disease and concomitant severe gastroparesis additional procedures may be added to facilitate or promote gastric emptying. Pyloromyotomy or cutting open the pyloric sphincter is commonly advocated. A pyloromyotomy reduces resistance to gastric outflow and may help improve gastric emptying. Pyloromyotomy can be performed laparoscopically at the same time as the Nissen fundoplication or endoscopically following surgery.
At Houston Heartburn and Reflux Center, I perform a longitudinal gastrectomy along the greater curvature that preserves the gastric antrum and ends just below the fundoplication. I have developed this technique several years ago and found great results in improving gastric emptying in a number of situations. The advantage of this approach over a pyloromyotomy is the actual increase in gastric emptying pressure and not just mechanically drain the stomach.
I recommend you consult with a competent acid reflux specialist to help you control both acid reflux and gastroparesis. I am assuming your symptoms are severe since you are taking high dose PPIs and Ranitidine. Medications do not cure either problem, and some patients develop delayed gastric emptying secondary to heartburn medication intake.
Hope this helps. Dr. Darido

#### Severe GERD after Gastric Bypass Surgery
Roux-en-Y Gastric Bypass procedure is considered the gold standard treatment for GERD in obese patients. The creation of a small gastric pouch diverts most of the acid produced by the stomach away from the distal esophagus. The Roux limb mechanism effectively prevents bile reflux into the esophagus and promotes esophago-gastric emptying by creating a negative pressure system. Studies in dogs have shown that the Roux limb must be at least 30 cm in length to prevent bile reflux. Measuring the small intestine intra-operatively is not an accurate process since the intestine is continuously contracting and relaxing. Furthermore, there are no studies in humans about the optimal Roux limb length that is associated with bile reflux prevention. Most bariatric surgeons have adopted a 75 cm Roux limb length for gastric bypasses performed for weight loss. The majority of obese patients are reflux free following gastric bypass surgery.
Once a year, a patient presents to my office with epigastric pain, heartburn and occasional bilious vomiting or nighttime bile liquid regurgitation years after gastric bypass surgery. The workup starts with upper endoscopy to evaluate the bypass anatomy, rule out gastritis, gastro-jejunostomy stricture, hiatal hernia and distal esophagitis. I try to approximate the length of the Roux limb especially when I am able to reach the jejuno-jejunostomy. I them perform an esophageal manometry and place a pH impedance catheter to check for reflux events.
The most common cause of GERD after Roux-en-Y gastric bypass surgery is a short Roux limb. The roux limb can be anatomically short requiring a lengthening procedure to fix the problem. It can also be functionally short in which case the treatment depends on the particular patient situation. In my practice, the most common cause of functionally short Roux limb is the presence of a hiatal hernia. When the gastric pouch herniates into the negative pressure system of the thoracic cavity above the diaphragm, reflux occurs. The negative chest pressure overcomes that of the alimentary limb favoring bile reflux into the gastric pouch and distal esophagus. All gastric bypass patients presenting to my office with GERD do not respond at all to proton pump inhibitor therapy. Most of these patients have evidence of Barrett’s esophagus on biopsies taken from the distal esophagus. Such findings are highly suggestive of bile reflux. The presence of gastric pouch mucosa inflammation or marginal ulcer as well bile pooling on upper endoscopy further indicate bile reflux. A cholescintigraphy may be performed in such cases but the yield of such a study is very poor. In my experience, a good hiatal hernia repair that restores the normal anatomy of 3 cm of tension free intra-abdominal esophagus results in GERD resolution. Obviously, if the Roux limb happens to be short intra-operatively, a lengthening procedure is added to the hiatal hernia repair.
In summary, GERD may occur following gastric bypass in the setting of a short Roux limb. Careful work-up and the proper treatment can safely and effectively resolve GERD.

#### Shocking Heartburn Triggers
If you are a heartburn sufferer, then you already know the common culprits causing heartburn. Spicy foods, caffeine, fried and fatty foods, as well as tomatoes, all top the list. However, we will be looking at some surprising triggers causing heartburn.
Smoking
If you are a smoker and suffer from heartburn, this addictive habit is making it worse for you. Smoking relaxes the valve between the stomach and esophagus, allowing an easier flow of acid into your throat. Smoking also reduces the amount of saliva made. Saliva usually flushes out the acid from the esophagus, as well as contains a natural acid fighter, bicarbonate.
Fish Oil Supplements
A great supplement helping to fight heart disease and numerous other problems. However, fish oil supplements can cause heartburn. In this case, it is the oil which is the culprit and not the fish. Fish is actually a great heartburn easing food, as it is low in fat with high protein content.
Pills
The next time you feel a pang of pain, don’t be so quick to reach for ibuprofen or naproxen (nonsteroidal anti-inflammatory drugs). These pills can cause heartburn, as well as other medication such as, antibiotics, calcium channel blockers and some sedatives are known to trigger heartburn.
Peppermint
Peppermint is a popular choice of remedy when it comes to easing stomach pain. This isn’t the case for heartburn sufferers, sadly. Menthol creates a numbing, soothing effect, loosening the valve which keeps stomach acid in the stomach. The influx of acid into the esophagus causes heartburn.
Genetics 
Inheriting physical traits from your parents, such as stomach function problems, may be responsible for your heartburn. Studies have shown 30% – 40% of your chances of heartburn depend on genetic factors. The rest is all on you! What you eat, exercise and whether you smoke or not (as mentioned above), are all lifestyle choices that can affect your chances of suffering from heartburn.

If you suffer from heartburn, daily or not, contact the Houston Heartburn and Reflux Center to see what is really causing your heartburn.

#### Side Effects of Heartburn Oral Medication
Waking up in the middle of the night with the burning sensation you know all too well can become tiresome. It’s easy to quickly pop some antacid and get back to bed, and deal with it the next day. However this can become a very easy routine to slide into. Life takes over; you eat late, eat the wrong foods, and just deal with your heartburn later. However, constantly popping antacids does have its side effects, which may make you rethink your medication.

Famotidine is an ingredient in oral heartburn medication and can be the cause of some unwanted side effects.
Common side effects

Nausea
Diarrhea
Stomach cramps
Infrequent bowel movements

Rare side effects 

Chills
Bleeding gums
Joint or muscle pain
Pale skin
Fever
Cough
Blood in your urine or stools
Fatigue
Shortness of breath

The body adjusts to the type of medicine you take; therefore, you may not even experience any of these side effects. However, the following are less common / rare, and require medical attention.

Change in taste or a bad aftertaste in your mouth
Loss of sexual desire
Continuous ringing or buzzing in the ear
Swelling of breasts or soreness in both males and females
Insomnia
Mood swings
Fear
Hair loss
Muscle stiffness
Hives

Before taking medication for your heartburn and suffering from these potential side effects, try to make lifestyle changes, which in turn will make you healthier. Look at the foods you eat and drinks you drink, and ask yourself if there an alternative. In most cases there are. Switch caffeine for herbal tea or chips for baked slices of veggies. Contact Houston Heartburn to learn more about controlling or preventing your heartburn.

#### Slipped Nissen Fundoplication: Why Do We Still See It?
Nissen fundoplication surgery, when PROPERLY done, is the most reliable, safest, and most effective treatment for GERD. Any fundoplication surgery is performed with a concomitant hiatal hernia repair. The purpose of a hiatal hernia repair is not to simply close the hiatal opening, but rather restore normal anatomy. Normal anatomy consists of 3 to 4 cm of intra-abdominal esophagus without any tension. It is a common misconception among general surgeon to suture fixate the gastroesophageal junction (GEJ), and fundoplication below the diaphragm. Such mechanical fixation is futile in the face of a dynamic structure like the GEJ. Indeed, GEJ is constantly moving up and down with breathing, coughing, and swallowing. GEJ is a MOBILE anti-reflux barrier. Any surgical intervention that does not fully mobilize the GEJ is bound to fail in the early post-operative period or shortly thereafter.
Such failure presents in the form of slipped Nissen with or without recurrent hiatal hernia. Slipped Nissen fundoplication is the axial movement of the esophagus back into the chest due to poor mobilization. Such axial movement drags the GEJ and upper part of the stomach through the fundoplication, hence the term slipped fundoplication. The fundoplication itself can move up into the chest through the hiatal opening resulting in recurrent hiatal hernia. Patients typically present with recurrent acid reflux with or without esophageal obstruction causing dysphagia.
The diagnosis of slipped Nissen fundoplication is made using a combination of upper endoscopy and UGI contrast study. On EGD, gastric mucosa looks pouching above the wrap and on UGI an hour glass appearance may be detected. The treatment consists of surgical exploration, reduction of hiatal hernia, esophageal mobilization, redo fundoplication and hiatal hernia repair.

#### Slipped Nissen Wrap
Tom from Conroe, TX sent us this question: “Would a slipped Nissen wrap be visible on a CXR and would it cause extreme shortness breath that is not due to heart or lung conditions?”
Dear Tom,
Slipped Nissen wrap is a recurrent hiatal hernia; the stomach “slips” through the fundoplication or wrap and it herniates back into the chest. This finding can be easily identified on CXR. A slipped Nissen wrap is almost always a direct result of poor esophageal mobilization during initial surgery. Symptoms associated with slipped Nissen fundoplication range from mild chest discomfort to severe heartburn and inability to swallow food. Shortness of breath may result from a slipped Nissen fundoplication, aka recurrent hiatal hernia. Shortness of breath may be precipitated by a heavy meal or gas accumulation in stomach. Obviously, shortness of breath is worse with a larger herniated stomach size.
If slipped Nissen fundoplication is suspected on CXR, additional diagnostic studies like UGI and upper endoscopy are indicated to evaluate the size of the hernia, associated pathology, state of wrap… Surgical revision is indicated in the form of redo hiatal hernia with or without mesh placement and redo Nissen fundoplication. Surgical revision, in experienced hands, has a high success rate. It is important to properly address the root cause of hiatal hernia recurrence to prevent a second wrap slippage. The root cause of slipped Nissen fundoplication is poor esophageal mobilization as I initially mentioned.

#### Slipped Stomach Through LINX™ Device
Jennifer from Austin sent us this question:” I have severe pain and difficulty swallowing after hiatal hernia repair and LINX™ surgery.
I would like to ask if you can describe the surgery that I need to have to fix this problem and what kind of surgeon can take care of it. Please and thank you so much.”
Dear Jennifer,
Contrast study and upper endoscopy pictures show a recurrent hiatal hernia with part of the stomach slipping through LINX™ device into chest. The LINX™ device is just below the diaphragm or breathing muscle. If the hiatal hernia recurrence occurred several months after initial surgery, the magnetic ring now tightly adherent to esophagus due to scar tissue formation, would have mostly likely migrated into chest along with the esophagus. Proximal stomach will remain in this case below the level of the LINX™ device.
The primary cause for hiatal hernia recurrence is poor esophageal mobilization. During hiatal hernia repair, lower esophagus and herniated stomach are completely freed from all surrounding scar tissue caused by hiatal hernia. This step is crucial to drop the lower esophagus and stomach back into original position below the breathing muscle. Once this step is accomplished, hiatal hernia repair is completed by closing the hiatal opening with sutures. A bioabsorbable mesh is sometimes used to reinforce the repair.
Additional risk factors for recurrent hiatal hernia include shortened esophagus, advanced patient age and severe coughing and/or dry heaving immediately after surgery. Patients typically develop dysphagia (difficulty swallowing), chest pain and recurrent acid reflux symptoms like heartburn and food regurgitation. I recommend evaluation by a competent acid reflux specialist followed by surgical exploration, reduction of hiatus hernia and LINX™ device, proper esophagus mobilization, and closure of hiatal opening with mesh reinforcement.

#### Stop Heartburn: Why Test for Acid Reflux?
Do you have frequent indigestion or a burning sensation in the center of your chest?
Do you regularly get sour or bitter-tasting fluids in your throat or mouth?
Do you avoid lying flat or bending over to prevent acid from backing up into your throat?

If you answered, “yes” to any of these questions, you might have chronic (more than twice per week) heartburn or GERD (gastro-esophageal reflux disease). Frequent or chronic heartburn may be associated with more serious medical problems such as difficulty in swallowing (dysphagia), narrowing of the esophagus (strictures), and Barrett’s esophagus. Barrett’s esophagus is precursor for esophageal cancer.
Ambulatory acid pH testing is the most definitive study for the diagnosis and staging of GERD because it measures frequency and amount of acid reflux into esophagus. As a result, the most appropriate treatment can be selected for you.
How it Works?

After administering intravenous sedation, Dr. Darido will first perform an upper endoscopy. He then places a Bravo capsule into your esophagus using a delivery device. The test involves a miniature pH capsule, approximately the size of a gelcap, which is temporarily attached to the wall of your esophagus.

Throughout the test period, the Bravo pH capsule will measure the pH in the esophagus and wirelessly transmit this information to a small recorder worn on your belt or waistband just like a mobile phone.
Once the test has been completed, you will need to return the recorder to Hospital and test data will then be uploaded to a computer. Dr. Darido will analyze the information to diagnose and stage your acid reflux.

#### Stretta: A Naive Approach to a Complex Problem
I read with great interest the recent study: “No evidence for efficacy of radiofrequency ablation for treatment of gastroesophageal reflux disease: a systematic review and meta-analysis” by Lipka et al. from the University of South Florida. The study included only randomized trials that measured the LES pressure and esophageal acid exposure. Only 4 trials in the literature satisfied these criteria. The results are quite interesting. LES pressure and acid control improved in two studies only. Quality of life improvement and ability to discontinue proton pump inhibitors were similar in the Stretta and control arms. Overall, Stretta procedure when compared with sham therapy did not show any significant benefit.
These results are no surprise to any reflux specialist who deals with acid reflux disease or GERD on a daily basis. Acid reflux is the result of a defective barrier between the esophagus and the stomach. This barrier is a complex anatomic structure that consists of the lower esophageal sphincter muscle, the diaphragmatic crura, and the angle of Hiss. The phrenoesophageal membrane holds all 3 structures together in a delicate balance. All four components function in synchrony with esophageal peristalsis and gastric contractions. The end result is a one-way movement of food into the stomach except when vomiting. Many acid reflux experts agree that GERD is a multifactorial problem. Stretta, on the other hand, is an endoscopic procedure during which radiofrequency energy is delivered to the lower esophageal sphincter. The end result is increased fibrosis in the muscle presumably leading to “better” lower esophageal sphincter function. Even if we assume that the lower esophageal sphincter muscle tone increases following Stretta, this is unlikely to translate into acid reflux resolution. Creating a distal esophageal stricture or a hypertonic sphincter does not seem to address the different components of the gastroesophageal junction (GEJ) area. Nissen fundoplication surgery, on the other hand, tackles a number of factors that contribute to reflux. A floppy and short Nissen wrap, the most reliable treatment for GERD, increases gastric emptying, increases lower esophageal resting pressure, moves the acid pocket away from the GEJ and reposition the diaphragmatic crura around the intra-abdominal esophagus. This is far more involved than distal esophageal narrowing. More research is needed to understand the effect of Nissen fundoplication on acid reflux resolution. However, we no longer assume that acid reflux is solely the result of lower esophageal sphincter muscle hypotonia or transient relaxation. As a result, and in light of our increased knowledge about acid reflux pathophysiology, Stretta and other endoscopic procedures that are currently on the market and that are FDA approved don’t make lot of sense to me. It is our ethical obligation to inform our patients about the limitations of these so called “no scar” procedures, and I highly commend the authors of this study for their work and critical thinking.

#### Superior Mesenteric Artery Syndrome, Gastroparesis and GERD
Superior mesenteric artery, SMA, syndrome is a rare disorder. Patients with SMA syndrome, like those with gastroparesis and GERD, present with epigastric pain, bloating, nausea, vomiting and early satiety as well as heartburn and food regurgitation. Symptoms are typically exacerbated by food intake.
SMA syndrome is thought to be the result of compression of the third part of the duodenum between the superior mesenteric artery anteriorly and the vertebral column posteriorly. This results in partial or complete obstruction of the third part of the duodenum leading to pain and vomiting. The compression may be secondary to a narrowed aorto-mesenteric angle that typically occurs with significant weight loss and loss of the fat pad which normally separates the SMA from the aorta. Other patients have a genetic predisposition for SMA syndrome. A low take-off of the SMA or short ligament of Treitz may lead to narrowing of the duodenal lumen.
The diagnosis of SMA syndrome is difficult. CT scan finding of narrowed aortomesenteric angle by itself is not enough to confirm the diagnosis. A comprehensive workup including upper endoscopy, gastric emptying study and upper gastrointestinal contrast study must be interpreted in conjunction with patient symptom and presentation. Gastroparesis may be associated with duodeno-paresis and dilated proximal duodenum and may be mistaken for SMA syndrome. The treatment of gastroparesis with a longitudinal gastrectomy largely differs from that of SMA syndrome.
Medical management is the first line treatment for SMA syndrome patients and it entails tube feeding beyond the obstruction. Most patients respond to medical treatment and can maintain their weight after tube feeding is stopped. Patients who fail medical treatment or whose symptoms persist despite weight gain are offered a surgical solution. The most common procedure performed for SMA syndrome is laparoscopic side to side duodeno-jejunostomy. A loop of jejunum 30 cm distal to the ligament of Treitz is typically anastomosed to the second portion of the duodenum in a retrocolic fashion. The success rate reported in the literature in various case series varies from 75 to 100%. The surgery is minimally invasive, safe and associated with low complication rate.

#### Thanksgiving Dinner and GERD
Thanksgiving is my favorite holiday of the year. It is a great to be thankful for the blessings we enjoy every day of our life. Like other holidays, Thanksgiving is celebrated with family and friends around a lavish table of rich food, decadent desserts and copious amounts of gravy. Thanksgiving dinner is indeed the biggest meal of the year for most Americans. As such heartburn is on the Thanksgiving menu for at least 30% of all Houstonians.
Overeating stretches the valve located between the esophagus and stomach. This valve prevents acid reflux from the stomach into the esophagus. Consequently, for some of us, with a weak valve, overeating on Thanksgiving Day results in painful consequences. Heartburn, maldigestion, food regurgitation, and abdominal pain are some of the symptoms of a GERD attack. If you suffer from GERD, educating yourself about the disease, and making the right choices will allow you to take control of your problem and prevent painful attacks as well as disease progression. Choose baked instead of fried Turkey. Avoid spicy food items. Consume gravy, butter and alcohol in moderation. Cranberry sauce is tart and for many reflux sufferers it may ruin your meal. Finally, have some dessert like a piece of pumpkin or pecan pie but avoid the coffee. Add whipped cream or ice cream and remember to keep your meal size as small as you can.
If you suffer from GERD, Houston heartburn and Reflux Center recommends eating wisely and in moderation to get through this holiday season. Seek the help of our reflux specialists to stage your disease and get the best treatment solutions. Finally, avoid overeating while masking your symptoms with proton pump inhibitors and other antacid medications. Remember, pills do not cure your GERD problem. They simply mask your symptoms while the underlying acid reflux problem is progressing.

#### The Difference Between Acid Reflux, Heartburn, and GERD
The words heartburn, acid reflux, and GERD are so closely related that they almost seem to run together and mean the same things.  However, once heartburn or acid reflux becomes GERD, you have much more than just a “common” problem.  GERD might as well be the third level of severity when it comes to acid problems.
This means your heartburn symptoms have included more than just a little acid reflux.  It’s also possibly causing weight loss, wheezing and vomiting.  Another common characteristic of GERD is that swallowing has become difficult.  This is all usually taking place after heartburn pills have quit working and your symptoms have become more frequent.

The key here is making sure your heartburn or acid reflux problem is properly treated.  It may seem like an extreme case, but GERD might actually be more common than you think.  According to WebMD, if there are 100 people who experience regular heartburn over a set of years…10 of them would develop GERD.  One out of 10 of those people would develop esophageal cancer.
The reasons for the condition to reach such extremes isn’t hard to understand.  The consistent bombardment of acid on your throat or esophagus eventually takes its toll.  Specifically, it can weaken and erode the esophagus and sometimes lead to the formation of ulcers along the lining.  This can throw your entire digestive process into chaos, leading to larger health problems.
Again, the key is to recognize just how serious the problem can get and not let consistent symptoms go untreated.  If you think your heartburn or acid reflux problems might need some medical analysis, call us at Houston Heartburn at 832-945-8717 or contact us here.

#### The Effect of Gastric Sleeve Surgery on Cough
I read with great interest the newly published study in SOARD (Surgery for Obesity and Related Disorders) by Frenkel et al. The authors attempt to elucidate the effect of sleeve gastrectomy on extra-esophageal reflux disease also known as silent reflux. Silent reflux or laryngo-pharyngeal reflux, LPR, is a poorly understood disorder. It is thought that gastric enzymes like pepsinogen are deposited in small quantities over the sensitive mucosal surface of the laryngo-pharyngeal area leading to a myriad of symptoms like chronic cough, globus, dry mouth, hoarseness and sometimes chronic inflammatory airway disease.
The role of gastric sleeve surgery in de novo GERD development or exacerbation of existing GERD is controversial. In my opinion, the controversy emanates from the great variability in performing a gastric sleeve among bariatric surgeons. Bariatric doctors in Houston for instance, use a bougie size ranging from 32 to 42. Some weight loss doctors in Houston perform a concomitant hiatal hernia repair on almost every gastric sleeve case while others only repair those hernias bigger than 4 cm in axial displacement. A group of sleeve doctors in Houston perform a radical antrectomy while others completely preserve the antrum. Furthermore, the technique of gastric sleeve surgery has greatly evolved over the past few years further adding to variability in outcomes and making it almost impossible to conduct long-term clinical data analysis. In the face of such variability, it is very difficult to establish any solid association or causation between gastric sleeve surgery and GERD.
Frenkel and colleagues used an animal model to study the effect of sleeve surgery on silent reflux. While the obese rat model is not perfect for neither sleeve surgery nor silent reflux evaluation, the article demonstrates a beneficial effect of gastric sleeve surgery on lung pathology examinations. The authors show that gastric sleeve surgery is not associated with pulmonary epithelium damage.
Silent reflux or LPR is very difficult to study. It is poorly understood and commonly missed in many patients. At Houston Heartburn and Reflux Surgery center and Houston Weight Loss Surgery Center, we have treated several patients with LPR and morbid obesity by performing hiatal hernia repair and gastric sleeve surgery. Our outcomes were great. Cough as well as other GERD related symptoms have completely resolved following proper hiatal hernia repair and gastric sleeve surgery. A twisted or narrowed sleeve will most definitively exacerbate reflux disease. I use a 40 French bougie and pay special attention to the incisura angularis. I do not resect the antrum completely but I make sure the gastric fundus is completely mobilized and resected. Equally important is the complete hiatal hernia reduction and posterior crural repair with interrupted pledgeted sutures. I believe that such an approach allows for effective and durable GERD resolution for most patients suffering with both obesity and GERD.

#### The History of Nissen Fundoplication: What Can We Learn?
The 360-degree fundoplication or Nissen fundoplication, the most reliable treatment for GERD, is named after Dr. Rudolf Nissen. A German surgeon with great power of observation and astute judgment. In 1936, he treated an advanced case of acid reflux disease in a 28-year-old man with a distal esophageal ulcer penetrating into the pericardium. Nissen resected the gastroesophageal junction and anastomosed the remaining esophagus to the gastric fundus. He then wrapped the newly formed anastomosis with surrounding gastric fundus wall in an effort to prevent leakage. The patient did well and Nissen noted in follow-up that the patient’s acid reflux symptoms have resolved.
During that period, the main treatment of acid reflux disease consisted of hiatal hernia repair. Hiatal hernia repair by itself has been associated with high failure rate. Still, Nissen did not attempt to duplicate his initial success with fundoplication till 1955. In that year, he operated on a 49-year-old acid reflux patient without hiatal hernia. He took down the phrenoesophageal membrane and mobilized the distal esophagus. He then passed the gastric fundus through the retro-esophageal space without dividing the short gastric blood vessels. He placed around 5 interrupted sutures around the distal 6 cm of the esophagus to create a long fundoplication in nowadays standards. He made sure to perform the fundoplication around a large boogie to prevent narrowing. Patient did well and Dr. Nissen reproduced his results in subsequent cases.
Over the past 60 years, the Nissen fundoplication has been perfected to become the safest, most effective treatment of GERD. The fundoplication is now laparoscopically performed through tiny incisions allowing for fast recovery and minimal pain. The short gastric blood vessels are divided and the gastric fundus is completely mobilized. A loose fundoplication is created and its length is limited to less than 2.5 cm to prevent postoperative dysphagia. To this day, the exact mechanism of action of a 360 or 270-degree fundoplication remains unknown. The mechanical reinforcement of the lower esophageal sphincter is a naïve assumption of the fundoplication mechanism of action. GERD is a multifactorial disease and in my opinion GERD is an esophago-gastric and sometimes an esophago-gastro-duodenal motility disorder like gastroparesis. Gastric fundus “relocation” whether in the form of a Toupet, Nissen or Dor fundoplication alters certain motility patterns resulting in the elimination of retrograde gastric content flow into the esophagus. To develop newer anti-reflux therapies, our thinking must evolve beyond the futile attempts of lower esophageal sphincter reinforcement using bands and magnets. A more rational target for GERD treatment appears to be the gastric fundus as it has been for the past 60 years. Gastric motility patterns in health and disease remain not fully elucidated. Research in this field is needed to improve our understanding of GERD and other diseases like gastroparesis, obesity and diabetes.

#### The Link Between Heartburn and Genetics
Generally, when people talk about something that “runs in the family,” it’s usually something good.  Why wouldn’t you talk about the genes that pass down athleticism, smarts, and good health?  It’s the bad stuff that people don’t always discuss, especially those chronic conditions that so many members of a family have to deal with.
Have you ever wondered if heartburn can run in the family?
A reasonable way to answer this question might be to say that it’s possible for heartburn to be genetic.  However, it might be better to say that certain hereditary conditions can be genetic, and those pose a consistent threat for heartburn.
For example, if certain digestive problems are prominent in your family, then that alone can help trigger frequent heartburn.
Some studies have shown a consistent presence of heartburn/acid reflux triggers in a family, yet it still might depend on the level of severity.  That means if you’ve got more than one person in your family who has been diagnosed with Barrett’s esophagus, you are more likely to be at risk than families with milder cases of heartburn.
Regardless of whether or not your heartburn is hereditary, you can still relieve and prevent it the same way that everyone does.  You should still watch what you eat and when you eat.  You should also avoid other habits or health problems that can trigger heartburn/acid reflux like obesity and smoking.
Our staff at Houston Heartburn are knowledgeable, experienced professionals who can help you understand why you have heartburn and how to treat it.  If we can help you in any way, contact us today to schedule a visit.

#### The Nissen Fundoplication: A Reliable Cure For Acid Reflux
“Long-term outcomes of patients receiving a magnetic sphincter augmentation device for gastroesophageal reflux” is a recent article published in the current issue of Clinical gastroenterology and Hepatology. The study is prospective in nature and includes 100 patients with GERD for at least 6 months and who are partially responsive to proton pump inhibitors with evidence of prolonged esophageal acid exposure on ambulatory pH testing. 14 centers in the United States and Netherlands participated in this study. Patients with a hiatal hernia with more than 3 cm in axial displacement or with Barrett’s esophagus were excluded. 85 patients were followed up 5 years after LINX™ procedure with 82 patients completing endoscopy at the 5-year mark.
70 out of 84 patients had greater than 50% reduction in GERD health related quality of life score. 15% of patients continued using proton pump inhibitors at 5 years. 7 patients had the LINX™ device removed, 8 patients had ongoing esophagitis, 5 patients developed de novo esophagitis, and 5 patients reported dysphagia. Overall, the complication rate and presence of esophagitis at 5 years is around 25% for LINX™ procedure. Assuming of course that those patients who were lost to follow up did well.
Esophageal pH monitoring or manometric studies were not performed at 5 years according to FDA protocol. I am not sure why would the protocol eliminate such important information for a new device like LINX™. Manometric data is extremely important to analyze at 5 years. We need to make sure there is no damage to esophageal motility in the setting of a constricting device like LINX™ continuously applied to the distal esophagus. pH analysis is equally important as it offers important insight on the long-term efficacy of a LINX™ device in controlling acid reflux. These important studies were surprisingly eliminated from the FDA protocol.
The authors continue with their analysis and conclude that LINX™ was not associated with any erosion because the magnets are specifically made in such a way not to cause erosion. They expand with each swallow rather than being a non-movable object constricting the esophagus and hence the risk of erosion is low. Most importantly for the authors of this study is the ability of LINX™ patients to vomit and belch contrary to Nissen fundoplication cases. LINX™ is described as a natural sphincter that mimics the Lower esophageal sphincter whereas the Nissen wrap completely eliminates acid reflux making it an “un-natural” solution for GERD. Suffice to say, these outrageous assumptions cannot be part of a peer-reviewed article published in a decent scientific journal.
I may be partial towards Nissen surgery because I am used to it and I have witnessed its efficacy hundreds of times. However, the obvious question regarding LINX™ procedure remains the same: what is the advantage of LINX™ over Nissen? What is the advantage of placing a foreign body with limited efficacy in controlling reflux compare to a Nissen wrap? What is the advantage of a device that is associated with higher complication rate and higher failure rate than a safe, reliable and time-tested procedure? Finally, shouldn’t we be concerned about the long-term effect of a constricting band on causing irreversible esophageal dysmotility? After all esophageal dysmotility itself is an important cause of GERD. Gastric secretion pooling in the esophagus causes cough, sore throat, aspiration, and hoarseness. Is LINX™ a solution for GERD or a cause of GERD? The answer could have been easily obtained by including esophageal motility studies in the FDA protocol for LINX™ patients 5 years after procedure implantation. We could have at least tested those patients whose symptoms did not improve or those patients who developed de novo esophagitis. The data was conveniently or inadvertently ignored. The question is why and who is responsible for these decisions? So far, the evidence in support of LINX™ is not that encouraging and the FDA ought to do a better job designing theses studies rather than rushing in approving these devices.

#### The Short Esophagus in the Era of PPIs
One of the hallmarks of gastroesophageal reflux disease, GERD, is a retracted esophagus into the mediastinum in response to repeated cycles of acid reflux. Indeed, chronic acid reflux contributes to the development and worsening of a hiatal hernia. Acid reflux causes the squamo-columnar junction to retract into the mediastinum. As the mucosa retracts, the underlying submucosa and muscularis layers follow. Slowly the intra-abdominal esophagus starts moving into the chest followed by the cardia, gastric fundus and remaining stomach. This in turn leads to worsening reflux as the lower esophageal sphincter function and gastro-esophageal junction anatomy and physiology are compromised. This dynamic situation creates a vicious circle where reflux leads to hiatal hernia formation and hiatal hernia development leads to worsening reflux.
The advent of proton pump inhibitors has resulted in lower incidence of mucosal damage. Consequently, the squamo-columnar junction is less likely to retract into the chest and away from reflux. As a result, one would expect a lower incidence of short esophagus formation. Indeed, there is a striking paucity of reference to the short esophagus in the current acid reflux literature. The short esophagus is defined as the inability of the gastroesophageal junction to lie with no tension at least 3 cm below the hiatal opening. In my own personal experience of hundreds of laparoscopic hiatal hernia repair and Nissen fundoplication surgeries performed over the past few years, I have not yet encountered a short esophagus. Prior to the advent of proton pump inhibitors and laparoscopic surgery in the early 1990s, the short esophagus was an important and commonly encountered problem in anti-reflux surgery. Its incidence, however, seems to be decreasing probably secondary to widespread use of proton pump inhibitors. In 2003, Dr. DeMeester reported an incidence of 3 to 14% in his review of several published studies. In 2012, Dr. Swanstrom reported a 6.4% incidence of short esophagus among anti-reflux surgery patients during an observation period between 2001 and 2009. It would be interesting to evaluate the incidence of short esophagus in a more recent series of GERD patients. I predict that the incidence will be no more than 1%.
In conclusion, esophageal retraction into the chest is a common finding in anti-reflux surgery and is both the result and cause of acid reflux disease. Proper distal esophagus dissection and release during hiatal hernia surgery is the most important component of anti-reflux surgery. I think that proton pump inhibitor treatment of GERD has reduced the incidence of esophageal shortening over the past 20 years. More studies are needed to confirm this observation. By decreasing gastric acid, PPIs halt the migration of esophageal mucosa into the chest. PPIs, however, do not seem to reduce the incidence of esophageal cancer, the fastest growing malignancy in north America. Is it possible that by preventing the migration of the squamo-columnar junction up into the chest and the shortening of the esophagus, while not reducing bile and other digestive enzyme reflux into the esophagus, PPIs are enhancing the transformation of squamous lining to Barrett’s esophagus and esophageal adenocarcinoma?

#### The Three Ws of Heartburn
When it comes to the causes and treatments of heartburn, you could break it all down into three factors. One or all of these points will be worth considering if you start feeling the usual symptoms of heartburn or acid reflux.  If you don’t know these already, get familiar with them now and keep them in mind.
What you eat
You should be all too familiar with the foods that can trigger heartburn.  Chocolate, spicy meals or high fat foods are some of the primary contributors.  If you’ve experienced heartburn more than a couple of times in your life, you should also be very familiar with which foods are most likely to trigger a bad case in you.  Sometimes certain foods affect people differently.  Large meals can cause you problems, including giving you such a bad case of heartburn, antacids may not fix the problem.
When you eat
Eating late at night before you go to bed or perhaps even laying down to rest can cause a problem.  If you’re lying flat, that makes it easier for acids to get to your throat and esophagus.  If you think you’re going to need it, it’s best to take antacid medication after breakfast.  Remember, you have to have food in your stomach before the medication can have the chance to work properly.
What you do
Antacids and PPIs can help relieve your heartburn symptoms, but you can’t become overly reliant on them.  Getting addicted to any kind of medication can be counterproductive.  More importantly, it’s important to understand that frequent acid reflux problems can mean you need more than medicine to fix the problem.  Frequent acid reflux or heartburn could be a sign of a larger health issue, and that means the next step is to see a doctor.
We know how to help people with ongoing or severe heartburn/acid reflux.  If we can help you, give us a call at 832-945-8717.

#### The Tight Nissen Fundoplication
Sabrina from Houston sent us this question: “I have had acid after the Lap Nissen. It was wrapped too tight I couldn’t get anything down. Any pills that I would take would get stuck. It had to be balloon twice. Now I guess the surgery is over. It wasn’t successful any way. It’s been a year and two months with constant Acid Reflux. I have to do something”.
Dear Sabrina,
Nissen fundoplication is the most effective and reliable treatment for acid reflux disease when properly performed. I have yet to see a Nissen fundoplication patient, at Houston Heartburn and Reflux Center, with persistent acid reflux after surgery. Many factors contribute to success of Nissen fundoplication. Surgeon expertise, knowledge, and understanding of acid reflux pathophysiology and Nissen fundoplication mechanism of action cannot be overemphasized. A tight wrap is indication of poorly performed fundoplication and possibly lack of understanding of how a Nissen fundoplication works. A number of general surgeons believe that Nissen fundoplication creates a high-pressure zone around the bottom of the esophagus to stop acid reflux. They tend to narrow the hiatal opening as much as they can and fail sometimes to create a floppy wrap. The end result is high post-operative dysphagia rate requiring multiple dilation and sometimes revision surgery.
At Houston Heartburn and Reflux Center, our dysphagia rate post Nissen fundoplication is almost zero. We maintain a very high patient satisfaction rate because of our meticulous approach to acid reflux disease. We do one thing and one thing only, but we do it right. We specialize in Nissen fundoplication surgery to achieve a very high success rate and very low complication rate.
I recommend you seek the advice of an experienced acid reflux specialist to evaluate your current problem. Revision Nissen fundoplication may be offered and is still associated with good outcome. There is no need for you to live with constant acid reflux.

#### The Unbeatable 360 Degree Fundoplication Also Known As Nissen Procedure
I read with great interest the recent article by Maret-Ouda et al: “Mortality from laparoscopic anti-reflux surgery in a nationwide cohort of the working-age population” that was recently published in the British Journal of Surgery. The purpose of this population-based analysis was to demonstrate the safety of minimally invasive Nissen fundoplication in Swedish hospitals. The authors analyzed patients that underwent the procedure from 1997 till 2013. 8947 patients were included with a median age of 48 years. Amazingly one death was directly related to surgery. In other words the mortality rate was 0.01% or 1 occurrence in 10000 patients. Along with a 0.4% 90-day reoperation rate, this study proves that Nissen surgery is a very safe procedure.
Furthermore, Nissen procedure is currently the only reliable and effective treatment for GERD. LINX™, Muse, TIF and Stretta procedures lack the reliability, durability and success rate provided by Nissen surgery. Antacid medications do not address the underlying problem. They simply mask the symptoms and put the patient at risk for a number of side effects including osteoporosis, magnesium deficiency, chronic renal failure, clostridium difficile colitis, altered gut microbiota, pneumonia, and dementia. Gastric acid secretion is part of normal physiology and blocking it for many years with powerful proton pump inhibitors, PPIs, does not seem as benign as we have assumed few years ago.
The problem with GERD treatment today is that many GERD patients with advanced disease are poorly managed with medications. PPI prescription has become a knee jerk reaction for any patient complaining of heartburn. The pharmaceutical industry has successfully reduced a complex medical problem that affects millions of people to a simple acid nuisance that can be eliminated with one OTC pill a day. This blind approach to GERD is unacceptable especially when effective and safe solutions are available. Patients with food regurgitation, chronic cough, hoarseness, nighttime symptoms and Barrett’s esophagus have advanced disease. Nissen procedure when performed by experienced surgeons who specialize in gastro-esophageal disorders is a reliable, effective, and safe solution. Many patients are unaware of more effective alternatives for treatment of acid reflux than medications. Houston Heartburn and Reflux Center is leading the charge in educating and helping acid reflux patients in Houston and all over Texas. If you or someone you know suffer from acid reflux do not hesitate to give us a call. We can help you.

#### Three Health Risks of a High Acidic Diet
There really aren’t many situations where the word “acid” has a positive connotation.  After all, most people are well aware of the negative effects of acid reflux and heartburn.  However, when it comes to a diet that is regularly high in acidic foods, there are actually several negative risks to the body.  Here are three examples:
Kidney Failure
A new study in the Journal of the American Society of Nephrology says that high levels of dietary acid were major factors in the progression of kidney failure.  Specifically they found that patients with high levels of acid in their diet were three times more likely to develop it.
Dr. Tanushree Banerjee (UC San Francisco) recommends people play close attention to the amount of high acidic foods in the diet in order to reduce the risks. “The high costs and suboptimal quality of life that dialysis treatments bring may be avoided by adopting a more healthy diet that is rich in fruits and vegetables,” she said.
Metabolic Syndrome
The Mayo Clinic describes Metabolic Syndrome as a cluster of conditions that includes high blood pressure, excess fat around the waistline, and abnormal levels of cholesterol.  These conditions are key contributors to two other major health problems – heart disease and type 2 diabetes.
New research conducted by the Washington University School of Medicine in St. Louis finds that uric acid can disrupt the normal flow of your metabolism.
Senior author, Kelle H. Moley, MD, also noted specific attention to the presence of fructose in a diet.  “There’s a growing feeling that uric acid is a cause, not a consequence, of metabolic syndrome. And now we know fructose directly makes uric acid in the liver,” she said.
Tooth Enamel Erosion
High acidic diets can also develop problems in your mouth.  High concentrations of carbonated drinks, wine, fruit juices and sweets can affect the health of your teeth structure.  In fact, acid reflux itself can cause significant damage.
Outside of controlling the amount of high acid food and drinks in your diet, there are several other things you can do to prevent tooth erosion.  One key strategy is simply not letting acidic foods linger in your mouth for long periods of time.
If you have additional concerns about the impacts of acidic foods or how they might be impacting your daily life, contact us at Houston Heartburn or 832-324-3200.

#### TIF: Is It Really A Fundoplication Surgery?
TIF, Transoral Incisionless Fundoplication, is a novel acid reflux procedure performed through the mouth using an endoscope. It is marketed as a fundoplication but is it really a fundoplication? Is the gastric fundus (upper part of the stomach) mobilized during TIF procedure to be partially or completely wrapped around the esophagus?
During a Nissen Fundoplication, the Gold standard surgery for acid reflux, the gastric fundus is EXTENSIVELY and COMPLETELY mobilized. This dissection is a key component for Nissen surgery to be successful and durable. Unfortunately, the gastric fundus is not mobilized at all during TIF. In fact, the fundus remains in its original position after TIF procedure and is not folded around the esophagus. What actually happens during TIF is gastric tissue plication or approximation in the immediate vicinity of the distal esophagus. Hence, by definition, TIF is not a fundoplication.
Whether TIF is an effective and durable solution for acid reflux disease, your guess is better than mine. Quality long-term studies on TIF patients are still lacking. A randomized study by Dr. J. Hunter comparing TIF to daily Omeprazole (PPI) showed a 36% failure rate in achieving adequate symptom control 6 months after TIF. This is a high failure rate. Moreover, intra-esophageal pH (the objective study to measure acid reflux) was improved but not normalized after TIF. Despite careful patient selection in this study (mild acid reflux, small hiatal hernia, and no GERD related complications) TIF failure rate was quite high. Indeed, TIF does not offer significant advantage over high-dose antacid medications.
Clearly, TIF falls short of the acid reflux control a Nissen fundoplication offers. Houston Heartburn & Reflux Center does not recommend TIF as it is not a fundoplication, cannot fix a hiatal hernia or a shortened esophagus, and is associated with a high failure rate.

#### Tips on How to Avoid Heartburn While You Hike
It’s National Take a Hike Day! A great opportunity to take on fall, and get out there and do some exercise! Hiking is a great way to be outdoors with your friends and family and get a good workout in.
If you are suffering from heartburn, plan ahead to make sure your hiking trip is a success. Follow these tips below to celebrate National Take a Hike Day to the fullest, without heartburn.
TIP 1: dress in loose and comfortable clothing, as tight clothes around your stomach can increase pressure and cause heartburn.
TIP 2: avoid eating large meals and carry small snacks with you to snack on throughout the day. Trail mixes, protein bars and even small tins of ready-to-eat tuna are all good options to snack on to prevent heartburn, and are easy and light to carry.
TIP 3: avoid caffeine and carbonated drinks on your hike, as these are well known heartburn triggers. Stick to water to prevent heartburn and dehydration.
TIP 4: carry some antacids with you, just in case you do get heartburn while on a hike. Take it slow, sip water and snack. Gentle exercise can help relieve heartburn symptoms, whereas more vigorous exercise can trigger it.

Planning ahead, keeping these four easy tips in mind will allow for a great hiking trip! Contact Houston Heartburn if you suffer from continuous heartburn, whether it’s from exercise or not. Dr. Darido can help put heartburn behind you!

#### Tis The Season for Heartburn in Houston
If you suffer from acid reflux disease, Christmas may be synonymous with heartburn for you. Large meals, rich food, alcoholic drinks and lots of chocolate exacerbate acid reflux related symptoms like heartburn and food regurgitation.
Dr. Darido, acid reflux specialist, at Houston heartburn and Reflux Center, recommends avoiding trigger foods as much as possible to limit heartburn. Acid reflux trigger foods are not the same for all patients. Most common trigger food items include fried chicken, tomato sauce, peppers and spices, lemon juice, chocolate and coffee. Smoking and alcohol are important triggers for acid reflux and particularly harmful bad for GERD patients. In the setting of acid reflux, smoking increases the risk of Barrett’s esophagus leading to esophageal cancer. Dr. Darido further recommends eating smaller meals more frequently. Chewing food slowly improves digestion and increase salivary secretion. Giving yourself 3 to 4 hours prior to lying down after a meal and raising the head of the bed helps prevent nighttime acid reflux symptoms.
Dr. Darido further warns against the indiscriminate use of proton pump inhibitors like Nexium, Prilosec and Dexilant. A number of acid reflux patients tend to load up on proton pump inhibitors prior to a holiday meal. Proton pump inhibitors do not stop acid reflux. These medications simply mask acid reflux symptoms giving you the illusion that gastric content is not refluxing back into the esophagus. In reality, reflux is occurring and damage to the esophagus is happening. In addition, Proton pump inhibitors are associated with a number of serious side effects. If you are dependent on proton pump inhibitors to control your symptoms, it is time to get evaluated by a competent acid reflux specialist.

#### Top 5 Foods That Ease Your Heartburn
Those who suffer from heartburn are usually familiar with foods that trigger heartburn, from caffeine to fried foods. However, with National Personal Chef’s Day falling on July 16th, it’s a good month to celebrate by experimenting with foods that can help calm your heartburn. Try some DIY recipes or even treat yourself by hiring a personal chef to cook up some yummy, heartburn-free meals!
Here are a few foods/ingredients that you can incorporate into your diet in an effort to prevent the horrible pain of acid reflux:
GINGER: is a natural anti-inflammatory. It has been used for centuries as a natural calming agent for stomach issues. Try chewing a piece of raw ginger or, for a less harsh taste, place ginger in hot water to make ginger tea and drink.
OATMEAL: high in fiber and low in fat makes oatmeal a perfect start to the day. Top it off with bananas, as they are known to fight stomach acid naturally.
BEANS: another great ingredient, full of fiber and protein. Beans are a great alternative to meat, as they prevent heartburn and are very filling.
APPLESAUCE: trying to avoid using oil and butter in foods can be difficult, but you’re setting yourself up for heartburn! Substituting butter and oils with applesauce will prevent this problem. Applesauce will reduce the amount of fat and increase fiber to your meal.
PASTA WITHOUT TOMATO SAUCE: we all crave a hearty plate of pasta from time to time. However, pasta drenched in classic tomato sauce will keep you up all night. Go for a thinner broth sauce instead and using whole-wheat pasta will increase your fiber intake, too!
Substituting your meals with these top 5 ingredients will allow you to have a peaceful meal with reduced chances of heartburn. If you have already tried these tips and still suffer from constant heartburn, make an appointment with Dr. Darido today!

#### Top Heartburn Myths
There are many “dos and don’t’s” when it comes to what to do when you experience a heartburn. Drink this, eat that, cut this out, increase that, and so on. Here are a few common heartburn myths to set the record straight.

Poor diets cause heartburn: this is more of a generalized assumption, as there are many trigger foods for heartburn, not only fatty, fried foods.
Drink milk to ease heartburn: milk can soothe your stomach by neutralizing excess acids. However, eventually milk will trigger more acid production, and you end up in a vicious cycle. Additionally, milk is difficult to digest, which can cause even more stomach acid.
Continue taking acid reflux medicines forever: medication may solve your problems in the short run; however, they can become addictive with severe potential side affects. It is always a good idea to consult your doctor to see what alternative therapies will help tackle your heartburn with less or no medication at all.
No more spicy food: this doesn’t mean you have to eat plain, boring food. Try spicy foods in moderation; however, stop if it triggers your heartburn every time. It is a good idea to create a diet plan, making sure you get a varied, healthy diet.
Too much acid causes heartburn: this is not the case. Heartburn is caused by the weakening of the esophagus sphincter. The sphincter’s function is to make sure there is no backflow of acid from the stomach into the throat. However, over time, as you experience more heartburn, the sphincter weakens. It is unable to handle the pressure, causing acid to leak into the throat, and then causing heartburn.
Make an appointment with Dr. Darido today to discuss your heartburn problems, and see how you can get relief today!

#### Top Summer Foods That Trigger Heartburn
Summer is fast approaching, which means it’s to time to indulge in all the yummy summer food about to come our way! From ice cream, to burgers to watermelons, the list of foods is endless for us to enjoy in the beautiful warm weather. However, did you know that some of your favorite summer foods can be the reason you’re up all night? Some foods you may not have even thought of can be the cause of your heartburn. Take a look at some popular, and surprising, summer foods that cause heartburn, alongside the alternative you can have instead.
Corn on the cob with butter: butter is known to be a heartburn trigger. Try sweetcorn boiled or grilled, without butter. Corn in the summer is usually naturally sweet and flavorful.
Ice Cream: the perfect summer food can be problematic for many. High in dairy and fat can cause heartburn for many people. Avoid chocolate and mint flavors, as both are known to trigger heartburn. Instead try a tasty sorbet, which is dairy free, fruity, and sweet!
French Fries: very greasy and high in fat. Try baked potatoes instead or making your own fries, baking them instead of frying.
Lemonade: made with acidic fruits, causes heartburn. Instead, sip on apple juice or cold water with a slice of lemon.
   
Lemon Meringue Pie: another citric based dessert, causing heartburn.
Ketchup and Mustard: ketchup is made from tomatoes, a known trigger; however, mustard is also made from another heartburn trigger, vinegar. Try something varied and different for your sandwiches. Try hummus, fresh herbs, or fresh slices of avocado.
Chili Dogs: the chili is spicy and tomato-based, two common heartburn triggers, while hot dogs can be high in fat. Instead, try a veggie, lean beef, or turkey dog and scratch the chili.
Beef Kabobs: beef can be high in fat and greasy. Try chicken, veggie, or fish kabobs instead for a healthier alternative.
   
Pineapple: an acidic fruit. Instead try papaya or mango, both of which can help in digestion.
Chocolate Mousse: a sweet treat for all! Chocolate and dairy products, such as mousse and puddings, can trigger heartburn. If dairy foods are one of your trigger foods, try a fruit-flavored gelatin to satisfy your sweet craving.
Funnel Cakes: high in fat and deep fried.
Root Beer Floats: root beer is carbonated, while ice cream can trigger heartburn due to its dairy and fat content.
   
Hamburgers: high in fat and very greasy. Try a lean chicken, veggie, or turkey burger instead.
Grilled Onions: great on hotdogs; however, onions are common triggers for digestive distress.
Grilled Peppers: spicy peppers, especially, can cause heartburn.
Hot Salsa: the two major culprits for triggering heartburn – spice and tomatoes. Tomatoes are acidic, which can cause heartburn. If you are more prone to spices causing heartburn, rather than tomatoes, try mild salsa. Even better, dip your chips in mashed avocado instead for a heartburn-free snack.
   
The above foods all contain common triggers of heartburn. Often, some people can eat some or all the foods without any problems. To identify which foods cause your heartburn, keeping a journal of what you eat and the effects it has on you, is a great way to begin.
If you are concerned about your heartburn and feel all these foods are already on your “no-go” list, make an appointment with Dr. Darido at Houston Heartburn to get the answers you need.
 

#### Top Tips to Calm Your Stress Levels
As a debatable topic, scientists are still looking for firm evidence that stress can cause heartburn.  However, they do believe that stress can cause your stomach to become more sensitive to smaller amounts of acid in the esophagus.
A 1993 study published in the American Journal of Gastroenterology revealed those who were stressed showed more painful symptoms to acid reflux. However, none of the patients showed an increase in acid reflux. Therefore, patients felt an increase in discomfort but it wasn’t found to be an increase in the amount of acid produced.

If you are someone who notices the symptoms of acid reflux when you are stressed, take note of some of these stress relieving tips!

Try some deep breathing exercises.
Exercise on a daily basis or try yoga.
Take up a hobby, or jump back into a hobby you may have sidelined.
Take frequent breaks at work.
Plan your day. Make a list of tasks you need to get done throughout the day. This will give a sense of organization, and help you feel like you are on top of things.
Avoid junk food, caffeine, alcohol. This may have helped in the past, but using a binge method will only create long-term problems and not a solution to your stress, such as weight problems.
Talk to your close friends and family to relieve your stress.
Make sure you get enough sleep, around 7-9 hours.
Try to find something that will make you laugh daily, whether it’s a daily joke online, or conversing with your loved ones or co-workers.

Handling stress can be difficult and cause numerous health conditions. Don’t let heartburn be one of them. Contact the Houston Heartburn & Reflux Center today to find the relief you need.

#### Toupet or Nissen Fundoplication for GERD Treatment?
Nissen fundoplication is currently the gold standard treatment for GERD. A floppy and short 360 degree wrap around the distal esophagus is the most durable and reliable solution to stop reflux of gastric content into the esophagus. The Toupet fundoplication or 270-degree wrap is equally effective in controlling GERD but tends to fall apart with time due to lack of strong serosal adhesions between the two edges of the wrapped gastric fundus. Traditionally, a Toupet fundoplication was advocated in cases of severe esophageal dysmotility in order to prevent post-operative dysphagia. While this recommendation falls under common sense observation, there is no evidence to support its veracity. Indeed, the short and floppy Nissen fundoplication should offer zero resistance to esophageal motility. Contrary to popular belief, acid reflux is not treated by creating an iatrogenic esophageal obstruction or constriction. Nissen fundoplication surgery mechanism of action is not well understood. Many factors are at play, and lower esophageal sphincter mechanical constriction or pressure augmentation is less likely to be a contributing factor to acid reflux control following Nissen fundoplication surgery. A proper fundoplication should neither prevent complete lower esophageal sphincter relaxation with swallowing nor increase resting sphincter pressure. Consequently, there is no role for a Toupet fundoplication in the setting of esophageal dysmotility. At Houston Heartburn and Reflux Center, a Toupet fundoplication is only performed in the rare case of a small gastric fundus. Less than 1% of anti-reflux cases performed at Houston Heartburn and Reflux Center require a partial fundoplication due to a tight or small gastric fundus despite full mobilization. I have no anatomic or physiologic explanation for factors that determine gastric fundus size. I have noticed that some patients have a very large fundus that can easily wrap around the distal esophagus and others have a very small fundus that can only allow for a partial wrap. Luckily, the majority of cases qualify for a floppy 360-degree wrap. In cases of Toupet fundoplication, I take full thickness bites on either side of the esophagus using permanent sutures to strongly anchor the gastric fundus around to esophagus. Suturing the gastric fundus to the esophageal mucosa (the strongest layer in the esophagus) is crucial to increase the longevity of a Toupet wrap. Gentle full thickness sutures placed and tied laparoscopically do not increase the risk of esophageal wall injury and leak.

#### Toupet vs Nissen Fundoplication: A New Study
“Clinical outcomes of a laparoscopic total vs 270-degree posterior fundoplication in chronic GERD” is a recent double blind randomized clinical trial published in JAMA (journal of American medical association). A total of 310 out of 407 available patients were followed for an average time of 16 years. 159 patients had a partial or Toupet fundoplication. The remaining patients had a Nissen fundoplication. Both groups were found to have equal control of reflux symptoms and similar improvements in quality-of-life scores. Of note, around 25% of patients in each group have resumed PPI intake. In addition, both groups had low dysphagia scores for both liquids and solids with no statistically significant difference. Interestingly, at two-year follow up, Nissen fundoplication group had a slightly higher dysphagia score to solids compared to partial fundoplication group (results published in a separate previous study). After 16 years, dysphagia score in the Toupet fundoplication group slightly increased to match that of the Nissen fundoplication group. Authors offer no explanation for this observation.
The authors are to be congratulated for a prospective long-term follow up analysis of two surgical techniques for treatment of acid reflux disease. However, dysphagia and GERD symptom scores are hard to interpret in the absence of objective data. The study would have been much more valuable if esophageal manometry and ambulatory pH testing were performed 16 years after surgery. 25% of patients in each group are back on PPIs 16 years after surgery. Does this mean than 25% of patients have a failed fundoplication? I doubt it. The only way to prove recurrent acid reflux after Nissen or Toupet fundoplication is to perform a comprehensive and thorough evaluation. Upper endoscopy is crucial to evaluate anatomy, rule out recurrent hiatal hernia, failed wrap… pH bravo study evaluate esophageal acid reflux over a period of 4 days. We have access to valuable testing modalities that can clearly demonstrate recurrent acid reflux and failed fundoplication surgery. I only wish the authors of this study can objectively re-evaluate those patients with recurrent symptoms in both groups and publish their data. Only then we can determine if Toupet fundoplication is as durable as a Nissen fundoplication.
Post-Nissen fundoplication dysphagia or difficulty swallowing is rare when surgery is performed by expert acid reflux specialists. Indeed, at Houston Heartburn and Reflux Center, our post-operative Nissen fundoplication dysphagia rate is zero. We only offer partial or Toupet fundoplication in cases of absent esophageal peristalsis on manometry. Rarely, gastric fundus is too small to perform a floppy Nissen fundoplication and a Toupet fundoplication is constructed instead.
Nissen fundoplication mechanism of action remains to be elucidated. Therefore, the optimal extent of wrapping to achieve the best acid reflux control remains unknown. However, there is clear evidence that shows both partial and Nissen fundoplications are equivalent in terms of acid reflux control. At Houston Heartburn and Reflux Center, Nissen fundoplication is our most performed procedure. Nissen fundoplication or wrap is constructed by suturing stomach to stomach. Full thickness bites are taken on both sides of the stomach to create a durable wrap. Toupet fundoplication, on the other hand, is constructed by suturing stomach to esophagus. This connection may be weaker than a stomach-to-stomach connection especially when distal esophagus wall is inflamed secondary to severe acid reflux. The result is a potentially weaker wrap that may fail over time.

#### Transoral Incisionless Fundoplication after Band Removal
A 53 year -old female patient presented to Houston Heartburn and Reflux Center with severe GERD related symptoms of several year duration. She had a Lap Band placed for morbid obesity around 10 years ago. Patient had been over-restricted in hopeless attempt to promote weight loss resulting in pseudo-achalasia, hiatal hernia development and GERD. Subsequently, her Lap Band was removed, and a concomitant sleeve gastrectomy was performed. Following surgery, patient did not lose weight and her GERD related symptoms got worse. She was evaluated by a gastroenterologist who elected to perform Transoral Incisionless Fundoplication, TIF, to manage her GERD. TIF was completed but patient acid reflux symptoms persisted.
I have discussed in several previous blogs the need to stage band removal and sleeve gastrectomy. I will not discuss this point in this current blog. I am going to concentrate on GERD management following Lap Band removal especially in light of esophageal dysmotility. Pseudo-achalasia secondary to Lap Band over-restriction is a serious problem with complicated pathophysiology. Blind application of novel anti-reflux modalities of dubious efficacy is better avoided. TIF has not been studied in patients with pseudo-achalasia and hiatal hernia formation secondary to over-restriction. In fact, TIF is barely effective for early stages of GERD in patients with normal esophageal motility. TIF neither restores normal anatomy like a hiatal hernia repair, nor it creates an anti-reflux barrier like a Nissen fundoplication. Indeed, TIF is a misnomer since it does not result in any form of a fundoplication; the gastric fundus remains in place following TIF.
Repeat upper endoscopy on our patient showed multiple loose T shaped fasteners in the cardia, large hiatal hernia and distal esophagitis. The angle of His was obliterated and whatever TIF is supposed to have achieved was no longer present. Endoscopy further demonstrated a large retained gastric fundus with preserved antrum and a good part of the distal gastric body. The last finding explains poor weight loss.
Redo sleeve gastrectomy with hiatal hernia repair is a great solution. This approach however has not been evaluated in the presence of pseudo-achalasia. I am concerned of incomplete reflux control with poor esophageal function. Furthermore, TIF spikes around the cardia prevent proper fundus resection with a linear stapler and increase the risk of leak. Hiatal hernia repair with gastric bypass is a great option. Insurance may not approve the bariatric portion especially if BMI is less than 35. A third option is hiatal hernia repair with Toupet fundoplication especially that a large portion of the gastric fundus was not resected. Patient chose the latter approach and underwent the procedure with no complications. Intra-operatively, moderate to severe adhesions around the GEJ were encountered secondary to TIF spikes. Post-operatively, patient reported complete GERD symptom resolution. She was free of proton pump inhibitor intake and recurrent food regurgitation.

#### Twisted Nissen Fundoplication
A poorly performed Nissen fundoplication will either fall apart or get displaced. The most common form of a displaced Nissen fundoplication is a slipped wrap. We have previously discussed wrap slippage (https://houstonheartburn.com/slipped-nissen-fundoplication-why-do-we-still-see-it). In short, a slipped Nissen fundoplication occurs because of poor surgical technique and incomplete esophageal mobilization during hiatal hernia repair. A less common form of displaced wrap is a twisted Nissen fundoplication. A twisted wrap is also the result of poor surgical technique, and incomplete mobilization of gastric fundus. Gastric fundus, (dome of stomach), is attached, laterally, to spleen via short gastric blood vessels, and posteriorly, to pancreas via posterior gastric blood vessels and scar tissue. A gastric fundus that is not fully mobilized to comfortably wrap around lower esophageal sphincter, with neither tension in the wrap nor torsion on the esophagus, results in two problems.
First, a poorly mobilized fundus tends to wrap below the esophageal sphincter on the stomach itself because there is not enough length to pull the fundus upward and wrap it around esophagus. This kind of wrap causes significant bloating, discomfort, and difficulty swallowing. Second, a poorly mobilized fundus that is “forced” into a Nissen fundoplication configuration is under lot of tension. A wrap under tension causes the gastric fundus to move back towards its original posterolateral position. In this process, the right lip of the fundoplication moves up and posterior while the left lip of the fundoplication moves down and anterior. The lower esophagus that is typically sutured to fundoplication is now twisted on its longitudinal axis resulting in chest pain, difficulty swallowing, and excessive salivation.
A twisted Nissen fundoplication is diagnosed by upper endoscopy. It requires surgical correction to alleviate debilitating symptoms like dysphagia and pain. A twisted Nissen fundoplication can be avoided using proper surgical technique. At Houston Heartburn and Reflux Center, our rate of slipped or twisted Nissen fundoplication is zero. Our success rate is 100%. If you struggle with acid reflux and you are looking for a safe, reliable, and effective solution for your GERD do not hesitate to give us a call.

#### Unsuspecting Acid Reflux Symptoms
As you feel the burning sensation start to rise, you may start to regret the soda you drank before bed, or the cheese pizza you had for dinner. However, food and drinks aside, did you know there are other symptoms to look out for that may come as a surprise?
Pain while you rest: as you lay down to relax, the chances are the acid will flow into your esophagus. Gravity helps the acid stay in your stomach while you are standing; therefore, it is always recommended to lay or sleep with your head raised.
Chest pain: a classic symptom of acid reflux, as acid is entering the esophagus and causing a burning sensation. This is usually mistaken for a heart attack.
Bitter taste: acid can make its way into the back of your throat, which will cause a horrible, bitter taste. In extreme cases, this can cause choking.
Post-meal pain: if you notice you always feel pain after a meal, especially a big meal, it usually means you have overeaten and your stomach cannot handle the excess food. This means there is only one place for it to go – up! Be sure to eat smaller portions, and do not lie down right after you have eaten.
Croaky voice: the acid flowing into your esophagus can actually irritate your vocal cords. You may think you are getting ill, but in reality it could be acid reflux. This is a clear sign if you notice it happening after you have eaten.
Cough: if stomach acid enters you lungs, you are likely to suffer from a chronic cough and wheezing.
Excess saliva: this could be a sign of acid reflux, as it’s the body’s way of washing out the acid from your esophagus.
Difficulty swallowing: as acid enters the esophagus again and again, it will become damaged. The continuous cycle of it being damaged and healing will eventually cause scarring. This will cause swelling in the lower esophagus, resulting in the narrowing of the esophagus, making it difficult to swallow.
  
 
Look out for these unsuspecting signs the next time you suffer from acid reflux. If the symptoms become too overwhelming, make an appointment with Dr. Darido today, and get back on track with a healthy, acid reflux free lifestyle!

#### Using a Food Journal to Fight Heartburn
One of the ways to control heartburn is to watch what you eat.  Sometimes, when that advice is given, it tends to sound too easy.  After all, with everything else going on in our lives, it isn’t always easy to monitor or even remember what we’ve eaten during the course of a day.  Not being able to track what you eat can lead to a certain combination of foods to trigger a bad case of heartburn.
So, what can you do?  One option is to keep a food journal.  This will help you keep track of not only what you eat each day, but also during the course of a week.  Here’s how you can make it work:
Be conscious of time
If you’re trying to identify the consistencies in which heartburn occurs, set an adequate timetable in which to monitor the frequency of symptoms.  When heartburn/acid reflux occurs, make note of when it happened and how long it stayed with you.
List the foods
Along with keeping an eye on time, keep track of what you eat during the course of the day.  Keep in mind, it doesn’t always have to be one food/drink, but also a combination of certain things that can trigger acid reflux.  You want to be able to identify what causes the problems.
Mention medications
If you frequently take medications for heartburn, make them a featured part of the journal.  Granted, you may not always need to, but it will be important to track the times you take anything.  You’ll especially want to make note of cases when medications didn’t help.  In cases like that, you should seek medical attention.
Add other details
Any details you can add to the journal can be helpful because acid reflux is not always triggered by food alone.  Some important side details include:

Lying down after eating
Eating on the run/too fast
The clothes you’re wearing (tight fitting)

These days, if someone wants to keep a journal, you have options.  Some may want to carry a physical book to write in.  However, you could also use a mobile device as well.
If we can help you develop an effective food journal or help analyze the results of one, contact us to schedule a visit.

#### Vagal Nerve Integrity Testing, Nissen Fundoplication and Gastroparesis
“Impact of vagus nerve integrity testing on surgical management in patients with previous operations with potential risk of vagal injury” is a new study published in surgical endoscopy. The authors advocate vagus nerve function testing prior to revision Nissen fundoplication surgery to better select the most suitable surgical option. The study is retrospective and includes 12 patients only. 8 patients had a positive vagal nerve injury test, of which 5 patients had an altered corrective surgery. Two patients had a pyloroplasty in addition to Nissen fundoplication, one had a pyloroplasty in addition to revision Nissen fundoplication and 3 patients had conversion of Nissen fundoplication to partial gastrectomy with Roux-en-Y construction. All patients had gastroparesis symptom resolution after revision surgery.
Vagal nerve injury following Nissen fundoplication is rare in experienced hands. At Houston Heartburn and Reflux Center, both posterior and anterior vagus nerves are clearly identified and preserved. Vagal nerve injury during Nissen fundoplication rarely leads to gastroparesis because the fundoplication itself increases gastric emptying. Furthermore, gastric emptying study and vagal nerve injury testing are associated with false negative as well false positive rates that may complicate the interpretation of results and subsequent patient management. There is also poor correlation between gastric emptying rate and patient symptoms. Should we investigate asymptomatic patients prior to revision Nissen fundoplication surgery, and should we address gastroparesis in asymptomatic patients who have abnormal gastric emptying studies? The authors of this study concluded that vagal nerve integrity testing prior to revision fundoplication surgery alters surgical decision making and improves outcome. Of note their treatment approach to gastroparesis relies on pyloroplasty or conversion to Roux-en-Y gastric bypass. Both approaches are not reliable in alleviating gastroparesis related symptoms and improving gastro-intestinal motility.
At Houston Heartburn and Reflux Center, I adopt a more selective approach when it comes to pre-operative testing for gastroparesis. Patients with bloating, nausea, postprandial fullness, and vomiting get a gastric emptying study. Patients with positive gastric emptying study typically improve after a properly performed Nissen fundoplication. Patients with severe gastroparesis or those who have solid food residue on upper endoscopy are offered revision Nissen fundoplication with antrum preserving longitudinal gastrectomy. I have had great success with this approach in terms of completely eliminating gastroparesis related symptoms and normalizing gastric emptying. I rarely perform a pyloroplasty in the setting of Nissen fundoplication to improve gastric emptying. I never offer Roux-en-Y gastric bypass surgery for treatment of gastroparesis. Gastric bypass with or without subtotal gastrectomy, in my opinion, is not a solution for gastroparesis. Patients with gastroparesis and acid reflux who are obese or cannot undergo a fundoplication procedure are offered an antrum preserving sleeve gastrectomy. Care must be taken not to narrow the incisura angularis and properly fix any associated hiatal hernia to prevent post sleeve gastrectomy acid reflux.
To conclude, vagal nerve integrity testing has limited role in a center of excellence for acid reflux management. I selectively use gastric emptying studies in my pre-operative work up for revision Nissen fundoplication surgery. I agree with the authors, however, that additional studies are needed to help define diagnostic and treatment guidelines for gastroparesis.

#### Valentine’s Day, Chocolate, and Heartburn
Valentine’s Day is synonymous with chocolate and flowers. Love may hurt sometimes, but chocolate may hurt you more. If you or your loved one suffers from acid reflux, heartburn may disrupt your Valentine’s day. Chocolate, rich in fat, sugar, and caffeine triggers heartburn in most acid reflux patients. The mechanism by which chocolate induces acid reflux and heartburn is not well known but it is believed that chocolate relaxes the lower esophageal sphincter muscle. A relaxed sphincter allows gastric content like acid to reflux into the food pipe and cause heartburn.
If you suffer from heartburn, Houston Heartburn and reflux Center recommends reducing or avoiding chocolate consumption, especially on Valentine’s day. The combination of chocolate with other heartburn trigger food items like champagne or coffee further exacerbates acid reflux. Houston Heartburn and reflux Center recommends flowers (lots of flowers) as an alternative to chocolate on Valentine’s day. Love can give you heartaches but if you suffer from acid reflux, chocolate consumption is most likely to give you heartburn.

#### Weight Lifting, Hiatal Hernia, and Acid Reflux
Case Presentation: Allen is a pleasant 60-year-old male with new onset heartburn, food regurgitation, bloating and excessive burping. He is otherwise healthy and maintains a healthy lifestyle. 6 months prior to presenting to Houston heartburn and Reflux Center, Allen started heavy weight lifting. He was using up to 400 pounds on leg presses and he has never weight earlier in his life. One month into his training regimen, he started experiencing heartburn during and after exercise. His acid reflux symptoms continued to progress, but he did not stop weight lifting. He started self-medicating with OTC heartburn pills like Prilosec and Nexium, but symptoms were hard to control especially at night.
Upon evaluation, Allen was found to have a Hill grade 3 hiatal hernia with distal esophagitis and increased esophageal acid exposure on ambulatory pH testing. Manometry showed good esophageal motility and decision was made to proceed with laparoscopic hiatal hernia repair and Nissen fundoplication for stage 3 GERD. During heartburn surgery, the hiatal hernia is dissected, and patient was found to have a 6 cm hiatus opening and loose mediastinal adhesions. Loose adhesions are suggestive of acute herniation. In the setting of this presentation, hiatal hernia development may be attributed to heavy weight lifting.
Hiatal hernia is associated with acid reflux disease. Furthermore, hiatal hernia contributes to acid reflux. Acid reflux, however, is the most common cause of hiatal hernia development and growth. Constant acid reflux into the esophagus not only damages the mucosal layer but also results in chronic inflammation in the muscularis layer that extends into the mediastinum. Esophageal circular and longitudinal muscles contract secondary to inflammation and retract into the chest like a spring. Mediastinal inflammation weakens the delicate fibers of the phreno-esophageal membrane surrounding the distal esophagus. Both, esophageal retraction into the chest and weakened phreno-esophageal membrane contribute to hiatal hernia formation and growth over time. The inflammatory process can also destroy the lower esophageal sphincter function and lead to low basal pressure on manometry. In certain cases, lower esophageal basal pressure is elevated with poor relaxation secondary to severe and dense adhesion formation around the sphincter due to severe acid reflux disease. During hiatal hernia surgery, mediastinal adhesions secondary to GERD related inflammation are dissected to release the retracted esophagus and restore normal anatomy. Normal anatomy consists of 3 to 4 cm of intra-abdominal esophagus.
Less common causes of hiatal hernia formation include genetic factors, smoking and processes that increase intra-abdominal pressure like chronic coughing and heavy lifting. There is little evidence in the literature to establish a causative relation between weight lifting and hiatal hernia formation. However, weight lifting when not done properly and in the absence of professional guidance can lead to serious joint, and muscle injury.  Older individuals, who may already have a small sliding hiatal hernia, are particularly prone to weight lifting related injuries and caution must be exercised to avoid hiatal hernia formation and acid reflux development.

#### What Gastroparesis Patients Go Through
Hello Dr. ELIAS DARIDO,
Since 2006 my daughter (at that time her weight was about 55 kg) had gastroparesis (vomiting, epigastric pain, weight loss) and GERD grade II. Since that time, she received medical treatments in the form of proton pump inhibitor, prokinetics, antacids but she noticed no significant improvement in her conditions. On April 2011, her condition was worse (45 kg), in the form of severe weight loss, excessive vomiting except for supplements. The CT enterography revealed SMAS with gastric outlet obstruction. On June 2011, she was subjected to laparotomy and a Duodeno-jejunostomy was done between the first part of the Duodenum and loop of jejunum. In her early post-operative period, she suffers from severe abdominal pain (peri-umbilical) post-prandial and still recurrent attacks of vomiting of all kind of foods. So. another CT abdomen with oral and IV contrast was done that revealed stenosis of the Duodeno-jejunostomy versus gastroparesis, gall bladder stones and mild ascites. The endoscopy revealed kink in the outlet of the efferent loop of the Duodeno-jejunostomy. So, another laparotomy was done to her on August 2011, by a midline incision, removal of the old scar, cholecystectomy, formal abdominal exploration of Duodeno-jejunostomy, entero-entrostomy between afferent and the efferent loop of the Duodeno-jejunostomy, a loop Gastro-jeunostomy with entero-enterostomy between the afferent and the efferent loops. All anastomosese were done using staplers (Blue reloads), 2 drains were inserted and she passed a smooth post-operative course with no complications. Partial improvement happened till December 2011, she re-complained of recurrent vomiting to low fatty meals, food containing proteins, meats and chicken, bread, all kind of oils and butter. Another gastric emptying study revealed delayed gastric emptying of solid meal (the same as previous one). An upper GI endoscopy was done on January 2012 that revealed chronic erosive gastritis, GRED grade II, Biliary reflux, Patent Duodeno-jejunostomy and gastro-jejunostomy. Biopsies revealed chronic gastritis with no H. pylori. no malignancy nor specific inflammations. Since that time, she is on medical treatment in the form of Proton pump inhibitor, prokinetics, Erthromycin, nutritional supplements and she followed medically and laboratory to correct any electrolytes disturbance or any hypo-albumineamia. On November 2014, she complained of bloody discharge from her mouth that discovered accidentally when she wakes up every day. Her lab profile was normal with no anemia. Her upper GI revealed chronic erosive gastritis, GRED grade II, Biliary reflux, Patent Duodeno-jejunostomy and gastro-jejunostomy. Biopsies revealed chronic gastritis with no H. pylori. no malignancy nor atypia. Since that time, she is on medical treatment in the form of Proton pump inhibitor, prokinetics, Erthromycin, nutritional supplements and she followed medically and laboratory to correct any electrolytes disturbance or any hypo-albumineamia. On June 2015, at Schon klinik, Nurnberg Furth, Germany, they reversed all the anastomosis except that at SMAS position and implanted Enterra II (40 Kg). After 2 adjustments, there was partial improvement by trying several times to eat low fat sea foods with cooked vegetables (in the beginning always she vomited but after walking about 30 min it could be pass), no carbohydrates except very small amount of dry bread, no oil or butter, no meat, no chicken etc. She always has severe pain at her upper part and/or lower part of her stomach, so she takes 3-4 times per day medication and sometimes injection to calm down the pain. Last month till now, she has again Biliary reflux (during sleeping and sometimes during her sitting down with us) and she lost weight (now her weight 36 kg). Her gastrographin meal (11 January 2017) showed delayed gastric emptying after 30 min. Her Upper GI report indicated GRED type II, Duodeno-jejunostomy, entero-enteric anastmosis, insertion of gastric pace maker, Biliary reflux, hugely dilated stomach and duodenum with competent pylorus, patent gastric outlet, chronic gastritis, no alceration, no masses.
Please Dr., after this long story of failed surgeries and continues pain till now, is your new procedure helpful for my daughter’s complicated case ????
Thank you very much for your attention and for the time you have dedicated to read this letter.
Gastroparesis is probably the most under-appreciated and most misunderstood disorders in medicine. It is a functional rather an anatomic problem. It is a motility disorder as opposed to a mechanical obstruction. Consequently, gastroparesis does not respond to a drainage procedure. A pyloroplasty or gastro-jejunostomy are not suitable solutions. Gastric resection and gastric bypass don’t work either because they do address the underlying problem which is decreased intestinal motility.
The gastric pacemaker makes perfect sense from a theoretical point view. The problem with gastric pacing is that we don’t understand at what frequency and amplitude pacing should be conducted. Furthermore, we don’t understand the underlying myoelectric pathophysiology of gastroparesis to effectively address it with pacing. Randomized, prospective controlled trials have shown no benefits of electric gastric pacing for treatment of gastroparesis.
In the face of such uncertainty and poor outcomes with currently available treatments for gastroparesis out of the box thinking and new studies are needed to come up with effective solutions for gastroparesis. Few years ago, several studies were published showing increased gastric emptying following sleeve gastrectomy. I took this concept and I have applied on several gastroparesis patients. I performed a longitudinal gastrectomy that preserved the gastric antrum and some of the gastric fundus. Patients did very well and experienced complete symptom resolution. I believe that this approach is worth studying and may be the most effective treatment for most gastroparesis patients.
Reference:
Surg Obes Relat Dis. 2012 Nov-Dec;8(6):811-3.
Laparoscopic longitudinal gastrectomy and duodenojejunostomy for treatment of diabetic gastroparesis.
Darido E, Farrell TM.

#### What Happens after LINX™ Surgery?
Harry from Houston sent us this question: “After over a year following LINX™ surgery I’m still having problems with food getting stuck.
It seems to happen mostly when I sit down to eat lunch or dinner and with certain foods.
It can be painful but I’m wondering if I’m eating too fast. I have no heartburn, so it seems to be working but at times my food gets stuck. What can I do? “
Dear Harry,
Dysphagia or difficulty swallowing is a common problem after LINX™ device placement for treatment of heartburn and acid reflux. LINX™ device, a bracelet of magnetic beads, creates a barrier against esophageal emptying of food into stomach. Flow across LINX™ device depends on food bolus pressure and esophageal wall compliance. The higher the pressure and the lower the compliance the greater is the flow. Food bolus pressure is generated by esophageal contractions. If you have weak esophageal contractions, LINX™ device placement is contraindicated. Esophageal contractions are measured prior to anti-reflux surgery using manometry. Esophageal wall compliance is not typically measured prior to surgery. Most patients with acid reflux have decreased wall compliance favoring backflow of acid into esophagus. LINX™ device placement causes increased scar tissue formation around distal esophagus. Scarring decreases esophageal wall compliance and sometimes may decrease esophagus lumen. Decreased esophageal wall compliance is a two-edge sword. It decreases acid reflux and heartburn, but it hinders swallowing. Esophageal lumen narrowing responds to balloon dilation. Esophageal wall compliance, on the other hand, may not be possible to alter without removing the LINX™ device.
Properly performed Nissen fundoplication is currently the most reliable treatment for acid reflux. Dysphagia post Nissen fundoplication surgery at Houston Heartburn and Reflux Center is very rare. A short and floppy Nissen fundoplication, unlike LINX™ device, creates very little resistance against esophageal food emptying into the stomach.

#### What Happens if You Ignore GERD Symptoms?
It is easy to pop an antacid and call it a day (or night). The last thing you want is another heartburn ruining whatever you may be doing. However, it is vital not to constantly ignore those GERD symptoms, as they may cause further health problems.

Esophagitis
This condition is known as the swelling and irritation of the esophagus. This occurs with frequent acid flowing from the stomach into the throat. The esophagus can become even more vulnerable to more harmful erosion and scarring over time. If esophagitis continues for along period of time, the scar tissue can narrow the esophagus. This is known as Esophageal Stricture. This condition makes it hard and painful to swallow. Due to the narrowing, large piece of food can get stuck, and chances of choking are increased. You may even end up loosing unnecessary weight, due to avoiding food and drinks.
Breathing difficulties
Even if you don’t suffer from asthma or lung problems, GERD can cause shortness of breath. If stomach acid is inhaled once vomited, it can make asthma worse.
Tooth decay
Acid making its way up from the stomach, into the throat and into the mouth can create a sour taste. If this happens often the acid can wear away the enamel of the tooth, causing tooth decay. The problem here is that, those who suffer from acid induced tooth erosion are unaware, until it reaches the advanced stages. In a University of Alabama study, 40% of GERD patients had substantial tooth decay, as well as 70% of those whose reflux reached the upper esophagus, compared to only 10% of those with no reflux.
Esophageal ulcers
Constant acid in the esophagus can wear away the lining, causing ulcers. If you spit up blood, or see it in your stool, you may be suffering from this. It is vital to see you doctor straight away.
Barrett’s esophagus
Ongoing, and more importantly, untreated GERD, can cause precancerous changes in cells known as Barrett’s esophagus. This condition, unfortunately, doesn’t cause any symptoms. An endoscopy is carried out to see whether or not you have this condition. A small number of people diagnosed with Barrett’s esophagus develop esophagus cancer, which is very deadly.
Esophageal Cancer
Those who suffer a serious case of GERD can develop cancer. 2010 saw 16,640 new cases of esophageal cancer in the US. Smoking, alcohol, and poor diet are all major risk factors. If you have been suffering from GERD for many years, or are over 50 and suffered for years on end, and notice you are loosing weight, it is crucial you are tested for esophageal cancer right away. Weight loss, along with trouble swallowing is a sign of this problem.
Don’t let GERD continue to take over your life, and possibly create more harm to your health than needed. Dr. Darido and his staff at Houston Heartburn can help you avoid this dangerous path. Make an appointment today!

#### What is a Hiatal Hernia?
Hiatus means gap in Latin. The hiatus is the gap or opening in the diaphragm (breathing muscle) through which the food pipe (esophagus) passes from the chest into the abdomen. The hiatus is normally wide enough to allow food going through the esophagus to pass into the stomach. If the hiatus gets too wide, a hiatal hernia occurs. With a wide opening, the upper part of the stomach tends to move up into the chest. When this happens, the barrier between esophagus and stomach is weakened. A weak barrier results in acid reflux as well as food regurgitation, pain, and vomiting.

Risk factors for developing a hiatal hernia include:

Heavy lifting
Chronic cough
Heredity
Obesity
Straining
Smoking
Age (60% of individuals aged 50 and over have a hiatal hernia)

If you have a symptomatic hiatal hernia, you may be a candidate for surgical repair. The surgery is done through tiny incisions and recovery is fast with very little pain. Hiatal hernia repair restores the integrity of the lower esophageal sphincter, stopping acid reflux. The success rate of hiatal hernia repair is highly dependent on the surgeon skill and experience in this field. Dr. Darido has extensive experience in Foregut minimally invasive surgery. Foregut is the specific area of the body that includes the lower esophagus, hiatal hernia, and stomach. Houston Heartburn and Reflux Center offers the best hiatal hernia repair program in the greater Houston area.

#### What to Take When Heartburn Strikes
Most of us love a big holiday dinner or a fun night out on the town. That is, unless you’re one of millions of Americans who suffer from heartburn, aka gastroesophageal reflux disease (GERD). It occurs when acidic contents of the stomach flow back up into the esophagus, irritating the lining of the esophagus, causing a burning sensation.
Simple changes in diet and lifestyle can help manage and control your heartburn. For example, things like avoiding caffeine, eliminating fatty or acidic foods, losing excess weight and quitting smoking. However, lifestyle changes offer only temporary relief. If you have daily symptoms or it occurs more than three times a week, medication is recommended for a short time. The problem is, with so many medications out there, which one do you take?
Antacids
These are the most popular and are over-the-counter, often recommended as initial treatment to help soothe minor heartburn. These include Tums, Maalox, Rolaids and Mylanta, which neutralize stomach acid to provide fast, short-term relief in mild cases of acid reflux. Some antacids come in liquid form to coat the lining of the esophagus and help reduce the amount of acid in the stomach. They won’t help reduce inflammation of the esophagus associated with GERD. Antacids are better for immediate relief after a big meal.
Oral suspension medicines
Medications like Pepto Bismol are sometimes used to treat heartburn and indigestion as well as nausea, diarrhea and ulcers in the throat, stomach and intestines. It’s short-lived in its effectiveness because once the coating wears off, it doesn’t do much.
Anti-gas, anti-flatulence
Some people experience pressure and bloating when they get heartburn. OTC products like Gas-X and Beano help relieve pressure, bloating, and gas in the digestive tract. It works by breaking up gas bubbles.
H-2-receptor blockers
Previously, available only with a prescription, H-2-receptor blockers like Pepcid AC and Zantac are now OTC. It’s effective for mild reflux and works by reducing the acid your stomach makes. While they don’t work immediately, they’re effective longer than antacids.
Proton Pump Inhibitors (PPIs)
The most powerful drugs for greatly reducing your body’s production of stomach acid and helping heal damaged esophageal tissue. These include Prilosec, Prevacid and Nexium and are usually taken under the care of a physician. They work well for heartburn when antacids or H2 blockers don’t. It’s taken by people if you have more frequent, severe symptoms. However, studies show that long-term use of the PPIs could cause cancer, so only use for a short time.

It’s important for patients to pay attention to the frequency and severity of their symptoms. Frequent episodes of heartburn may be signs of a more serious problem. See your doctor if you have GERD, because it causes severe problems if left untreated.
If you’re experiencing heartburn or acid reflux on a regular basis, contact Houston Heartburn.

#### What Triggers Esophagitis?
Being woken up by terrible acid reflux, each and every night, can get very frustrating, let alone painful. Esophagitis is the inflammation of the esophagus (throat). A recent article by The Orange County Register discusses this condition and how doctors are seeing more patients with this problem; doing all the things you are meant to do to avoid acid reflux weren’t working, “Gastroenterologists only saw a case once in a lifetime, but now some are starting to see new cases once every week.”
Symptoms of esophagitis include:

Food sticking to the throat while trying to swallow
Difficulty swallowing
Heartburn not improving, even if using antacids

Here are a few factors that can cause this condition:
Acid Reflux: the lower esophageal sphincter is a valve-like structure, keeping acidic contents from the stomach out of the esophagus. If the valve opens when it shouldn’t or doesn’t close correctly, the acidic contents are pushed up into the esophagus, causing acid reflux.
Diet: an allergist can be great at helping to determine which foods will cause allergic reactions; however, foods such as soy, milk, eggs, wheat, nuts and seafood can be responsible for creating an allergic reaction in the esophagus. Citrus fruits, caffeine, garlic, chocolate, and tomato-based foods are also known to trigger esophagitis.

Medications: aspirin and ibuprofen are popular medications that are known to aggravate the esophagus. Antibiotics, such as tetracycline and doxycycline, can contribute to esophagitis, as well as potassium chloride.
Esophagitis is a treatable condition. Depending on your symptoms and severity of the conditions, many times treatment is non-invasive and effective. Pain relief can also be achieved through medications, but your doctor may likely suggest a change in diet and exercise. Obesity and smoking are two major factors in development of this condition; therefore, diet and exercise are key. Severe cases may mean surgery is necessary. Similar to a hiatus hernia procedure, a part of the stomach is wrapped around the esophageal sphincter. This will prevent gastric fluids finding themselves back in the esophagus. Come see Dr. Darido at Houston Heartburn to determine the right steps for you.
 
 

#### When Heartburn Goes From Problem to Serious Condition
Heartburn is common enough that it’s easy to think of it as just something that happens to everyone.  There is some truth to that, but it’s important to recognize that it’s also something that can evolve from an incident to a serious condition.  Once heartburn and acid reflux become more of an ongoing problem, then you have to take it more seriously.
William C. Orr, PhD, a clinical professor of medicine and specialist in gastrointestinal disorders at the University of Oklahoma Health Sciences Center, told Web MD, “When heartburn is not appropriately treated, acid reflux can cause erosion and ulcers in the lining of the esophagus,” he said.  “It’s extremely painful and greatly affects the patient’s lifestyle.”
In other words, frequent acid reflux could lead to very serious health concerns, such as GERD or Barrett’s Esophagus.  Here are some warning signs that you have more than just a “common” heartburn/acid reflux issue:

The number of occurrences have increased over time
You feel pain while swallowing
It becomes more difficult to swallow
You develop hoarseness in your voice
You experience extreme cases of weight loss
Your acid reflux/heartburn episodes cause vomiting
You notice darker/blacker bowl movements

When these symptoms occur, you have to concern yourself with possible damage to the esophagus or the threat of esophageal cancer.  It’s important to have a comprehensive knowledge of how acid reflux/heartburn can affect your daily life and health.
GERD (gastroesophageal reflux disease) is when acid flows up from the stomach and hits the esophagus, causing its structure to weaken.
Barrett’s Esophagus can develop after the long-term effects of GERD have taken a toll.  Eventually, the type of tissue that is generally associated with your intestines start forming on your esophagus.  This condition increases the odds of cancer forming in your throat.
With the right medical attention, you can address the threats associated with GERD or Barrett’s Esophagus, and that is what we do every day at Houston Heartburn.  Contact us today if you feel your heartburn/acid reflux has developed into more than just a random issue.

#### When to Stop PPIs after Nissen Fundoplication?
Acid reflux patients often wonder when does heartburn go away after Nissen fundoplication? The short answer is immediately.  Properly performed hiatal hernia repair and Nissen fundoplication restore a competent anti-reflux barrier. Consequently, acid reflux patients who have taken PPIs for years are consulted to stop all form of heartburn medications immediately after surgery. There is no need to taper down PPI dose after Nissen fundoplication. Some are concerned about rebound gastric acid secretion after stopping PPIs. Nissen fundoplication is so effective at stopping acid reflux even in the case of transient increase in gastric acid secretion.

#### Which Health Conditions Cause Heartburn?
Any health problem can be difficult to deal with, let alone it causing another problem; heartburn. The following are various health conditions which can cause heartburn.
Slow digestion
Delayed gastric emptying is where the stomach doesn’t empty in the correct direction. Instead, food goes the opposite way and therefore, causes reflux. This cause of heartburn is more common with people who have diabetes. If blood sugar is too high for too long, the nerves that help food move along the digestive tract, can be damaged.

Hiatal hernia
This health condition causes part of the stomach to bulge through the diaphragm and into the chest. This results in acid being able to flow straight through into the chest, making the lower esophagus sphincter (LES) work inefficiently. You may never know you have hiatal hernia, with the only symptom being chronic acid reflux.

Pregnancy 
During the first trimester, hormonal changes weaken and relax the LES. However, as time goes by and the baby starts to grow, the pressure on the abdomen may push the valve out of position. The valve in normal circumstances, stops acid flowing up the wrong way. If the valve is moved or there is an abnormal valve, acid will flow through, causing heartburn.

Obesity 
Being overweight, as well as over eating, eating too quickly and eating too fast, can all cause heartburn. Similar to being pregnant, the excess weight by overeating, or if you are overweight, can add pressure to your stomach, potentially pushing acid through into your esophagus.

If you find yourself in any of these situations, call Houston Heartburn today, and start a road to recovery, without the burn!

#### Who Gets Barrett’s Esophagus?
Who Gets Barrett’s Esophagus?
Barrett’s esophagus is a change in the cells lining your esophagus. Normal esophagus cells are flat (squamous) and do not secrete mucous. Barrett’s esophagus consists of columnar cells that secrete mucous like colon cells. Most patients with Barrett’s esophagus have severe and longstanding GERD. Barrett’s esophagus increases your odds of developing esophageal cancer.
So who gets Barrett’s esophagus?  How do you know when you have it?
You are more likely to develop Barrett’s esophagus if you have GERD and you are middle aged or older, white, male, cigarette smoker and obese. Barrett’s Esophagus doesn’t necessarily have “symptoms”.  However, if you frequently experience GERD related symptoms, it’s important to seek treatment as soon as possible.  It is estimated that 1 out of every 10 people who have GERD will be diagnosed with Barrett’s Esophagus.
At Houston Heartburn and Reflux Center, Barrett’s esophagus is diagnosed by an acid reflux specialist using upper endoscopy. Esophagus lining is sampled (biopsies are obtained through the scope) and evaluated under the microscope. Dysplasia is the presence of precancerous cells. High grade dysplasia indicates a high risk for cancer development. Resection of Barrett’s lining with high grade dysplasia is recommended to prevent cancer development.
There are different resection modalities of Barrett’s esophagus with high grade dysplasia. Radiofrequency ablation is the most commonly used. The procedure is done through the mouth using a scope and a special probe that burns off abnormal cells.
If you suffer from frequent heartburn, don’t wait until it is too late. You can prevent Barrett’s esophagus from developing. Contact Houston Heartburn and Reflux Center to learn more about the different ways you can avoid and treat the symptoms of GERD, Barrett’s Esophagus and advanced acid reflux.  You can reach us at 832-945-8717.

#### Why Breakfast is the Best Time to Take Heartburn Medication
When we think of medications that are designed to provide relief, it’s easy to automatically think you take them all when a problem starts.  For example, when you get a headache, you take a pain reliever to fix the problem as soon as possible.  Therefore, it’s easy to think that when you get heartburn, it’s best to take a drug like Nexium or Prilosec right after you experience the symptoms.
However, a recent study has given heartburn sufferers a greater understanding about how these drugs actually work.  It highlighted factors related to:
When the medication was taken
If it was bought over-the-counter or prescribed by a physician
What type of heartburn drugs are used
The study, which was posted in the June 2014 issue of The American Journal of Gastroenterology, found that only a third of people who were buying medications, were using them properly.  In doing so, heartburn symptoms remain and money is wasted.  More people were using them properly when they were prescribed by a doctor.
There are different types of heartburn medicine, and this study focused on what’s known as proton pump inhibitors.  The ideal time to take them is before breakfast because food helps activate the drugs.  They don’t generally provide immediate relief of heartburn (like antacids), and can take up to seven days before you start to feel the real benefits.
Dr. John Lipham, director of the Digestive Health Center at Keck Medicine at the University of Southern California, said people tend to put all heartburn drugs into the same category.  “But these [proton pump inhibitor] medicines don’t work that way,” he said. “They need to be stimulated by acid and need to build up in your system. You have to take them at the correct time each day and you also need to take them every day to get the maximum effectiveness of the medications.”
With breakfast being the ideal time to take the medication, you’ll want to pick out acid-inducing foods and drinks to make it work. This would include eggs, cheese, yogurt, milk or coffee.
If you’re taking heartburn/acid reflux medication and still experiencing severe symptoms, it’s important to get help. Proton Pump Inhibitors are not a long term solution. Call us at Houston Heartburn at 832-234-3100.

#### Why Heartburn Medications Don’t Always Work
When people begin to experience heartburn or acid reflux, a typical reaction is to reach for antacids or other medications.  There are plenty of times where that reaction can be effective.  If they work properly, the symptoms should subside in a short amount of time.  However, there are also times where people turn to heartburn medications and they don’t work.  Not only is that bad news for your discomfort, but it can also mean there are bigger problems that need to be addressed.

One of the reasons the medications might not be working is that your acid reflux problem is more severe than you thought.  In cases like those, drugs aren’t going to be enough.  You need to see your doctor or a specialist.
Another reason why the drugs aren’t working is that you’re not actually experiencing acid reflux.  Instead, you could be experiencing symptoms that are more closely tied to heart disease.  Again, it’s important to visit a doctor in order to get a proper diagnosis of the problem.
Sometimes people think that as long as they have antacids or PPIs on stand-by, that they can eat whatever they want (and how much they want).  That’s not necessarily true.  It’s very possible that if you eat a large meal loaded with fat and acidic triggers, it might be too much for medication to handle.  If you go to bed or lie down immediately afterwards, that can also complicate the problem.
Sometimes anti-heartburn medications aren’t as effective because they aren’t taken at the right time.  It’s important to read the directions on the label to learn the ideal time to use them.  It could be minutes before or after eating a meal.  For example, if you’ve got a PPI like Prilosec, you don’t want to take that before meals – especially breakfast.  In order for the drug to block acid, there has to be food in the stomach to create it.
The bottom line is, if the medications aren’t working, you have a problem that needs further examination.  Take time to visit a doctor or specialist before it becomes a bigger health issue.  Houston Heartburn can help you. Contact us today to schedule a visit.

#### Why Is GERD a Progressive Disease?
Gastroesophageal reflux disease is a multifactorial problem that tends to get worse with time. GERD patients start with occasional symptoms like heartburn and food regurgitation once or twice a month. This is the first stage of GERD. Symptoms are effectively controlled by lifestyle changes that include weight loss, smoking and alcohol intake cessation. We further advise patients to avoid trigger foods like hot and spicy items, tomato sauce, chocolate and coffee… In addition, reduction of meal size is especially important as most of us these days eat large meals. Overeating stretches the stomach and stresses the anti-reflux barrier resulting in reflux.
When patients don’t take control of their early stage GERD, disease is most likely to progress. Acid reflux control requires understanding and commitment. Understanding GERD is crucial to fighting the disease. One must appreciate the danger of using antacids to control early GERD symptoms. For antacids effectively mask acid reflux symptoms but they don’t stop reflux. Masking symptoms allows patients to comfortably continue with certain lifestyle habits that favor reflux. Continued reflux with no symptoms slowly but surely causes GERD to progress and evolve into stage 3 and 4. At this stage patients have poor symptom control despite maximizing their antacid medications including the powerful and dangerous proton pump inhibitors.
GERD progresses because continued reflux weakens the anti-reflux barrier via a number of different mechanisms. Persistent acid and bile reflux damages the highly coordinated esophageal motility. Weak peristaltic activity favors longer reflux episodes. As acid and non-acid esophageal exposure increases, dysmotility worsens further exacerbating the problem. Furthermore, persistent reflux causes esophageal muscles to slowly retract in a cephalad direction. This cephalad movement drags the gastro-esophageal junction from the abdominal cavity into the chest leading to hiatal hernia formation. Indeed, the association between hiatal hernia and acid reflux is very strong. Hiatal hernias weaken the diaphragmatic pinch over the lower esophagus causing reflux and chronic reflux causes hiatal hernias to develop and grow.
Reflux begets more reflux and antacid medications like proton pump inhibitors, PPIs, do not stop disease progression. Early lifestyle changes rather than masking symptoms with PPIs are crucial to preserve the anti-reflux barrier.

#### Will Relieving Your Heartburn Create More Problems?
Proton pump inhibitors (PPIs) are a popular method of relieving severe heartburn or acid reflux. However, PPIs have recently come under attack. Can using a PPI to help one health problem actually create another or more health problems?
Jolene Rudell, 33, is fit and healthy and put down her fainting to the stress of being in medical school. However, her physician made her aware that it could be her PPI after she lost consciousness two weeks after fainting. Ms. Rudell has been using PPIs for nearly a decade.

Prilosec, Prevacid, and Nexium are all examples of PPIs, which help to lower acid in the stomach. Almost 4/10 Americans depend on these drugs to help their heartburn, according to a New York Times article. A PPI works by blocking the acid production in the stomach. As much as they may help to relieve acid reflux, more recently the Food and Drug Administration have issued warnings to the negative effects of using PPIs long term.
Effects of long-term PPI use
Studies and research by the FDA have suggested prolonged use of these drugs can decrease the amount of nutrients absorbed from foods into the blood, as well as increased risks of infection and bone fractures. Clostridium difficile is a bacterium that can cause infection, especially in the elderly. Therefore, it is recommended the elderly only use these drugs for a short period. Stomach acid helps to kill bacteria; therefore, suppressing the production of normal acid levels may cause patients to be more vulnerable to these infections.
Studies have also shown that the longer a patient uses a PPI, the higher the chance of less and less nutrients and minerals being absorbed into the bloodstream. It may also reduce the effectiveness of other medications you may be taking at the same time. Other claims include increased weight gain and even pneumonia.
Stomach acid plays a key role in bodily functions by breaking downs foods, absorbing nutrients, and helping in the correct functioning of the pancreas and gallbladder. The longer the use of PPIs, the more harm they are actually doing to your body than good.

However, many drug companies are dismissing these claims, stating elderly patients are more vulnerable to bone fractures and infections as they age.
PPIs can be very addictive. Some patients stay on the drugs much longer than the recommended period of 8-12 weeks. Dr. Shoshana J. Herzig of Beth Israel Deaconess Medical Center in Boston, mentions “Studies have shown that once you’re on them, it’s hard to stop taking them…it’s like an addiction.” The problem here is that the issue is not being prevented or “solved”, but more controlled. If a patient comes off the medication, the problem will arise once again. Instead of making lifestyle changes, which is far healthier than using drugs, patients are opting for the ‘easier’ solution – take medicine while being able to eat the wrong foods, which in reality doesn’t help their acid reflux.
Can you make the lifestyle changes you need to lower your heartburn and prevent additional health problems? If you are having trouble with this, make an appointment with Dr. Darido to discuss your options at the Houston Heartburn & Reflux Center.

#### Will TIF Procedure Correct or Cure Dysphagia?
Donald from Houston sent me this question few days ago. Dysphagia or difficult swallowing is common with acid reflux. Constant gastric content reflux into the esophagus damages esophageal motility leading to difficulty swallowing. It is no surprise that GERD patients, with years of heartburn and food regurgitation, present to our center with significant dysphagia symptoms. We routinely perform esophageal manometry testing prior to Nissen fundoplication surgery to evaluate esophageal motility, bolus clearance and lower esophageal sphincter pressure. In general, we advocate Nissen fundoplication or a 360 degree wrap for most of our acid reflux patients. The only absolute contraindication for a full wrap is a small gastric fundus that prevents us from performing a floppy Nissen fundoplication. Following Nissen fundoplication and complete cessation of acid reflux, esophageal motility improves and dysphagia resolves.
TIF or transoral incisionless fundoplication is not a fundoplication by any stretch of the imagination. It is a misnomer. Indeed, gastric fundus is not touched during TIF procedure. Rather, a small amount of gastric tissue is bunched up around the lower esophageal sphincter. The end result is limited, and short-term acid reflux control. Consequently, dysphagia secondary to acid reflux is not likely to resolve after TIF procedure.
Other causes of dysphagia include achalasia, esophageal cancer, peptic stricture… Dysphagia treatment in these cases depends on the underlying cause. For instance, laparoscopic Heller myotomy is offered for achalasia patients and obviously TIF procedure has no role in these cases.

#### You Age Faster With Proton Pump Inhibitors
Several large studies have been recently published showing a link between chronic long-term use of proton pump inhibitors like Nexium, Prilosec, and Dexilant and the development of dementia, chronic renal failure and heart disease (myocardial infarction). Proton pump inhibitors or PPIs are used by millions of people all over the world. PPIs are a very common prescription medication for PCPS and gastroenterologists. PPIs in the US are over the counter medications and many patients use these powerful drugs on a daily basis with no medical supervision.
A recent study published in Circulation Research demonstrates a cause effect relationship between PPI use and endothelial cell damage. Damage to the blood vessel lining explains brain, heart and kidney damage that has been repeatedly observed in several human epidemiological studies. Indeed, “Long-term use of PPIs may not be good for your body” said Dr. John Cooke a senior author on the study from the department of cardiovascular sciences at Houston Methodist.
The researchers have found that PPIs impair the function of lysosomes in endothelial cells. Lysosomes eliminate unwanted cellular products to keep cells free of damaged proteins and free radicals. Lysosomes contain the same proton pump present in the stomach that produces acid. PPIs block lysosome proton pump function preventing the acidification of lysosomes. As a result, damaged proteins are no longer destroyed and eliminated. Instead, they accumulate in cells leading to aging and death. This may partly explain the increased incidence of vascular dementia, myocardial infarction and renal failure.
Acid secretion is part of normal physiology. GERD is not a disease of increased acid secretion. GERD is the result of gastric juice escaping into the esophagus in the setting of normal acid secretion. GERD is a complex multifactorial problem. Current medical treatment in the form of PPI therapy does not address the underlying GERD pathophysiology nor does it improve patient quality of life. Rather, it is associated with accelerated aging and serious side effects.
Future studies will continue to unravel the side effects of PPIs. GERD is a complex medical problem and the “one pill fits all” treatment model is no longer accepted. If you suffer from weekly GERD related symptoms, get evaluated by a reflux specialist. Visit our website www.houstonheartburn.com and learn more about the disease. Schedule a free consultation and rid yourself of a problem that has many more effective and safer solutions than a purple pill every day.

#### You’ve been diagnosed with Barrett’s now what?
Barrett’s esophagus is the result of longstanding acid reflux that causes abnormal changes to occur in the affected cells of the esophagus. This condition increases your risk of developing esophageal cancer. Fortunately, the risk is small at 0.5% chance per year or 10% risk over 20 years. It is very important, however, to properly manage your GERD to prevent worsening of your condition and progression to cancer.
In addition to periodic surveillance, Houston Heartburn and Reflux Center, Barrett’s patients are offered a new treatment modality called ablation.
What is Ablation?
The abnormal cells of the affected esophagus are burnt using a special instrument inserted through the endoscope. Normal cells grow in the subsequent weeks after treatment and replace the esophageal lining. This procedure is reserved for advanced cases of Barrett’s esophagus. It should be noted that ablation does not eliminate GERD. Patients need to continue anti-reflux medications or undergo an anti-reflux surgery like the Nissen Fundoplication. The Nissen procedure reconstructs the weakened Lower Esophageal Sphincter, improving the barrier function to acid reflux. A successful anti-reflux procedure has a high likelihood of preventing esophageal cancer.
At Houston Heartburn and Reflux Center, we closely follow our Barrett’s patients. Upper endoscopy is performed every 1 to 3 years in order to evaluate the extent and progression of Barrett’s disease.

#### Your Diet after Nissen Fundoplication
When and what can I eat after Nissen fundoplication surgery for heartburn is a very common question. At Houston Heartburn and Reflux Center we have adopted a dietary guideline for our patients to follow after Nissen fundoplication surgery. Following anti-reflux surgery, the distal part of the esophagus or food pipe is swollen. Swelling or edema develops because of tissue dissection during surgery and takes around two to three weeks to subside. When the esophageal wall swells up, its lumen narrows. Indeed, on day one after Nissen fundoplication, esophageal lumen diameter is as wide as a straw. Solid food can’t go through a straw. Accordingly, heartburn patients are counseled to adopt a liquid diet for the first two weeks after surgery. Liquid diet consists of broth, protein shake, yogurt…Following this initial phase, patients transition to a soft or puree diet that consists of blended food. This baby food diet helps post-surgical patients gradually transition to regular diet around one month after surgery. These guidelines are not written in stone and some patients progress to regular diet faster than others. It is important, however, to follow these recommendations to avoid problems. Starting regular diet too early after surgery may cause food impaction in the esophagus. Food impaction causes significant discomfort and may lead to severe retching and dry heaving. This creates unwanted pressure around the gastro-esophageal junction that may disrupt the hiatal hernia repair and fundoplication.
Of note, acid reflux and heartburn trigger food items like spices, coffee, tomato soup… can be resumed immediately after surgery. I offer coffee to my patient on day one after surgery.

#### Your Diet Matters If You Have Acid Reflux Disease
Whether you are overweight or not, if you suffer from acid reflux you need to modify your diet. What you eat, how you eat, and when you eat, play a critical role in acid reflux disease management.
1. What you eat:
Certain food items trigger a reflux episode. It might be red wine for some or tomato sauce for others. It is not well understood why and how certain food items cause acid reflux. Some like mint, chocolate, and alcohol are believed to relax the lower esophageal sphincter. Irrespective of the cause, avoiding these trigger food items prevents acid reflux.

2. How you eat:
The upper part of the stomach is called gastric fundus. As you are enjoying your meal, the gastric fundus gradually stretches to accommodate the consumed food. Eating too much food during a meal over-stretches the gastric fundus. Excessive distention puts pressure on the lower esophageal sphincter. With time, the sphincter weakens and acid escapes into the esophagus. Most people resort to tums and antacid medications to alleviate their symptoms. They develop a habit of overeating and medicating instead of changing their eating habits to prevent worsening acid reflux symptoms.
3. When you eat:
Food consumption before going to bed at night worsens nighttime acid reflux. When lying flat, acid reflux tends to stay longer in the esophagus, causing more damage. Raising the head of the bed allows gravity to protect the esophagus from acid reflux. Most importantly, however, is to avoid eating 4 hours prior to going to bed to make sure your stomach is empty by the time you lay down.
In summary, understand your acid reflux disease and listen to your body. Adopt a reflux-friendly diet and don’t over-medicate yourself with tums and antacids. At Houston Heartburn and Reflux Center, we target the causes of reflux and not only the symptoms. If you have acid reflux disease, please contact us.

### Pages

#### 4 Stages of GERD
The Four Stages of GERD and Treatment Options
Reflux disease is a chronic and progressive condition. Treatment options depend on the disease stage. The disease stage is determined by the severity of reflux into the esophagus. This in turns depends on how frequent and how long are the reflux episodes. The longer and the more frequent acid reflux episodes are the more significant is the damage to the esophagus. GERD is also associated with a spectrum of symptoms that ranges from mild heartburn to severe chest pain mimicking a heart attack. GERD treatment options are highly dependent upon an individual’s GERD stage.
Stage 1: Mild GERD
Patients experience mild symptoms once or twice a month. Treatment relies on lifestyle changes and over-the-counter acid suppressive medications.
Stage 2: Moderate GERD
Patients experience more frequent symptoms requiring daily prescription acid suppressive medications. Untreated GERD symptoms affect patient daily activities and are associated with esophageal inflammation.
Stage 3: Severe GERD
Patients with severe GERD have poorly controlled symptoms on prescription medications. Their quality of life is substantially lower. Patients are more likely to have erosive esophageal inflammation. A thorough evaluation by a GERD expert is highly recommended. A successful anti-reflux procedure that restores the integrity of the lower esophageal sphincter cures GERD and improves patient quality of life.
Stage 4: Reflux induced precancerous lesions or esophageal cancer
Stage 4 is the result of many years of untreated severe reflux. 10% of patients with long-term GERD progress to stage 4. They develop a pre-cancerous condition called Barrett’s esophagus. Barrett’s esophagus may progress to cancer if untreated. There are different modalities of treatment for Barrett’s esophagus aimed at preventing progression to cancer. Close follow up and management by a reflux expert is highly recommended.
Treat the Cause, Not the Symptoms
Stage 3 and 4 patients have a very weak lower esophageal sphincter the LES and/or a hiatal hernia. If you have stage 3 or 4 GERD, you have an anatomical medical condition. Medications simply suppress the symptoms; Medications do not and cannot treat the cause. At Houston Heartburn and Reflux Center, we can help you treat the cause of GERD through a minimally invasive surgical procedure. From initial consultation to diagnostic work-up, surgery, and post-op visits Houston Heartburn and Treatment Center:

Facilitates a coordinated team approach of healthcare professional dedicated to the treatment of GERD.
Offers access to an efficient, streamlined medical diagnostic program to confirm if you have GERD and/or hiatal hernia.
Works with experienced surgeons who are specialist heartburn and reflux physicians.
Acts as a liaison with healthcare providers to provide you with the best experience possible.
Will help you meet your insurance requirements and assist in the insurance claim process.
Will vigorously defend any insurance appeals process, if you are denied the benefits you are due.

#### Acid Reflux
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						Life Is Too Short to Live with HeartburnNovember 19, 2024		
			
	
		
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						Laryngopharyngeal Reflux (LPR) – A Patient’s ReviewOctober 24, 2024		
			
	
		
						Diet After Nissen Fundoplication Surgery and Hiatal Hernia RepairAugust 25, 2024		
			
	
		
						Persistent Gastroparesis Following LINX™ to Nissen Fundoplication ConversionAugust 10, 2024		
			
	
		
						Nissen Fundoplication Versus PPIs for Barrett’s EsophagusJuly 25, 2024		
			
	
		
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#### Additional Resources
Weight Loss Surgery
Houston Weight Loss Surgery Center, the office of Dr. Elias Darido, is dedicated to the treatment of Morbid Obesity. Dr. Darido’s goal is to provide an effective treatment for obesity based on the latest scientific discoveries in this field. Dr. Darido is renowned for his expertise in the surgical treatment of morbid obesity and diabetes. He has developed several innovative and minimally invasive surgical approaches for treatment of obesity and advanced type-two diabetes.
Nissen Fundoplication
A Nissen fundoplication, also known as a laparoscopic Nissen fundoplication when done through laparoscopic surgery, is a surgical procedure used to treat gastroesophageal reflux disease (GERD) and hiatal hernia. It is usually performed after medical therapy has failed in the case of GERD, but it is the first-line procedure in the case of a Type II (paraesophageal) hiatus hernia.
EGD – esophagogastroduodenoscopy
Esophagogastroduodenoscopy (EGD) is a test to examine the lining of the esophagus, stomach, and first part of the small intestine (the duodenum).
EGD is done in a hospital or medical center. The procedure uses an endoscope. This is a flexible tube with a light and camera at the end.

#### Agruras
En Houston Heartburn and Reflux Center, nuestra meta es ofrecer un enfoque integral y comprensivo en el tratamiento de su acidez o agruras. Estamos orgullosos de ofrecer un tratamiento personalizado para todos nuestros pacientes.
Especialista en Acidez Estomacal y Reflujo Acido
En Houston Heartburn and Reflux Center, la práctica del médico especialista, el Dr. Darido, es dedicada al tratamiento del reflujo acido, cirugía anti-reflujo, y a otros problemas que afecten el área gastroesofagal. La meta del Dr. Darido es brindar excelencia en tratamientos junto con un cuidado altamente especializado del paciente. El Dr. Darido es reconocido por su experiencia en cirugías avanzadas-La cirugía mínimamente invasiva (CMI)-Endoscopía diagnostica y quirúrgica.
El Dr. Elias Darido habla sobre el Reflujo Acido en el programa Great Day Houston con Deborah Duncan.
En este video El Dr. Darido explica cómo se controla el reflujo acido, que tratamientos hay disponibles para tratar la acidez estomacal o agruras.
Los Síntomas Del Reflujo Acido
El reflujo acido varía entre las personas, presentándose con diferentes síntomas, precipitado por diferentes factores, y puede ocurrir a diferentes horas del día. La acidez estomacal o agruras es un síntoma clásico del reflujo acido gástrico. Una acidez severa puede causarle dolor en el pecho. El reflujo acido gástrico puede llegar a la parte alta del esófago y al área del cuello provocando un sabor agrio en la boca, en la garganta, una tos seca, y provocando ronquera o disfonía.
Pida una consulta con el Dr. Darido
Baje su folleto de informacion gratis para PREVENIR Y TRATAR SU Acidez o REFLUJO ACIDO.

PORQUE DEBE ELEGIR HEARTBURN AND REFLUX CENTER?

En Houston somos los expertos en la cura de la acidez o agruras
Ofrecemos información y un enfoque comprensivo sobre la enfermedad del reflujo ácido
Tenemos lo último en soluciones y tratamientos para el reflujo ácido
La mayoría de los seguros médicos cubren los tratamiento

#### Appt Form
Request Appointment
To request an appointment, call us at 832-945-8717 or complete the secure form below.

#### Barrett's Esophagus
Have you been told you have Barrett’s esophagus? 
A properly performed Nissen Fundoplication and hiatal hernia repair may be your best solution.

Severe acid reflux leads to Barrett’s esophagus. Barrett’s esophagus increases the risk of esophageal cancer. If  you are looking for safe and effective treatment for both acid reflux and Barrett’s esophagus,  Houston Heartburn and Reflux Center can help you.
Start ConsultationPeople from all over the US travel to Houston Heartburn and Reflux Center for their Nissen Fundoplication surgery. We provide a fast-track approach where your first appointment can be virtual. Acid reflux testing followed by surgery, all performed in less than one week.
Nissen Fundoplication by the numbers

At Houston Heartburn & Reflux Center, we do one thing and one thing only, but we do it right!
15-Star Reviews1Success Rate1Hour Surgery100’s
Of Satisfied Patients
95%
Would Recommend Someone
1-2 Hour
Procedure Duration
The ProblemWeak valve (anti-reflux barrier) between esophagus and stomach results in acid reflux and Barrett’s esophagus.
Our SolutionNissen Fundoplication safely and reliably restores the anti-reflux barrier, stops reflux and allows Barrett’s esophagus to regress back to normal.
Our Outcome99.9% success rate & hundreds of satisfied patients.
The CaveatComprehensive acid reflux testing. Proper patient selection. Flawless surgery technique.
Patient Testimonial: Houston Heartburn
I suffered from acid reflux for 20 years. I have been on meds for it for those 20 years. About 18 years ago my bone density went from good to severe osteopenia. So doctor adds another medicine. All these years later by research I find that the acid reflux meds cause osteoporosis. I can’t go one day without the protonix. My blood pressure is high, my sleep pattern is sketchy, my acid reflux, even with meds comes and goes. The fear of getting Barrett’s syndrome (esophagus disease) worries me. My research leads me to Dr. Darido. He is confident in his medical practice. He explains everything in detail. I had to have a complete heart work up due to my age (65), which I should have had years ago anyway. The surgery for me was not painful. Even the large hiatal hernia repair has been good. The incisions are sore, but I did well. I can only take my bp and depression meds for a month, so go over your meds with the doctor. My blood pressure has not been this good in 20 years. The damage acid reflux and a hiatal hernia can do to your body is amazing. Do it. Consider the surgery. Make your life better. Dr Darido is the first man that told me he would change my life, and actually did! Lol.
Anne N
Read more reviews!
Start Your Consultation Here
	
		
						Nissen Fundoplication Versus PPIs for Barrett’s EsophagusJuly 25, 2024		
			
	
		
						Heartburn, Smoking and Barrett’s EsophagusApril 15, 2019		
			
	
		
						Question of the week regarding Barrett’s esophagusJanuary 8, 2018		
			
	
		
			
		
	
				
				
					
				
				
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#### Comparison of Heartburn Treatments
Comparison of Heartburn Treatments

Edit

	Nissen FundoplicationLINX™TIF

	Success RateExcellent*GoodLow

	Normalization of Esophageal pH100%60%Low

	Covered by InsuranceAlwaysOccasionallyOccasionally

	InvasivenessMinimally InvasiveMinimally InvasiveNo Incisions

	Hospital Stay1 Night1 NightOutpatient

	Time Off WorkOne WeekOne WeekFew Days

	Hiatal Hernia RepairYesYesNo

	Dysphagia after ProcedureNoYesNo

	Foreign ObjectsNoYesNo

	DurabilityVery HighUnknownLow

	ReversibilityReversibleReversibleReversible

	Long-term ComplicationsVery LowDevice erosion, Esophageal dilation, persistent refluxRecurrent reflux

	Short-term Complication rate< 1 %< 1 %< 1 %

	Weight Loss4 to 15 PoundsVariableNone

	ContraindicationsPrevious Stomach SurgeryLarge hiatal hernia,
Barrett's esophagus
Esophageal dysmotiliy
Previous stomach surgeryLarge Hiatal Hernia

*The success rate of Nissen Fundoplication when performed by heartburn and acid reflux experts is very high reaching almost 100% at Houston Heartburn And Reflux Center.
Comparison of Heartburn TreatmentsProcedure ComparisonNissen FundoplicationLINX™TIFProcedure Comparison

  
    
      Success Rate
      Excellent*
      Good
      Low
    
    
      Normalization of Esophageal pH
      100%
      60%
      Low
    
    
      Covered by Insurance
      Always
      Occasionally
      Occasionally
    
    
      Invasiveness
      Minimally Invasive
      Minimally Invasive
      No Incisions
    
    
      Hospital Stay
      1 Night
      1 Night
      Outpatient
    
    
      Time Off Work
      One Week
      One Week
      Few Days
    
    
      Hiatal Hernia Repair
      Yes
      Yes
      No
    
    
      Dysphagia after Procedure
      No
      Yes
      No
    
    
      Foreign Objects
      No
      Yes
      No
    
    
      Durability
      Very High
      Unknown
      Low
    
    
      Reversibility
      Reversible
      Reversible
      Reversible
    
    
      Long-term Complications
      Very Low
      Device erosion, Esophageal dilation, persistent reflux
      Recurrent reflux
    
    
      Short-term Complication Rate
      &lt; 1 %
      &lt; 1 %
      &lt; 1 %
    
    
      Weight Loss
      4 to 15 Pounds
      Variable
      None
    
    
      Contraindications
      Previous Stomach Surgery
      Large hiatal hernia, Barrett's esophagus, Esophageal dysmotility, Previous stomach surgery
      Large Hiatal Hernia
    
  

Nissen Fundoplication

  
    
      Short-term Complication Rate
      &lt; 1 %
      &lt; 1 %
      &lt; 1 %
    
    
      Hospital Stay
      1 Night
      1 Night
      Outpatient
    
    
      Normalization of Esophageal pH
      100%
      60%
      Low
    
    
      Weight Loss
      4 to 15 Pounds
      Variable
      None
    
    
      Covered by Insurance
      Always
      Occasionally
      Occasionally
    
    
      Success Rate
      Excellent*
      Good
      Low
    
    
      Invasiveness
      Minimally Invasive
      Minimally Invasive
      No Incisions
    
    
      Dysphagia after Procedure
      No
      Yes
      No
    
    
      Foreign Objects
      No
      Yes
      No
    
    
      Time Off Work
      One Week
      One Week
      Few Days
    
    
      Contraindications
      Previous Stomach Surgery
      Large hiatal hernia, Barrett's esophagus, Esophageal dysmotility, Previous stomach surgery
      Large Hiatal Hernia
    
    
      Reversibility
      Reversible
      Reversible
      Reversible
    
    
      Durability
      Very High
      Unknown
      Low
    
    
      Long-term Complications
      Very Low
      Device erosion, Esophageal dilation, persistent reflux
      Recurrent reflux
    
    
      Hiatal Hernia Repair
      Yes
      Yes
      No
    
  

LINX™

  
    
      Short-term Complication Rate
      &lt; 1 %
      &lt; 1 %
      &lt; 1 %
    
    
      Hospital Stay
      1 Night
      1 Night
      Outpatient
    
    
      Normalization of Esophageal pH
      100%
      60%
      Low
    
    
      Long-term Complications
      Very Low
      Device erosion, Esophageal dilation, persistent reflux
      Recurrent reflux
    
    
      Success Rate
      Excellent*
      Good
      Low
    
    
      Contraindications
      Previous Stomach Surgery
      Large hiatal hernia, Barrett's esophagus, Esophageal dysmotility, Previous stomach surgery
      Large Hiatal Hernia
    
    
      Invasiveness
      Minimally Invasive
      Minimally Invasive
      No Incisions
    
    
      Covered by Insurance
      Always
      Occasionally
      Occasionally
    
    
      Time Off Work
      One Week
      One Week
      Few Days
    
    
      Reversibility
      Reversible
      Reversible
      Reversible
    
    
      Durability
      Very High
      Unknown
      Low
    
    
      Weight Loss
      4 to 15 Pounds
      Variable
      None
    
    
      Hiatal Hernia Repair
      Yes
      Yes
      No
    
    
      Dysphagia after Procedure
      No
      Yes
      No
    
    
      Foreign Objects
      No
      Yes
      No
    
  

TIF

  
    
      Short-term Complication Rate
      &lt; 1 %
      &lt; 1 %
      &lt; 1 %
    
    
      Time Off Work
      One Week
      One Week
      Few Days
    
    
      Contraindications
      Previous Stomach Surgery
      Large hiatal hernia, Barrett's esophagus, Esophageal dysmotility, Previous stomach surgery
      Large Hiatal Hernia
    
    
      Success Rate
      Excellent*
      Good
      Low
    
    
      Normalization of Esophageal pH
      100%
      60%
      Low
    
    
      Durability
      Very High
      Unknown
      Low
    
    
      Hiatal Hernia Repair
      Yes
      Yes
      No
    
    
      Dysphagia after Procedure
      No
      Yes
      No
    
    
      Foreign Objects
      No
      Yes
      No
    
    
      Invasiveness
      Minimally Invasive
      Minimally Invasive
      No Incisions
    
    
      Weight Loss
      4 to 15 Pounds
      Variable
      None
    
    
      Covered by Insurance
      Always
      Occasionally
      Occasionally
    
    
      Hospital Stay
      1 Night
      1 Night
      Outpatient
    
    
      Long-term Complications
      Very Low
      Device erosion, Esophageal dilation, persistent reflux
      Recurrent reflux
    
    
      Reversibility
      Reversible
      Reversible
      Reversible
    
  

*The success rate of Nissen Fundoplication when performed by heartburn and acid reflux experts is very high reaching almost 100% at Houston Heartburn And Reflux Center.

#### Contact Houston Heartburn & Reflux Center
Request an Appointment Today and Get the Relief You Need!
Every day, people like you choose Houston Heartburn for acid reflux treatment. We focus exclusively on Heartburn &amp; GERD management and have seen cases of every kind. We have helped thousands of Houstonians eliminate acid reflux and regain their normal life. To request an appointment call us at (832) 945-8717 or complete our online form. A member of our team will be in touch with you within 24 hours to schedule your initial appointment.
Located in the Heart of Houston
2100 W. Loop South, Suite 1115A
Houston, TX 77027
Satellite Clinics
Townsen Memorial Hospital
1475 Farm to Market 1960 Bypass Rd E
Humble, TX 77338
Travel &amp; Accommodations
Patients traveling from outside Houston can get airport and hotel information here.
People from all over the US and Canada travel to Houston Heartburn for their Nissen Fundoplication surgery.

We provide a fast-track approach where your first appointment can be virtual. Acid reflux testing followed by surgery, all performed in less than one week.
Excellence is never an accident. It is always the result of high intention, sincere effort, and intelligent execution; it represents the wise choice of many alternatives.
Aristotle

#### Contact Us
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#### Cookie Policy
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#### Diagnosis of GERD
Acid Reflux Testing: Why is it important
GERD cannot be accurately diagnosed based upon symptoms only. The majority of patients with reflux disease don’t see a physician. They either ignore their symptoms or self-diagnose and often self-medicate. Studies have shown that 32% of all Proton Pump Inhibitor (PPI) users are not refluxing and should not be using these powerful medications. At Houston Heartburn and reflux Center, we adopt a comprehensive evaluation using state of the art diagnostic testing. These tests and procedures only provide complete clarity if they are coordinated and conducted properly. Dr. Darido personally oversees and interprets every performed study. The following are the most commonly used studies:
Upper Endoscopy: also called EGD
Dr. Darido inserts a thin, flexible, lighted tube into the esophagus and stomach to visualize the inner lining of this area. The test can detect inflammation, erosion, abnormal growths, and hiatal hernias. During the procedure the patient is sedated. Small tissue samples called biopsies may be taken from areas that appear abnormal. A specialist examines these samples under a microscope to check for inflammation or other changes resulting from acid reflux.
Ambulatory pH Monitoring
pH testing can check for the level of acid in your esophagus. This is the most accurate and objective test for diagnosing GERD. A small sensor is placed in the esophagus to measure acid exposure for a period of 24 to 48 hours. Upon completion of the test, Dr. Darido interprets the results using a special computer program. The test will show the amount and duration of acid exposure to the lower esophagus.
Esophageal Manometry
This test measures the strength of your esophageal contractions. It checks for the ability of the esophagus to move food down into the stomach. It also detects the presence of a hiatal hernia as well as other conditions affecting the lower esophageal sphincter like achalasia that can mimic GERD. Manometry is required if the Nissen Fundoplication is considered as a treatment option.
Barium Swallow: also called upper GI series
This test is done using X-ray imagery. It visualizes the esophagus and stomach anatomy. It checks for the presence of a hiatal hernia and the backflow of contrast into the esophagus.
Gastric Emptying Study
This study evaluates the emptying function of your stomach. Patients with delayed gastric emptying (gastroparesis) may suffer from acid reflux. The treatment in this case is focused on promoting gastric emptying to alleviate acid backup into the esophagus. Dr. Darido is in the process of developing a new surgical procedure for the treatment of severe gastroparesis. The procedure is called Longitudinal Gastrectomy and Duodeno-Jejunostomy.
As you further investigate us, you will recognize the thoroughness of Houston Heartburn and reflux Center treatment Program, and you will come to appreciate why we do what we do. Our absolute commitment is to be there for you in your fight against acid reflux.

Guidelines for Surgical Treatment of Gastroesophageal Reflux Disease (GERD) Read more

#### Finance with Cherry
URL: https://houstonheartburn.com/finance-with-cherry/

#### Gastroparesis
There is no established treatment guideline for medically refractory gastroparesis. Gastric pacemaker, pyloromyotomy (endoscopic or laparoscopic), gastric bypass, and gastric resection are associated with limited success. For this reason, Dr. Darido at Houston Heartburn and Reflux Center, has developed a novel procedure to promote gastric emptying: An antrum preserving longitudinal gastrectomy along the Magenstrasse line.
The procedure is minimally invasive, safe, and associated with fast recovery. Most importantly, it has shown great efficacy in more than 50 patients. All patients experienced symptom relief immediately after surgery with complete resolution of nausea, vomiting and bloating. All patients regained the ability to tolerate regular diet.
Around 60% of the lateral aspect of the stomach is cut out to decrease stomach volume and promote gastric emptying. Surgery is performed as an outpatient procedure, and full activity is possible in one week.
Is Gastroparesis Surgery Appropriate for You?
At Houston Heartburn and Reflux Center, each patient receives thorough evaluation by Dr. Darido himself. Dr. Darido will recommend the most appropriate treatment for you. If you struggle with delayed gastric emptying, give us a call. We may be able to help you.
	
		
						I cannot express enough gratitude to Dr. Darido for saving my life. I was suffering from severe gastroparesis, and my condition had reached a point where I was ready to give up. I relied on a G/J Tube for daily venting and a Central Line for TPN, and I could barely get out of bed due to debilitating nausea and excruciating pain. Multiple doctors had told me there was nothing more they could do, and I was left to believe that my life was coming to an end.
In a desperate search for hope, I came across Dr. Darido through a Facebook support group and decided to seek his help as a last resort. From the moment I met him, I knew I was in the right hands. He performed surgery, and almost immediately, I began to feel better.
Over time, my improvement has been nothing short of miraculous. My G/J Tube was removed, followed by my Central Line, and just this week, a follow-up test confirmed that my gastroparesis is completely gone. After almost five years, I can eat and drink again. Four months post-op, I feel 20 years younger and am back to living a life that is enjoyable and full of joy.
Dr. Darido&#8217;s expertise, compassion, and dedication gave me back the life I thought I had lost. I wholeheartedly recommend him to anyone facing similar challenges. He truly is a life-saver.
Mindy L		
			
	
		
						I am a 40 year old mom of 4. I had surgery for gastroparesis and GERD about 10 months ago. I found Dr. Darido online and did lots of research before decided to meet with him and get surgery done. I traveled from Missouri to Texas because there is no one in my area that would do a surgery like Dr. Darido. It was well worth the time, travel, and money. I have had another gastric emptying test and my gastroparesis is gone! I don&#8217;t have GERD or any heartburn anymore. I am totally back to living my life and feeling great. I was told there was no way to cure gastroparesis. I couldn&#8217;t imagine living like that the rest of my life. Dr. Darido is a miracle worker. He gave me quality of life again.
Jessie C		
			
	
		
						I want to start by saying, I struggled with Gastroparesis and GERD for what seemed like forever. It was terrible everyday vommiting, nausea, bloating, pain. It made life miserable and I was at my end. I saw a review on Dr. Darido and decided to investigate further. I quickly realized the incredible talents of this man. I setup a consultation, had all my records faxed, and within a 2 weeks was scheduled for surgery. I had his novel procedure Antrum perserving longitudinal gastrectomy done as well as a Hiatal Hernia repair. I no longer struggle with gastroparesis, and my stomach emptying has normalized. He saved my life. If you struggle with gastroparesis don’t think its over! Dr. Darido can help you! He was bery caring after the procedure and has checked on me almost daily. This man is a blessing!
Benjamin Wilson		
			
	
		
						Dr. Darido saved my life. I have severe gastroparesis and have struggled with extreme bloating/stomach distention, pain, nausea with vomiting, unable to eat&#8230; this was what I dealt with every day&#8230; it wasn’t a life, it was a struggle to live. Dr. Darido performed a specialized surgical technique That he created specifically for those with gastroparesis. My stomach is no longer distended, no nausea or vomiting, and I can actually eat!!! For the first time in a long time I am excited for what the future brings!
Adrien Whatley		
			
	
		
						I am forever grateful for Dr. Darido! I had been told there was nothing that could be done for my gastroparesis. I traveled to Houston from Alabama. After all the necessary tests, Dr. Darido told me he could help me. I had a partial gastrectomy and 10-weeks later I feel like a new person! All my post-op tests are normal! This surgery changed my life! Thank you so much!
Allyson P		
			

Gastroparesis Blog Articles	
		
						Best Treatment for Hiatal Hernia and Diabetic GastroparesisMay 19, 2025		
			
	
		
						Gastroparesis, Hiatal Hernia, Heartburn and Gastric PacemakerFebruary 4, 2025		
			
	
		
						Gastroparesis Severity ScoreJuly 16, 2024		
			
	
		
						Is It GERD or Gastroparesis?April 9, 2023		
			
	
		
						My Gastroparesis Is Worse after TIFMarch 20, 2023		
			
	
		
						Gastroparesis, PPIs, and HeartburnNovember 28, 2022		
			
	
		
						Nissen Fundoplication and GastroparesisAugust 25, 2022		
			
	
		
						Bile Reflux and GastroparesisJune 17, 2022		
			
	
		
						Can COVID Infection Cause Gastroparesis?January 9, 2022		
			
	
		
						Gastroparesis in the Setting of Previous PyloromyotomyNovember 12, 2021		
			
	
		
			
		
	
				
				
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#### Gastroparesis Surgery
There is no established treatment guideline for medically refractory gastroparesis. Gastric pacemaker, pyloromyotomy (endoscopic or laparoscopic), gastric bypass, and gastric resection are associated with limited success. For this reason, Dr. Darido at Houston Heartburn and Reflux Center, has developped a novel procedure to promote gastric emptying: An antrum preserving longitudinal gastrectomy.
The procedure is minimally invasive, safe, and associated with fast recovery. Most importantly, it has shown great efficacy in more than 50 patients. All patients experienced symptom relief immediately after surgery with complete resolution of nausea, vomiting and bloating.
Around 40% of the lateral aspect of the stomach is cut out to decrease stomach volume and promote gastric emptying. Surgery is performed as an outpatient procedure, and full activity is possible in one week.
Is Gastroparesis Surgery Appropriate for You?
At Houston Heartburn and Reflux Center, each patient receives thorough evaluation by Dr. Darido himself. Dr. Darido will recommend the most appropriate treatment for you. If you struggle with delayed gastric emptying, give us a call. We may be able to help you.
Patient Testimonials
	
		
						I cannot express enough gratitude to Dr. Darido for saving my life. I was suffering from severe gastroparesis, and my condition had reached a point where I was ready to give up. I relied on a G/J Tube for daily venting and a Central Line for TPN, and I could barely get out of bed due to debilitating nausea and excruciating pain. Multiple doctors had told me there was nothing more they could do, and I was left to believe that my life was coming to an end.
In a desperate search for hope, I came across Dr. Darido through a Facebook support group and decided to seek his help as a last resort. From the moment I met him, I knew I was in the right hands. He performed surgery, and almost immediately, I began to feel better.
Over time, my improvement has been nothing short of miraculous. My G/J Tube was removed, followed by my Central Line, and just this week, a follow-up test confirmed that my gastroparesis is completely gone. After almost five years, I can eat and drink again. Four months post-op, I feel 20 years younger and am back to living a life that is enjoyable and full of joy.
Dr. Darido&#8217;s expertise, compassion, and dedication gave me back the life I thought I had lost. I wholeheartedly recommend him to anyone facing similar challenges. He truly is a life-saver.
Mindy L		
			
	
		
			
		
	
		
	Gastroparesis FAQ’s
What is gastroparesis?
Gastroparesis is a condition where the stomach empties food more slowly than normal without any physical blockage, leading to early fullness, nausea, bloating, and vomiting.
What causes gastroparesis?
Causes include:

Diabetes
Prior stomach or esophageal surgery
Viral infections
Certain medications (especially narcotics)
Neurological or connective tissue disorders
Idiopathic causes (unknown origin)

What is medically refractory gastroparesis?
Medically refractory gastroparesis occurs when symptoms are no longer controlled with dietary changes and medications
What is the best treatment for medically refractory gastroparesis?
Currently, there is no surgical treatment guideline for medically refractory gastroparesis. Several procedures have been developed to help alleviate symptoms

Endoscopic therapy: G-POEM for patients unresponsive to medications
Gastric electrical stimulation: For severe nausea and vomiting
Botox injections: Temporary relief in select cases
Gastric bypass: Most of the stomach is bypassed like what is offered for weight loss

Which procedure did Dr Darido develop for gastroparesis?
Dr Darido, at Houston heartburn and Reflux Center, developed APLG (antrum preserving longitudinal gastrectomy) to promote gastric emptying in medically refractory gastroparesis cases. The procedure is currently considered experimental. However, it is less invasive and safer than gastric bypass. It is more reliable than G-POEM and gastric pacing and results so far have been very promising.

Related Articles
	
		
						Best Treatment for Hiatal Hernia and Diabetic GastroparesisMay 19, 2025		
			
	
		
						Gastroparesis, Hiatal Hernia, Heartburn and Gastric PacemakerFebruary 4, 2025		
			
	
		
						Gastroparesis Severity ScoreJuly 16, 2024		
			
	
		
						Is It GERD or Gastroparesis?April 9, 2023		
			
	
		
						My Gastroparesis Is Worse after TIFMarch 20, 2023		
			
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#### GERD Treatment
What is GERD and how does it relate to heartburn?
GERD, or gastro-esophageal reflux disease, occurs when stomach acid repeatedly backs up, or refluxes, into the esophagus. GERD is also known as acid reflux disease. Heartburn is a burning sensation below the breastbone area. Heartburn is a common symptom of GERD.
It is estimated that one million people in the Houston area alone suffer from heartburn. Around 50 million US adults have heartburn several times weekly. You are not alone. At Houston Heartburn and Reflux Center we help you take control of your disease and gain your life back.
The Symptoms that say you have GERD
GERD varies widely from person to person by presenting different symptoms, precipitated by different triggers, and occurring at different times of the day. Heartburn is the classic symptom of acid reflux. Severe heartburn may cause chest pain. Acid reflux can reach the upper esophagus and neck area leading to sour mouth taste, sore throat, dry cough, and hoarseness. Other symptoms of acid reflux include regurgitation of food or acid when you hiccup, burp, bend over, or lie down. Certain “Alarm Symptoms” should be taken very seriously, including difficulty swallowing which could signal esophageal cancer or chest pain related to an evolving cardiac event.
What causes GERD?
The stomach normally produces acid to help digest food. GERD occurs when the valve (lower esophageal sphincter) between the stomach and esophagus loses its ability to function as a barrier. When acid refluxes into the esophagus it results in a painful burning sensation called heartburn. Other causes for acid reflux include poor esophageal motility and delayed gastric emptying also known as gastroparesis.
What causes the valve to malfunction?
Many factors contribute to the gastro-esophageal valve malfunction. Overeating, alcohol, cigarette smoking, hiatal hernia, pregnancy and chemicals in certain foods are significant factors that affect the ability of the lower esophageal sphincter to hold acid down in the stomach. When the valve is mildly damaged, you may experience only mild reflux. The more the LES weakens, the more often you will experience reflux symptoms. And the more you reflux, the weaker the valve becomes. It is a vicious circle.
Concerned about your heartburn related GERD or acid reflux ?
GERD does not get better by itself. It is a long-term condition that affects your quality of life, health and longevity. Take Control and contact Houston Heartburn and Reflux Center today to seek a comprehensive heartburn evaluation and treatment.
Heartburn and Acid Reflux FAQ’s
What is heartburn?
Heartburn is a burning sensation behind the breastbone that may move upward toward the throat.
Does heartburn come from the heart?
No. Heartburn is not a heart problem. However, heartburn and heart attacks can feel similar, so severe or new chest pain should always be evaluated immediately.
What causes heartburn?
Heartburn occurs when acid splashes from the stomach into the esophagus through a weakened antireflux barrier. It is the most common symptom of GERD.
What helps with a sudden heartburn attack?
Over-the-counter antacids like Tums, Rolaids, or Maalox can neutralize acid quickly and provide fast relief.
What’s the difference between acid reflux and GERD?
The terms are often used interchangeably. GERD refers to chronic acid reflux caused by a weak antireflux barrier, allowing stomach contents to rise into the esophagus.
What are the 4 stages of GERD?

Stage 1: Mild symptoms once or twice a month
Stage 2: Weekly symptoms controlled with medications
Stage 3: Severe symptoms poorly controlled with medications
Stage 4: Complications such as Barrett’s esophagus, a precancerous condition

What are the symptoms of acid reflux?
Common: heartburn
Other symptoms: bloating, burping, chest pain, regurgitation, throat clearing, globus sensation, facial congestion, sore throat, bad breath, tooth erosion, hoarseness, voice fatigue, wheezing, shortness of breath.
Does acid reflux cause cancer?
Yes. Chronic acid reflux is the only known risk factor for Barrett’s esophagus, a precursor for esophageal cancer.
Who is the best acid reflux specialist in Houston?
The best specialists are those who focus exclusively on the diagnosis and comprehensive management of GERD. Houston Heartburn and Reflux Center, led by Dr. Elias Darido, provides specialized evaluation and treatment tailored to each patient.

#### Get Started
Comprehensive Heartburn &amp; Acid Reflux Treatment Starts Here
At the Houston Heartburn and Reflux Center, our goal is to offer a comprehensive approach to treating your Heartburn condition. We take pride in offering a customized treatment plan for all our patients.
To schedule your appointment, please call us at 832-945-8717

Our Mission
We aim to provide a comprehensive and compassionate treatment plan to all of our patients. Reflux disease is a chronic and progressive condition with serious long-term consequences. We know that each patient is unique and one pill does not fit all. Our mission at Houston Heartburn and Reflux Center is to educate, treat, and prevent.
Why Choose Houston Heartburn and Reflux Center?

Houston’s Top Heartburn and Reflux experts
Comprehensive approach to heartburn and reflux disease
State of the art Acid reflux solutions
Covered By Most Insurance Plans

#### Guideline to GERD Management
Dr. Darido’s approach to Heartburn and Acid Reflux Management
Download your FREE copy of our informational booklet on managing heartburn and acid reflux.  In this informative guide, you will learn about:

Dr. Elias Darido: Houston&#8217;s most recognized Acid Reflux specialist
What is GERD?
GERD Stages
GERD and Diet
What to eat? When to eat? How much to eat? When you have acid reflux
The latest technologies in GERD management
Acid reflux diagnosis using smart pills
Esophageal function evaluation using manometry
Esophageal evaluation using endoscopy
Minimally invasive solutions for GERD
Nissen fundoplication procedure

Dr. Elias Darido – Houston Heartburn and Reflux Specialist
“Proper diagnosis and effective heartburn treatment “ is the vision of Dr. Elias Darido, founder of Houston Heartburn and Reflux Center. In today’s healthcare environment, there is much more to offer to control gastro-esophageal acid reflux disease (GERD). Many physicians have adopted a treatment model based on anti-reflux medications, typically Proton Pump Inhibitors (PPIs) like Nexium, Dexilant and Prevacid. Unfortunately, PPIs don’t cure the problem of acid reflux but rather control the symptoms. Symptom control alone is, however, not enough when managing a chronic and progressive condition like gastro-esophageal reflux disease (GERD). At Houston Heartburn and Reflux Center, Dr. Darido aspires to provide a comprehensive care for GERD patients in Houston and around the world.
Download your free guide today!

#### Heartburn
URL: https://houstonheartburn.com/heartburn/

#### Heartburn Surgery
Have Severe Heartburn and Nothing is Working?
We Offer Heartburn Surgery with 100% Success Rate

  The experts at Houston Heartburn and Reflux Center are now offering a safe, effective, reliable, and durable treatment for GERD
Get Help NowPeople from all over the US travel to Houston Heartburn for their Heartburn surgery.

We provide a fast-track approach where your first appointment can be virtual. Acid reflux testing followed by surgery, all performed in less than one week.
Dr. Elias Darido, MD, FACS
Dr. Darido has been in practice for 15 years and has maintained a strong safety record. As a Fellow of the American College of Surgeons, he specializes in a wide range of advanced laparoscopic surgeries involving the gastro-esophageal area. He is especially focused on the upper part of the stomach also called gastric fundus. The gastric fundus is used to wrap the esophagus to prevent acid reflux, a procedure called Nissen Fundoplication. Dr. Darido has successfully performed more than 1,000 Heartburn surgeries in his career.
Heartburn Surgery by the numbers

At Houston Heartburn &amp; Reflux Center, we do one thing and one thing only, but we do it right!
15-Star Reviews1Success Rate1Hour Surgery100’s
Of Satisfied Patients
95%
Would Recommend Someone
1-2 Hour
Procedure Duration
The ProblemWeak valve (anti-reflux barrier) between esophagus and stomach results in acid reflux.
Our SolutionNissen Fundoplication safely and reliably restores the anti-reflux barrier.
Our Outcome99.9% success rate &amp; hundreds of satisfied patients.
The CaveatComprehensive acid reflux testing. Proper patient selection. Flawless surgery technique.
Patient Testimonial

This review is long overdue. My Mom had surgery in February 2021 with Dr. Darido (Laparoscopic Nissen Fundoplication). His hard work and expertise has completely changed my Mom’s life. We were at a point where we were hopeless &#8211; she had horrible symptoms EVERY DAY from her severe GERD. Many doctors were not helpful &#8211; they kept changing medications, thinking it would help FOR YEARS. We kept going back with issues and she was getting worse. My sister did some research and found Dr. Darido and his team. I wish we found him sooner. We traveled from Las Vegas, NV &#8211; he did testing on a Tuesday and did surgery on a Thursday. I cannot thank Dr. Darido and his team enough, THANK YOU SO MUCH! You gave me my Mom back. We appreciate everything you guys did, and we plan on coming back for future follow-ups if necessary. THANK YOU.
Sheila H
Read more reviews!
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						Is Nissen Fundoplication the Best We Can Do?September 18, 2025		
			
	
		
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						Most Frequent Nissen Fundoplication Question: Am I Able to Vomit After Surgery?September 12, 2025		
			
	
		
			
		
	
				
				
					
				
				
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#### Home
Houston&#8217;s Most Experienced Acid Reflux SurgeonLife is too short to live with HeartburnWe do one thing and one thing only. But we do it right.Get Relief Now!We provide comprehensive and compassionate treatment to all patients suffering from reflux disease and heartburn. Reflux disease is a chronic and progressive condition with serious long-term consequences. We know that each patient is unique and one pill does not fit all. Our mission at Houston Heartburn and Reflux Center is to educate, treat, and prevent.
Houston Heartburn &amp; Acid Reflux Specialist
Having completed over 1,000 successful Nissen Fundoplication surgeries, the practice of Dr. Elias Darido is dedicated to the treatment of heartburn, acid reflux surgery, and other disorders affecting the gastro-esophageal area. Dr. Darido’s goal is to provide excellence in treatment along with compassionate care in a highly specialized treatment center. Dr. Darido is renowned for his expertise in advanced minimally invasive reflux surgery (small incision surgery). Read more.
Dr. Elias Darido discusses Acid Reflux Management
As a leading local expert of Heartburn and Acid Reflux, Dr. Darido explains Acid Reflux management at a recent program of Great Day Houston with Deborah Duncan.
The Symptoms that indicate Acid Reflux
Acid reflux varies widely from person to person by presenting different symptoms, precipitated by different triggers, and occurring at different times of the day. Heartburn is the classic symptom of acid reflux. Severe heartburn may cause chest pain. Acid reflux can reach the upper esophagus and neck area leading to sour mouth taste, sore throat, dry cough, and hoarseness.  Read more
A Unique Center Dedicated For Acid Reflux Treatment
Our Patients Say it Best!
We’re appreciative of our patient testimonials!
Read ReviewsLatest Blog Posts
	
		
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#### Home
We provide comprehensive and compassionate treatment to all patients suffering from reflux disease and heartburn.  Reflux disease is a chronic and progressive condition with serious long-term consequences. We know that each patient is unique and one pill does not fit all. Our mission at Houston Heartburn and Reflux Center is to educate, treat, and prevent.
Houston Acid Reflux Specialist
Houston Heartburn and Reflux Center, the practice of Dr. Elias Darido, is dedicated to the treatment of heartburn, acid reflux surgery, and other disorders affecting the gastro-esophageal area. Dr. Darido’s goal is to provide excellence in treatment along with compassionate care in a highly specialized treatment center.  Dr. Darido is renowned for his expertise in advanced minimally invasive reflux surgery (small incision surgery).  Read more.
Dr. Elias Darido discusses Acid Reflux Management
Watch Dr. Darido explain Acid Reflux management at a recent program of Great Day Houston with Deborah Duncan.
The Symptoms that indicate Acid Reflux
Acid reflux varies widely from person to person by presenting different symptoms, precipitated by different triggers, and occurring at different times of the day. Heartburn is the classic symptom of acid reflux. Severe heartburn may cause chest pain. Acid reflux can reach the upper esophagus and neck area leading to sour mouth taste, sore throat, dry cough, and hoarseness.
Read more
Our Patients Say it Best!
We’re appreciative of our patient testimonials! See all reviews here.
832-945-8717
Request a FREE Consultation with Dr. Elias Darido
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#### Houston Heartburn - Espanol
Dr. Elias DaridoPuede llamar para una consulta professional
(832) 945-8717Sobre centro de Reflujo y Acidez Stomacal de Houston
Houston Heartburn ofrece tratamiento integral y compasivo a todos los pacientes que sufren de enfermedad de reflujo y acidez estomacal. Enfermedad por reflujo es una condición crónica y progresiva con graves consecuencias a largo plazo. Sabemos que cada paciente es único y una pastilla no vale para todo. Nuestra misión en el centro de reflujo y acidez estomacal de Houston es educar, tratar y prevenir.
Condiciones tratadas

Reflujo ácido
GERD
Hernia de hiato
Acalasia
Enfermedad de úlcera péptica
Gastroparesia
Y muchos más

Síntomas comunes

Ardor de estómago
Regurgitación de alimentos
Dolor abdominal
Tos crónica
Dolor de garganta
Eructos excesivos
Asfixia por la noche

Beneficios exclusivos

Procedimiento mínimamente invasivo
Un dolor mínimo
Rápida recuperación
Noche de hospital
Enfoque seguro
Los resultados del artículo

Por los números
100’s
De pacientes satisfechos
95%
Recomendaría a alguien
1-2 Horas
La duración del procedimiento
Testimonios de Pacientes
No puedo expresar que emocionada estoy que encontré Houston Heartburn &amp; Reflux Center y más con, el Dr. Darido! Yo había sufrido con reflujo y lo que me pareció simplemente GERD, durante más de 30 años. No sabía que allí era cualquier opción! Sólo le siguen apareciendo medicamentos de venta libre reflujo y llamar buena. Dr. Darido me consiguió para la prueba inmediatamente después de nuestro primer encuentro y descubrió una hernia hiatal muy grande. La cirugía subsecuente ha sido un tremendo éxitoso, por lo men’s no tengo nigun symptoma de acidez, y no me di cuenta hasta que se corrigió, cuánto esta hernia había afectado mi vida y la salud!
Sharon T.
Houston pirosis y reflujo centro, la práctica del Dr. Elias Darido, está dedicada al tratamiento de la acidez gástrica, cirugía de reflujo ácido y otros trastornos que afectan el área gastro-del esófago. Nuestra meta es proveer excelencia en el tratamiento y cuidado compasivo en un centro de tratamiento especializado. Es conocido por su experiencia en cirugía mínimamente invasiva reflujo.

#### Houston Heartburn Blog
FiltersCategoryResetAchalasiaAcid Reflux and Gastric BypassAcid reflux and Lap BandAcid Reflux BlogAcid Reflux TestingAsthma and HeartburnBarrett&#039;s EsophagusBile RefluxEsophagus MotilityGallbladderGastroparesisGERD and DietGERD and Gallbladder DiseaseGERD and Gastric Sleeve SurgeryGERD and StressGERD Treatment OptionsHiatal Hernia SurgeryLINX™LPRNissen FundoplicationPPI Side EffectsQuestion of the weekRevision Acid Reflux SurgerySchatzki&#039;s RingStrettaTIFApplyFilters	
		
						Is It a Sluggish Gallbladder or GERD?2 Jan at 7:46 am		
			
	
		
						GERD-Friendly Holiday Meal GuideDecember 1, 2025		
			
	
		
						H Pylori vs GERDOctober 27, 2025		
			
	
		
						Refluxstop™: A Novel Procedure for Acid RefluxSeptember 22, 2025		
			
	
		
						Is Nissen Fundoplication the Best We Can Do?September 18, 2025		
			
	
		
						Nissen Fundoplication vs NexiumSeptember 15, 2025		
			
	
		
						Most Frequent Nissen Fundoplication Question: Am I Able to Vomit After Surgery?September 12, 2025		
			
	
		
						Best Treatment for Hiatal Hernia and Diabetic GastroparesisMay 19, 2025		
			
	
		
						Heartburn: A Warning Sign for Barrett’s EsophagusMay 16, 2025		
			
	
		
						Gastroparesis, Hiatal Hernia, Heartburn and Gastric PacemakerFebruary 4, 2025		
			
	
		
						Life Is Too Short to Live with HeartburnNovember 19, 2024		
			
	
		
						Hiatal Hernia Repair Without FundoplicationNovember 11, 2024		
			
	
		
						Laryngopharyngeal Reflux (LPR) &#8211; A Patient&#8217;s ReviewOctober 24, 2024		
			
	
		
						Diet After Nissen Fundoplication Surgery and Hiatal Hernia RepairAugust 25, 2024		
			
	
		
						Persistent Gastroparesis Following LINX™ to Nissen Fundoplication ConversionAugust 10, 2024		
			
	
		
						Nissen Fundoplication Versus PPIs for Barrett’s EsophagusJuly 25, 2024		
			
	
		
						Gastroparesis Severity ScoreJuly 16, 2024		
			
	
		
						Is Ozempic Exacerbating Your Heartburn?June 9, 2024		
			
	
		
						Hiatal Hernia Repair with or without MeshFebruary 9, 2024		
			
	
		
						New GERD Surgery: BICORN ProcedureNovember 30, 2023		
			
	
		
						Twisted Nissen FundoplicationNovember 6, 2023		
			
	
		
						LINX™ Surgery effect on esophageal motility and complianceOctober 3, 2023		
			
	
		
						Does Anxiety Affect Nissen Fundoplication Outcome?June 8, 2023		
			
	
		
						Chronic Sinusitis, Balloon Sinuplasty and GERDMay 15, 2023		
			
	
		
						Slipped Stomach Through LINX™ DeviceApril 20, 2023		
			
	
		
						Is It GERD or Gastroparesis?April 9, 2023		
			
	
		
						My Gastroparesis Is Worse after TIFMarch 20, 2023		
			
	
		
						Long term Dysphagia after LINX™ SurgeryFebruary 6, 2023		
			
	
		
						How Long Does Acid Reflux Last?December 31, 2022		
			
	
		
						Bile reflux after Nissen FundoplicationDecember 8, 2022		
			
	
		
						LINX™ Removal without Nissen FundoplicationNovember 29, 2022		
			
	
		
						Gastroparesis, PPIs, and HeartburnNovember 28, 2022		
			
	
		
						Can Gastritis Cause Acid Reflux?November 21, 2022		
			
	
		
						Can I Vomit after Nissen Fundoplication?November 17, 2022		
			
	
		
						LINX™ Surgery and Vagus Nerve IrritationNovember 15, 2022		
			
	
		
						Nissen Fundoplication and GastroparesisAugust 25, 2022		
			
	
		
						Nissen Fundoplication and Eosinophilic EsophagitisAugust 19, 2022		
			
	
		
						Bile Reflux and GastroparesisJune 17, 2022		
			
	
		
						Toupet vs Nissen Fundoplication: A New StudyMay 14, 2022		
			
	
		
						How Do I Strengthen My Acid Reflux Barrier?February 27, 2022		
			
	
		
						Dysphagia and Persistent Acid Reflux after LINX™ SurgeryFebruary 14, 2022		
			
	
		
						Endoscopic Acid Reflux Treatment: StrettaFebruary 4, 2022		
			
	
		
						High Dose Proton Pump Inhibitors, Are They Any Good?January 31, 2022		
			
	
		
						Can COVID Infection Cause Gastroparesis?January 9, 2022		
			
	
		
						Is Nissen Fundoplication Covered by My Insurance?December 28, 2021		
			
	
		
						Acid Reflux and Heartburn with Keto DietDecember 22, 2021		
			
	
		
						How Long Does LINX™ Surgery Last?December 7, 2021		
			
	
		
						Gastroparesis in the Setting of Previous PyloromyotomyNovember 12, 2021		
			
	
		
						Nissen Fundoplication Surgery in CanadaNovember 6, 2021		
			
	
		
						Nissen Fundoplication Surgery in HoustonOctober 21, 2021		
			
	
		
						Medium Size Hiatal Hernia: Now What?September 14, 2021		
			
	
		
						Heartburn, Acid Reflux and Gastroparesis Treatment in San Antonio, TXAugust 28, 2021		
			
	
		
						Nissen Fundoplication and Esophageal CancerAugust 22, 2021		
			
	
		
						Advanced Acid Reflux and FastingAugust 12, 2021		
			
	
		
						Can I Have LINX™ Surgery for GERD and Gastroparesis?July 28, 2021		
			
	
		
						Robotic Hiatal Hernia Repair and Nissen FundoplicationJuly 27, 2021		
			
	
		
						Heartburn during PregnancyJuly 19, 2021		
			
	
		
						Does LINX™ Surgery Cause Bloating and Fullness?July 4, 2021		
			
	
		
						Best Diet for Acid Reflux and HeartburnJune 12, 2021		
			
	
		
						LINX™ Surgery and PregnancyJune 5, 2021		
			
	
		
						How Successful Is Heartburn Surgery in The Setting of Gastroparesis?May 31, 2021		
			
	
		
						How Successful Is Nissen Fundoplication?May 27, 2021		
			
	
		
						LINX™ for Acid Reflux: Side Effects and Esophageal Wall ComplianceMay 25, 2021		
			
	
		
						LINX™ Device Placement after Sleeve GastrectomyMay 16, 2021		
			
	
		
						What Happens after LINX™ Surgery?May 10, 2021		
			
	
		
						LINX™ Revision Surgery: Nissen or Toupet FundoplicationMay 1, 2021		
			
	
		
						Is GERD a Curable Disease?April 28, 2021		
			
	
		
						Bloating after Nissen FundoplicationApril 13, 2021		
			
	
		
						Chest pain after Toupet FundoplicationMarch 30, 2021		
			
	
		
						Properly Performed Nissen FundoplicationMarch 20, 2021		
			
	
		
						Gallbladder, Digestive or Acid Reflux Issues?March 2, 2021		
			
	
		
						Slipped Nissen WrapFebruary 21, 2021		
			
	
		
						Hiatal Hernia Repair: When and Why?February 13, 2021		
			
	
		
						Acid Reflux: Try Not to Self-Treat Heartburn in 2021January 3, 2021		
			
	
		
						Nissen Fundoplication: Before or After Pregnancy?December 10, 2020		
			
	
		
						Gastroparesis after LINX™ Removal SurgeryNovember 11, 2020		
			
	
		
						Nissen Fundoplication: Where You Go First MattersOctober 30, 2020		
			
	
		
						Do I have Gastroparesis or Heartburn?October 19, 2020		
			
	
		
						PPIs, Diabetes and GastroparesisOctober 11, 2020		
			
	
		
						Nissen Fundoplication and Gallbladder FunctionOctober 6, 2020		
			
	
		
						Are You Taking Omeprazole after Nissen fundoplication?September 11, 2020		
			
	
		
						How Do We Evaluate Dysphagia at Houston Heartburn and Reflux Center?September 9, 2020		
			
	
		
						Are Proton-Pump Inhibitors Associated with Increased COVID-19 Risk?August 21, 2020		
			
	
		
						Does Acid Reflux Develop Suddenly?August 19, 2020		
			
	
		
						Dor vs Nissen Fundoplication for Heartburn TreatmentAugust 6, 2020		
			
	
		
						Nissen Conversion to Toupet FundoplicationJuly 30, 2020		
			
	
		
						Nissen Fundoplication, Dysphagia and GastroparesisJuly 23, 2020		
			
	
		
						Achalasia, Hiatal Hernia and HeartburnJuly 14, 2020		
			
	
		
						Late Complications of LINX™ Device for Heartburn TreatmentJuly 6, 2020		
			
	
		
						Chronic Cough and Acid RefluxJune 28, 2020		
			
	
		
						Esophageal Hypersensitivity and Nissen FundoplicationJune 22, 2020		
			
	
		
						Hiatal Hernia Repair in the Setting of GastroparesisJune 17, 2020		
			
	
		
						Is It Gallbladder Disease, Heartburn or Acid Reflux?June 9, 2020		
			
	
		
						Does Gastroparesis Cause Heartburn?May 25, 2020		
			
	
		
						LINX™ Surgery Complications and Efficacy: A New StudyMay 20, 2020		
			
	
		
						Do Hiatal Hernias Increase in Size with Weightlifting?May 17, 2020		
			
	
		
						POEM after Toupet Fundoplication for AchalasiaApril 27, 2020		
			
	
		
						The Tight Nissen FundoplicationApril 20, 2020		
			
	
		
						Hoarse voice, chronic cough, pneumonia and GERDApril 3, 2020		
			
	
		
						Will TIF Procedure Correct or Cure Dysphagia?March 20, 2020		
			
	
		
						Houston Heartburn Advocates Social DistancingMarch 15, 2020		
			
	
		
						Heartburn Medications after Nissen FundoplicationFebruary 26, 2020		
			
	
		
						Persistent Heartburn after Nissen FundoplicationFebruary 23, 2020		
			
	
		
						Heartburn, Esophageal Spasm, and Functional DyspepsiaFebruary 11, 2020		
			
	
		
						Pain Following LINX™ Surgery for HeartburnFebruary 7, 2020		
			
	
		
						Burping after Nissen fundoplicationJanuary 29, 2020		
			
	
		
						Acid Reflux and Heartburn after Lap Band RemovalJanuary 23, 2020		
			
	
		
						100% Houston Heartburn Patient SatisfactionJanuary 18, 2020		
			
	
		
						Fundoplication Surgery for Heartburn treatmentJanuary 11, 2020		
			
	
		
						Difficulty Swallowing with LINX™ Surgery for HeartburnDecember 23, 2019		
			
	
		
						Acid reflux and Heartburn after Gastric Bypass SurgeryDecember 17, 2019		
			
	
		
						Acid Reflux and Pain with Swallowing after Nissen fundoplicationDecember 9, 2019		
			
	
		
						Gastroparesis in the Setting of PancreatitisNovember 20, 2019		
			
	
		
						LINX™ for Heartburn and Difficulty SwallowingOctober 12, 2019		
			
	
		
						Probiotics for GERD and HeartburnOctober 4, 2019		
			
	
		
						Best Treatment for Gastroparesis?September 21, 2019		
			
	
		
						A Cancer Linked Compound Found in ZantacSeptember 15, 2019		
			
	
		
						Are You a Candidate for Nissen Fundoplication?September 11, 2019		
			
	
		
						Does LINX™ Device Cause Chest Pain?September 5, 2019		
			
	
		
						Long-Term Poorly Understood LINX™ ComplicationsSeptember 2, 2019		
			
	
		
						Nissen Fundoplication and DysphagiaAugust 19, 2019		
			
	
		
						Nissen Fundoplication Improves Quality of LifeAugust 3, 2019		
			
	
		
						Vagal Nerve Integrity Testing, Nissen Fundoplication and GastroparesisJuly 23, 2019		
			
	
		
						Esophageal Kinking, Heartburn and Hiatal Hernia SurgeryJuly 14, 2019		
			
	
		
						Severe Acid Reflux Disease and GastroparesisJuly 8, 2019		
			
	
		
						Contraindications for Nissen Fundoplication SurgeryJune 22, 2019		
			
	
		
						Acid and Bile Reflux following Stomach SurgeryJune 10, 2019		
			
	
		
						Your Diet after Nissen FundoplicationMay 19, 2019		
			
	
		
						When to Stop PPIs after Nissen Fundoplication?May 16, 2019		
			
	
		
						Nissen Fundoplication for Acid Reflux treatmentMay 3, 2019		
			
	
		
						Heartburn Pills Raise Risk of Liver CancerApril 23, 2019		
			
	
		
						Heartburn, Smoking and Barrett’s EsophagusApril 15, 2019		
			
	
		
						GERD Surgery in Houston: When and Where?April 9, 2019		
			
	
		
						Are You Looking for a Heartburn Specialist in Houston?April 3, 2019		
			
	
		
						Does Fasting Increase Heartburn?April 2, 2019		
			
	
		
						Endoflip for Heartburn Treatment: Tailoring the FundoplicationMarch 28, 2019		
			
	
		
						Nissen vs Toupet Fundoplication for Heartburn TreatmentMarch 20, 2019		
			
	
		
						LINX™ for Heartburn: A Dysphagia ProblemMarch 11, 2019		
			
	
		
						Functional Heartburn and Heartburn PillsMarch 8, 2019		
			
	
		
						Heartburn, Acid Reflux and Nissen Fundoplication RevisionMarch 3, 2019		
			
	
		
						Does Coffee Give You Heartburn?February 27, 2019		
			
	
		
						Robotic Hiatal Hernia Repair for Severe HeartburnFebruary 26, 2019		
			
	
		
						Heartburn Treatment Options in HoustonFebruary 20, 2019		
			
	
		
						Heartburn Pills: The Good, Bad, and UglyFebruary 18, 2019		
			
	
		
						Valentine’s Day, Chocolate, and HeartburnFebruary 13, 2019		
			
	
		
						Heartburn Treatment after Sleeve GastrectomyFebruary 12, 2019		
			
	
		
						Weight Lifting, Hiatal Hernia, and Acid RefluxFebruary 11, 2019		
			
	
		
						Heartburn Moment of the Super BowlFebruary 3, 2019		
			
	
		
						Manometry and Heartburn Treatment in HoustonFebruary 2, 2019		
			
	
		
						Gastric Diverticulum and Heartburn TreatmentJanuary 31, 2019		
			
	
		
						Gastroparesis following Nissen Fundoplication SurgeryJanuary 21, 2019		
			
	
		
						LINX™ Acid Reflux Surgery Revision in HoustonJanuary 14, 2019		
			
	
		
						New Year, New Resolution: Take control of Your HeartburnJanuary 2, 2019		
			
	
		
						Tis The Season for Heartburn in HoustonDecember 22, 2018		
			
	
		
						Jackhammer EsophagusDecember 12, 2018		
			
	
		
						Can Chewing Tobacco Cause Heartburn?November 28, 2018		
			
	
		
						Is Thanksgiving Synonymous with Heartburn for You?November 21, 2018		
			
	
		
						National GERD Awareness Week: Why Does It Matter?November 18, 2018		
			
	
		
						Bile Reflux after Mini Gastric Bypass Revision to Roux-en-Y Gastric BypassOctober 31, 2018		
			
	
		
						LINX™ Device for Heartburn Treatment in HoustonOctober 26, 2018		
			
	
		
						Fundoplication, Hiatal Hernia Repair and Esophageal DysmotilityOctober 19, 2018		
			
	
		
						Cough and sore throat: Cold, Flu or Acid Reflux?October 16, 2018		
			
	
		
						Case of the Week: Recurrent Gastroparesis SymptomsOctober 10, 2018		
			
	
		
						Is Keto Diet a Good Option for GERD Patients?October 1, 2018		
			
	
		
						Recurrent Heartburn after Nissen FundoplicationSeptember 15, 2018		
			
	
		
						Acid reflux, Bile reflux, and Gallbladder SurgeryJuly 29, 2018		
			
	
		
						Hiatal Hernia Repair Improves Quality of LifeJuly 15, 2018		
			
	
		
						GERD after Sleeve GastrectomyJuly 2, 2018		
			
	
		
						Question of the Week: Revision Nissen Fundoplication &#8211; Options and OutcomesJune 22, 2018		
			
	
		
						Question of The Week: Band to Sleeve RevisionJune 15, 2018		
			
	
		
						Question of the week: Severe Cough after Gastric Band RemovalJune 7, 2018		
			
	
		
						Nissen Fundoplication DurabilityMay 31, 2018		
			
	
		
						Acid Reflux after Gastric Bypass SurgeryMay 13, 2018		
			
	
		
						Esophageal Hypersensitivity and GERDApril 30, 2018		
			
	
		
						Transoral Incisionless Fundoplication after Band RemovalMarch 31, 2018		
			
	
		
						Question of the Week: Partial vs Full Fundoplication for GERDMarch 12, 2018		
			
	
		
						Slipped Nissen Fundoplication: Why Do We Still See It?March 3, 2018		
			
	
		
						PPI Use and Lupus erythematosusFebruary 12, 2018		
			
	
		
						Question of the week: GERD Treatment OptionsJanuary 21, 2018		
			
	
		
						Question of the week regarding Barrett’s esophagusJanuary 8, 2018		
			
	
		
						Are You Contemplating Sleeve Surgery in 2018?January 7, 2018		
			
	
		
						Why Is GERD a Progressive Disease?December 11, 2017		
			
	
		
						Proton Pump Inhibitors Mortality RiskOctober 13, 2017		
			
	
		
						Revision Acid Reflux SurgerySeptember 11, 2017		
			
	
		
						Hurricane Harvey: Together We HealSeptember 2, 2017		
			
	
		
						Heller Myotomy Versus Peroral Endoscopic Myotomy (POEM)July 15, 2017		
			
	
		
						Severe GERD after Gastric Bypass SurgeryJune 26, 2017		
			
	
		
						Does Nissen Fundoplication Affect the Magenstrasse?June 13, 2017		
			
	
		
						Question of the Week: Can TIF procedure be done in cases of esophageal dysmotility due to scleroderma?June 4, 2017		
			
	
		
						Long-Term effect of Nissen Fundoplication on Barrett’s EsophagusMay 21, 2017		
			
	
		
						A New Hybrid Procedure for GERD: Anterior Fundoplication-SleeveMay 15, 2017		
			
	
		
						Superior Mesenteric Artery Syndrome, Gastroparesis and GERDApril 27, 2017		
			
	
		
						Question of the Week: Do PPIs Cause Delayed Gastric Emptying?April 25, 2017		
			
	
		
						Incomplete Symptom Resolution Following Heller Myotomy for AchalasiaApril 4, 2017		
			
	
		
						Does Bile Reflux Increase Following Cholecystectomy?March 13, 2017		
			
	
		
						Laparoscopic vs Open GERD SurgeryMarch 9, 2017		
			
	
		
						Revision Hiatal Hernia SurgeryMarch 6, 2017		
			
	
		
						What Gastroparesis Patients Go ThroughFebruary 27, 2017		
			
	
		
						End Stage Acid Reflux DiseaseFebruary 22, 2017		
			
	
		
						Hiatal hernia Repair, Nissen Fundoplication and the Hypercontractile EsophagusFebruary 12, 2017		
			
	
		
						Demystifying the Role of Hiatal Hernia Repair and Nissen Fundoplication SurgeryFebruary 10, 2017		
			
	
		
						Achalasia and Obesity: Changing Treatment ParadigmsFebruary 7, 2017		
			
	
		
						The History of Nissen Fundoplication: What Can We Learn?January 27, 2017		
			
	
		
						Gastroparesis Following Nissen Fundoplication and Hiatal Hernia RepairJanuary 15, 2017		
			
	
		
						Biologic Mesh Use in Hiatal Hernia RepairDecember 7, 2016		
			
	
		
						Thanksgiving Dinner and GERDNovember 24, 2016		
			
	
		
						A GERD Patient with An Asymptomatic Peptic StrictureNovember 17, 2016		
			
	
		
						The Effect of Gastric Sleeve Surgery on CoughNovember 14, 2016		
			
	
		
						Toupet or Nissen Fundoplication for GERD Treatment?October 31, 2016		
			
	
		
						Chest Pain Two Years Following LINX™ SurgeryOctober 19, 2016		
			
	
		
						The Short Esophagus in the Era of PPIsSeptember 26, 2016		
			
	
		
						Esophageal Outflow Obstruction and GERDSeptember 4, 2016		
			
	
		
						An Evidence Based Approach to the Treatment of GERDAugust 21, 2016		
			
	
		
						Budd-Chiari Syndrome, GERD, Schatzki’s ring, and Nissen SurgeryAugust 9, 2016		
			
	
		
						Overweight and Suffering from Heartburn? We Can HelpJuly 27, 2016		
			
	
		
						Can Distal Esophageal Narrowing Be A Solution For GERD?July 22, 2016		
			
	
		
						Case of The Week: Perfect TIF &#8211; Severe RefluxJuly 6, 2016		
			
	
		
						EndoStim: A Novel Anti-Reflux ProcedureJune 27, 2016		
			
	
		
						Schatzki’s Ring: A Variant Form of GERDJune 9, 2016		
			
	
		
						The Nissen Fundoplication: A Reliable Cure For Acid RefluxMay 29, 2016		
			
	
		
						You Age Faster With Proton Pump InhibitorsMay 20, 2016		
			
	
		
						Case of the Week: GERD, Silent Reflux and LaryngospasmMay 9, 2016		
			
	
		
						Gastroparesis and PyloroplastyApril 18, 2016		
			
	
		
						The Unbeatable 360 Degree Fundoplication Also Known As Nissen ProcedureApril 11, 2016		
			
	
		
						I Have a Lap Band: Should I Be Taking Antacid Medications?March 11, 2016		
			
	
		
						Severe Acid Reflux Disease After Lap Band RemovalMarch 1, 2016		
			
	
		
						Proton Pump Inhibitors Delay Gastric EmptyingFebruary 15, 2016		
			
	
		
						Gastroparesis vs GERD: When You Have A Hammer In Your Hand, Everything Around You Starts Looking Like A NailJanuary 27, 2016		
			
	
		
						2016 Resolution: Cure Acid Reflux Disease in HoustonJanuary 14, 2016		
			
	
		
						Stretta: A Naive Approach to a Complex ProblemDecember 29, 2015		
			
	
		
						Houston Acid Reflux Specialist Replies to Your Question: Does Eggnog make my Heartburn worse?December 24, 2015		
			
	
		
						Gastroparesis from an Acid Reflux Specialist PerspectiveDecember 10, 2015		
			
	
		
						Obesity and GERD: Weight loss surgery optionsDecember 1, 2015		
			
	
		
						Acid Reflux on Thanksgiving Day: Do You Need To Call An Acid Reflux Specialist?November 25, 2015		
			
	
		
						The Link Between Heartburn and GeneticsNovember 19, 2015		
			
	
		
						Tips on How to Avoid Heartburn While You HikeNovember 17, 2015		
			
	
		
						GERD: An Intriguing Disease On the RiseNovember 11, 2015		
			
	
		
						Using a Food Journal to Fight HeartburnNovember 10, 2015		
			
	
		
						The Three Ws of HeartburnNovember 6, 2015		
			
	
		
						Why Heartburn Medications Don’t Always WorkNovember 5, 2015		
			
	
		
						How to Make a Heartburn-Free SandwichNovember 3, 2015		
			
	
		
						Can Vinegar Help Your Heartburn?November 1, 2015		
			
	
		
						Mid Afternoon Snacks for Heartburn SufferersOctober 29, 2015		
			
	
		
						Avoiding Heartburn on HalloweenOctober 28, 2015		
			
	
		
						Top Tips to Calm Your Stress LevelsOctober 27, 2015		
			
	
		
						Facts on Spicy FoodsOctober 15, 2015		
			
	
		
						Facts on Citrus FoodsOctober 13, 2015		
			
	
		
						Daily Habits to Reduce HeartburnOctober 4, 2015		
			
	
		
						Can Breathing Reduce Heartburn?October 1, 2015		
			
	
		
						Shocking Heartburn TriggersSeptember 29, 2015		
			
	
		
						The Difference Between Acid Reflux, Heartburn, and GERDSeptember 24, 2015		
			
	
		
						Who Gets Barrett’s Esophagus?September 22, 2015		
			
	
		
						Facts about CaffeineSeptember 20, 2015		
			
	
		
						Heartburn and the Challenges You Face While Eating OutSeptember 18, 2015		
			
	
		
						Pregnancy, In Vitro Fertilization &#038; GERDSeptember 13, 2015		
			
	
		
						What Happens if You Ignore GERD Symptoms?September 6, 2015		
			
	
		
						Quick Tips to Avoid Heartburn While ExercisingSeptember 4, 2015		
			
	
		
						Which Health Conditions Cause Heartburn?September 2, 2015		
			
	
		
						Be Aware of Drugs That Cause HeartburnAugust 29, 2015		
			
	
		
						Why Breakfast is the Best Time to Take Heartburn MedicationAugust 26, 2015		
			
	
		
						Unsuspecting Acid Reflux SymptomsAugust 22, 2015		
			
	
		
						Can the Heat Make Heartburn Worse?August 18, 2015		
			
	
		
						When Heartburn Goes From Problem to Serious ConditionAugust 13, 2015		
			
	
		
						Three Health Risks of a High Acidic DietAugust 11, 2015		
			
	
		
						Side Effects of Heartburn Oral MedicationAugust 9, 2015		
			
	
		
						GERD – Fast FactsAugust 6, 2015		
			
	
		
						Is Your Job Giving You Heartburn?August 4, 2015		
			
	
		
						How Heartburn Treatment Makes for a Great Reality Television ShowAugust 1, 2015		
			
	
		
						Heartburn at Night: Food and Drinks to AvoidJuly 29, 2015		
			
	
		
						Gaining a Better Understanding of Acid Reflux in 2015July 27, 2015		
			
	
		
						Top 5 Foods That Ease Your HeartburnJuly 24, 2015		
			
	
		
						National Refreshment Day – Which Drinks Will Ease Your Heartburn Today?July 23, 2015		
			
	
		
						Will Relieving Your Heartburn Create More Problems?July 21, 2015		
			
	
		
						What to Take When Heartburn StrikesJuly 14, 2015		
			
	
		
						Avoiding HeartburnJuly 10, 2015		
			
	
		
						Heartburn and PregnancyJuly 8, 2015		
			
	
		
						Is Your Sleeve Surgery Causing Acid Reflux?July 2, 2015		
			
	
		
						Here&#8217;s To HeartburnJune 30, 2015		
			
	
		
						Heartburn 101June 26, 2015		
			
	
		
						Natural Ways To Help HeartburnJune 24, 2015		
			
	
		
						Heartburn and AnxietyJune 19, 2015		
			
	
		
						Achalasia TreatmentJune 17, 2015		
			
	
		
						Top Heartburn MythsJune 9, 2015		
			
	
		
						Can Your Beverage Cause Your Heartburn?June 5, 2015		
			
	
		
						Power Foods to Fight AcidityJune 1, 2015		
			
	
		
						Is Your Lap Band Causing You Heartburn?May 29, 2015		
			
	
		
						Is Your Weight Causing Heartburn?May 23, 2015		
			
	
		
						Do Allergies Cause GERD?May 22, 2015		
			
	
		
						Cut the Cravings, Cut the HeartburnMay 20, 2015		
			
	
		
						Heartburn on VacationMay 16, 2015		
			
	
		
						Chronic Cough, Throat Clearing, and Hoarse Voice: Are these symptoms related to acid reflux?May 14, 2015		
			
	
		
						Recipes for HeartburnMay 13, 2015		
			
	
		
						&#8220;Don&#8217;t Super Size Me&#8221;&#8230;Control Your Portion Size and Stop Acid RefluxMay 12, 2015		
			
	
		
						How to Control Your Heartburn with Portion ControlMay 8, 2015		
			
	
		
						Top Summer Foods That Trigger HeartburnMay 6, 2015		
			
	
		
						My PCP Told Me I Have GERD; Now What?May 4, 2015		
			
	
		
						TIF: Is It Really A Fundoplication Surgery?April 27, 2015		
			
	
		
						What Triggers Esophagitis?April 22, 2015		
			
	
		
						What is a Hiatal Hernia?April 17, 2015		
			
	
		
						Your Diet Matters If You Have Acid Reflux DiseaseApril 10, 2015		
			
	
		
						Acid Reflux Treatment in Houston: What is Esophageal Manometry?April 6, 2015		
			
	
		
						Stop Heartburn: Why Test for Acid Reflux?March 29, 2015		
			
	
		
						How Does Nissen Fundoplication Work to Stop Acid Reflux?March 22, 2015		
			
	
		
						Long-Term Consequences of Untreated Acid RefluxMarch 14, 2015		
			
	
		
						Acid Reflux Surgery: Are You A Candidate?March 10, 2015		
			
	
		
						Houston, we have a heartburn problemMarch 7, 2015		
			
	
		
						Nighttime Heartburn is Keeping Houston AwakeMarch 4, 2015		
			
	
		
						You’ve been diagnosed with Barrett’s now what?February 28, 2015		
			
	
		
						How do I select a heartburn and reflux doctor in Houston, TX?February 17, 2015		
			
	
		
						Lifestyle Changes To Keep Heartburn At BayFebruary 8, 2015		
			
[vc_wp_posts number="5"][vc_wp_categories options="count"]

#### Houston Heartburn Nobilis Health - Radio
Imagine a Life without Heartburn
Houston Heartburn and Reflux Center offers comprehensive and compassionate treatment to all patients suffering from reflux disease and heartburn. Reflux disease is a chronic and progressive condition with serious long-term consequences. We know that each patient is unique and one pill does not fit all. Our mission is to educate, treat, and prevent.
[vc_raw_html]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[/vc_raw_html]Conditions Treated

Acid reflux
GERD
Hiatal hernia
Achalasia
Peptic ulcer disease
Gastroparesis
And many more

Common Symptoms

Heartburn
Food regurgitation
Abdominal pain
Chronic cough
Sore throat
Excessive burping
Choking at night

Unique Benefits

Minimally invasive procedure
Minimal pain
Fast recovery
Overnight hospital stay
Safe approach
Durable results

By the numbers
100’s
Of Satisfied Patients
95%
Would Recommend Someone
1-2 Hour
Procedure Duration
Patient Testimonial: Houston Heartburn
I can’t properly express how thrilled I am that I found Houston Heartburn and Reflux, and more specifically, Dr. Darido! I had suffered with reflux and what I thought was simply GERD, for over 30 years. I just didn’t know there was any option! I would just continue popping OTC reflux medications and call it good. Dr. Darido got me in for testing immediately following our first meeting and discovered a very large hiatal hernia. The subsequent surgery has been a tremendous success, to say the least. Not a sign of any heartburn and I didn’t realize until it was corrected, how much this hernia had affected my life and health!
Sharon T.

#### Houston Heartburn Nobilis Health - Start
Imagine a Life without Heartburn
Houston Heartburn and Reflux Center offers comprehensive and compassionate treatment to all patients suffering from reflux disease and heartburn. Reflux disease is a chronic and progressive condition with serious long-term consequences. We know that each patient is unique and one pill does not fit all. Our mission is to educate, treat, and prevent.
[vc_raw_html]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[/vc_raw_html]Conditions Treated

Acid reflux
GERD
Hiatal hernia
Achalasia
Peptic ulcer disease
Gastroparesis
And many more

Common Symptoms

Heartburn
Food regurgitation
Abdominal pain
Chronic cough
Sore throat
Excessive burping
Choking at night

Unique Benefits

Minimally invasive procedure
Minimal pain
Fast recovery
Overnight hospital stay
Safe approach
Durable results

By the numbers
100’s
Of Satisfied Patients
95%
Would Recommend Someone
1-2 Hour
Procedure Duration
Patient Testimonial: Houston Heartburn
I can’t properly express how thrilled I am that I found Houston Heartburn and Reflux, and more specifically, Dr. Darido! I had suffered with reflux and what I thought was simply GERD, for over 30 years. I just didn’t know there was any option! I would just continue popping OTC reflux medications and call it good. Dr. Darido got me in for testing immediately following our first meeting and discovered a very large hiatal hernia. The subsequent surgery has been a tremendous success, to say the least. Not a sign of any heartburn and I didn’t realize until it was corrected, how much this hernia had affected my life and health!
Sharon T.

#### Houston Heartburn Nobilis Health - TV
Imagine a Life without Heartburn
Houston Heartburn and Reflux Center offers comprehensive and compassionate treatment to all patients suffering from reflux disease and heartburn. Reflux disease is a chronic and progressive condition with serious long-term consequences. We know that each patient is unique and one pill does not fit all. Our mission is to educate, treat, and prevent.
[vc_raw_html]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[/vc_raw_html]Conditions Treated

Acid reflux
GERD
Hiatal hernia
Achalasia
Peptic ulcer disease
Gastroparesis
And many more

Common Symptoms

Heartburn
Food regurgitation
Abdominal pain
Chronic cough
Sore throat
Excessive burping
Choking at night

Unique Benefits

Minimally invasive procedure
Minimal pain
Fast recovery
Overnight hospital stay
Safe approach
Durable results

By the numbers
100’s
Of Satisfied Patients
95%
Would Recommend Someone
1-2 Hour
Procedure Duration
Patient Testimonial: Houston Heartburn
I can’t properly express how thrilled I am that I found Houston Heartburn and Reflux, and more specifically, Dr. Darido! I had suffered with reflux and what I thought was simply GERD, for over 30 years. I just didn’t know there was any option! I would just continue popping OTC reflux medications and call it good. Dr. Darido got me in for testing immediately following our first meeting and discovered a very large hiatal hernia. The subsequent surgery has been a tremendous success, to say the least. Not a sign of any heartburn and I didn’t realize until it was corrected, how much this hernia had affected my life and health!
Sharon T.

#### Imagine a Life without Heartburn
Imagine a Life without Heartburn
Houston Heartburn and Reflux Center offers comprehensive and compassionate treatment to all patients suffering from reflux disease and heartburn. Reflux disease is a chronic and progressive condition with serious long-term consequences. We know that each patient is unique and one pill does not fit all. Our mission is to educate, treat, and prevent.
[vc_raw_html]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[/vc_raw_html]Conditions Treated

Acid reflux
GERD
Hiatal hernia
Achalasia
Peptic ulcer disease
Gastroparesis
And many more

Common Symptoms

Heartburn
Food regurgitation
Abdominal pain
Chronic cough
Sore throat
Excessive burping
Choking at night

Unique Benefits

Minimally invasive procedure
Minimal pain
Fast recovery
Overnight hospital stay
Safe approach
Durable results

By the numbers
100’s
Of Satisfied Patients
95%
Would Recommend Someone
1-2 Hour
Procedure Duration
Patient Testimonial: Houston Heartburn
I can’t properly express how thrilled I am that I found Houston Heartburn and Reflux, and more specifically, Dr. Darido! I had suffered with reflux and what I thought was simply GERD, for over 30 years. I just didn’t know there was any option! I would just continue popping OTC reflux medications and call it good. Dr. Darido got me in for testing immediately following our first meeting and discovered a very large hiatal hernia. The subsequent surgery has been a tremendous success, to say the least. Not a sign of any heartburn and I didn’t realize until it was corrected, how much this hernia had affected my life and health!
Sharon T.

#### Insurance & Financing
Does Insurance Cover Acid Reflux Surgery?
Your medical insurance covers hiatal hernia repair and Nissen fundoplication. Our insurance specialists at Houston heartburn and Reflux Center Center help you answer all your financial questions.
Please contact us at 832-945-8717 or fill the form on this page and a member of our staff will contact you shortly.
The self-pay cost for hiatal hernia repair and Nissen fundoplication in Houston ranges from $13,000 to $16,000 depending on the hospital and your length of stay.
Do you offer financing options for acid reflux surgery?
Yes, we offer convenient financing through these companies:
Cherry

Prosper Healthcare

Care Credit

*Subject to credit approval. Minimum monthly payments required. Visit www.carecredit.com for details.
United Medical Credit

#### Laparoscopic Heller Myotomy
Laparoscopic Heller Myotomy
The esophagus (food pipe) passes food from mouth to stomach. A valve in the esophagus called lower esophageal sphincter (LES), located at the junction of stomach and esophagus, allows passage of food to stomach, and prevents backflow of stomach acid into esophagus.
Achalasia and gastroesophageal junction outflow obstruction (EGJOO) are two rare conditions where the lower esophageal sphincter fails to relax during food swallowing. Thus, food and liquids get stuck in the esophagus and patients report difficulty swallowing, also known as dysphagia.
Both achalasia and EGJOO are chronic and progressive diseases. Most patients, especially in the early stages of disease, present with heartburn rather than dysphagia. It is very important to differentiate between gastro-esophageal reflux disease (GERD) and achalasia or EGJOO because treatment is different.
High resolution esophageal manometry, an outpatient test performed by Dr. Darido, confirms the diagnosis of both achalasia and EGJOO.
There are 3 types of achalasia:
Type 1 achalasia shows complete absence of esophageal motility and a persistently high-pressure area at the level of the non-relaxing lower esophageal sphincter.
Type 2 achalasia shows a non-relaxing lower esophageal sphincter and pan-esophageal pressurization. The same pressure is found throughout the esophagus at the same time.
Type 3 achalasia is characterized by diffuse esophageal spastic contractions in addition to a non-relaxing lower esophageal sphincter.
Treatment for both achalasia and EGJOO aims at relaxing the tight lower esophageal sphincter to facilitate swallowing. Laparoscopic Heller myotomy and Toupet Funoplication is the traditional surgical procedure to relax the tight lower esophageal sphincter muscle. Surgery is performed under general anesthesia and through tiny incisions. The thick outer muscle tissue between the esophagus and stomach is cut open. This is followed by a partial fundoplication (wrapping the stomach around the esophagus) to prevent acid reflux.  Surgery allows food and liquid to pass easily into stomach. More than 90% of patients report resolution and improvement in their symptoms.
Other modalities for achalasia and EGJOO treatment include:

Endoscopic balloon dilation of the lower esophageal sphincter
Endoscopic Botox injection of the lower esophageal sphincter
POEM procedure or Endoscopic lower esophageal sphincter excision.

With each procedure, the desired outcome must be balanced with risks, side effects, and durability.
Is Heller Myotomy surgery appropriate for you?
At Houston Heartburn and Reflux Center, each patient receives a thorough evaluation for heartburn and acid reflux. Depending on your condition, Dr. Darido will recommend the appropriate treatment that suits you best. Achalasia is a chronic and progressive condition and treatment is tailored accordingly.

Patient Testimonials

#### Laparoscopic Hiatal Hernia Repair
The esophagus or food pipe crosses from the chest into the abdomen through an opening in the breathing muscle called hiatus. A hiatal hernia develops when the hiatal opening enlarges leading to herniation of the stomach into the chest. There are four types of hiatal hernia:

Type one hiatal hernia is the most common and is also called sliding hiatal hernia. The gastroesophageal junction moves up and down the hiatus.

Type two hiatal hernia occurs when the gastro-esophageal junction remains attached at the level of the hiatus and the stomach herniates into the chest.

Type three hiatal hernia is characterized by displacement of the gastric fundus and body into the chest.

Type four hiatal hernia is like type three hiatal hernia with other organs such as colon and spleen herniating into the chest.

Both type 3 and 4 hiatal hernias are associated with gastric volvulus. Gastric volvulus occurs when the stomach twist on itself in the chest leading to obstruction and decreased gastric blood perfusion. Patients present with acute onset pain and bloating without being able to vomit. This condition is considered is a surgical emergency requiring immediate repair to prevent gastric tissue necrosis, sepsis and possible death.
Hiatal hernias are associated with acid reflux disease. Laparoscopic hiatal hernia repair is an important component of any anti-reflux surgery. Hiatal hernia surgery consists of

Hernia sac complete dissection and resection
Distal esophagus mobilization
Crural muscle approximation with pledgeted sutures
Occasional use of biologic mesh to reinforce the repair

The minimally invasive procedure performed through tiny incisions allows for fast recovery with minimal post-operative pain and complications. When performed by an experienced surgeon, laparoscopic hiatal hernia repair is safe and effective. It allows the restoration of normal anatomy, thereby eliminating the risk of stomach strangulation, acid reflux, and difficulty swallowing food.
Download a case study presentation on Hiatal Hernia Repair by Dr. Elias Darido

Is hiatal hernia surgery appropriate for you?
At Houston Heartburn and Reflux Center, Dr. Darido offers a thorough and comprehensive evaluation for hiatal hernia and acid reflux patients. Depending on your reflux stage, Dr. Darido will recommend the appropriate treatment that suits you best.
Hiatal Hernia FAQ’s
What is a hiatal hernia?
A hiatal hernia occurs when the upper part of the stomach slips upward through the diaphragm into the chest. This displacement weakens the antireflux barrier and commonly contributes to GERD.
How many types of hiatal hernias exist?
There are two types:

Type I (Sliding): Most common; the junction between the esophagus and stomach slides upward. Type hernias are typically associated with GERD
Type II (Paraesophageal): Part of the stomach herniates alongside the esophagus through a weak hiatus. These hernias are typically associated with discomfort and difficulty swallowing as well as risk of stomach volvulus. Stomach volvulus occurs when the stomach twists on itself leading to obstruction.

How is hiatal hernia repair done?
Repair is performed laparoscopically or robotically through small incisions. The stomach is returned to the abdomen, the hiatus is tightened, and the antireflux valve is restored (often with Nissen fundoplication).
Who should have their hiatal hernia repaired?
Candidates include patients with:

Chronic GERD symptoms
Poorly controlled symptoms despite medications
Esophagitis or Barrett’s esophagus
Paraesophageal hernia causing discomfort, shortness of breath, anemia, or early fullness
Large hernias at risk of twisting or obstruction

Who is the best hiatal hernia surgeon in Houston?
Surgeons specializing in GERD and hiatal hernia repair with high surgical volumes achieve the best outcomes. Dr. Elias Darido at Houston Heartburn and Reflux Center focuses exclusively on these conditions and offers extensive expertise.

Blog topics on Hiatal Hernia

	
		
						Hiatal Hernia Repair Without FundoplicationNovember 11, 2024		
			
	
		
						Hiatal Hernia Repair with or without MeshFebruary 9, 2024		
			
	
		
						How Long Does Acid Reflux Last?December 31, 2022		
			
	
		
						Medium Size Hiatal Hernia: Now What?September 14, 2021		
			
Load More

#### Laparoscopic Nissen Fundoplication
&nbsp;
Nissen Fundoplication Surgery
in Houston
Medically reviewed by Dr Elias Darido, MD, FACS — Board-Certified Foregut Surgeon and Acid Reflux Specialist
Last updated: March, 2026
Dr. Elias Darido has performed over 1,000 Nissen fundoplication and hiatal hernia procedures and specializes exclusively in acid reflux management at Houston Heartburn and Reflux Center. He is fellowship-trained in foregut surgery and has been recognized as a leading acid reflux expert in the greater Houston area.

&nbsp;
What Is a Nissen Fundoplication?
A properly performed Nissen fundoplication surgery, for the right patient, is the most reliable treatment for gastroesophageal reflux disease (GERD). During the procedure, the upper portion of the stomach (called the fundus) is wrapped around the lower esophageal sphincter (LES) to create a new, functional anti-reflux valve. Nissen fundoplication restores the anti-reflux barrier to stop any reflux from the stomach into the esophagus.
The procedure is named after Dr. Rudolf Nissen, who first performed it in 1955. It remains the gold standard surgical treatment for chronic acid reflux that hasn&#8217;t responded to medication, and it is one of the most studied anti-reflux operations in the world.
At Houston Heartburn, Dr. Darido performs Nissen fundoplication using a minimally invasive laparoscopic or robotic-assisted approach, which means smaller incisions, less pain, and a faster recovery compared to traditional open surgery.
Key facts at a glance:

Procedure time: Typically 60-90 minutes
Hospital stay: Usually same-day or one overnight stay
Return to work: Most patients return within 1 week
Return to full activity: 4-6 weeks
Long-term success rate: 85-95% of patients report significant improvement or complete resolution of reflux symptoms. At Houston Heartburn and Reflux Center, our estimated long-term success rate is higher than 95% due to meticulous surgical technique and proper patient selection.

&nbsp;
How Does a Nissen Fundoplication Work?
The root cause of GERD is a weak or dysfunctional anti-reflux barrier. The anti-reflux barrier is a complex anatomical and physiological structure that prevents stomach content from escaping up into the esophagus. The most commonly known component of the anti-reflux barrier is the lower esophageal sphincter &#8211; a muscular ring that acts as a one-way valve between your esophagus and stomach. When this valve doesn&#8217;t close properly, stomach acid flows back into the esophagus, causing heartburn, regurgitation, and over time, potential damage to the esophageal lining.
The remaining anatomical components of the anti-reflux barrier are:

Right and left crura of diaphragm: these are the muscular edges of the opening in the breathing muscle that support the lower esophageal sphincter.
Phrenoesophageal membrane: the fibrous tissue that connects the lower esophageal sphincter to the crura
Angle of His: the sharp angulation between esophagus and stomach creates a flap that closes the bottom of the esophagus in response to increased stomach pressure.

The physiological component of the anti-reflux barrier include but are not limited to:

Esophagus peristalsis: the ability of the esophagus to flush acid down back into stomach
Stomach emptying: the ability of the stomach to empty its content into intestines at a certain rate
TLESR: transient lower esophagus sphincter relaxation is the ability of the stomach to release gas without acid reflux

A Nissen fundoplication not only works by anatomically reconstructing the anti-reflux barrier but also by restoring its physiological components. Herein lies the superior reliability of this procedure in stopping acid reflux. Contrary to popular belief, Nissen fundoplication does not simply mechanically reinforce a weak valve. Rather, Nissen fundoplication restores a complex anatomical and physiological structure to completely stop any reflux from the stomach into the esophagus. Here&#8217;s what happens step by step:

Small incisions are made. The surgeon creates 5 small incisions (each about 5-12mm) in the upper abdomen. A camera and surgical instruments are inserted through these ports.
The hiatal hernia is repaired (if present). The majority of patients with chronic GERD also have a hiatal hernia, where the upper stomach pushes through the diaphragm. The surgeon pulls the stomach back into its proper position below the diaphragm and closes the widened hiatal opening with sutures. This step is critical and often overlooked &#8212; a fundoplication without proper hernia repair is a common reason for surgical failure.
The fundus is wrapped around the esophagus. The upper portion of the stomach is wrapped 360 degrees around the lower esophagus. This wrap creates minimal external pressure on the lower esophageal sphincter. The 360 degree wrap is indeed constructed short and floppy to avoid difficulty swallowing after surgery. The wrap stops reflux by restoring the angle of His, improving stomach emptying, improving esophagus peristalsis and preventing acid reflux with TLESR (transient lower esophagus sphincter relaxation).

The wrap is secured. The wrap is sutured in place to ensure it maintains its position long-term.

The result is a one way valve that functions the way a healthy anti-reflux barrier should &#8212; allowing food and liquid to pass down into the stomach while preventing acid, bile and digestive enzymes from traveling back up.

&nbsp;
Nissen Fundoplication vs. Toupet Fundoplication: What&#8217;s the Difference?
At Houston Heartburn and Reflux Center, Dr. Darido performs both Nissen (360-degree) and Toupet (270-degree partial) fundoplications. The choice between them depends on your specific anatomy and diagnostic results.

Nissen (360°)
Toupet (270°)

Wrap
Full wrap around the esophagus
Partial wrap (back of the esophagus)

Best for
Patients with normal esophageal motility and classic GERD symptoms
Patients with weak esophageal motility or swallowing concerns

Acid reflux control
Excellent reflux control
Excellent reflux control

Dysphagia risk
Low
Low

Ability to burp/vomit
More restricted
More preserved

Durability
High
Lower

&nbsp;
Both procedures are highly effective. The decision is primarily made based on intra-operative findings. Very few patients have a small stomach fundus that does not allow for a floppy 360 degree wrap to be constructed. Your pre-operative workup, particularly esophageal motility testing (manometry), which measures how well your esophagus contracts and moves food, also determines the type of wrap you get. If you have weak or absent motility, a partial wrap is offered. This is why a thorough diagnostic evaluation before surgery matters &#8212; not every patient should receive the same type of wrap.

&nbsp;
Download a case study presentation by Dr. Elias Darido

&nbsp;

&nbsp;
Who Is a Candidate for Nissen Fundoplication?
Not every patient with heartburn needs surgery. A Nissen fundoplication is typically recommended when:

Medications are no longer effective. You&#8217;ve been taking proton pump inhibitors (PPIs) like omeprazole or pantoprazole for years and your symptoms are breaking through, or your reflux has worsened despite medication.
You want to stop taking PPIs long-term. There is growing concern about the long-term side effects of PPIs, including bone density loss, kidney issues, and nutrient malabsorption. Many patients seek surgery specifically to eliminate their dependence on daily medication.
You have a large hiatal hernia contributing to your reflux. Hiatal hernias don&#8217;t respond to medication at all &#8212; they are a structural problem that requires a structural solution.
You have volume reflux or regurgitation. PPIs reduce acid production but don&#8217;t stop the physical backflow of stomach contents. If you experience regurgitation (food or liquid coming back up), medication alone won&#8217;t solve this.
You have extra-esophageal reflux symptoms. Chronic cough, hoarseness, throat clearing, asthma-like symptoms, or dental erosion caused by reflux often respond poorly to medication but improve significantly after fundoplication.
Objective testing confirms GERD. At Houston Heartburn and Reflux Center, we require objective diagnostic confirmation before recommending surgery. This includes an upper endoscopy (to assess the anatomy, esophagus lining inflammation, and rule out other conditions). In certain cases, we obtain ambulatory esophagus pH testing (to measure esophagus acid exposure over 4 days). If anti-reflux surgery is decided, esophageal manometry (to evaluate esophagus motility) is performed.

Who is NOT a candidate?

Patients whose symptoms are controlled well on medication and who are comfortable continuing medication long-term
Patients with certain esophageal motility disorders (such as achalasia) that require different surgical approaches
Patients with uncontrolled medical conditions that make general anesthesia high-risk
Patients whose testing does not confirm pathologic acid reflux (some patients have functional heartburn that won&#8217;t respond to fundoplication)
Patients with morbid obesity are better served with hiatal hernia repair and weight loss surgery

This is why proper pre-operative workup matters. Dr. Darido has seen many patients referred from other practices where surgery was recommended without adequate testing. At Houston Heartburn and Reflux Center, every surgical candidate completes a comprehensive evaluation before any procedure is discussed.

&nbsp;
The Pre-Operative Workup: What to Expect
A thorough evaluation for proper patient selection is what separates a successful outcome from a failed one. At Houston Heartburn and Reflux Center, the standard pre-surgical workup includes:
Upper Endoscopy (EGD) A scope is passed through the mouth to visually inspect the esophagus, stomach, and duodenum. This identifies the presence and size of a hiatal hernia, any esophageal damage (such as Barrett&#8217;s esophagus – a precancerous condition, or esophagitis), and rules out other conditions.
Esophageal Manometry A thin catheter is placed through the nose into the esophagus to measure the strength and coordination of esophageal contractions as well as lower esophagus sphincter pressure. This test determines whether a full Nissen wrap or a partial Toupet wrap is more appropriate for you.
pH Testing (pH Bravo capsule) A 96 hour acid monitoring study that measures how much acid is actually refluxing into your esophagus. This provides objective proof of GERD and helps predict how well surgery will work for you.
Barium Swallow (Upper GI Series) An X-ray study where you drink a contrast liquid while images are taken. This shows the size and position of a hiatal hernia and evaluates the anatomy of the esophagus and stomach.

&nbsp;
What Happens During Surgery: Step by Step
Before the procedure

You&#8217;ll stop all medications that thin the blood one week prior to surgery
Nothing to eat or drink after midnight the night before
Surgery is performed under general anesthesia

During the procedure

5 small incisions are made in the upper abdomen (the largest is typically 12mm). All incisions are infiltrated with long-acting numbing medications to decrease pain after surgery
Dr. Darido uses laparoscopic or robotic-assisted instruments with a high-definition camera
The hiatal hernia is repaired first, bringing the stomach back below the diaphragm
The fundus of the stomach is then wrapped around the lower esophagus and secured with sutures
The entire procedure typically takes 60-90 minutes

Immediately after

Most patients go home the same day or after one overnight observation
You&#8217;ll start on a liquid diet and gradually advance to soft foods over 2-4 weeks
Pain is typically managed with over-the-counter medications within a few days

&nbsp;
Recovery After Nissen Fundoplication
The First 2 Weeks

Diet: Clear liquids for the first day, progressing to full liquids like yogurt, Jello, and strained soups. Protein shakes are recommended. You can drink coffee or tea.
Activity: Light walking is encouraged immediately. Avoid lifting anything over 10-15 pounds.
Common experiences: Mild difficulty swallowing (expected and temporary), bloating, and some shoulder pain from the gas used during laparoscopic surgery.
Work: Most patients with desk jobs return to work within 5-7 days.

Weeks 2-4

Diet: Gradual transition to soft, pureed foods. Use a blender to pure ground meat, tuna, and chicken. Avoid bread, pasta, rice, and raw vegetables during this phase &#8212; these can be difficult to swallow while the surgical area is still swollen.
Activity: Gradual return to exercise. Walking, light jogging, and upper body movement can resume.
Swallowing: Any post-operative dysphagia (difficulty swallowing) typically resolves within 2-4 weeks after surgery as swelling decreases and the wrap settles.

Weeks 4-6

Diet: normal diet. Most patients are eating comfortably by week 4-6, though portion sizes may be smaller initially.
Activity: Avoid heavy weight lifting and core-intensive exercise till 6 weeks after surgery

6 Weeks and Beyond

Most patients are fully recovered and eating a normal diet
The majority of patients stop all reflux medications permanently
Follow-up appointment with Dr. Darido to evaluate outcomes

What about long-term side effects?

Gas bloat: Some patients experience increased bloating or difficulty belching in the first few months. This typically improves over time as the body adjusts to the new anatomy.
Difficulty vomiting: The fundoplication wrap makes it harder to vomit. Most patients view this as a minor inconvenience, but it&#8217;s important to be aware of.
Recurrence: In approximately 5-15% of patients, reflux symptoms may return over time. This can happen if the wrap loosens, slips, or if a hiatal hernia recurs. Revision surgery is possible in these cases.

&nbsp;
Success Rates and Long-Term Outcomes
Nissen fundoplication has been studied extensively for over 75 years. The research consistently shows:

85-95% of patients report significant improvement or complete resolution of heartburn and regurgitation symptoms. At Houston Heartburn and Reflux Center, our success rate is 100%
80-90% of patients are able to stop taking PPIs entirely after surgery. At Houston heartburn and Reflux Center, all patients stop PPIs after surgery
Patient satisfaction rates are consistently high in long-term follow-up studies. At Houston Heartburn and Reflux Center, we have performed more than 1,000 Nissen fundoplications and we have more than 1,000 satisfied patients.
Durability: The procedure maintains its effectiveness in the majority of patients at 10 and 20-year follow-up. At Houston Heartburn and Reflux Center, our Nissen Fundoplication durability is more than 99%

The strongest predictor of a good outcome is proper patient selection, thorough pre-operative testing, and flawless surgical technique. In expert hands, patients with objectively confirmed GERD, a clear anatomic defect (such as a hiatal hernia) or weak lower esophagus sphincter pressure on manometry, and symptom relief on PPIs tend to have the best surgical outcomes.

&nbsp;
Nissen Fundoplication Cost and Insurance
Nissen fundoplication is a medically necessary procedure for the treatment of GERD and is covered by most insurance plans. Coverage typically requires documentation of:

Failed or inadequate response to medical therapy (usually 3-6 months of PPI use)
Objective evidence of GERD (pH testing, endoscopy findings)
Presence of a hiatal hernia or anatomic defect

At Houston Heartburn and Reflux Center, our team handles insurance verification and prior authorization. We work with most major insurance carriers. If you&#8217;re unsure about your coverage, [contact our office] for a benefits check before your first appointment.
For self-pay patients, we offer transparent pricing and payment plan options. Please call (832) 945-8717 to discuss self-pay rates.

&nbsp;
Why Choose Houston Heartburn for Nissen Fundoplication
Specialized expertise. Unlike general surgeons who perform fundoplication occasionally, Dr. Darido focuses exclusively on foregut surgery &#8212; acid reflux, hiatal hernias, and esophageal conditions. This level of specialization translates to refined technique, fewer complications, and better outcomes.
Comprehensive diagnostic workup. Every patient undergoes objective testing before surgery is recommended. We don&#8217;t operate on patients who won&#8217;t benefit from surgery. This commitment to proper evaluation is why our outcomes consistently exceed national averages.
Revision surgery experience. Dr. Darido regularly treats patients whose previous fundoplication (performed elsewhere) has failed. This experience with complex, redo cases gives him a deep understanding of what makes a fundoplication succeed long-term and what causes them to fail.
High patient satisfaction.
Check out our reviews &amp; Testimonials&nbsp;

&nbsp;
Frequently Asked Questions
Is there a surgery for acid reflux?Yes. Acid reflux can be effectively treated with hiatal hernia repair and Nissen fundoplication. This combination restores the antireflux barrier and stops the backflow of acid, resolving symptoms such as heartburn and food regurgitation.
How reliable is Nissen fundoplication?When performed correctly by an experienced reflux specialist and offered to the right patient, Nissen fundoplication is the most reliable and durable treatment for GERD.
How safe is Nissen fundoplication?In expert hands, Nissen fundoplication is a very safe procedure with a complication rate of less than 1%.
Nissen fundoplication vs. PPIs – what’s the difference?Vomiting is less likely because the procedure creates a one-way valve: food enters the stomach, but stomach contents cannot reflux upward. If you develop food poisoning, the stomach empties its contents downward into the intestines without issue.
Can I belch after Nissen fundoplication?Belching is reduced because refluxing air upward becomes difficult. However, most patients burp less because they swallow less saliva and air once acid reflux is eliminated. As a result, bloating and excessive burping often improve significantly.
Will I lose weight after Nissen fundoplication?No. This is not a weight-loss procedure and does not reduce stomach size. Patients may lose a few pounds initially during recovery but typically return to baseline afterward.
How long does a Nissen fundoplication last?A well-performed Nissen fundoplication can last many years. Durability depends on surgeon skill, creating a tension-free repair, patient weight (BMI &gt; 35 decreases long-term success), and patient age.
What can I eat during recovery?Your esophagus becomes temporarily swollen, making the opening feel as narrow as a straw. A gradual diet helps healing:

Weeks 1&ndash;2: Full liquid diet
Weeks 3&ndash;4: Soft or pur&eacute;ed foods
After 4 weeks: Advance to a regular diet as tolerated

This staged plan reduces discomfort and protects the repair.
Who is the best Nissen fundoplication surgeon in Houston?The best surgeons are those who specialize in GERD and perform high volumes of antireflux procedures with proven outcomes. At Houston Heartburn and Reflux Center, Dr. Elias Darido focuses exclusively on GERD and hiatal hernia surgery, offering patients extensive expertise and individualized care.
Does insurance cover Nissen fundoplication?Yes. Insurance plans routinely cover this medically necessary surgery.

&nbsp;
Related Resources

Hiatal Hernia Surgery — Many fundoplication patients also require hiatal hernia repair
Toupet Fundoplication — Learn about the partial wrap alternative
LINX Procedure — A different surgical approach to treating GERD
Is GERD Curable? — Understanding your long-term treatment options
Diet After Fundoplication — What to eat during your recovery

&nbsp;
Ready to Find Out If Nissen Fundoplication Is Right for You?
Schedule a consultation with Dr. [Name] at Houston Heartburn. During your visit, we&#8217;ll review your medical history, discuss your symptoms, and determine whether additional testing or a surgical evaluation is the right next step.
Schedule Now
&nbsp;
Houston Heartburn serves patients throughout the Greater Houston area, including The Woodlands, Sugar Land, Katy, Pearland, and surrounding communities.

&nbsp;
About the Author
Dr. Elias Darido, MD, FACS
Dr. Elias Darido is a board-certified surgeon specializing exclusively in foregut surgery, including acid reflux, hiatal hernia repair, and esophageal conditions. He completed his fellowship in advanced laparoscopic foregut surgery at the University of North Carolina at Chapel Hill and has performed over 1,000 anti-reflux procedures. He is a member of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), the American College of Surgeons (ACS), and the American Society for Metabolic and Bariatric Surgery (ASMBS). Dr. Darido has published numerous peer-reviewed articles on foregut surgery and is a recognized expert in complex and revision anti-reflux surgery.
Read More
&nbsp;

&nbsp;
References

Gastro-Oesophageal Reflux Disease. Lancet. 2013. Bredenoord AJ, Pandolfino JE, Smout AJ.
The Contribution of Allison and Nissen to the Evolution of Hiatus Herniorrhaphy. Hernia: The Journal of Hernias and Abdominal Wall Surgery. 2001. Read RC.
ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease. The American Journal of Gastroenterology. 2021. Katz PO, Dunbar KB, Schnoll-Sussman FH, et al
Laparoscopic General Surgery. The New England Journal of Medicine. 1994. Soper NJ, Brunt LM, Kerbl K.
Indications, Benefits and Outcome of Laparoscopic Nissen Fundoplication. Digestive Diseases. 1996. Peters JH, DeMeester TR.
Comparison of Medical and Surgical Therapy for Complicated Gastroesophageal Reflux Disease in Veterans. The New England Journal of Medicine. 1992. Spechler SJ.
Nissen Fundoplication for Gastroesophageal Reflux Disease. Evaluation of Primary Repair in 100 Consecutive Patients. Annals of Surgery. 1986. DeMeester TR, Bonavina L, Albertucci M.
The Esophagogastric Junction. The New England Journal of Medicine. 1997. Mittal RK, Balaban DH.
Effect of Increased Intra-Abdominal Pressure on the Esophagogastric Junction: A Systematic Review. Journal of Clinical Gastroenterology. 2022. Siboni S, Bonavina L, Rogers BD, et al.
Current Concepts of the Antireflux Barrier. Gastroenterology Clinics of North America. 1990. Mittal RK.
Pathophysiology of Gastroesophageal Reflux Disease. World Journal of Surgery. 2017. Menezes MA, Herbella FAM.&nbsp;
Long-Term (&gt;10 Years) Outcomes of Laparoscopic Nissen Fundoplication: A Systematic Review and Meta-Analysis. Annals of Surgery. 2025. Principe J, Angeramo CA, Barros Sosa J, et al.New
Long-Term (15-Year) Objective Evaluation of 150 Patients After Laparoscopic Nissen Fundoplication. Surgery. 2019. Csendes A, Orellana O, Cuneo N, Mart&iacute;nez G, Figueroa M.
Esophageal Motility Disorders and Gastroesophageal Reflux Disease. The New England Journal of Medicine. 2020. Mittal R, Vaezi MF.
Gastroesophageal Reflux Disease. The New England Journal of Medicine. 2022. Fass R.
An Evidence-Based Approach to the Treatment of Gastroesophageal Reflux Disease. JAMA Surgery. 2015. Patti MG.
Analysis of the Causes of Failed Antireflux Surgery and the Principles of Treatment: A Review. JAMA Surgery. 2015. Patti MG, Allaix ME, Fisichella PM.
Gastroesophageal Reflux Disease: A Review. The Journal of the American Medical Association. 2020. Maret-Ouda J, Markar SR, Lagergren J.
Gastroesophageal Reflux Disease Treatment: Side Effects and Complications of Fundoplication. Clinical Gastroenterology and Hepatology: The Official Clinical Practice Journal of the American Gastroenterological Association. 2013. Richter JE.
Persistent Dysphagia Is a Rare Problem After Laparoscopic Nissen Fundoplication. Surgical Endoscopy. 2019. Nikolic M, Schwameis K, Semmler G, et al.
Complications of Antireflux Surgery. The American Journal of Gastroenterology. 2018. Yadlapati R, Hungness ES, Pandolfino, JE.
Gastro-Oesophageal Reflux Disease. Lancet. 2013. Bredenoord AJ, Pandolfino JE, Smout AJ.
Total vs Partial Fundoplication in the Treatment of Gastroesophageal Reflux Disease: A Meta-analysis. Archives of Surgery. 2009. Varin O, Velstra B, De Sutter S, Ceelen W.
AGA Clinical Practice Update on the Personalized Approach to the Evaluation and Management of GERD: Expert Review. Clinical Gastroenterology and Hepatology : The Official Clinical Practice Journal of the American Gastroenterological Association. 2022. Yadlapati R, Gyawali CP, Pandolfino JE.

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						Nissen Fundoplication vs NexiumSeptember 15, 2025		
			
	
		
						Most Frequent Nissen Fundoplication Question: Am I Able to Vomit After Surgery?September 12, 2025		
			
	
		
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#### Laparoscopic Partial Fundoplication
Laparoscopic Partial Fundoplication
Partial Fundoplication also known as Toupet Fundoplication is an anti-reflux procedure that is occasionally used to treat acid reflux in Lieu of Nissen fundoplication.
Like Nissen fundoplication, laparoscopic partial fundoplication surgery is performed under general anesthesia via five tiny incisions. Unlike Nissen fundoplication (360-degree wrap), the upper part of the stomach (fundus) is only partially wrapped around lower esophagus (270-degree wrap). Hence the name partial fundoplication. A partial wrap creates minimal resistance to food passage from esophagus into stomach. This is particularly useful in cases of poor or absent esophageal motility. The esophagus is too weak to push food against a full wrap. In rare cases, gastric fundus is too small to perform a floppy full wrap or Nissen fundoplication. In this situation, a partial wrap is offered to avoid post-operative dysphagia or difficulty swallowing.
Studies have shown that both partial and full wrap are equally effective in terms of acid reflux control. Several acid reflux surgeons prefer partial fundoplication over Nissen fundoplication for fear of post-operative dysphagia. At Houston Heartburn and Reflux center, post Nissen fundoplication dysphagia is extremely rare. Therefore, our most performed anti-reflux procedure is laparoscopic Nissen fundoplication. A 360-degree wrap is more robust than a partial wrap resulting in better durability and improved reliability.
Is partial fundoplication surgery appropriate for you?
At Houston Heartburn and Reflux Center, each patient receives thorough evaluation for heartburn and acid reflux including pre-operative manometry and UGI contrast study. Esophageal manometry accurately measures motility and lower esophageal sphincter pressure. Depending on these results, Dr. Darido will recommend the most appropriate treatment for you.

#### LINX™ Revision Surgery
LINX™ Reflux Management system consists of a bracelet of magnetic beads that is placed around the esophagus to reinforce the weakened lower esophageal sphincter. LINX™ or magnetic sphincter augmentation procedure is done under general anesthesia using the same approach as a laparoscopic Nissen fundoplication.
During swallowing, as food passes through the esophagus, LINX™ magnetic beads separate allowing the food bolus to pass into stomach and then close preventing acid reflux.
In 2012 the FDA approved LINX™ procedure for GERD treatment based on a prospective study that was published in the New England Journal of Medicine. 100 patients with increased esophageal acid exposure underwent the procedure. At one year follow up, 58% of patients had normal esophageal acid exposure. The most frequent adverse event was dysphagia (difficulty swallowing), which occurred in 68% of patients.
Subsequent follow up of this patient cohort at 5 years after LINX™ implantation showed:
12% persistent heartburn
1% persistent food regurgitation
15% dependency on proton pump inhibitors
6% difficulty swallowing
7% LINX™ device removal
At Houston Heartburn and Reflux Center, Dr Darido does not offer magnetic sphincter augmentation or LINX™ surgery. Dr Darido offers hiatal hernia repair and Nissen fundoplication, the gold standard treatment for acid reflux disease. However, if you had magnetic sphincter augmentation or LINX™ surgery and you continue to struggle with heartburn, food regurgitation, chest pain or difficulty swallowing we can help you.
Is LINX™ revision surgery appropriate for you?
At Houston Heartburn and Reflux Center, each patient receives a thorough evaluation for heartburn and acid reflux. Depending on your symptoms and work up findings, LINX™ device removal and conversion to Nissen or Toupet fundoplication may be indicated. Please request an appointment to see if LINX™ revision surgery is appropriate for you.
Read a testimonial from Zachary M on LINX™ Surgery from Dr. Darido
Read a testimonial from Christie F on LINX™ Surgery

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						Persistent Gastroparesis Following LINX™ to Nissen Fundoplication ConversionAugust 10, 2024		
			
	
		
						LINX™ Surgery effect on esophageal motility and complianceOctober 3, 2023		
			
	
		
						Slipped Stomach Through LINX™ DeviceApril 20, 2023		
			
	
		
						Long term Dysphagia after LINX™ SurgeryFebruary 6, 2023		
			
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#### Locations
URL: https://houstonheartburn.com/locations/

#### Meet Dr. Darido
Dr. Elias Darido – Houston Heartburn and Reflux Specialist
“Proper diagnosis and effective heartburn treatment “ is the vision of Dr. Elias Darido, founder of Houston Heartburn and Reflux Center. In today’s healthcare environment, there is much more to offer to control gastro-esophageal acid reflux disease (GERD). Many physicians have adopted a treatment model based on anti-reflux medications, typically Proton Pump Inhibitors (PPIs) like Nexium, Dexilant and Prevacid. Unfortunately, PPIs don’t cure the problem of acid reflux but rather control the symptoms. Symptom control alone is, however, not enough when managing a chronic and progressive condition like gastro-esophageal reflux disease (GERD). At Houston Heartburn and Reflux Center, Dr. Darido aspires to provide a comprehensive care for GERD patients in Houston and around the world.
Dr. Darido grew up in Lebanon. He attended the prestigious American University of Beirut. After graduating from medical school with honors, he moved to the United States. He trained in general surgery at Good Samaritan Hospital and The University of Cincinnati. Two institutions that are renowned for their surgical tradition. Afterwards, he was accepted as the advanced laparoscopic Foregut surgery fellow at the University of North Carolina, Chapel Hill. There he completed two additional years of subspecialty training in acid reflux management and surgery.
Dr. Darido has been in practice for 15 years and has maintained a strong safety record. He specializes in a wide range of advanced laparoscopic surgeries involving the gastro-esophageal area. Dr. Darido is especially focused on the upper part of the stomach also called gastric fundus. The gastric fundus is used to wrap the esophagus to prevent acid reflux, a procedure called Nissen Fundoplication. Dr. Darido has successfully performed more than 1000 Nissen Fundoplication surgeries in his career. Dr. Darido has been asked to lecture about gastric fundus function and role in different diseases like reflux, delayed gastric emptying and morbid obesity. He has numerous publications, and he is currently actively involved in clinical research related to gastro-esophageal surgery.
In his own words, Dr. Darido chose to specialize in the treatment of heartburn and reflux because, “ gastro-esophageal reflux disease is a challenging condition. A combination of science, experience, intuition and dedication are needed to assure that GERD patients are well taken care of ”.
Dr. Darido holds the following designations:

Fellow of the American College of Surgeons
Board Certified The American Board of Surgery
Member American Society of Metabolic and Bariatric Surgery (ASMBS)
Member Society of American Gastrointestinal Endoscopic Surgeons (SAGES)
Member American College of Surgeons (ACS)
Member Texas Medical Association (TMA)
Harris County Medical Association (HCMA)
Houston society of Bariatric Surgeons
Fellowship Trained in Advanced Laparoscopy Surgery
Fellowship Trained in Metabolic and Bariatric Surgery

Elias Darido, MD, FACS
Download Dr. Darido’s approach to Heartburn and Acid Reflux Management

#### Nissen Fundoplication
Acid Reflux Treatment with 100% Success Rate

Struggling with severe acid reflux? Are you looking for a safe, effective, reliable, and durable solution? Let the experts at Houston Heartburn and Reflux Center help you.
Get Help NowPeople from all over the US travel to Houston Heartburn for their Nissen Fundoplication surgery.

We provide a fast-track approach where your first appointment can be virtual. Acid reflux testing followed by surgery, all performed in less than one week.
Dr. Elias Darido, MD, FACS
Dr. Darido has been in practice for 15 years and has maintained a strong safety record. As a Fellow of the American College of Surgeons, he specializes in a wide range of advanced laparoscopic surgeries involving the gastro-esophageal area. He is especially focused on the upper part of the stomach also called gastric fundus. The gastric fundus is used to wrap the esophagus to prevent acid reflux, a procedure called Nissen Fundoplication. Dr. Darido has successfully performed more than 1,000 Nissen Fundoplication surgeries in his career.
Nissen Fundoplication by the numbers

At Houston Heartburn &amp; Reflux Center, we do one thing and one thing only, but we do it right!
15-Star Reviews1Success Rate1Hour Surgery100’s
Of Satisfied Patients
95%
Would Recommend Someone
1-2 Hour
Procedure Duration
The ProblemWeak valve (anti-reflux barrier) between esophagus and stomach results in acid reflux.
Our SolutionNissen Fundoplication safely and reliably restores the anti-reflux barrier.
Our Outcome99.9% success rate &amp; hundreds of satisfied patients.
The CaveatComprehensive acid reflux testing. Proper patient selection. Flawless surgery technique.
Patient Testimonial

This review is long overdue. My Mom had surgery in February 2021 with Dr. Darido (Laparoscopic Nissen Fundoplication). His hard work and expertise has completely changed my Mom’s life. We were at a point where we were hopeless &#8211; she had horrible symptoms EVERY DAY from her severe GERD. Many doctors were not helpful &#8211; they kept changing medications, thinking it would help FOR YEARS. We kept going back with issues and she was getting worse. My sister did some research and found Dr. Darido and his team. I wish we found him sooner. We traveled from Las Vegas, NV &#8211; he did testing on a Tuesday and did surgery on a Thursday. I cannot thank Dr. Darido and his team enough, THANK YOU SO MUCH! You gave me my Mom back. We appreciate everything you guys did, and we plan on coming back for future follow-ups if necessary. THANK YOU.
Sheila H
Read more reviews!
	
		
						Is Nissen Fundoplication the Best We Can Do?September 18, 2025		
			
	
		
						Nissen Fundoplication vs NexiumSeptember 15, 2025		
			
	
		
						Most Frequent Nissen Fundoplication Question: Am I Able to Vomit After Surgery?September 12, 2025		
			
	
		
			
		
	
				
				
					
				
				
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#### Non Surgical Treatment
URL: https://houstonheartburn.com/non-surgical-treatment/

#### Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Houston Heartburn (HoustonHeartburn.com) uses and discloses health information about you for treatment, to obtain payment for treatment, for administrative purposes, and to evaluate the quality of care that you receive. This notice describes our privacy practices. You can request a copy of this notice at any time.
Treatment, Payment, Health Care Operations
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We are permitted to use and disclose your medical information to those involved in your treatment. For example your care may require the involvement of another doctor. When we refer you to another doctor, we will share some or all of your medical information with that physician to facilitate the delivery of care. Since the physician in this practice is a specialist, when we provide treatment, we may request that your primary care physician receive or provide information
about your particular condition so that he or she can appropriately treat you for other medical conditions, if any.
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We are permitted to use or disclose your medical information for the purposes of health care operations, which are activities that support this practice and ensure that quality care is delivered. For example, we may engage the services of a professional to aid this practice in its compliance programs; this person will review billing and medical files to ensure we maintain our compliance with regulations and the law. Or we may ask another physician to review this practice’s charts and medical records to evaluate our performance so that we may ensure that only the best health care is provided by this practice.
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There are situations in which we are permitted by law to disclose or use your medical information without your written authorization or an opportunity to object. In other situations we will ask for your written authorization before using or disclosing any identifiable health information about you. If you choose to sign an authorization to disclose information, you can later revoke that authorization, in writing, to stop future uses and disclosures. However, any revocation will not apply to disclosures or uses already made or taken in reliance on that authorization.
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Is released pursuant to legal process, such as a warrant or subpoena;
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We may disclose your medical information as required by the Texas workers’ compensation law.
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Required by Law
We may release your medical information where the disclosure is required by law.
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The United States Department of Health and Human Services created regulations intended to protect patient privacy as required by the Health Insurance Portability and Accountability Act (HIPAA). Those regulations create several privileges that patients may exercise. We will not retaliate against a patient
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You may request that we restrict or limit how your protected health information is used or disclosed for treatment, payment, or healthcare operations. We do NOT have to agree to this restriction, but if we do agree, we will comply with your request except under emergency circumstances.
To request a restriction, submit the following in writing: (a) The information to be restricted, (b) what kind of restriction you are requesting (i.e. on the use of information, disclosure of information or both), and (c) to whom the limits apply. Please send the request to the address and person listed below. You may also request that we limit disclosure to family members, other relatives, or close personal friends that may or may not be involved in your care.
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You may inspect and/or copy health information that is within the designated record set, which is information that is used to make decisions about your care. Texas law requires that requests for copies be made in writing and we ask that requests for inspection of your health information also be made in writing. Please send your request to the person listed below.
We can refuse to provide some of the information you ask to inspect or ask to be coped if the information:

Includes psychotherapy notes.
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Is subject to the Clinical Laboratory Improvements Amendments of 1988.
Has been compiled in anticipation of litigation.

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Wasn’t created by this practice or the physicians here in this practice.
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If the information is accurate and complete.

Even if we refuse to allow an amendment you are permitted to include a patient statement about the information at issue in your medical record. If we refuse to allow an amendment, we will inform you in writing. If we approve the amendment, we will inform you in writing, allow the amendment to be made and tell others that we know have the incorrect information.
Accounting of Certain Disclosures
The HIPPA privacy regulations permit you to request, and us to provide, an accounting of disclosures that are other than for treatment, payment, health care operations, or made via an authorization signed by you or your representative. Please submit any request for an accounting to the person listed below.
Your first accounting of disclosures (within a 12 month period) will be free. For additional requests within that period we are permitted to charge for the cost of providing the list. If there is a charge we will notify you and you may choose to withdraw or modify your request before any costs are incurred.
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We may contact you by telephone, mail, or email to provide appointment reminders, information about treatment alternatives, or other health-related benefits and services that may be of interest to you.
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If you are concerned that your privacy rights have been violated, you may contact the person listed below. You may also send a written complaint to the United States Department of Health and Human Services. We will not retaliate against you for filing a complaint with the government or us. The contact information for the United States Department of Health and Human Services is:
U.S. Department of Health and Human Services HIPAA Complaint 7500 Security Blvd., C5-24-04, Baltimore, MD 21244
Our Promise to You
We are required by law and regulation to protect the privacy of your medical information, to provide you with this notice of our privacy practices with respect to protect health information, and to abide by the terms of the notice of privacy practices in effect.

#### Our Center
Houston Heartburn and Reflux Center
Our Mission
We aim to provide a comprehensive and compassionate treatment plan to all of our patients. Reflux disease is a chronic and progressive condition with serious long-term consequences. We know that each patient is unique and one pill does not fit all. Our mission at Houston Heartburn and Reflux Center is to educate, treat, and prevent.
Imagine a Life without Heartburn
We believe in liberating our patients from the burden of acid reflux disease to improve their quality of life. If you suffer from heartburn, food regurgitation, bloating, chronic cough, and sore throat you are not alone. Thousands of heartburn patients in Houston are destined to take a pill every day. Pills like Nexium, Omeprazole, Prevacid and Dexilant have side effects and don’t stop reflux. These medications simply mask symptoms!
When acid reflux takes over your life, every aspect of daily living including basic functions like sleeping, working, exercising and enjoying a meal with friends and family is affected. What&#8217;s next for you, what’s the alternative, Is there a solution?
This is where we come in.
We safely and effectively cure acid reflux. We are driven to master the complexity of GERD management and treatment. That is our passion. Where others say, “we’re done here, take a pill and see you in 6 months” we say, “let’s make a diagnosis and eradicate the problem.” We do not rest until we’ve deciphered all your symptoms and their root cause to deliver results that offer reliable and durable relief from acid reflux.
This is who we are at Houston Heartburn and Reflux Center.
Hospital Affiliations

Houston Methodist (TMC)
Memorial Hermann (Memorial City)
First Surgical Hospital
Woodlands Specialty Hospital
EHS-Deerbrook Hospital

#### Patient Forms
Medical Records Release Form
Informed Consent Nissen Hiatal Hernia
Informed Consent Endoscopy
Informed Consent Manometry
Post Op Diet

#### Payment
Send a secure payment to Houston Heartburn &amp; Reflux Center.

#### Payment Thanks
Thank you for making a payment.

#### Privacy Policy
Introduction
This website is operated by Elias F Darido, MD PLLC (collectively the &#8220;Company&#8221;, &#8220;We&#8221; or “Us”) respect your privacy and the Company is committed to protecting it through our compliance with this policy.
This policy describes the types of information we may collect from you or that you may provide when you visit this website (our &#8220;Website&#8221;) and our practices for collecting, using, maintaining, protecting and disclosing that information.
This policy applies to information we collect:

On this Website
In email, text, phone and other electronic messages between you and this Website.
Through mobile and desktop applications you download from this Website, which provide dedicated non-browser-based interaction between you and this Website.

It does not apply to information collected by:

Us offline or through any other means, including on any other website operated by Company or any third party (including our affiliates and subsidiaries) that may link to or be accessible from or on the Website. Note that patient health information will be governed by a separate HIPAA Notice of Privacy Practices provided by your healthcare provider at the time of services.

Please read this policy carefully to understand our policies and practices regarding your information and how we will treat it. This policy is incorporated into our Terms of Use and creates a contract between the Company and you. If you do not agree with our policies and practices, your sole choice is not to use our Website. By accessing or using this Website, you agree to this privacy policy and the Terms. This policy may change from time to time. All changes are effective immediately when we post them, and apply to all access to and use of the Website thereafter. Your continued use of this Website after we make changes is deemed to be acceptance of those changes, so please check the policy periodically for updates.
Children Under the Age of 16
Our Website is not intended for children under 16 years of age. No one under age 16 may provide any personal information to or on the Website. We do not knowingly collect personal information from children under 16. If you are under 16, do not use or provide any information on this Website or on or through any of its features/register on the Website, make any purchases through the Website, use any of the interactive or public comment features of this Website or provide any information about yourself to us, including your name, address, telephone number, email address or any screen name or username you may use. If you are aware that we have inadvertently collected personal information from a child under the age of 16, please write to us using the information on our contact page to request deletion of that information.
Information We Collect About You and How We Collect It
We collect several types of Personal Information from and about users of our Website, including information:

By which you may be personally identified, such as name, postal address, email address, and telephone number.
Consumer information, like your preferences or a consumer profile based on your use of the website.
Insurance information.
General health information, like your gender, height, weight or generalized medical conditions that you may be seeking information about.
Social media information, such as social media handles, content and other data shared with us through third-party features that you use on our Site and other services (such as apps, tools, payment services, widgets and plug-ins offered by social media services, like Facebook, Instagram and LinkedIn, that may have referred you to our Site).
Information about your device, your internet connection, the equipment you use to access our Website, and usage details.

We collect this information:

Directly from you when you provide it to us.
Automatically as you navigate through the site. Information collected automatically may include usage details, IP addresses and information collected through cookies, pixels, web beacons and other tracking technologies.

Information You Provide to Us
The information we collect on or through our Website may include:

Information that you provide by filling in forms on our Website. This includes information provided at the time of registering to use our Website, subscribing to our service, posting material, or requesting further services. We may also ask you for information when you enter a contest or promotion sponsored by us, and when you report a problem with our Website.
Records and copies of your correspondence (including email addresses), if you contact us.
Your responses to surveys that we might ask you to complete for research purposes.
Details of transactions you carry out through our Website and of the fulfillment of your orders. You may be required to provide financial and personal information before placing an order through our Website.
Your search queries on the Website.

Mobile Numbers and Text Messaging
The user agrees any mobile phone number(s) provided by them to Elias F Darido, MD PLLC shall be unique to that user. The user agrees mobile number(s) provided are not shared with, or common to, other users. If a user changes their mobile phone number(s), it is the user&#8217;s responsibility to contact us to update their mobile phone number in a timely manner.

Message/data rates may apply per phone plan.
Message frequency varies.
Some carriers may not be supported.
Reply STOP to end messages.

Information We Collect Through Automatic Data Collection Technologies
As you navigate through and interact with our Website, we may use automatic data collection technologies to collect certain information about your equipment, browsing actions and patterns, including:

Details of your visits to our Website, including traffic data, location data, logs and other communication data and the resources that you access and use on the Website.
Information about your computer and internet connection, including your IP address, operating system and browser type.

The information we collect automatically may include personal information, or we may maintain it or associate it with personal information we collect in other ways or receive from third parties. It helps us to improve our Website and to deliver a better and more personalized service, including by enabling us to:

Estimate our audience size and usage patterns.
Store information about your preferences, allowing us to customize our Website according to your individual interests.
Speed up your searches.
Recognize you when you return to our Website.

The technologies we use for this automatic data collection may include:

Cookies (or browser cookies). A cookie is a small file placed on the hard drive of your computer. You may refuse to accept browser cookies by activating the appropriate setting on your browser. However, if you select this setting you may be unable to access certain parts of our Website. Unless you have adjusted your browser setting so that it will refuse cookies, our system will issue cookies when you direct your browser to our Website.
Flash Cookies. Certain features of our Website may use flash cookies to collect and store information about your preferences and navigation to, from and on our Website. Flash cookies are not managed by the same browser settings as are used for browser cookies.
Web Beacons. Pages of our Website and our emails may contain small electronic files known as web beacons (also referred to as clear gifs. pixel tags and single-pixel gifs) that permit the Company, for example, to count users who have visited those pages or opened an email and for other related website statistics (for example, recording the popularity of certain website content and verifying system and server integrity).
Javascript which uses third-party services to store data about activities and transactions.
Trackable telephone numbers which keep track of phone calls made to some phone numbers on this site.
Offline website data – including both local and remote storage of activities.
Geo-targeting information about your general location at the time of use of the site.

We may tie this information to personal information about you that we collect from other sources or you provide to us.
By using the Site, you consent to our use of these Tracking Technologies. You can decide if and how your computer will accept a cookie by configuring your preferences or options in your browser. However, if you choose to reject cookies, you may not be able to use certain online products, services or features on the Website. For example, we may not be able to recognize your computer or device, and you may need to log in every time you visit. You can get more information about Cookies and Tracking Technologies, and instructions on how to opt out of these items, you may visit All About Cookies. You may also learn more at the Digital Advertising Alliance or the NAI industry opt-out platform.
How We Use Your Information
We use information that we collect about you or that you provide to us, including any personal information:

To present our Website and its contents to you.
To provide you with information, products or services that you request from us.
To fulfill any other purpose for which you provide it.
To provide you with notices about your account/subscription, including expiration and renewal notices.
To carry out our obligations and enforce our rights arising from any contracts entered into between you and us, including for billing and collection.
To notify you about changes to our Website or any products or services we offer or provide through it.
To allow you to participate in interactive features on our Website.
In any other way we may describe when you provide the information.
For any other purpose with your consent.

Your Access to and Control Over Information
You may opt out of any future contacts from us at any time. You can do the following at any time by contacting us via the email address or phone number given on our website. The jurisdiction in which you reside may dictate the rights available to you, but they may include the right to:

See what data we have about you, if any.
Change/correct any data we have about you.
Opt-out of our sharing of certain information.
Have us delete any data we have about you.
Express any concern you have about our use of your data.

If applicable, you may exercise any of your rights by submitting a verifiable data subject request to us by using the information in the “Contact Us” section below. You may make a request related to your Personal Information or on behalf of someone for which you have authorization. You must include your full name and email address in your request. We may require you to confirm your identity and/or legal standing for the request as well as your residency to obtain the information.
Please note that we will ask you to verify your identity before responding to such requests, and we may deny your request if we are unable to verify your identity or authority to make the request.
Disclosure of Your Information
We may disclose aggregated information about our users, and information that does not identify any individual, for any reason without restriction.
We may disclose personal information that we collect or you provide as described in this privacy policy:

To fulfill the purpose for which you provide it.
To allow our service providers to complete a service we have contracted with them to provide.
For any other purpose disclosed by us when you provide the information.
With your consent.
To any potential acquirer, successor or assignee as part of any business transaction for the merger, sale, transfer, assignment or reorganization of our business or assets.
To comply with any court order, law or legal process, including to respond to any government or regulatory request.

Privacy of Collected Data
We will never use the statistical analytics tool to track or to collect any names or email addresses of visitors to our site. Google will not associate your IP address or device ID with any other data held by Google. Neither we nor Google will link, or seek to link, an IP address or a device ID with the identity of a computer user.
Information About Remarketing
We specifically share your information with Google (including YouTube, Google Analytics, Google AdSense, Google Business Profiles) and Meta (including Facebook and Instagram). We use Google Analytics to help us understand how our customers use the Site. Read more about how Google uses your Personal Information or opt-out of Google Analytics. You have the option to manage Google&#8217;s personalized ads by visiting the Google advertising center. You can read more about how Meta uses your Personal Information and how to manage your Meta ad preferences. You can read Vimeo’s privacy policy and information on Vimeo’s video privacy settings. Please note that depending on your settings, the next time you access our Services the analytics may be reactivated, so you may have to disable the technology each time.
This website uses Google remarketing to advertise online using text or image ads on the Google Display Network. Remarketing is a feature that lets us reach people who have previously visited our site, and show them relevant ads when they visit other sites on the Google Display Network.
For websites using remarketing, a third-party DoubleClick cookie is used to enable remarketing for products like AdWords on the Google Display Network. When someone visits our website, a few lines of code will drop an anonymous browser cookie. This cookie is a small file that stores information. The cookie will store the site visit, but does not store any sensitive information, such as visitor name, address or any other piece of information that might personally identify the visitor. The cookie will be enabled for a set period of time, such as 30 or 60 days, at which time, the cookie expires.
What is the Google Display Network?
A group of more than a million websites, videos, and apps where ads can appear. Sites in this network have partnered with Google to show relevant ads.
Opting out of Remarketing
Visitors may opt out of Google’s use of cookies by visiting the Ads Preferences Manager.
Visitors may opt out of a third-party vendor’s use of cookies by visiting the Network Advertising Initiative opt-out page.
Do Not Track Signals
Our Site currently does not respond to Do Not Track (“DNT”) signals and operates as described in this Policy, whether or not a DNT signal is received.
Global Privacy Control
Some browsers and browser extensions support the Global Privacy Control (“GPC”) that can send a signal to the websites you visit indicating your choice to opt-out from certain types of data processing, including data sales. GPC is a web-browser level setting, maintained by either a browser or a browser extension, that is typically set by the user, not the website. In certain regions, when we detect such a signal, we will make reasonable efforts to respect your choices indicated by a GPC setting as required by applicable law.
Changes to Our Privacy Policy
Our Privacy Policy may change from time to time and all updates will be posted on this page. If you feel that we are not abiding by this privacy policy, you should contact us immediately via the email address or phone number given on our website.
Contact Information
If there are any questions regarding this privacy policy you may contact us using the information below.
Houston Heartburn and Reflux Center
2100 W. Loop South, Suite 1115B
Houston, TX 77027
(832) 945-8717

#### Surgical Treatment
Surgical Treatment of GERD
Reflux disease is a chronic and progressive condition. Treatment options depend on the disease stage. The disease stage is determined by the severity of reflux into the esophagus. This in turns depends on how frequent and how long are the reflux episodes. The longer and the more frequent acid reflux episodes are the more significant is the damage to the esophagus. GERD is also associated with a spectrum of symptoms that ranges from mild heartburn to severe chest pain mimicking a heart attack. GERD treatment options are highly dependent upon an individual’s GERD stage
Stage 1: Mild GERD
Patients experience mild symptoms once or twice a month. Treatment relies on lifestyle changes and over-the-counter acid suppressive medications.
Stage 2: Moderate GERD
Patients experience more frequent symptoms requiring daily prescription acid suppressive medications. Untreated GERD symptoms affect patient daily activities and are associated with esophageal inflammation.
Stage 3: Severe GERD
Patients with severe GERD have poorly controlled symptoms on prescription medications. Their quality of life is substantially lower. Patients are more likely to have erosive esophageal inflammation. A thorough evaluation by a GERD expert is highly recommended. A successful anti-reflux procedure that restores the integrity of the lower esophageal sphincter cures GERD and improves patient quality of life.
Stage 4: Reflux induced precancerous lesions or esophageal cancer
Stage 4 is the result of many years of untreated severe reflux. 10% of patients with long-term GERD progress to stage 4. They develop a pre-cancerous condition called Barrett’s esophagus. Barrett’s esophagus may progress to cancer if untreated. There are different modalities of treatment for Barrett’s esophagus aimed at preventing progression to cancer. Close follow up and management by a reflux expert is highly recommended.

#### Symptoms of GERD
URL: https://houstonheartburn.com/symptoms-of-gerd/

#### Terms of Use
Introduction
This website is operated by Elias F Darido, MD PLLC (collectively the &#8220;Company&#8221;, &#8220;We&#8221; or “Us”). The use of our website is subject to the following terms and conditions of use, as amended from time to time (the “Terms”). The Terms are to be read together by you with any terms, conditions or disclaimers provided in the pages of our website. Please review the Terms carefully. They constitute a legal contract between you and the Company. The Terms apply to all users of our website, including without limitation, users who are browsers, customers, merchants, vendors and/or contributors of content. If you access and use this website, you accept and agree to be bound by and comply with the Terms and our Privacy Policy. If you do not agree to the Terms or our Privacy Policy, you are not authorized to access our website, use any of our website’s services or place an order on our website.
Use of Our Website
The information on this Site is for information or educational purposes only. It is not intended to provide medical advice or diagnose any condition. You agree to use our website for legitimate purposes and not for any illegal or unauthorized purpose, including without limitation, in violation of any intellectual property or privacy law. By agreeing to the Terms, you represent and warrant that you are at least the age of majority in your state or province of residence and are legally capable of entering into a binding contract.
You agree to not use our website to conduct any activity that would constitute a civil or criminal offense or violate any law. You agree not to attempt to interfere with our website’s network or security features or to gain unauthorized access to our systems.
You agree to provide us with accurate personal information, such as your email address, mailing address and other contact details in order to complete your order or contact you as needed. You authorize us to collect and use this information to contact you in accordance with our Privacy Policy.
General Conditions
We reserve the right to refuse service to anyone, at any time, for any reason. We reserve the right to make any modifications to the website, including terminating, changing, suspending or discontinuing any aspect of the website at any time, without notice. We may impose additional rules or limits on the use of our website. You agree to review the Terms regularly and your continued access or use of our website will mean that you agree to any changes.
You agree that we will not be liable to you or any third party for any modification, suspension or discontinuance of our website or for any service, content, feature or product offered through our website.
Consent to Electronic Communications
You agree that we may communicate with you electronically regarding your use of the website or the services and that any notices, agreements, disclosures or other communications that we send to you electronically will satisfy any legal communication requirements including any requirement that the communications be in writing. To withdraw your consent to receiving electronic notices, please notify us at the information on the Contact page of our website.
SMS Terms and Conditions
By providing your mobile phone number and opting in to receive text messages from Elias F Darido, MD PLLC, you consent to receive SMS communications related to appointment reminders, scheduling confirmations, post-procedure instructions, billing notifications, practice updates, and promotional or marketing messages such as special offers, new services, and announcements.

Message frequency varies and message and data rates may apply.
You may opt out of receiving text messages at any time by replying STOP to any message.
Consent to receive SMS messages is not a condition of purchase or service.
Carriers are not liable for delayed or undelivered messages.

Products or Services
All purchases through our website are subject to product availability. We may, in our sole discretion, limit or cancel the quantities offered on our website or limit the sales of our products or services to any person, household, geographic region or jurisdiction.
Prices for our products are subject to change, without notice. Unless otherwise indicated, prices displayed on our website are quoted in U.S. dollars.
We reserve the right, in our sole discretion, to refuse orders, including without limitation, orders that appear to be placed by distributors or resellers. If we believe that you have made a false or fraudulent order, we will be entitled to cancel the order and inform the relevant authorities.
We do not guarantee the accuracy of the color or design of the products on our website. We have made efforts to ensure the color and design of our products are displayed as accurately as possible on our website.
Links to Third-Party Websites
Links from or to websites outside our website are meant for convenience only. We do not review, endorse, approve or control, and are not responsible for any sites linked from or to our website, the content of those sites, the third parties named therein, or their products and services. Linking to any other site is at your sole risk and we will not be responsible or liable for any damages in connection with linking. Links to downloadable software sites are for convenience only and we are not responsible or liable for any difficulties or consequences associated with downloading the software. Use of any downloaded software is governed by the terms of the license agreement, if any, which accompanies or is provided with the software.
Patient Portal Account Creation
To access and use the Patient Portal, we may require you to first register for an Account. You must provide accurate, current and complete information during the registration process and you must keep your information updated. You are responsible for maintaining the confidentiality of your account and password and for restricting access to your computer or device, and you agree to accept responsibility for all activities that occur under your registration, username, password and/or patient account. We may, in our sole discretion, terminate your account or use of the portal at any time and for any or no reason.
Use Comments, Feedback, and Other Submissions
You acknowledge that you are responsible for the information, profiles, opinions, messages, comments and any other content (collectively, the “Content”) that you post, distribute or share on or through our website or services available in connection with our website, including our social media sites. You further acknowledge that you have full responsibility for the Content, including but limited to, with respect to its legality, and its trademark, copyright and other intellectual property ownership.We do not wish to receive any confidential, proprietary or sensitive information from you via the website or your comments.
You agree that any content submitted by you in response to a request by us for a specific submission may be edited, adapted, modified, recreated, published, or distributed by us. You further agree that we are under no obligation to maintain any Content in confidence, to pay compensation for any Content or to respond to any Content.
You agree that you will not post, distribute or share any Content on our website that is protected by copyright, trademark, patent or any other proprietary right without the express consent of the owner of such proprietary right. You further agree that your Content will not be unlawful, abusive or obscene nor will it contain any malware or computer virus that could affect our website’s operations. You will be solely liable for any Content that you make and its accuracy. We have no responsibility and assume no liability for any Content posted by you or any third-party.
We reserve the right to terminate your ability to post on our website and to remove and/or delete any Content that we deem objectionable. You consent to such removal and/or deletion and waive any claim against us for the removal and/or deletion of your Content.
Your Personal Information
Please see our Privacy Policy to learn about how we collect, use, and share your personal information.
Errors and Omissions
Please note that our website may contain typographical errors or inaccuracies and may not be complete or current. We reserve the right to correct any errors, inaccuracies or omissions and to change or update information at any time, without prior notice (including after an order has been submitted). Such errors, inaccuracies or omissions may relate to product description, pricing, promotion and availability and we reserve the right to cancel or refuse any order placed based on incorrect pricing or availability information, to the extent permitted by applicable law. We do not undertake to update, modify or clarify information on our website, except as required by law.
Disclaimer and Limitation of Liability
You assume all responsibility and risk with respect to your use of our website, which is provided “as is” without warranties, representations or conditions of any kind, either express or implied, with regard to information accessed from or via our website, including without limitation, all content and materials, and functions and services provided on our website, all of which are provided without warranty of any kind, including but not limited to warranties concerning the availability, accuracy, completeness or usefulness of content or information, uninterrupted access, and any warranties of title, non-infringement, merchantability or fitness for a particular purpose. We do not warrant that our website or its functioning or the content and material of the services made available thereby will be timely, secure, uninterrupted or error-free, that defects will be corrected, or that our websites or the servers that make our website available are free of viruses or other harmful components.
The use of our website is at your sole risk and you assume full responsibility for any costs associated with your use of our website. We will not be liable for any damages of any kind related to the use of our website.
In no event will we, or our affiliates, our or their respective content or service providers, or any of our or their respective directors, officers, agents, contractors, suppliers or employees be liable to you for any direct, indirect, special, incidental, consequential, exemplary or punitive damages, losses or causes of action, or lost revenue, lost profits, lost business or sales, or any other type of damage, whether based in contract or tort (including negligence), strict liability or otherwise, arising from your use of, or the inability to use, or the performance of, our website or the content or material or functionality through our website, even if we are advised of the possibility of such damages.
Certain jurisdictions do not allow limitation of liability or the exclusion or limitation of certain damages. In such jurisdictions, some or all of the above disclaimers, exclusions, or limitations, may not apply to you and our liability will be limited to the maximum extent permitted by law.
Indemnification
You agree to hold us and our affiliates, including any party involved in creating, producing or delivering the site, harmless against any losses, liabilities, claims, expenses (including legal fees) in any way arising from, related to or in connection with your use of our website, your violation of the Terms, or the posting or transmission of any materials on or through the website by you, including but not limited to, any third party claim that any information or materials provided by you infringe upon any third party proprietary rights.
Entire Agreement
The Terms and any documents expressly referred to in them represent the entire agreement between you and us in relation to the subject matter of the Terms and supersede any prior agreement, understanding or arrangement between you and us, whether oral or in writing. Both you and we acknowledge that, in entering into these Terms, neither you nor we have relied on any representation, undertaking or promise given by the other or implied from anything said or written between you and us prior to such Terms, except as expressly stated in the Terms.
Termination
We reserve the right, in our sole discretion, to restrict, suspect, or terminate these Terms and your access to all or any part of the Site or the Content at any time and for any reason without prior notice or liability. We also reserve the right to cease providing the Site or the Services at any time.
Waiver
Our failure to exercise or enforce any right or provision of the Terms will not constitute a waiver of such right or provision. A waiver by us of any default will not constitute a waiver of any subsequent default. No waiver by us is effective unless it is communicated to you in writing.
Severability
If any of the provisions of the Terms are determined by any competent authority to be invalid, unlawful or unenforceable, such provision will to that extent be severed from the remaining Terms, which will continue to be valid and enforceable to the fullest extent permitted by law.
ADA Compliance Notice
We are committed to making the website’s content accessible for all. If you are having difficulty accessing, viewing and/or navigating any content on the website, or if you notice any content, feature or functionality that you believe is not fully accessible to people with disabilities, please contact us using the information provided on the contact page of our website using “Website Access” as the subject. Please provide a description of the feature you feel is not fully accessible or a suggestion for improvement. We will use it to accommodate all our customers and improve our overall accessibility policies.
Questions or Concerns
Please send all questions, comments and feedback to us using the information provided on the contact page of our website.

#### Testimonials
Read and hear our patient testimonials
Cough resolution following Nissen Fundoplication performed by Dr. Darido
Nissen fundoplication for treatment of silent reflux or LPR
Hiatal hernia repair and Nissen fundoplication outcome: Complete GERD symptom resolution.
Resolution of Barrett’s esophagus following Nissen Fundoplication
Watch a patient discuss his relief after suffering from chronic cough and hiatal hernia.
Sleeve gastrectomy and hiatal hernia repair.
Many patients suffering from Acid Reflux refer to over the counter medications costing them money and their health. At Houston Heartburn, we help patients get permanent relief.
Hear how a patient obtained relief after suffering with Acid Reflux for over 30 years. Her reflux surgery has been life changing and now she enjoys eating foods she never thought possible.
Watch a patient discuss his relief after suffering from chronic cough and acid reflux for over 40 years.
Watch another patient describe her heartburn experience and the results she obtained from visiting Dr. Darido.

#### Thank You
We have received your submission and will get back to you shortly.
Dr. Darido and team at Houston Heartburn
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#### Thank You
Thank you for requesting our guide.
Please check your email for the download link.

#### Thank You for Commenting on our Blog
We have received your comment and if you have chosen to be contacted, a member of our team will be in touch with you shortly.
Dr. Darido and team at Houston Heartburn
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#### TIF Surgery Procedure
Incisionless Acid Reflux Treatment in Houston
TIF: Transoral Incisionless Fundoplication

TIF (Transoral Incisionless Fundoplication) treats the underlying cause of GERD without incisions. The surgery is performed through the mouth using a device called EsophyX. EsophyX enables the manipulation and plication of tissue around the esophagus to create a partial wrap of the stomach. This is believed to reconstruct the weakened lower esophageal sphincter to prevent acid reflux. The procedure is heavily marketed as a non-surgical alternative to the traditional Nissen Fundoplication.
TIF however is not a Nissen. A key step in Nissen fundoplication surgery is the complete mobilization of the stomach fundus to create a complete wrap. The mobilized and repositioned stomach fundus prevents acid from refluxing into the esophagus. This mechanism is not duplicated by TIF because the stomach fundus cannot be dissected and mobilized during TIF.
Advantages

Minimal pain
No scars
Fast recovery time
Very few side effects

Disadvantages

Hiatal hernia cannot be repaired
Does not reliably stop reflux like Nissen Fundoplication Surgery
Poor long-term outcomes with high recurrence rates

Is TIF surgery appropriate for you?
At Houston Heartburn and Reflux Center, each patient receives a thorough evaluation for heartburn and acid reflux. Depending on your reflux stage, Dr. Darido will recommend the appropriate treatment that suits you best. Reflux disease is a chronic and progressive condition, and treatment is tailored accordingly. TIF surgery may be indicated for some patients. Please request an appointment to see if TIF surgery is appropriate for you.

Blog topics on TIF Procedure

	
		
						Life Is Too Short to Live with HeartburnNovember 19, 2024		
			
	
		
						Nissen Fundoplication and GastroparesisAugust 25, 2022		
			
	
		
						Nissen Fundoplication: Where You Go First MattersOctober 30, 2020		
			
	
		
						Will TIF Procedure Correct or Cure Dysphagia?March 20, 2020		
			
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#### Travel & Accommodations
Many of our patients come from outside the Houston metro area. Houston is home to the world-renowned Texas Medical Center.  To assist those patients traveling here, we have compiled a travel and hotel information guide. Our knowledgeable staff can often help you make your trip more affordable and enjoyable.
[vc_custom_heading text="Houston's Airports" use_theme_fonts="yes"]Houston Intercontinental Airport – international and domestic travel, located in north Houston, 45-minute drive to our office.
Houston Hobby Airport – domestic and local travel, located in southwest Houston, 30-minute drive to our office.
Private Transportation to and from the airports can be booked online with Transporter Houston
[vc_custom_heading text="Online Reservations" use_theme_fonts="yes"]
Orbitz
Travelocity

Expedia
Cheapflights

Travelzoo
Priceline

[vc_custom_heading text="Houston hotels near our clinic" use_theme_fonts="yes"]Crowne Plaza Houston Medical Center Galleria
2712 Southwest Freeway | Houston, TX 77098
​(713) 523-8448
Rates: Approx $99/night
DoubleTree by Hilton Hotel Houston &#8211; Greenway Plaza
6 E Greenway Plaza
Houston, TX 77046
(713) 629-1200
Rates: Approx $104/night
Residence Inn Marriott- Houston Medical Center/NRG Park
7710 South Main Street
Houston, TX 77030
(713) 660-7993
Medical Rates: $119-129
Crowne Plaza Hotel- Medical/Reliant
8686 Kirby Drive
Houston Texas 77054
(713) 795-8416
Medical Rates: $80-90
Springhill Suites &#8211; Medical Center/NRG Park
1400 Old Spanish Trail
Houston, Texas 77054
(713)796-1000
Medical Rates: $119-129
Holiday Inn- NRG Area / Medical Center
8111 Kirby Drive
Houston, Texas 77054
(713)790-1900
Medical Rates: $85
Courtyard by Marriott Houston Medical Center/NRG Park
7702 Main Street
Houston, TX 77030
(713) 668-4500
Medical Rates: $119-129
Drury Inn &amp; Suites Galleria
1615 West Loop
Houston, TX 77027
(713) 963-0700
Medical Rate: $99
Hampton Inn &amp; Suites – Houston Medical Center – NRG Park
1715 Old Spanish Trail
Houston, TX 77054
(713) 797-0040
Medical Rate: $119-129
Comfort Suites Medical Center/NRG Stadium
1055 McNee Road, East of Main Street
Houston, TX 77054
(713) 668-1436
Medical Rates: $85

#### Umbilical Cord Hernia
Expert Care for Umbilical HerniasSafe and Effective Solutions forYour Comfort and Recovery
Book a ConsultationWhat is an Umbilical Hernia?An umbilical hernia occurs when fat or intestines bulge through a weak spot in the navel or belly button (umbilicus). The bulge is painless most of the time. It increases in size with coughing or straining and can often be reduced with mild pressure.However, an inability to reduce the hernia indicates incarceration, which means the contents are stuck in the hernia pouch and may require immediate attention.
Highlight Risk Factors:

Women are three times more likely to develop umbilical hernias due to pregnancy.
Older age and obesity increase the likelihood of occurrence.

Explore Your Treatment OptionsWe understand that every patient’s needs are unique. 
Book a Consultation01Open Belly Button Hernia RepairYour umbilical hernia specialist makes a small incision just below the belly button, dissects the hernia pouch and then reduces the herniated fat and intestines into the belly. The hernia defect is then closed with sutures and sometimes reinforced with a mesh.02Laparoscopic RepairYour umbilical hernia specialist places 3 to 4 tiny incisions away from the belly button. A camera scope and long instruments are inserted into the belly through these incisions to dissect the hernia pouch and suture repair the defect in the abdominal wall. A mesh is then applied against the abdominal wall to reinforce the repair. This approach is reserved for umbilical hernias larger than 4 to 5 cm in diameter.03Robotic RepairSimilar to laparoscopic repair but performed with advanced robotic technology for precision.04Watchful Waiting4% of all umbilical hernias may strangulate within the next five years if not surgically repairedIncreasing belly button pain indicates strangulation. Strangulation results from the interruption of blood supply to the squeezed intestines in the hernia sac. A strangulated umbilical hernia requires immediate surgical repair to prevent complicationsFrequently Asked Questions About Umbilical Hernias
How do I know if I need surgery?Surgery is typically recommended if the hernia causes pain, increases in size, or shows signs of complications like incarceration or strangulation. Consult with a specialist to determine the best course of action for your condition.
Is Umbilical Hernia Repair Safe?Belly button hernia repair is very safe and effective. Complication rate is very low. Surgery takes less than one hour to complete. You then spend couple of hours in recovery waking up from anesthesia before you leave home. Recovery is fast and is associated with very little pain or discomfort. At Houston umbilical hernia repair center, your surgeon injects a long-acting numbing medication around the incisions that eliminates from umbilical hernia surgery.
What happens if I don’t treat my hernia?While some small hernias can be monitored, untreated hernias have a risk of complications such as strangulation, which requires emergency surgery. It’s important to consult with a specialist to assess your risks.
How long is the recovery time?Recovery is typically fast, with most patients resuming normal activities within a few days to a week. Your specialist will provide detailed aftercare instructions to ensure a smooth recovery.
Take the First Step Toward a Pain-Free Life – Schedule Your Consultation Today!
Don’t let an umbilical hernia hold you back from living your best life. Our team of experienced specialists is here to provide personalized care and effective solutions tailored to your needs.
Book a Consultation

#### Website Accessibility
Houston Heartburn and Reflux Center is continuously working to improve the accessibility of content on our website. Below, you’ll find a few recommendations to help make your browsing experience more accessible:

If you have trouble seeing web pages, the US Social Security Administration (https://www.ssa.gov/accessibility/) offers these tips for optimizing your computer and browser to improve your online experience.

- Use your computer to read web pages out loud 

- Use the keyboard to navigate screens

- Increase text size

- Magnify your screen

- Change background and text colors

- Make your mouse pointer more visible (Windows only) 

If you are looking for mouse and keyboard alternatives, speech recognition software such as Dragon Naturally Speaking http://www.nuance.com/dragon/index.htm may help you navigate web pages and online services. This software allows the user to move focus around a web page or application screen through voice controls.

If you are deaf or hard of hearing, there are several accessibility features available to you.
Closed Captioning

Closed captioning provides a transcript for the audio track of a video presentation that is synchronized with the video and audio tracks. Captions are generally visually displayed over the video, which benefits people who are deaf and hard of hearing, and anyone who cannot hear the audio due to noisy environments. Most of our video content includes captions.
Volume Controls
Your computer, tablet, or mobile device has volume control features. Each video and audio service has its own additional volume controls. Try adjusting both your device’s volume controls and your media players’ volume controls to optimize your listening experience.

If the recommendations above do not meet your needs, we invite you to contact us at 832-945-8717 for assistance.