Dear Dr. Roach: I am so tired of gastric juices coming up and spraying my mouth. I am currently on a "last resort" medicine. My doctor wants to try it for three weeks. If it doesn't work, he's going to perform a Nissen fundoplication. From what I've read, there would be nothing more coming up. Could you explain this procedure? What will happen with swallowed air, and what will happen if I get sick to my stomach and (shudder) need to vomit? -- S.S.

Dr. Roach: Large volumes of stomach acid coming into the mouth is an accepted indication for surgical treatment of reflux disease. Sometimes, the acid is associated with excess saliva and is called "water brash."

Prior to considering surgery, it is worthwhile to make sure the medication treatment is as good as it can be. Proton pump inhibitors such as omeprazole should be taken 30 minutes before eating. Weight loss is helpful if overweight. Raising the head of the bed 6 to 8 inches (by inserting blocks under the legs of the head of the bed or using a plastic wedge under the mattress) and avoiding dietary triggers (coffee, chocolate, carbonated drinks, high-fat foods) should be tried. Baclofen, a powerful muscle relaxant with many possible side effects, may be the "last resort" medicine you are taking.

When all else fails, surgery may relieve symptoms. A Nissen fundoplication is when the upper part of the stomach, the fundus, is plicated (wrapped) around the esophagus and stitched in place. This can be done via endoscopy or as an open procedure. It is effective at reducing symptoms in 85 percent to 90 percent of patients.

Most people are unable to vomit and have less or no ability to belch, leading to bloating, increased intestinal gas and flatulence. Discomfort during eating is common. There are modifications of the surgical procedure designed to reduce side effects and complications while maintaining effectiveness, but a description of what these all are technically is in your surgeon's domain.


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