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Swallowing, Heartburn and Esophageal Disease Center (SHED)

The Swallowing, Heartburn and Esophageal Disease Center provides both primary treatment and second opinion evaluations for benign throat, esophagus and stomach disorders.

Explore This Program

About the Program

As part of the Massachusetts General Hospital Digestive Healthcare Center, the Swallowing, Heartburn and Esophageal Disease Center (SHED) brings together a multidisciplinary team of gastroesophageal specialists who provide expert diagnosis, cutting-edge medical and surgical interventions and ongoing care for benign throat, esophagus and stomach disorders.

Our board-certified digestive health specialists work together to help patients diminish episodes of discomfort, including:

  • Chronic cough
  • Chronic heartburn
  • Difficulty swallowing
  • Noncardiac chest pain
  • Postsurgical esophageal symptoms

Diagnosis and treatment may include a combination of medication, lifestyle changes, endoscopic therapies and, when appropriate, surgical procedures.

Mass General surgeons and gastroenterologists work collaboratively to provide comprehensive, personalized treatment for patients with gastroesophageal conditions. Our surgeons specialize in complex surgical techniques, such as Transoral Incisionless Fundoplication (TIF procedure) and magnetic sphincter augmentation (LINX procedure), which are both procedures for the treatment of gastroesophageal reflux disease (GERD), and endoscopic myotomy (POEM procedure) for the treatment of achalasia. 

Advanced Diagnostic Motility Evaluation Services

The SHED team provides highly specialized, expert analysis for a range of diagnostic and therapeutic procedures. Our endoscopists are available to confer with referring physicians. Diagnostic services include:

  • Endoscopic ultrasound, which creates an image of the esophagus using sound waves
  • High-resolution manometry, which measures pressure within the gastrointestinal tract using special sensors
  • Esophageal motility test, which measures the esophagus’s ability to move
  • pH probe testing, used to diagnose gastroesophageal reflux
  • Wireless Bravo pH testing
  • Impedance/pH testing to determine if stomach contents are coming up into the esophagus
  • EndoFLIP, cutting-edge technology for evaluating esophageal motility

Our diagnostic radiology team comprises dedicated imaging specialists whose practice focuses specifically on GI scans. They are nationally recognized for expertise in all forms of sophisticated imaging and offer a full range of advanced diagnostic techniques, including:

  • Fiber optic evaluations, which measures a patient’s ability to swallow
  • Video-fluoroscopic swallowing studies, which captures video X-rays after the patient has taken barium
  • Barium esophagrams, which captures images after the patient has taken barium, an element that helps with X-ray imaging
  • Speech pathology assessments to identify speech and language deficits

Conditions We Treat

SHED is a leading referral center in New England for the treatment of achalasia, a common swallowing problem. We provide treatment and ongoing care for the full range of gastroesophageal and swallowing conditions, including:

Achalasia

What is it/What causes it?

  • Achalasia occurs when the valve at the bottom of your esophagus that allows food into the stomach does not open causing a sensation of obstruction or regurgitation of food
  • This can often be subtle with changes in swallowing happening over time and leading to significant difficulty with solid food
  • Some patients may actually have a sensation of reflux although this could be from retained food in the esophagus

Symptoms

  • Difficulty swallowing often to solid food but occasionally with liquids
  • Waking up at night with a cough or the regurgitation of stomach acid/food debris
  • Chest pain particularly after eating
  • Weight loss

Types

  • There are several types and forms of achalasia all which are amenable to treatment
  • There are other disease processes that can mimic achalasia and are important to rule out in making the diagnosis

 Diagnosis

  • An endoscopy (EGD/scope) of the esophagus can demonstrate a hypertensive or overly compliant lower valve
  • A barium swallow which is a test where contrast material is swallowed and x-rays are taken which can clearly outline a tapering of the distal esophagus
  • Most critical in making the diagnosis is functional esophageal testing called esophageal manometry which will measure pressures throughout the esophagus

Treatment

  • Options for treatment include endoscopy and dilation, Botox therapy to the lower esophageal valve and surgical options
  • Surgery can include a laparoscopic approach with an opening of the distal esophageal valve muscle and a partial wrap to control reflux
  • Endoscopic options include a POEM procedure where no incisions are made and the valve is opened through a procedure performed through the mouth
  • Rarely patients with “end-stage achalasia” required the removal of the esophagus and reconstruction with the stomach
Gastroesophageal Reflux Disease (GERD)

What is it/What caused it?

  • Gastroesophageal reflux disease occurs when there is stomach acid that flows back into the esophagus (tube from your mouth to your stomach) and causes pain or an acid taste in the back your throat
  • It is common for many patients to experience symptoms of reflux and most are controlled with lifestyle modification, dietary change and medication alone
  • Many patients with reflux also have a small hiatal hernia. Having a hiatal hernia is not typically a situation when you can feel a “bulge” or protrusion of the hernia in the abdominal wall
  • Smaller hernias can lead to gastroesophageal reflux and large hernias can cause the blockage of food passing from the esophagus to the stomach. Please reference paraesophageal hiatal hernia

 Symptoms

  • Burning in the throat or chest occasionally associated with eating
  • Waking up at night with a cough or the regurgitation of stomach acid
  • Chest pain or abdominal pain particularly after eating
  • A sour taste in the back of the throat
  • Worsening asthma type symptoms or shortness of breath

 Risk factors

  • Advancing age
  • Obesity
  • A poorly functioning lower esophageal valve

 Types

  • Hiatal hernias are graded by size on a scale of 1 through 4
  • 1 is the smallest and is the most common associated with symptoms of heartburn or gastroesophageal reflux
  • Types 2 through 4 are when larger portions of the stomach protrude through the diaphragm causing a variable number of symptoms. Please reference paraesophageal hiatal hernia

Diagnosis

  • An endoscopy or scope of the esophagus can demonstrate inflammatory changes in the esophagus. It can also examine the esophagus for changes consistent with Barrett's esophagus
  • A barium swallow which is a test where contrast material is swallowed well x-rays are taken which can clearly outline a small hiatal hernia
  • For patients who have refractory or ongoing reflux despite aggressive lifestyle modification and medication change, other tests might be performed including pH testing to look at the amount of acid in the esophagus and manometry which measures the strength and contraction of the esophagus when you swallow

 Causes

  • Small hiatal hernias
  • Obesity
  • Persistent pressure on the stomach and esophagus/diaphragm with coughing, weight lifting, aggressive exercise, straining with bowel movements which disrupt the valve between the stomach and esophagus

Treatment

  • For most, surgical treatment is not necessary to manage gastroesophageal reflux disease
  • Weight loss is important particularly if your BMI is greater than 30
  • Dietary modification including avoiding products such as tomato, citrus, chocolate and caffeine which tend to worsen symptoms.
  • Elevation of the head of your bed particularly with choking or gagging at night
  • Smaller meals and avoiding meals late in the evening
  • Often your doctor may recommend medication to help control reflux symptoms
    • The options include antacids which neutralize stomach acid such as Mylanta or Tums; medications to reduce acid production known as H2 receptor blockers such as famotidine or Pepcid; medications that block acid production and heal the esophagus known as proton pump inhibitors such as omeprazole or Prilosec
  • Surgery can play a role in the management of gastroesophageal reflux disease but only with significant study and testing prior to any procedure to ensure success
    • Surgical options include endoscopic approaches such as a transoral incisionless fundoplication (TIF); the placement of a LINX device which is a tiny ring of magnetic beads to augment the valve; and a fundoplication with the surgeon uses the top of the stomach to reconstruct the valve typically done in a laparoscopic or minimally invasive fashion

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Hiatal Hernia/Paraesophageal Hernia

A condition that occurs when the upper part of the stomach pushes up into the chest through a small opening in the diaphragm, resulting in retention of acid and other contents that can easily back up (reflux or regurgitate) into the esophagus.

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Reoperative Foregut Surgery

Our experienced team of surgeons specialize in all types of complex reoperative foregut surgery. Each case is discussed in detail at regularly scheduled conferences where our multidisciplinary team of surgeons and gastroenterologists identify the ideal reoperative strategy with the aid of cutting-edge imaging techniques, state-of-the-art equipment, and decades of medical and surgical expertise. The specifics of your previous therapeutic and surgical interventions will be reviewed and we will create an operative plan that is safest and most effective for your individual case. 

 What is re-operative foregut/hernia surgery? What causes it?

  • Previous hiatal hernia surgery can fail and occasionally can lead to the return of previous symptoms or the development of new symptoms
  • Occasionally there can be an early failure of surgery leading to more acute symptoms such as the sensation of food getting “stuck”
  • Many patients will have the mild return of pre-surgical symptoms and do not need a “redo” procedure, and the decision of further surgery is not made without significant multidisciplinary (surgery/GI) consultation

 Symptoms

  • Return of heartburn/GERD type symptoms
  • The sensation of food getting stuck in the chest (dysphagia)
  • Chest pain or abdominal pain particularly after eating
  • Shortness of breath
  • Dark or black stools which can be indicative of gastrointestinal bleeding
  • Most concerning is the potential for “strangulation” where the stomach's blood supply is cut off. This is occasionally a result of the previous surgery and “surgical scar” formation

Risk factors for failure of previous surgery

  • Time from repair – increasing time can lead to breakdown
  • Increasing weight gain or obesity can lead to breakdown of previous surgery
  • Heavy lifting or “core/abdominal” exercises can lead to failure of previous surgery

Types of Failures

  • “Slipping” of the previous “wrap” onto the stomach or into the chest leading to the sensation of food getting stuck in the esophagus
  • An “unwrapping” of the previous surgery causes a significant return of GERD type symptoms
  • The stomach “herniating” or moving into the chest causing chest/abdominal pain or the above symptoms

Diagnosis/Workup

  • In considering a “redo” procedure, it is critical to perform comprehensive testing, often similar to testing performed prior to the initial surgery
  • This testing includes an EGD, and measures of esophageal function (pH testing, manometry, barium swallow, and often gastric emptying studies)

Treatment

  • If determined that “redo” surgery is required, this can often be performed with minimally invasive techniques. This is a particular surgical strength of the Mass General staff
  • Occasionally, particularly with third and fourth time “redo” operations, these procedures require a more traditional approach through an open incision, where Mass General surgeons are also expert and experienced
Zenker's Diverticulum

What is it/What causes it?

  • Zenker's diverticulum is a pouch located in the neck where food can get stuck or lodged
  • It is caused by a weakness in the muscles of the cervical esophagus (the tube between the mouth and the stomach)
  • Zenker's diverticulum happens in a very characteristic position in the posterior aspect of the esophagus in the neck

Symptoms

  • The regurgitation of undigested or recently swallowed food. This can happen at unpredictable times and at different intervals of time from eating
  • The development of pneumonia in the setting of food regurgitating into the lungs
  • Halitosis

Risk factors

  • The causes of developing a Zenker's diverticulum is somewhat unknown but it is proposed that longstanding gastroesophageal reflux may contribute to the development of a Zenker's diverticulum

Diagnosis

  • An endoscopy or scope of the esophagus can demonstrate an outpouching in the cervical or neck portion of the esophagus. It occasionally can be difficult to get a endoscope past this diverticulum into the rest of the esophagus
  • A barium swallow which is a test where contrast material is swallowed well x-rays are taken can clearly delineate the size and position of a Zenker's diverticulum

Treatment

  • Surgery to correct a Zenker's diverticulum comes in several forms:
    • A traditional approach is a small incision in the left neck where the outpouching or diverticulum is removed and the muscle that caused this is opened
    • A second approach is a transoral stapling where the common wall between the outpouching in the esophagus is divided
    • We also are now working on endoscopic approaches for treatment of Zenker's diverticulum
  • Most approaches require a 1 day admission although many patients are sent home the same day with the slow advancement of their diet

Care During COVID-19

Our dedicated physicians, nurses and staff are committed to providing the best possible specialty care⁠—safely and effectively. We have taken unprecedented steps to ensure office visits and procedures (endoscopy and surgery) are welcoming and safe. Your health is our top priority.

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Leaders in the Medical Management of GI Motility Disorders and Surgical Treatment of GERD and Hiatal Hernias

SHED's collaborative physicians specialize in the surgical treatment of GERD and hiatal hernias. In addition, we are a leading resource for patients who have had previously unsuccessful antireflux operations.

As a high-volume center, we have achieved excellent results in repairing hiatal hernias and relieving patients of GERD symptoms. Nearly 75% of patients undergoing surgery can discontinue acid suppressive medications and more than 90% of patients undergoing surgery at Mass General expressed a high degree of satisfaction with their outcomes. [Source: D.W. Gee et al. (2008). Measuring the Effectiveness of Laparoscopic Nissen Fundoplication: Long Term Results. Archives of Surgery 43, 482–487.]

Easy Access for Patients & Referring Physicians

We pair patients and referring physicians with an experienced care coordinator who helps assess patient needs and coordinates all necessary appointments and tests.

All requests are triaged the same day, and the patient and referring physician will be called back to schedule an appointment within one business day. Patients and referring physicians may request an appointment online or call 617-724-1020 to speak with our care coordinator.

Procedures

Minimally Invasive Procedures

Minimally invasive treatments are often options for patients who would have required traditional open surgery in the past. These new techniques have the benefit of faster recovery times, smaller surgical scars and greater nerve preservation. Minimally invasive options include:

Magnetic Sphincter Augmentation (LINX)

A flexible band of magnetic titanium beads is placed around the esophagus to support the lower esophageal sphincter (the muscle that opens and closes to allow food to enter and stay in the stomach) by restoring the body’s natural barrier to reflux (treatment for GERD).

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Laparoscopic Anti-Reflux Surgery

Treatment for GERD and hiatal hernias.

Laparoscopic Repair

Typically of an enlarged opening in the diaphragm (treatment for hiatal and paraesophageal hernias).

Per Oral Endoscopic Myotomy (POEM)

Using a specialized endoscopic tool, a small slit is made in the inner lining of the esophagus to tunnel down to the sphincter muscle. The muscle fibers that block the passage of food are divided, and the slit in the esophagus is repaired (treatment for achalasia).

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Laparoscopic Heller Myotomy

Small incisions are made in the abdomen to allow access to the esophageal sphincter muscle, where the muscle fibers that block the passage of food are divided (treatment for achalasia).

Endoscopic, Transoral Treatment for Zenker’s Diverticulum

A specialized instrument is passed through the mouth to divide the common wall between the Zenker's diverticulum and the esophagus, opening the diverticulum and splitting the muscle. This approach avoids a traditional neck incision.

Laparoscopic Procedures

For cancers and GIST tumors of the esophagus, stomach and gastroesophageal junction.

Transoral Incisionless Fundoplication (TIF)

A minimally invasive procedure with no incisions in the abdomen to treat gastroesophageal reflux disease (GERD).

Learn more

Reoperative Hiatal Hernia Surgery
Reoperation for recurrent hiatal hernias after prior hiatal hernia surgery.
Per Oral Pyloromyotomy (POP)
Gastroparesis (delayed gastric emptying) occurs when the stomach takes too long to empty out food—a disorder caused when the vagus nerve is damaged or otherwise stops working. One treatment for gastroparesis is POP, a technique that allows surgeons to open up the pylorus using only a gastroscope, as opposed to the traditional treatment that requires an open or laparoscopic surgical procedure.

Clinical Research Studies and Trials

SHED physicians are active in clinical trials and research studies related to gastroesophageal and swallowing disorders, allowing us to bring our patients promising new treatments as quickly as possible.

Our surgeons have helped evaluate first generation endoluminal therapies, such as the NDO Plicator and the Bard EndoCinch Suturing System, involving minimally invasive surgeries performed through the esophagus. We are currently evaluating newer developments in this area such as the Esophyx Totally Intraluminal Fundoplication (TIF).


Grand Rounds

Massachusetts General Hospital’s Medical Grand Rounds is a CME-accredited weekly seminar series dedicated to improving patient care and presenting new approaches in medicine and surgery.


Contact Us

The Swallowing and Heartburn Center at the Massachusetts General Hospital Digestive Healthcare Center provides both primary treatment and second opinion evaluations for throat, esophagus and stomach disorders.