Prof. (USC) Dr. med. Jörg Zehetner is a renowned specialist in visceral surgery with a particular focus on upper abdominal surgery. He has outstanding expertise in the treatment of diseases of the esophagus and stomach, including cancer, gastroesophageal reflux (GERD) and obesity. He is also one of the leading experts in bariatric surgery and the surgical treatment of complex hiatal and abdominal wall hernias. As a specialist in surgery with a focus on visceral surgery and a long-standing professor at the University of Southern California (USC), he combines excellent medical expertise with international experience.
Dr. Zehetner completed his medical training in Switzerland, Austria and Spain before completing his surgical residency in renowned clinics in Switzerland and Austria. After working for several years as a senior physician in Linz, he continued his career in the USA, where he spent seven years researching and teaching at the University of Southern California (USC) in Los Angeles. He has received several awards for his outstanding teaching achievements and is an honorary member of the Society of Graduate Surgeons at USC.
Since 2015, Dr. Zehetner has worked as an attending physician at the Hirslanden Klinik Beau-Site and in his own practice in Bern. In 2017, he took over the practice completely and founded Swiss1Chirurgie AG, which is now represented at several locations in Switzerland. Swiss1Chirurgie is now the largest private practice for obesity surgery and reflux surgery in Switzerland. Together with the Center for Bariatric Surgery (ZfbC), it treats around 3,500 patients a year. This comprehensive care is complemented by the specialist network of Helvetius Holding AG, which includes Swiss1Surgery as well as gastroenterology and general medical practices. As a result, patients benefit from interdisciplinary care at the highest level.
Dr. Zehetner is considered one of Europe's leading experts in reflux and obesity surgery and is particularly in demand when it comes to complex reoperations. He has extensive experience in minimally invasive surgery, including high-precision robotic surgery. His particular focus is on the treatment of gastroesophageal reflux disease (GERD), a condition that can lead to serious consequences such as chronic bronchitis or esophageal cancer if left untreated. Dr. Zehetner is the only surgeon in Switzerland who has mastered all established and new surgical methods in reflux surgery. This enables him to select the optimal treatment strategy for each individual patient and offer highly precise, personalized therapy.
The editors of the Leading Medicine Guide were able to find out more about the connection between sleep apnea and reflux in an interview with Dr. Zehetner.
Reflux and sleep apnoea are two widespread conditions that at first glance appear to be unrelated. However, more and more scientific findings indicate that they are closely linked. While nocturnal reflux can irritate the airways and significantly impair the quality of sleep, sleep apnoea also appears to promote the reflux of stomach acid. This complex alternating mechanism can not only significantly reduce the quality of life of those affected, but also have long-term health consequences. A closer look at this connection shows why early diagnosis and targeted treatment is crucial in both areas.
Gastroesophageal reflux (GERD) and sleep apnoea are two common conditions that are often linked. Various underlying causes and risk factors can contribute to both GERD and sleep apnea and at the same time exacerbate the symptoms.
Overweight and obesity are important risk factors. People who are overweight have an increased risk of developing both GERD and sleep apnea. “Personally, as a reflux expert and also as an obesity expert, I often see patients who are overweight, have sleep apnoea and suffer from reflux. There is sometimes an overlap here. Reflux and sleep apnea are two different medical conditions that can be considered independently of each other, but there are some correlations in terms of causes and risk factors. One risk is being overweight (often from a BMI of 27), as this causes more pressure on the stomach on the one hand and on the throat area on the other. It has been found that 70% of overweight patients heal their sleep apnea if they lose a reasonable amount of weight. Patients with sleep apnea also have a stronger negative pressure in the chest. This is due to the fact that the patient, who suddenly breathes in strongly again during sleep apnea, triggers a negative pressure in the thorax, which causes stomach acid to be drawn upwards. This then has various effects. However, it is not known whether sleep apnoea is caused by stomach acid being drawn upwards or whether the patient makes a reflex breathing pause because stomach acid has come upwards. There are also speculations that there are sensors in the esophagus that close the epiglottis when irritation occurs in order to protect the lungs,” explains Prof. Dr. Zehetner and adds:
“Another risk factor is alcohol consumption, as alcohol causes the entire throat and pharynx area to become slack. Of course, smoking and an unhealthy diet are also risk factors. When it comes to diet, it is particularly about eating too many ready-made products or fast food and too much food. Coffee plays a small role, because although coffee is actually good for digestion, caffeine can lead to a relaxation of the lower esophageal sphincter, which can cause stomach acid to shoot upwards. And when the acid is there and this causes the patient to reflexively pause for 30-40 seconds to breathe, they suddenly take a deep breath and “bring up” even more acid."
Nocturnal reflux can exacerbate the symptoms of sleep apnea in various ways and has a significant impact on the quality of sleep of those affected.
During sleep, especially in the supine position, the relaxed muscles and reduced swallowing reflex increase the likelihood of stomach acid rising into the esophagus. The repeated nocturnal awakenings caused by the reflux symptoms or breathing interruptions lead to a fragmentation of sleep and a significant reduction in sleep quality. The constant waking and repeated disturbances prevent a restful night's sleep and can lead to a chronic sleep deprivation situation. These sleep disturbances in turn promote a worsening of sleep apnoea and reflux and lead to a further reduction in quality of life, as those affected suffer from fatigue and reduced performance during the day as well as from the stressful symptoms at night.
“It is often the relatives who notice regular and continuous snoring, accompanied by pauses in the patient's breathing - so-called breathing pauses, which can last from a few seconds to a minute, followed by loud gasping. During the day, the patient experiences headaches and suffers from difficulty concentrating and daytime tiredness, because the breathing pauses at night increase the CO2 content in the brain and reduce the supply of oxygen. Patients with these symptoms often go to their GP and are often given a mask for the night, with which they are ventilated with positive pressure. This treats the sleep apnea, but not the cause. However, the possible causes of obesity or reflux must be treated! For this reason, patients and treating physicians who suspect sleep apnoea should carry out or recommend a gastroscopy with acid measurement. This is carried out over a period of 48 hours or more using a small capsule (Bravo or Alpha capsule), which can be used to measure how much acid comes up when lying down without a cable in the nose,” recommends Prof. Dr. Zehetner.
Various diagnostic procedures are used to determine whether a patient with sleep apnoea also has reflux that requires treatment. The choice of the appropriate method depends on the clinical symptoms, the severity of the complaints and the available resources.
“A key part of the diagnosis is a detailed medical history, as many patients with sleep apnoea also suffer from frequent heartburn or other reflux symptoms. During the consultation, we try to find out exactly what the patient's reflux and sleep apnoea are like and whether there are any connections with their lifestyle. Functional investigations are carried out in our gastroenterology group practice. In addition to gastroscopy, these include a pressure measurement of the esophagus and the aforementioned acid measurement at the end of the esophagus. Gastroscopy can also be used to assess whether a hiatal hernia is present and the end of the esophagus can also be visually assessed. Inflammation and changes in the mucous membrane can also be detected. All of this can be done in one day. The patient only takes the acid measurement capsule with them and returns to us after approx. 48 hours to evaluate the results,” says Prof. Dr. Zehetner, describing the diagnostic procedure.
Treatment for patients suffering from both gastroesophageal reflux (GERD) and obstructive sleep apnea (OSA) should be holistic and include both drug and non-drug approaches, as well as surgery if necessary.
As both diseases can influence each other, targeted treatment is crucial to alleviate symptoms and improve the quality of life of those affected. One of the most important measures is lifestyle adjustment.
“If a patient is slightly overweight (BMI 25-27), we offer nutritional advice. For patients with a BMI over 28, we offer a consultation at our Center for Bariatric Surgery to discuss conservative therapy with GLP-1 (slimming injection) and close monitoring. For patients with a BMI of 35 or more, we recommend laparoscopic gastric bypass surgery as the gold standard. The sleeve gastrectomy is not ideal for patients with reflux. In patients who are not overweight, the symptoms need to be better verified, for example whether they have a chronic cough or voice changes, or whether they have already had lung problems such as bronchitis or pneumonia. Then I would always recommend reflux surgery. There is of course a small percentage of patients who, despite reflux clarification and/or surgery, need a breathing device for the night to create positive pressure,” says Prof. Dr. Zehetner and adds:
“There are other treatment methods for sleep apnea that are interesting for patients who do not have reflux: Sleep apnea splints. These splints are placed in the mouth like braces and push the lower jaw forward. This creates more space in the throat, which is why you snore less and have fewer sleep apnea episodes. Such a splint would then have to be worn every night. If the patient has a misaligned jaw, it is sometimes advisable to see an oral surgeon to have it corrected - although this is very rare in connection with sleep apnoea”.
Initial success varies with the different methods:
With reflux surgery: after approx. 2-3 weeks
With bariatric surgery: after approx. 3 months
It can take up to six months for the sleep apnoea to disappear, as the gastric mucosa and the reflux sensors in the lungs need this long to normalize and regress.
Lifestyle plays a crucial role in the interaction between gastroesophageal reflux disease (GERD) and obstructive sleep apnea (OSA), as both conditions are influenced by various factors of daily life.
An unhealthy diet, obesity, alcohol and nicotine consumption and certain sleeping habits can aggravate both reflux and sleep apnoea. However, targeted lifestyle adjustments can often significantly alleviate the symptoms of both conditions. Certain foods such as high-fat foods, carbonated drinks, chocolate, coffee, citrus fruits and spicy foods can increase stomach acid production and exacerbate reflux. Late meals should also be avoided, as lying down with a full stomach encourages reflux. An easily digestible, low-acid diet with high-fiber foods can relieve the gastrointestinal tract and reduce reflux symptoms.
“Good sleep hygiene is important. You shouldn't eat too much in the evening; small portions are better. The last meal should ideally be two hours before going to bed. Nicotine, caffeine and alcohol should also be avoided. It is also unhealthy to spend too much time in front of a screen, whether watching TV or using a cell phone. The ideal bedroom temperature is 16-20 °C. And then, of course, it is important to take time to get a good night's sleep. However, patients suffering from sleep apnoea can lie in bed for as long as they like - they simply lack regular and continuous sleep,” says Prof. Dr. Zehetner and concludes our conversation:
“I personally perform around 150 reflux operations, and around 350 bariatric operations are carried out at the Beau-Site Clinic in Bern, making us the number one in Switzerland. As a tip, I would like to say that if someone notices poor sleep, reflux should always be considered. There is also silent reflux without acid regurgitation or heartburn, but it can still lead to inflammation of the esophagus. Patients often have a long ordeal before the correct diagnosis is made”.
Thank you very much, Professor Dr. Zehetner, for this important information on reflux and sleep apnea!
