When Surgery is Needed to Correct Acid Reflux

01/16/2018

A romantic evening in town, an excessively rich meal late in the evening, wine, and a couple of peppermints from the checkout counter sets the stage for a night of discomfort, indigestion, and choking on undigested food and sour acid regurgitated into the mouth...You have just crossed over into the Twilight Zone of gastroesophageal reflux disease (GERD). 

GERD refers to the regurgitation of stomach contents into mouth and airways. 

Food and acid are typically prevented from reflux by competent function of the lower esophageal sphincter, a ring of muscle in the lower esophagus, which is assisted in its job by the diaphragm, maintaining a mechanical barrier at the top of the stomach and lower esophagus to prevent backflow of acid and symptoms of reflux. Heartburn, also called acid indigestion, is the most common symptom of GERD. However, if left untreated, GERD can cause esophageal ulcers, esophageal bleeding, and narrowing of the esophagus (peptic stricture). 

What causes GERD? 

GERD results due to a failure of the mechanical barriers to reflux: 

1. Incompetent (overly relaxed) esophageal sphincter which no longer controls backflow.

2. A hiatal hernia (top of the stomach bulges over the diaphragm) 

3. Overly filled stomach with delayed emptying (because the stomach does not empty while we sleep.) 

The interaction of all of these factors is a fairly complex mechanical and physiologic interchange. For more in depth information about physiologic, dietary, and weight loss options for GERD, please see the article in this issue by Dr. Steve Porter on pages 29-31 titled "Acid Reflux: The Burning Issue". 

Once GERD is identified, a number of treatment options can be prescribed. 

Surgical Options 

Nissen fundoplication is an anti-reflux operation that helps patients who have persistent symptoms despite medical treatment. The upper part of the stomach (gastric fundis) is wrapped around the lower esophagus and is sutured to the stomach, which helps the lower esophageal sphincter (the valve between the esophagus and stomach) close more effectively. This prevents the gastric acid backflow which causes GERD. The esophageal hiatus is also narrowed using sutures to treat hiatal hernia, preventing the upper part of the stomach from sliding up through enlarged esophageal hiatus of the diaphragm. This procedure is usually done laparoscopically, i.e., without actually opening the abdomen. 

Studies have shown fundoplication to be a safe and effective procedure with nearly 90% of patients being symptom-free after 10 years. Post-surgery complications can include trouble swallowing (dysphagia), irritable bowel (which may last 2 weeks), and the fundoplication can come undone over time in 5-10% of cases, which may warrant a repeat surgery. 

Laparoscopic (videoscopic) Procedure

A videoscopic surgical procedure is an alternative to the traditional or what is known as "open" surgery, in which a large incision is made. This technologically advanced option allows the surgeon to use minimally invasive surgery to treat GERD. Videoscopic surgery eliminates the need for a long incision. Small incisions only millimeters in size are made to accommodate small tubes called "trocars." These create a passageway for special surgical instruments and a laparoscope. 

A fiberoptic instrument called a laparoscope is inserted into the abdominal wall. This device transmits images from within the body to a video monitor, allowing the surgeon to see the operative area on the screen. In a laparoscopic Nissen fundoplication procedure, small surgical tools and a laparoscope are used to repair the muscle that separates the stomach and esophagus. 

This procedure has many advantages over a traditional surgery including minimal scarring and reduced recovery time. Hospital stays are reduced and total recovery time is reduced to half. The risk of infection is also minimal because of very small puncture sites. 

Best yet, the laparoscopic surgery often requires a hospital stay of less than 24 hours instead of four to five days as in the case of traditional surgery. In many cases, a patient’s total recovery time can be as little as one to two weeks, compared to the four to six weeks time for traditional surgery. 

If you have failed to respond to conservative therapy, or suffer from complications of reflux disease such as ulcers, strictures or Barrett’s esophagus, it may be time to consider a surgical approach. 

Who are good candidates for the procedure? 

Surgical candidates are those whose heartburn is not well controlled with medicine, those who want to fix the problem without having to take medicine long term, and those who have complications from reflux such as ulcers, strictures, hernias or Barrett's esophagus. 

What can I expect before and after the surgery? 

Patients are counseled before the operation about lifestyle and dietary adjustments that are needed for the first six weeks following surgery. They are advised to eat smaller amounts of food at each meal, chew their food well, and avoid chewing gum and drinking carbonated beverages to make sure that they heal properly from the surgery. 

The success rate for the minimally invasive surgery is 90 to 95% for patients who have typical symptoms of GERD such as heartburn, regurgitation, and belching. For those with less typical symptoms, including hoarseness and chronic cough, the surgery is about 70 to 80% effective in relieving their symptoms.

-LeGrand Belnap, MD, FACS

-Original Publish Date: Fall 2011

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