The standard surgical treatment for GERD

The standard surgical treatment for GERD is fundoplication. The goal of this procedure is twofold:

There are two primary approaches:

In general, the overall long-term benefits of these procedures are similar. Some studies report that more than 90% of patients are free of heartburn after the operation and satisfied with their choice, even after 5 years. The procedure relieves GERD-induced coughs and some other respiratory symptoms in up to 85% of patients. (Its effect on asthma associated with GERD, however, is unclear.) It may enhance stomach emptying and improve peristalsis in about half of patients. (It may actually cause abnormal peristalsis in about 14% of patients, although in such cases the problem does not appear to be very significant.)

Still, it has other significant limitations and postoperative problems. For example, the results of one 2003 survey suggested that 18% of surgical patients would still required anti-GERD medications and that 38% would have new symptoms (e.g., gas, bloating, trouble swallowing), with most occurring more than a year after surgery. Other studies have reported similar results. Also, fundoplication does not cure GERD. Finally, evidence -- a 2002 Swedish study -- strongly suggests that the procedure does not reduce the risk for esophageal cancer in high-risk patients, such as those with Barrett's esophagus.

Candidates. Fundoplication is recommended for patients whose condition includes one or more of the following:

Fundoplication has little benefit for patients with impaired stomach motility (an inability for the muscles to move spontaneously).

The Open Nissen Fundoplication Procedure. Until recently, most fundoplication procedures for GERD have been the 360° Nissen fundoplication. This is a called an open procedure because it requires wide surgical incisions.

When performed by experienced surgeons, the procedure shows results that are equal to those of standard open fundoplication and recovery time is faster.

Overall, laparoscopic fundoplication appears to be safe and effective in people of all ages, even very small babies. Laparoscopy is more difficult to perform in certain patients, including those who are obese, who have a short esophagus, or who have a history of previous surgery in the upper abdominal area. It may also be less successful in relieving atypical symptoms of GERD including cough, abnormal chest pain, and choking. In about 8% of laparoscopies, it is necessary to convert to open surgery during the procedure because of unforeseen complications.

Other Variations. There are now a number of variants of fundoplication procedures. Examples include the following:

Many surgeons report that such limited fundoplications result in earlier feeding and discharge from the hospital and a lower incidence of complications (trouble swallowing, gas bloating, gagging) than the full Nissan fundoplication. A British study, however, reported no significant differences in swallowing problems.

Postoperative Problems and Complications after Fundoplication. Postoperative problems can include a delay in intestinal functioning causing bloating, gagging, and vomiting. They usually resolve in a few weeks. A 2003 study suggested, however, that 38% of patients develop such symptoms, and most occur more than year after the procedures. If symptoms persist or if they start weeks or months after surgery, particularly if vomiting is present, then surgical complications are likely. Complications include the following:

Reasons for Treatment Failure. Long-term failure rates after fundoplication have been reported at 30% after 5 years to 63% after 10 years. Hiatal herniation is the most common reason for surgical failure and the need for a repeat fundoplication. Other common reasons for reoperation include breakdown, slippage, and excessive tightness of the wrap. Surgeon experience can lessen complication risks. Some studies have reported repeat operations after open procedures in between 9% and 30% of cases and 13% after laparoscopy. (Repeat surgery usually has good results.)

Surgical Treatments Using Endoscopy

A number of treatments that make use of endoscopy are being used or investigated for increasing LES pressure and preventing reflux as well as for treating severe GERD and its complications.

Transoral Flexible Endoscopic Suturing. Transoral flexible endoscopic suturing (sometimes referred to as Bard's procedure) uses a tiny device at the end of the endoscope that acts like a miniature sewing machine. It places stitches in two locations near the LES, which are then tied to tighten the valve and increase pressure. There is no incision and no need for general anesthesia.

Radiofrequency. Radiofrequency energy generated from the tip of a needle (sometimes called the Stretta procedure) heats and destroys tissue in the problem spots in the LES. Either the resulting scar tissue strengthens the muscle, or the heat kills the nerves that caused the malfunctioning. Patients may experience some chest or stomach pain afterwards. Few serious side effects have been reported, although there have been reports of perforation, hemorrhage, and even death. A recent study reported that 81% of patiens remained symptom free up to 3 years following the Stretta procedure.

Implants. In 2003, the FDA approved the Enteryx procedure as a treatment option for people who have persistent symptoms of GERD and who regularly take and respond to PPIs. In 2005, however, the manufacturer of Enteryx (Boston Scientific), voluntarily removed Enteryx from clinical use due to problems related to the difficult injection technique.

Techniques to Stop Bleeding. Endoscopic ablation treatment of bleeding involves using a probe passed through the endoscopic tube that applies electricity or heat to coagulate blood and stop the bleeding.

Dilation Procedures. Strictures (abnormally narrowed regions) may need to be dilated (opened) with endoscopy. Dilation may be performed by inflating a balloon in the passageway. About 30% of patients who need this procedure require a series of dilation treatments over a long duration in order to fully open the passageway. Long-term use of proton-pump inhibitors may reduce the duration.

A 2002 study also suggested that dilation may help correct swallowing problems that can occur after fundoplication. In the study dilation improved dysphagia in 67% of the surgical patients who had experienced it.

A recent advance is the development of small-caliber upper endoscopy, which does not require sedation and can be performed in the physician's office.

Gastroesophageal Reflux Disease (GERD)

GERD occurs when excess stomach acid flows up into the esophagus because of a weak LES. Almost everyone experiences reflux and heartburn at one time or another, often after a large meal. However, prolonged and frequent acid in the lower esophagus can cause injury such as inflammation, ulceration, scar formation, and stricture and, after a long period of time, even cancer. Some people have severe symptoms with no tissue damage, while others may have few symptoms and much tissue injury. Reflux inflammation or esophagitis along with ulceration commonly occurs.

It is known that GERD is aggravated by heavy meals, nicotine, fatty foods, obesity, and lying flat in bed. Symptoms are reduced by making lifestyle changes that avoid these culprits. Medications are also very effective in treating GERD. Still, these treatments do not always work and, especially in younger patients facing a lifetime of medication, surgery may become a treatment option.

Laparoscopy

Most females have heard of laparoscopy, also known as "bellybutton" or "Band-Aid" surgery. Gynecologists have long used this technique to tie the Fallopian tubes and to inspect the female reproductive organs. Now this technique has been expanded to include correction of severe reflux disease and esophagitis. With new video technology, the laparoscope has become a miniature television camera. Exquisite magnification is now possible, showing the abdominal organs in great detail.

Laparoscopic Fundoplication

Fundoplication means folding or wrapping, and that is exactly what the surgeon does to the upper stomach in this procedure. The patient is first given a general anesthesia. Then the abdomen is inflated with carbon dioxide, a harmless gas, through a small incision at the naval. The laparoscope, a thin tube carrying the videocamera, is inserted. Four pinpoint incisions are then made in the upper abdomen through which needle-like instruments are inserted. These act as the hands of the surgeon, allowing him or her to dissect and suture. The upper part of the stomach is wrapped and sutured around both sides of the esophagus. This technique restores normal pressure to the LES and prevents acid from refluxing into the esophagus. The patient is usally started on clear liquids the first day after surgery and discharged later that day.

The five tiny incisions heal quickly leaving only slight blemishes. Typically the patient returns to normal activities within a week. A soft diet is recommended for 1 to 2 weeks. Pain is very minimal, usually requiring no medication after 1-2 days.

What Are the Benefits?

The main benefit is the elimination or improvement in heartburn symptoms without the need for regular medication. The risk of a subsequent stricture of the esophagus may be reduced as well. The surgery requires no large, painful incision. There is a very short hospital stay and very rapid recovery. The hospital expense is usually less in comparison to the older open method and since the patient can return to work much quicker, there are far less lost wages.

What Are the Complications?

There is always a very rare risk with general anesthesia for any type of surgery. Internal bleeding or infection may also occur. A common but usually short-term problem is called gas-bloat. Since the LES muscle has been tightened, the patient may be unable to belch, resulting in a feeling of bloating and discomfort. Eating frequent small meals slowly and chewing thoroughly helps. In a few instances, especially in heavy patients or where abdominal surgery has been previously performed, the surgeon may be unable to do the laparoscopic technique and must resort to the traditional but still effective open surgery.

Are There Other Treatment Options?

The primary alternative to laparoscopic surgery is medication to reduce stomach acid. The best of these drugs are called the proton pump inhibitors. These drugs in adequate dosage can almost eliminate stomach acid. Patients can take these drugs for prolonged periods of time and may make surgery unnecessary. It is usually only in those patients where this treatment is ineffective, or when the patient does not wish to take long term medication, that surgical repair is considered.

Who Can't Have the Procedure?

In some instances the surgeon will not recommend the procedure. The following list is a general one and each case is individually evaluated:

Poor normal muscle function in the main portion of the esophagus. This is also called dysmotility and is measured by a pressure recording technique in the esophagus

The following conditions make this type of surgery more difficult and at times not possible:

In each situation, the surgeon will weigh the benefit for the patient against the risks, always considering other medical problems and always making a recommendation that is in the patient's best interest.

Summary