Gastroesophageal Reflux Disease and Heartburn

Description

Alternative Names

Surgery

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

• To increase LES pressure and, therefore, prevent acid back-up (reflux).
• To repair any present hiatal hernia.

There are two primary approaches:

• Open Nissen fundoplication (the more invasive technique).
• Laparoscopic fundoplication.

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 five 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 -- notably an important 2002 Swedish study -- now 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:

• Esophagitis (inflamed esophagus).
• Symptoms that persist or are recurrent in spite of anti-reflux drug treatment.
• Strictures.
• In children who fail to gain or maintain weight.

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.

• With this procedure, the physician wraps the upper part of the stomach (fundus) completely around the esophagus to form a collar-like structure.
• The collar places pressure on the LES and prevents stomach fluids from backing up in to the esophagus.
• Open fundoplication requires a six- to 10-day hospital stay.

Click the icon to see an illustrated series detailing gastroesophageal reflux surgery.

Laparoscopic Fundoplication. The standard invasive fundoplication procedure has been replaced in many cases by a less invasive fundoplication procedure that uses laparoscopy. In the operation:

• Tiny incisions are made in the abdomen.
• Small instruments and a tiny camera are inserted through tubes through which the surgeon can view the region.
• The surgeon creates a collar using the fundus, although the area is smaller to work with.

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:

• Toupt fundoplication employs only a partial wrap. Partial fundoplication procedures may be more effective in patients with poor or no esophageal motility (spontaneous muscle contraction). Those with normal motility, who may do better with the full-circle wrap.
• Others use a very short and "floppy" Nissen full wrap.

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:

• An excessively wrapped fundus. This is fairly common and can cause difficulty swallowing (dysphagia) or experience gagging, gas, bloating, or inability to burp. (A follow-up procedure that dilates the esophagus using an inflated balloon may help correct dysphagia, although not other symptoms.)
• Bowel obstruction.
• Wound infection.
• Injury to nearby organs.
• Respiratory complications, such as a collapsed lung. These are uncommon, particularly with laparoscopic fundoplication.
• Muscle spasms after swallowing food. This can cause intense pain and patients may require a liquid diet, sometimes for weeks. This is a rare complication in most patients, but can be very high in children with neurologic abnormalities. Such children are, unfortunately, at very high risk for GERD in the first place.

Reasons for Treatment Failure. Long-term failure rates after fundoplication have been reported at 30% after five year 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) is under investigation. The objective is to heat and destroy 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. Although studies report significantly improved symptoms, its long-term advantages are still unclear. For example, in one study, patients reported improved quality of life, but there were no changes in LES pressure, leading some investigators to believe that radiofrequency only reduced symptoms, which can mask persistent disease.

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. Using a needle catheter, a doctor injects into the muscle of the lower esophageal sphincter (LES) a liquid solution that solidifies into a spongy material. The implant is permanent and may help to reduce or eliminate the need for medications by preventing stomach acid from backing up into the esophagus.

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.