Gastroesophageal reflux disease (GERD) occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach (esophagus). This backwash (acid reflux) can irritate the lining of your esophagus.
Many people experience acid reflux from time to time. However, when acid reflux happens repeatedly, it can cause GERD. Most people are able to manage the discomfort of GERD with lifestyle changes and medications. However, some may need surgery to ease symptoms or when medical management fails. Low-risk, highly efficient surgical options for GERD can provide long-term relief from debilitating symptoms. Many options exist.
GERD is an exceedingly common disease in our society. One out of five adults suffers from GERD, and approximately 20 million patients are on some form of “acid blocker” such as a proton-pump inhibitor (PPI). However, even on medication, 40% still suffer from symptoms.
Though a long-term acid blockade is generally considered safe, there is growing press coverage regarding potential long-term risks of these drugs; there is little debate about the long-term cost to the patient and healthcare system. Importantly, though PPIs may stop acid production, they do not deal with the persistent mechanical reflux of gastric contents (even if low in acid) upward to the esophagus. Thus PPIs may not be the perfect solution for everyone.
GERD is caused by ineffective functioning of the “valve” between the esophagus and the stomach known as the lower esophageal sphincter (LES). LES dysfunction is often related to decreased tone of the sphincter muscle itself or to a structural issue such as a hiatal hernia (HH) affecting the LES function.
Multiple conditions can also increase risk for GERD, including obesity, pregnancy and gastroparesis. Lifestyle contributors to GERD include alcohol, smoking, large and late meals, acidic foods and some medications (particularly non-steroidal anti-inflammatory drugs). Coffee can also exacerbate reflux symptoms.
Indications and Work-up for Surgical Management of GERD
There are a wide range of indications for surgical management for GERD. Some of the common ones include the failure of medications to resolve symptoms, endoscopic evidence of persistent esophagitis and patient unwillingness to take medications long-term.
Patients with long-term GERD can develop esophagitis or the pre-cancerous condition known as Barrett’s esophagus, which may require reflux surgery to reduce symptoms and risk for development of esophageal cancer. Though some patients with a hiatal hernia (HH) are asymptomatic, many HH patients have significant or persistent symptoms and some even reflux up to the upper airway, inducing or exacerbating symptoms including shortness of breath and chest pain. Others have a persistent cough, hoarseness or “lump in the throat” known as laryngeal globus. Patients with chronic obstructive pulmonary disease or asthma can experience worsening symptoms due to excessive reflux.
Proper workup for patients with reflux symptoms is fairly intensive and includes a minimum of three elements: 1) endoscopy to directly visualize the esophagus and stomach, 2) pH testing, usually either (Bravo/pH impedance) and 3) assessment of the motor function of the esophagus (an esophageal motility study such as direct LES pressure measurement known as manometry) or in some cases with “endoflip,” a probe used during endoscopy to assess the size, motility and pressure in the esophagus. Some patients require cross-sectional imaging such as computed tomography to assess large HH.
Following clinical, endoscopic, pH and pressure assessment, and when needed the anatomic assessment with imaging, surgical options can be determined. Some gastroenterologists, as well as most gastrointestinal reflux surgeons, direct the needed testing and help to lay out the optimal treatment options.
Which Surgical Option is Best?
Multiple surgical procedures are available based on esophageal function and patient interest. There is no absolute perfect procedure, and a thorough discussion of the pros and cons of each procedure is important to make an informed consent.
Many of these procedures can be done in an outpatient setting with minimal time out of work. All of the anti-GERD surgeries except for the TIF procedure (described below) require HH repair if present at same operative setting. I perform virtually all GERD operations with a minimally invasive, robotic-assisted approach.
Traditional approaches to GERD surgery aim to recreate the LES valve mechanism between the esophagus and the stomach. All these operations, including the Nissen, Toupet, Belsey and Dor fundoplications wrap the upper portion of stomach to varying degrees around the distal esophagus to recreate the LES valve mechanism and thereby prevent GERD. Most are performed through the abdomen, with the Belsey classically performed through the chest. Most if not all of these procedures can be done laparoscopically or robotically depending on surgeon’s preference.
The most common (usually transient) side effect of fundoplication is mild difficulty or discomfort swallowing (dysphagia) and frequently a sense of bloating because of the inability to burp (i.e. to release swallowed air from the stomach). Long-term studies suggest fundoplication is associated with seven to 10 years of reflux relief; about 30% of patients require resumption of some form of medication for reflux symptoms after 7 years. Revisional GERD surgery is safe but requires an experienced surgeon as redo reflux surgery is more complex and difficult than initial surgery.
Many centers have moved to a new approach to reflux surgery as technology has evolved. Based on significant study, many experienced reflux surgeons have evolved to a different approach using a novel LINX® reflux management system. LINX is essentially a carefully sized, flexible string of magnetic titanium beads surgically placed around the esophagus at the LES. The band of beads responds to the swallow by opening up to let food pass downward, then closes (due to the magnetic cores within the titanium beads) to prevent reflux of stomach contents back into the esophagus.
Postoperative recovery takes time – sometimes a sense of pain/dysphagia occurs for a period of weeks to a few months, though this can be treated and typically resolves leading to exceptional reflux control. Long-term (12-year) follow-up data reveal that 90% of patients are still off PPI with this device – significantly superior durability of symptom control compared to fundoplication. In the rare instance that the patient does not tolerate the LINX device, it can be removed, and about 75% patients still have good reflux control post removal. (Reversal of fundoplication is extremely difficult if at all possible.)
Two other newer approaches to reflux approach the LES endoscopically. These “endoluminal” approaches include Stretta®, and TIF procedures. Stretta® essentially uses electrical energy delivered by a device on the endoscope to induce heat leading to inflammation to bulk up or thicken the LES to restore the natural barrier to reflux in order to decrease GERD. It takes weeks-to-months to experience reflux relief with this approach, and long term data reveal that about 58% of patients are back on PPIs at five years post Stretta®. TIF (trans-oral incisionless fundoplication) is also an endoscopic antireflux procedure, actually an endoluminal fundoplication essentially recreating the LES valve mechanism much the same way as a Nissen fundoplication would, but from the inside of the esophagus. Effects are more immediate than Stretta®, however like Stretta, about 50% of patients are back on PPIs at five years (based on meta-analysis of TIF procedures). Overall, though less efficient than surgical fundoplication or LINX®, these endoscopic approaches can be helpful in certain groups of patients such as those with small (<2cm) HH, high operative risk, or patients who have had previous GERD surgery or for other reasons may not be ideal candidates for reoperation.
Ultimately, assessment of endoscopy, pH measurement, esophageal pressure assessment and, when appropriate, anatomical assessment determine an array of options for surgical management of GERD that fit the individual patient’s needs. Once the assessment is complete, a careful conversation between an experienced provider and the patient will lead to the best individualized solution for each patient’s GERD.
GERD is one of the most common problems leading patients to seek medical treatment. Nearly 1 in 10 adults in the United States take medications for reflux-related symptoms. GERD can be miserable for patients, and long-term medications may not always be the best option for treatment, especially in patients with refractory symptoms. Surgical therapy for reflux has substantially evolved, particularly with the advent of less-invasive approaches such as laparoscopic and robotic surgery. Evolving technologies provide rapid and durable symptom relief with good long-term control of GERD and off medications.
Dr. Srinivasa Gorjala, MD, FACS
Dr. Gorjala is a general/bariatric surgeon specializing in laparoscopic, endocrine and bariatric surgery. He received his medical degree from New Jersey School and completed his surgery training at the Medical College of Georgia. Dr. Gorjala has brought various surgical innovations to the Northside Hospital Network, such as advanced in thyroid and parathyroid surgery, including intraoperative parathyroid localization as assays. He has a multi-disciplinary approach and a complete 360-care model for bariatric surgery.