When is surgical intervention appropriate?
Most people with mild GERD can successfully control symptoms through lifestyle changes or medical therapy. For patients who experience inadequate symptom control, severe regurgitation or side effects from medication, surgical intervention may be appropriate. Further, if patients are concerned about the long-term side effects or costs associated with medical therapies, are at high risk for osteoporosis, have complications of GERD (e.g., Barrett’s esophagus, peptic stricture) or have extra-esophageal manifestations of GERD (e.g., asthma, hoarseness, cough, chest pain, aspiration) surgical intervention may also be appropriate.
The most common antireflux surgery is known as a fundoplication. Fundoplication procedures involve wrapping the stomach’s fundus around the end of the esophagus and stitching it in place to reinforce the gastroesophageal junction and the antireflux barrier. Fundoplications have been performed for over 50 years and have proven successful at alleviating GERD symptoms.
The primary benefit of all fundoplication procedures is the ability to treat reflux via anatomic reconstruction of the antireflux barrier. Rather than suppress acid as with medical therapy, antireflux surgery aims to eliminate abnormal acid exposure by restoring the anatomic structures that naturally prevent abnormal reflux.
Goals of Antireflux Surgery[1-4]
The goal of a fundoplication is to restore the normal functions of the gastroesophageal junction by wrapping the upper portion of the stomach (the fundus) around the esophagus either partially (e.g., Hill, Toupet and Dor procedures) or totally (e.g., Nissen) in order to:
- Reduce a hiatal hernia (if present) by repairing the enlarged opening of the diaphragm and ensuring the stomach and esophagus are properly below the diaphragm.
- Restore the angle at which the esophagus enters the stomach
- Increase the pressure of the lower esophageal sphincter (LES) to prevent reflux and recreate a one-way valve
Though fundoplication was first performed as open surgery, technological advances in the 1990s enabled a laparoscopic approach while preserving the tenets of antireflux surgery. Laparoscopic fundoplication involves accessing the abdomen via 3-5 incisions of 5-12 mm in length. Patients are sedated for the procedure while surgeons dissect anatomy and repair any hiatal hernia before the fundoplication. Laparoscopic fundoplication can be performed on patients with any size hiatal hernia and patients typically return to work within 1-2 weeks.
The “gold standard” for antireflux surgery has been the laparoscopic Nissen, a total fundoplication which wraps the fundus 360-degrees around the esophagus and results in a supraphysiologic (more than is natural) antireflux valve. Because the esophagus and the stomach are modified beyond normal anatomy, functions such as belching and vomiting may be limited. Some surgeons can also create a partial fundoplication (e.g. less than 360-degrees) which more closely mimics normal anatomy. However, laparoscopic partial fundoplications can require more surgical precision and are not as common.
In a randomized study, 90% of patients who had laparoscopic Nissen fundoplications reported symptom control three years post-operatively. However, it is important to remember that laparoscopic fundoplication is a surgical procedure with inherent risks associated including bleeding, infection and injury to internal organs. While results vary by surgeon, a meta-analysis of laparoscopic Nissen fundoplications indicated complications including post-operative dysphagia (26%), bloating (36%) and increased flatulence (65%).
An incisionless approach is also available for patients with smaller hiatal hernias. This procedure, called Transoral Incisionless Fundoplication (TIF), is performed through the mouth with no abdominal incisions and patients typically return to work in less than a week. Associated complications, which usually resolve within a few weeks of surgery, are typically lower than for laparoscopic procedures. Learn more about TIF.
 Jobe, B.A., et. al. Endoscopic Appraisal of the Gastroesophageal Valve After Antireflux Surgery. Am J of Gastro 2004.
 Nissen R, The Treatment of Hiatal Hernia and Esophageal Reflux by Fundoplication. Hernia 1964;30:488-496.
 Adler, R.H., et. al. A valve mechanism to prevent gastroesophageal reflux and esophagitis. Surgery 1958;44:63-75.
 Little, A., et. al. Mechanisms of Action of Antireflux Surgery: Theory and Fact. World J of Surg. 1992;16:320-5.
 Lundell, L., et al. Comparing laparoscopic antireflux urgery with esomeprazole in the management of patients with chronic gastro-oesophageal reflux disease: a 3-year interim ananalysis of the LOTUS trial. Gut 2008; 57: 1207-1213.
 Varin, O., et al. Total vs Partial Fundoplication in the Treatment of Gastroesophageal Reflux Disease: A Meta-Analysis. Arch Surg. 2009; 144(3): 273-278.