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 anchoring it in place to reinforce the gastroesophageal junction and the antireflux barrier. Fundoplications have been performed for over 50 years and are proven successful at alleviating GERD symptoms.
The primary benefit of all fundoplication procedures is the ability to treat the reflux via an anatomic rec0nstruction of the antireflux barrier. Rather than supress the acid from being produced, for which is serves a role in digestion, antireflux surgery aims to eliminate abnormal acid exposure in the esophagus.
Goals of Antireflux Surgery: the goal of surgery is to restore the normal functions of the GE junction by wrapping the upper portion of the stomach (the fundus) around the esophagus either partially (e.g., Hill, Toupet, TIF, or Dor procedures) or totally (e.g., Nissen) in order to : Reduce a hiatal hernia ( if present) by repairing the enlarged opening, Restore the angle at which the esophagus enters the stomach, or Increase the pressure of the lower esophageal sphincter ( LES ) to prevent reflux and recreate a one-way valve.
Laparoscopic Surgery: Though fundoplication was first performed as “open surgery”, advances in technology allowed the procedures to be performed by minimally invasive methods using the laparoscope. Laparoscopic fundoplication can be performed on patients with any size hiatal hernia and patients typically return to normal activities in several days. The Nissen procedure involves the wrapping of the stomach 360 degrees around the lower esophagus. Because the Nissen alters the anatomy beyond usual, functions such as belching and vomiting may be altered. Patient symptoms of GERD are usually greatly helped and most patients are able to greatly reduce or discontinue antireflux medications.
Incisionless Surgery: A procedure requiring no incisions on the body is also available for patients with smaller hiatal hernias. This procedure is called Transoral Incisionless Fundoplication, or TIF. It is performed through the mouth and patients typically return to normal activities in just a few days. Most complications associated with antireflux surgery are usually less frequent with TIF. Both procedures have some post-operative dietary guidelines and both require general anesthesia and patients are kept for an overnight stay in the hospital.