SURGICAL OPTIONS FOR ACID REFLUX

Acid reflux occurs when the stomach acid flows backward up into the esophagus (or the food pipe). This causes undesirable symptoms and can potentially result in esophageal damage. Chronic or severe acid reflux is known as gastroesophageal reflux disease (GERD). GERD is one of the most commonly diagnosed gastrointestinal disorders. In the United States, studies estimate a prevalence of 1 in 5 people.

The most common symptom is an uncomfortable burning sensation felt in the middle of the upper abdomen and/or the lower chest. Other typical symptoms include regurgitation of fluid into the esophagus and difficulty swallowing (dysphagia).

Mild or moderate reflux symptoms can often be relieved with diet, lifestyle changes, and medications. Unfortunately, for some, these methods do not help and need surgical help.

People with severe GERD have several surgical options to manage their reflux burden. Surgeries involve closing off or narrowing the lower end of the esophagus to prevent acid reflux. Some also focus on repairing or replacing the valve at the bottom of the esophagus that normally keeps acid from moving backward from the stomach.

Determining which procedure to perform depends on how advanced the disease is and how well the symptoms are controlled by medicine.

When To Consider Acid Reflux Surgery?

Surgery for acid reflux is usually a last resort. Your doctor will initially try to manage your symptoms with diet and lifestyle changes.

Surgery should be considered if you have long-standing acid reflux and fail to respond or respond poorly to acid suppression therapy, diet, and lifestyle modifications.

Acid reflux surgery may also be considered if you have serious GERD complications, such as inflammation of the esophagus (esophagitis). This can lead to ulcers and bleeding. The tissue damage can even cause scars that can constrict the esophagus, making swallowing difficult.

How To Determine If You Are A Good Candidate For Reflux Surgery?

You may be a good candidate for surgery when:

• Medications like proton pump inhibitors (PPI) fail to relieve your acid reflux.
• You want to stop taking medication.
• You have esophagitis.
• You have a hiatal hernia.
• You have Barrett’s esophagus.
• You have a narrowing of your esophagus.
• You have ongoing symptoms (hoarseness, wheezing, coughing, and tooth enamel erosion).
• You are young and need to avoid long-term PPI use.

Surgery is contraindicated if you are an anesthetic risk due to the poor health of your lung or heart.

Required Testing Before Anti-reflux Surgery

The tests performed before anti-reflux surgery are necessary to determine if you are a good candidate for the procedure.

In general, you should have an upper endoscopy performed. Additional testing includes a 24-hour pH test with impedance and contrast esophagogram.

Tests to check how well the muscles in your esophagus work, including esophageal manometry and esophageal motility studies, can also be performed.

Upper Endoscopy

Upper endoscopy, also called an upper gastrointestinal endoscopy, is a procedure used to visually examine your upper digestive system. It involves placing a small camera (on the end of a long, flexible tube) through the mouth and into the upper gastrointestinal tract allowing evaluation of the esophagus, stomach, and the first part of the small intestine (duodenum).

This is generally done as an outpatient procedure under mild to moderate sedation. The purpose of endoscopy is to assess the integrity of the lower esophageal sphincter (LES), which is the bundle of muscles that helps prevent the contents of the stomach from moving back up the esophagus.

It is also used to evaluate for reflux-related damage and to identify any alternative or coexisting disease processes that may be contributing to symptoms.

24-Hour pH Test And Esophageal Impedance pH Study

In a 24-hour pH test, a thin, soft plastic tube is inserted through your nose and into the lower part of the esophagus above the LES. There are sensors on the tube that detect and record acid reflux episodes.

It is also designed to record and determine if your symptoms correlate with reflux episodes. This test is conducted over a 24-hour period during which you are off the acid-suppression medications but can continue routine activities.

Many doctors also utilize the 24-hour test for the evaluation of reflux in certain people. It involves the same procedure as described above. Additionally, the esophageal impedance detects whether or not the fluid reflux is acidic.

You may have non-acid or weakly acid reflux or continue to have symptoms despite high-dose acid suppression. The impedance study can provide valuable information in these cases.

Esophageal Manometry

Esophageal manometry is a test that shows whether your esophagus is working properly. The procedure measures the contractions in the esophagus after you swallow. The test also measures the force and coordination of esophageal muscles as they move food to your stomach.

A thin, flexible tube (that contains pressure sensors) is passed through your nose, down your esophagus, and into your stomach. This test is mainly used to evaluate for any underlying esophageal motility disorders that may be contributing to a person’s symptoms.

Surgeries For Acid Reflux

There are various procedures that surgeons may use to help ease GERD symptoms. The type of surgery depends on several factors, including your health status and disease progression.

For instance, your healthcare provider may recommend a simple procedure if you do not experience full relief of symptoms with medication even early in the disease.

If you are not experiencing complete relief from medication, performing a sphincter augmentation procedure such as LINX can remove the need for medication or reduce the dose to a single tablet daily or every other day.

If your doctor thinks that your lower esophageal sphincter is severely damaged, a Nissen procedure is usually recommended.

Let’s now take a closer look at each of these procedures.

Fundoplication

Fundoplication means the folding of the fundus, the tissue at the top of the stomach. By folding the fundus around the opening between the stomach and esophagus, the doctor reinforces this area to prevent stomach acid from coming up into the esophagus.

Fundoplication is the gold standard of acid reflux surgeries. The procedure can augment, strengthen, or recreate the LES valve.

The most common type of fundoplication is a Nissen fundoplication, in which the stomach is wrapped 360 degrees around the lower esophagus. Partial fundoplication techniques involve a wrap that does not go entirely around the esophagus. These include Toupet 270-degree posterior wrap and Watson anterior 180-degree wrap.

Surgeons may perform fundoplication as laparoscopic or keyhole surgery or as an open procedure.

The laparoscopic procedure involves several small incisions (less than 1 cm or ½ inch) wherein miniaturized instruments (including a thin tube with a light and camera called a laparoscope) are used to make the process less invasive.

The benefit of this type of minimally invasive technique is that it results in less pain, smaller scars, a shorter hospital stay, a faster return to work, and a lower risk of subsequent hernias and wound infections.

During open surgery, the surgeon makes a long incision in your stomach to access the esophagus. This is more invasive, and the surgical wound is much larger, meaning that recovery time is often longer.

To prepare for this surgery, you may be asked to do the following:

• Consume clear liquids only for at least 24-48 hours before the surgery. Solid foods, juices, and colored sodas are not allowed.
• Medications to help clear out your digestive tract during the final 24 hours before surgery may be prescribed.
• Anti-inflammatory medications, such as acetaminophen (Tylenol) or ibuprofen (Advil), should not be taken.

Transoral Incisionless Fundoplication (TIF)

Transoral means the procedure is done through the mouth without any external incisions.

TIF is a procedure that is used when open fundoplication is not the appropriate way to treat acid reflux symptoms. It is performed without surgery by restoring the natural reflux barrier between the stomach and the esophagus.

Doctors use a special TIF device (called an EsophyX) that is inserted through your mouth and down the esophagus. The TIF device is equipped with grippers and fasteners that form skin folds at the base of the esophagus. The folds then create a new stomach valve that prevents stomach acid reflux.

The procedure can be a good option for those with GERD that is unrelieved by medications or if you do not want to undergo invasive surgery. The recovery time is also minimal. After the procedure, you may stay in the hospital overnight, or you may be able to go home the same day if you feel well.

Multiple studies have shown that the TIF procedure is performed successfully in up to 99% of patients. Only about 2% experience issues during or after the procedure, such as internal bleeding or a tear.

Bard EndoCinch Procedure

The Bard EndoCinch procedure is a minimally invasive alternative to surgery for the treatment of chronic acid reflux.

Instead of wrapping part of the stomach around the lower esophageal sphincter, the EndoCinch procedure uses sutures to create pleats at the LES. These pleats, or plications, are then cinched together to reduce the size of the esophagus opening. This will restrict food from traveling upward into the food pipe.

The procedure is not as commonly performed as others and is not covered by all insurance carriers.

Linx Surgery

This surgery uses a special device called a Linx which is a tiny ring of magnetic titanium beads strung together. When wrapped around the LES, the Linx compresses and strengthens the sphincter.

Due to the magnetic nature of the Linx, it can open and close so that food can pass through. This usually happens while preventing stomach acid from entering the esophagus.

Linx surgery is an effective, safe, and minimally invasive procedure that has a short recovery time.

Stretta Procedure

The Stretta procedure is usually done as an outpatient procedure and uses radiofrequency energy along with an endoscope. It is a non-surgical procedure that is minimally invasive and has a rapid recovery time.

During the procedure, the doctor inserts an endoscope down the esophagus. The tube delivers radiofrequency waves to the area where the esophagus joins the stomach.

The radio waves emitted create tiny cuts in the esophageal tissue. When these cuts heal, they form scar tissue which will strengthen the area and block the nerves that respond to acid reflux. And it is safe, considering the endoscope also delivers water to prevent any heat damage to other areas of the body.

The Pros And Cons Of Acid Reflux Surgery

Advantages Of Acid Reflux Surgery

Surgeries can help prevent complications such as esophagitis and Barret's esophagus.

It also helps avoid long-term medications.

There are also specific benefits of each of the procedures that we discussed earlier. Like, the main advantage of transoral incision-less fundoplication is that it is not an open, laparoscopic operation. It is performed endoscopically.

Likewise, the LINX procedure has minimal side effects and a persistent dysphagia rate of less than 1%.

Drawbacks And Complications

Although anti-reflux surgery is considered both safe and effective, complications and undesirable side effects can occur. Make sure to discuss the complications with your surgeon before undergoing an operation.

Nissen fundoplication and Toupet fundoplication are associated with side effects like persistent dysphagia (in approximately 2%) and bloating after a meal (35 to 40% of the cases), and the inability to throw up when needed. This is rarely severe and generally resolves within the first 6 months after surgery. 

Other reported complications of fundoplication include:

• Infection of the surgical site.
• Piercing of the lining or walls in your stomach, esophagus, tissues around your lungs, spleen, liver, diaphragm, vagus nerves, aorta, vena cava, and heart. This is more likely during laparoscopic procedures.
• Stitches break open and expose the surgical area.
• Nausea and gagging.
• Dumping syndrome (food travels too fast from your stomach to your intestines).
• Lung infections, like pneumonia.
• Persistent reflux and requirement for follow-up surgery.

Complications of TIF include

• Sore throat
• Chest pain
• Shoulder pain
• Some surgery options can be costly.

How Do I Prepare For Anti-Reflux Surgeries?

Tell your doctor about dietary or herbal supplements and medications that you are taking. You may be asked to stop taking them so that they don’t interfere with the surgery.

Ask your doctor if you should stop taking medications like blood thinners (if you are on them). These can increase your risk of complications during surgery.

Have your spouse, children, or any family member available to take you home when your surgery is completed.

How Does The Recovery Look Like?

Recovery time may vary depending on the type of surgery and the person. More invasive surgeries require a longer recovery time. Some may require up to 6 weeks of rest before returning to work.

Typically, you will be spending 1 to 3 days in the hospital following anti-reflux surgery. This will allow your doctor to monitor your immediate recovery. If you are not experiencing any side effects, if you can eat, drink, and swallow without any problem, you may be allowed to go home.

The dietary restriction post-procedure varies between individuals. However, most people gradually return to a solid diet over 2–8 weeks.

Some doctors may recommend that you take only liquid or crushed medications following the surgery and for several weeks as you recover.

Outcomes Following Anti-Reflux Surgery

Fundoplication is a highly effective surgery for treating long-term acid reflux and reflux-related symptoms. Moreover, the outcomes after laparoscopic anti-reflux surgery are generally excellent.

According to several short-term (1–5 years) and long-term studies (5–10 years), the vast majority of people report an effective reduction in their symptoms, an improved quality of life, and a high level of satisfaction after having the surgery.

Likewise, many people undergoing anti-reflux surgery have been taken off of reflux medication afterward. More importantly, people have consistently reported that if they were to do things over, they would still decide to undergo anti-reflux surgery.

However, there are a few key things to consider to minimize the recurrence of symptoms, long-term issues, and the need for another surgery. These include:

• Avoid foods that can worsen your symptoms.
• Exercise and stay fit.
• Prop yourself up when you sleep to keep the stomach acid from seeping into your esophagus.
• Eat smaller portions throughout the day rather than large, infrequent meals.
• Limit reflux triggers, like alcohol, caffeine, and cigarette smoking.

Final Thoughts

Anti-reflux surgery, when performed by experienced surgeons and in appropriately selected conditions, is a safe and effective option. This is especially beneficial in most people who do not tolerate medical therapy or in those who have inadequate or incomplete relief of GERD symptoms from appropriate medical therapy.

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References:

• DeMeester, Tom R. “Surgical Options for the Treatment of Gastroesophageal Reflux Disease.” Gastroenterology & hepatology vol. 13,2 (2017): 128-129.
• https://www.niddk.nih.gov/health-information/digestive-diseases/acid-reflux-ger-gerd-adults/definition-facts

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