Surgery for Gastroesophageal Reflux Disease (GERD)
GERD stands for GastroEsophageal Reflux Disease.
Gastroesophageal Reflux (GER) is the backflow of acid and food particles that seep out of the stomach and up into the esophagus, commonly known as heartburn, a painful, burning feeling in the chest, most commonly occurring after a meal. Heartburn on a regular basis can lead to damage and scarring in the esophagus. Frequent heartburn, occurring several times a week to several times a day, may be associated with a more severe condition known as Gastroesophageal Reflux Disease (GERD). Heartburn is so common, it often is not associated with a serious disease like GERD.
Surgical Treatments Available
Most people can get sufficient relief from lifestyle changes and medical therapy and do not require surgery. If symptoms are severe, or there are complications and medical treatment does not help, your doctor may recommend surgery.
- Nissen Fundoplication – pronunced NIH-sun FUN-doh-plih-KAY-shun
Nissen fundoplication was developed and named after a German Surgeon, Rudolf Nissen, born 1896. Nissen Fundoplication surgery is an operation for gastroesophageal reflux disease (GERD) that wraps the upper part of the stomach (fundus) around the esophagus in order to prevent reflux. This surgery strengthens the valve called the lower esophageal sphincter (LES) between the esophagus and the stomach.
This operation is done either by traditional open surgery or by laparoscopic surgery. Fundoplication surgery using a laparoscopic technique is being done more often. When choosing a surgeon to do your surgery, the surgeon’s experience is the most important consideration. Before choosing your surgeon, find out the number of these procedures he or she has performed and the success rate of those surgeries. If you are considering the surgery, you may want to consult a gastroenterologist (a doctor who specializes in digestive diseases) to evaluate your GERD symptoms or to get an opinion on whether surgery is necessary.
- Open Fundoplication Procedure
This is 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 lower esophageal sphincter (LES) and prevents stomach fluids from backing up in to the esophagus. Open fundoplication requires wide surgical incisions and a 6 to 10 day hospital stay.
- Laparoscopic Fundoplication Procedure
Four or five small punctures are made in the abdomen permitting insertion of a telescope for viewing and instruments to do the operation. This can be accomplished in some people on an outpatient basis or with just one overnight stay in the hospital. The surgeon creates a collar using the fundus, although the area is smaller to work with. When performed by experienced surgeons, the Laparoscopic fundoplication procedure shows results that are equal to those of the open fundoplication procedure and recovery time is faster. This procedure may also be advised for people without a hiatus hernia who suffer from severe reflux.While some studies indicate that laparoscopic fundoplication improves GERD symptoms in 76% to 98% of people who have the surgery, no studies have proven that laparoscopic fundoplication surgery is effective in maintaining healing of the esophagus over the long term.
About 10% to 20% of the people who have surgery to relieve GERD symptoms continue to have symptoms or develop new problems (such as difficulty swallowing, intestinal gas, or bloating) after the surgery. These continuing or new symptoms may or may not respond to treatment with medications. Also, one study showed that 16% of the people needed second operations within 10 to 12 years to deal with complications caused by the first surgery.
All operations for GERD should be considered major surgery even if the operations are safe and the risks they pose are small. The aims of surgery for GERD are to correct any hernia which might exist and to wrap a portion of the stomach around the esophagus, thus creating a new valve mechanism to prevent reflux. If complications of GERD exist, such as scarring or ulcer formation, these are also corrected at the same time.
- Partial Fundoplication
Partial fundoplication (toupet procedure) involves wrapping the stomach only partway around the esophagus. Full fundoplication involves wrapping the stomach around the esophagus so that it completely encircles it. Most fundoplication surgery uses the full fundoplication method.
Gastropexy involves attaching the stomach to the diaphragm so that the stomach cannot move through the opening in the diaphragm into the chest. Fundoplication is done more often than gastropexy.
- Angelchik Ring
An artificial ring called an Angelchik ring may be surgically placed around the esophagus to reinforce the valve called the lower esophageal sphincter (LES) between the esophagus and stomach. Because of complications involved with its use (such as movement of the ring to other places in the body), this procedure is now rarely used.A person should discuss these and other risk factors with their physicians, who can evaluate their condition and advise them on an appropriate treatment plan. It is important that a person follow the treatment plan advised by their physicians.
Risks or Complications Following Fundoplication Surgery Include
- Difficulty swallowing because the stomach is wrapped too high on the esophagus or is wrapped too tightly. This complication may be more likely to occur in people who receive fundoplication surgery using a laparoscopic surgical technique.
- The esophagus slides out of the wrapped portion of the stomach so that valve (lower esophageal sphincter) is no longer supported.
- Heartburn comes back (relapse of reflux).
- Bloating and discomfort from gas buildup because the person is not able to burp.
- Excess gas (flatulence).
- Risks associated with anesthesia and major surgery (infection, bleeding, and breathing problems from the anesthetic). About 1 in 500 people (0.2%) who have this surgery die from anesthesia or complications from the surgery.
For some people, the side effects of surgery (bloating caused by gas buildup, swallowing problems, pain at the surgical site) are as bothersome as GERD symptoms. The fundoplication procedure cannot be reversed, and in some cases it may not be possible to relieve the symptoms of these complications, even with a second surgery. Second surgeries are more difficult to do, less successful, and more risky. Therefore, it is extremely important that the first procedure be considered carefully, and be done by an experienced surgeon who is more likely to be successful the first time.
When fundoplication surgery is successful, it eliminates the need for long term drug treatment. When trying to decide between surgery and drug treatment, weigh the cost, risks and potential complications of the surgery and the possible risk of complications against the cost and inconvenience of long term (often lifetime) drug therapy.
A person should discuss surgery very carefully with both a surgeon and medical physician.