The goal of treating gastroesophageal reflux disease (GERD) surgically is to reduce or eliminate gastric juice from refluxing up into the esophagus. Antireflux surgery controls GERD symptoms better than medical therapy, and also frequently enables patients to stop or reduce the need for antacid medications. To achieve the goal of stopping gastroesophageal reflux, interventions need to: (1) restore the function of the lower esophageal sphincter, and (2) reduce or repair a hiatal hernia, if present. There are 3 approaches that we offer to appropriate patients:
For more information about gastroesophageal reflux disease, click here.
Generally, GERD surgery is indicated for patients who have symptoms of GERD (including LPR symptoms) that are inadequately controlled by medical therapy. Occasionally patients seek out surgical treatment because of side effects of medical therapy or as an alternative to medical therapy.
The LINX procedure is performed laparoscopically under general anesthesia through small incisions made in the abdomen. Using a video camera and special operating instruments, the hiatal hernia if present is repaired (snugging the diaphragm opening around the esophagus), and then the LINX system – a bracelet of magnetic beads – is implanted laparoscopically around the lower esophagus to augment the lower esophageal sphincter. The beads will open up when swallowed liquid or food goes down, but then closes, which decreases acid reflux. Surgery takes about 1 hour and most patients spend the night in the hospital. Upon discharge, patients can resume normal non-strenuous activities of daily living and return to work within 1-4 weeks (depending on the nature of the work). Click here for more details about the LINX Reflux Management System.
Laparoscopic fundoplication is performed under general anesthesia through small incisions made in the abdomen. Using a video camera and special operating instruments, the hiatal hernia is repaired (snugging the diaphragm opening around the esophagus), then part of the stomach is folded around the lower esophagus and sutured in place, reestablishing the antireflux valve mechanism. Surgery takes 1-2 hrs and most patients spend the night in the hospital. Upon discharge, patients can resume normal non-strenuous activities of daily living and return to work within 1-4 weeks (depending on the nature of the work). Click here for more details about laparoscopic fundoplication.
Transoral incisionless fundoplication (TIF) is also performed under general anesthesia, but no incisions are made. Instead, a special device (EsophyX) is introduced through the mouth over a flexible endoscope. This device is capable of reducing a small hiatal hernia (< 2 cm or about 3/4 inch) and then folding part of the stomach around the lower esophagus to re-establish the antireflux valve mechanism. TIF surgery takes about 1 hour and most patients spend the night in the hospital. Upon discharge patients can resume normal non-strenuous activities of daily living and return to work within 1-4 weeks (depending on the nature of the work). Click here for more details about TIF using EsophyX.
All medical interventions have their pros and cons. In treating gastroesophageal reflux disease surgically, the success at controlling reflux is associated with a greater potential for side effects of food sticking (dysphagia) or excess gas and bloating (gas-bloat syndrome). Laparoscopic fundoplication has the greatest measured success at controlling reflux; however, one in 20 patients will experience some long-term side effects that are noticeable in their daily lives. Though it is very rarely troublesome, sometimes it is enough that they request a revision or undoing of the fundoplication. The LINX procedure and the TIF EsophyX procedure both have a very low incidence of bloating side effects. The LINX procedure does have more issues with swallowing problems (food sticking) than the EsophyX, but it may have greater success at controlling GERD symptoms long-term than TIF/EsophyX.
Laparoscopic fundoplication can be performed in patients with any size hiatal hernia, and weakened esophageal peristalsis (the ability of the esophagus to push food into the stomach) is not a major issue in our institute as we perform many partial fundoplications. The primary limitation, then, is the potential for bloating side effects.
Transoral fundoplication (TIF) is limited to patients with a hiatal hernia of < 2 cm, which is determined during preoperative testing. We do not generally perform the procedure on patients with a body mass index (BMI) > 30-35, patients who have Barrett’s esophagus, or patients who have serious complications related to reflux (e.g. aspiration, asthma exacerbation, chronic cough), because the success at controlling gastroesophageal reflux disease (measured by testing) is not as great as a laparoscopic fundoplication. A laparoscopic fundoplication can be performed if the transoral procedure fails.
The LINX procedure can be performed in patients with a hiatal hernia of < 3 cm. It cannot be implanted in patients with weak esophageal body peristalsis, in patients who have an allergy to nickel, titanium, or iron, or in patients who will need to have MRIs performed. Additionally, patients with recurring strictures or Barrett’s esophagus may not be candidates. The most noticeable side-effect of the LINX is difficulty swallowing. This seems to peak at 4-6 weeks after surgery and then gradually subsides, although occasionally the device has been removed for persistent troubles with swallowing. A laparoscopic fundoplication can be performed if the LINX procedure fails.
In general, we think the first decision a patient needs to make is whether or not he or she is ready to have an invasive treatment for GERD. This involves weighing the severity of symptoms against the risks and downsides of surgery. Once this decision is made, it becomes much easier to sort out the appropriate procedure, and we will help with the whole decision process. Because the laparoscopic fundoplication can be performed regardless of hernia size and esophageal pushing ability, and because it is readily covered by health insurance, it remains the most common procedure we perform. The EsophyX/TIF and LINX procedures both have the benefit of lower side effect profiles, but are limited to select patients, and insurance coverage is variable.
Although these GERD procedures have a low incidence of complications overall, no intervention is risk-free. All of the procedures are performed under a general anesthetic and carry a small risk of postoperative infection, bleeding, prolonged recovery, or other complications associated with any major surgery.
Almost all patients are discharged the same day. At the time of discharge, you should be able to resume normal, non-strenuous activities of daily living. Most people find their pain is well controlled on oral narcotics (if needed) and 90% are off of oral narcotics by a week after surgery. Although there are some minor differences in postoperative pain and energy levels with the three procedures, these are fairly minor. With the laparoscopic fundoplication and EsophyX transoral fundoplication, the consistency of food intake is restricted for 3-4 weeks after surgery. The LINX procedure does not have the same restrictions. Most patients are able to return to non-manual labor within 1-2 weeks of surgery, and manual labor within a month.
Maximizing medical therapy — Although most patients have already been treated with strong anti-acid therapy (e.g. proton pump inhibitors such as omeprazole, Dexilant, Nexium) prior to coming to see us, there are certain modifications of medical therapy that may be helpful and we are happy to discuss these with you. Lifestyle modification (most notably weight loss and elevation of the head of the bed) can lead to a dramatic improvement in symptoms in some patients with acid reflux and GERD.
Living with symptoms — It is important to remember that in many instances, the reason patients consider surgery is because of persistent symptoms. Sometimes concerns about cancer development is another reason. Please consider how troublesome your symptoms are and how much they affect your quality of life, and discuss your concerns with us so that we can help you make the best decision.