Gastroesophageal Reflux Disease (GERD)

Reflux Surgery

The easiest way to treat reflux symptoms is to block acid production in the stomach. In most cases, acid irritation causes the symptoms. Acid can be blocked by using several medications. More than half of all patients get better with acid-suppression therapy. Many physicians will treat a patient who has reflux with acid suppression for about two months before pursuing other treatment.

Surgery for acid reflux is considered as an option if:

• Symptoms do not improve with medications or return after medication is stopped.
• Lifelong medication is needed.
• The patient is unwilling or unable to take medication regularly for a prolonged time.
• There is severe damage to the esophagus due to reflux.

The purpose of surgery is to repair the stomach valve that is allowing acid to leak into the esophagus. Certain tests will be performed prior to surgery to ensure that the patient's condition is likely to be helped by surgery.

Patients are generally evaluated using endoscopy, 24-hour pH studies, manometry or barium X-rays.

Fundoplication Surgery

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In most cases, the operation performed to correct gastroesophageal reflux is a procedure called fundoplication. The upper portion of the stomach (the fundus) is wrapped (plicated) around the lower portion of the esophagus and anchored securely below the diaphragm.

As a result:

• The physical barrier that allows passage of material in or out of the stomach is strengthened.
• A flap valve is created at the entrance of the stomach.
• The wrap "inflates" as the stomach fills; a full stomach has a tighter valve than an empty one.
• All the factors that normally create valve pressure (esophageal muscle, the diaphragm and abdominal pressure) are superimposed on each other for maximum effect.

The operation is effective long term in stopping esophageal reflux and relieving symptoms.

More than 90 percent of patients who have fundoplication surgery are able to leave hospital the next day, eating a soft diet. Most people are able to return to their normal activities, work or school within one to two weeks after surgery. The satisfaction rate with this procedure is 96 percent at one year.

Fundoplication has undergone several improvements. Using a laparoscope and several very small incisions, the surgeon can operate without making a large incision to open the abdomen. The operation is the same, but the patient is spared the long hospital stay and prolonged recovery time of open surgery. There is also less pain after surgery, less chance of wound infection and smaller scars because of the smaller incisions.

Five small abdominal incisions are used for laparoscopic fundoplication. Each incision is .5 to 1 centimeter (less than 1/2 inch) long.

What Can I Expect if I am Referred to a Surgeon?

The gastroenterologist will work closely with the surgeon in deciding about the best options for treatment. Generally, four tests are performed prior to anti-reflux surgery. These include endoscopy, contrast radiography (X-ray), esophageal and sphincter manometry (testing of pressures generated at different points in the esophagus) and 24-hour esophageal pH monitoring (to demonstrate abnormal acid concentrations in the esophagus). These tests will determine whether your symptoms are due to reflux, the extent of damage to the esophagus and whether a defective valve is the main cause of the problem.

Potential Complications

Surgical complications occur in 2 to 4 percent of patients who undergo laparoscopic surgery. The risk of death after this operation is less than one in 500. Complications specific to fundoplication usually concern the stomach wrap.

The benefits generally outweigh the risks for patients who have symptoms requiring surgery.