Surgical Options For Reflux - Gastroesophageal Reflux Disease: Digestive Disorders

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Surgical options for reflux

Medication and lifestyle changes can successfully control 95% of GERD cases, but for a few patients, surgery is the best option. For example, surgery may be preferable for young patients who find the prospect of taking PPIs for life unappealing. Other indications for surgery are occasional cases of erosive esophagitis that do not improve with drug therapy, strictures that recur despite treatment, or pneumonia or recurrent respiratory problems due to acid reflux that don't improve with drug therapy.

The goal of surgery is to tighten the LES. The operations are generally effective and may eliminate the need for all GERD medications.

Fundoplication

The most common antireflux operation is the Nissen (360-degree) fundoplication. Also known as a stomach wrap, the operation creates a vacuum effect that prevents stomach acid from surging upward.

The procedure involves grabbing a portion of the top of the stomach and looping it around the lower end of the esophagus and LES to create an artificial sphincter or pinch valve. It prevents stomach acid from backing up into the esophagus (see Figure 6). The wrap must be tight enough to prevent the acid from coming back up, but not so tight that food can't enter and a satisfying belch can't escape. In addition to curing heartburn and GERD-induced respiratory symptoms, the procedure may enhance stomach emptying and improve abnormal peristalsis in some patients.

Figure 6: Surgery for GERD Most cases of GERD can be managed successfully with medications. But in a few cases, a surgical procedure called fundoplication may be used to fold the top of the stomach around itself to create a high-pressure zone that functions as a lower esophageal sphincter (LES).

Over time, however, the stomach wrap can loosen. At this point, the patient would need to undergo surgery to redo the procedure or would have to resume medications. A study in the Journal of the American Medical Association found that 62% of patients who had undergone the Nissen fundoplication procedure 10 years earlier were regularly using antireflux medications.

Some surgeons perform fundoplication as a laparoscopic procedure, in which special instruments and cameras are inserted into tiny incisions in the upper abdomen. Patients recover much faster from laparoscopy than from open surgery. Most patients go home in two days, and within a week or two they are able to swallow without pain or the feeling that food is catching on the way down.

An even newer approach is endoscopic surgery, in which a specialist uses an endoscope inserted down the esophagus to perform the surgery. No abdominal incision is necessary. The number of surgeons trained in this procedure is limited, however, and the long-term results are unknown.

Radiofrequency catheter ablation

The FDA approved radiofrequency catheter ablation to treat reflux in 2000. Also known as the Stretta procedure, it involves applying controlled radiofrequency energy through a flexible catheter that extends to the LES. The procedure, which takes less than an hour, "zaps" the LES and the upper part of the stomach, causing the lining of the lower esophagus to expand slightly. As a result, the valve tightens, creating a more effective barrier between the esophagus and stomach. Patients undergoing this procedure can expect to get back to their regular activities the next day.

Studies show that the Stretta procedure works well for most patients who have not had success with medication. In a 2003 study in Lancet, 94 patients were followed for a year after they had the procedure. The percentage of patients requiring PPIs fell from 98% to 30% after surgery. Complications from the procedure occur in no more than 10% of patients and are generally not serious.

Endoscopic suturing systems

Another minimally invasive approach is to tighten the LES with sutures. One procedure that achieves results comparable to radiofrequency catheter ablation is known as the Bard endoscopic suturing system. The procedure uses a thin, flexible endoscopic tube with something that resembles a mini sewing machine at its tip. The device is inserted down the patient's throat and is used to place stitches on either side of the LES. The doctor then ties the sutures together to tighten the valve.

A similar technique is called plication, in which a single pleat is made in the tissue to tighten the LES. Another procedure can be done with a device, called the Wilson-Cook endoscopic suturing device, to make several small pleats in the tissue. Because these procedures are newer, there are, as yet, no long-term data on their effectiveness.

Injections

A final technique involves injection of inert materials into the muscles lining the end of the esophagus, to create a mechanical barrier that blocks reflux. Initial results with collagen and Teflon were not very encouraging because particles sometimes moved from the injection site or dissolved. However, the availability of newer synthetic materials that stay fixed has led to renewed interest in this therapy. While this technique may be easier to perform than the others, more testing is needed before injections become widely used.

Last updated:	August 21, 2007