Surgical Treatment For Reflux
None of us wants to consider surgery. Certainly it is better to try to treat our reflux conservatively but when conservative treatment fails to provide adequate relief the next option is generally considered to be medications. For many if not most people, short term usage of medications to treat GERD is effective and may be needed only now and them to treat flares or H Pylori infection. For others, medical management of GERD becomes a long term issue.
Recently, I’ve been writing about the concerns of long term usage of Proton Pump Inhibitors. On the other hand, the risk of Barrett’s esophagus (a precancerous condition) is increasing making adequate GERD treatment critical. When other treatments fail and long term usage of PPIs is not desired or effective, surgery may be considered.
Surgery for GERD involves tightening the sphincter at the junction of the esophagus and the stomach. This procedure is called a fundoplication. Traditionally fundoplication was done as open procedure which meant a hospital stay and increased risk of complications. Interestingly, a few months ago I reported on the research about the long term efficacy of Fundoplication compared to long term use of Proton Pump Inhibitors (PPIs). This research was based on primarily the open Fundoplication procedure and does not include the new concerns about long term usage of PPIs. Newer research is now coming out comparing the now more common laproscopic fundoplication to long term PPI usage.
The majority of fundoplications being done in the US now are called laproscopic. In the laproscopic procedure the stomach is wrapped around the base of the esophagus effectively increasing the pressure at this sphincter. (See figure below). Research review by Herbella and Patti (2010) shows that this procedure is indicated for patients who have a chronic cough, who aren’t adequately treated with medication, who have poor medication compliance, or who may need to be on PPIs for a very long term. There may actually be a cost savings with this procedure when compared to the long term cost of medication. Additionally, Lundell et.al. noted that 3 years after surgery, patients who underwent laproscopic fundoplication had better control than those who continued to take PPIs. There was a low 3% complication rate. There were side effects that included difficulty swallowing (on average up to 3 months after the procedure) and increased flatulence that lasted the entire three years of the study. These authors also suggested that the procedure may be a good choice for those who need control of reflux in a way other than long term PPI usage.
Over the years there have been other attempts at increasing the esophageal pressure without invasive surgery but instead using an endoscopic procedure. Many of these procedures (e.g. BARD Endocinch, Enteryx) did not last and are no longer being performed in the United States but the Esophyx-TIF (Transoral incisionless fundoplication) is currently available.
In the Esophyx-TIF, small clips are placed in the esophagus under general anesthesia using an endoscopy. The advantages of this procedure are less downtime and it is not considered an open surgical procedure so wound healing and complications should be lessened. Cadière, et al., did find minimal post surgical side effects when they studied 86 patients; however, two of these patients did have esophageal perforations (a hole in the esophagus) during the procedure. In this study, 85% of patients were not using PPIs at one year after the procedure. Because this is a relatively new procedure the long term effectiveness is not known.
So, what does all this mean? I think it’s important to weigh all of your options if you find yourself in need of long term management of GERD. Can you be controlled by preventive treatments, or medications? Are long term medications such as PPIs an option for you? Are you getting effective treatment from your medical management?
If you decide to consider a surgical procedure, it’s important to discuss all of the options with your surgeon. Does he or she prefer a specific type of procedure? Are you interested in a different type? Does he do this type? If your surgeon does not do one of the procedures in which you are interested ask why. If it’s simply due to experience consider a second opinion if you would like to look into that procedure as an option. Ask your surgeon about his experience including the number of procedures he’s done. Ask about her success rates and complication rates. Generally, the more times a surgeon has performed a procedure the less likely there is to be a complication. Once you get all of this information you will be better able to make an informed decision for yourself.
Cadière GB, et. al. (2008). Antireflux transoral incisionless fundoplication using EsophyX: 12-month results of a prospective multicenter study. World J Surg. 32(8):1676-88.
Herbella, FA & Patti, MG (2010).Gastroesophageal reflux disease: From pathophysiology to treatment.World J Gastroenterol. 16(30): 3745–3749.
Lundell L, et al. (2008). Comparing laparoscopic antireflux surgery with esomeprazole in the management of patients with chronic gastro-oesophageal reflux disease: a 3-year interim analysis of the LOTUS trial. Gut. 57(9):1207-13.