Surgery

Surgery

The standard surgical treatment for GERD is fundoplication. The goal of this procedure is twofold:

• To increase LES pressure and, therefore, prevent acid back-up (reflux).
• To repair any present hiatal hernia.

There are two primary approaches:

• Open Nissen fundoplication (the more invasive technique).
• Laparoscopic fundoplication.

In general, the overall long-term benefits of these procedures are similar. Some studies report that more than 90% of patients are free of heartburn after the operation and satisfied with their choice, even after 5 years. The procedure relieves GERD-induced coughs and some other respiratory symptoms in up to 85% of patients. (Its effect on asthma associated with GERD, however, is unclear.) It may enhance stomach emptying and improve peristalsis in about half of patients. (It may actually cause abnormal peristalsis in about 14% of patients, although in such cases the problem does not appear to be very significant.)

Still, it has other significant limitations and postoperative problems. For example, the results of one 2003 survey suggested that 18% of surgical patients would still required anti-GERD medications and that 38% would have new symptoms (e.g., gas, bloating, trouble swallowing), with most occurring more than a year after surgery. Other studies have reported similar results. Also, fundoplication does not cure GERD. Finally, evidence -- a 2002 Swedish study -- strongly suggests that the procedure does not reduce the risk for esophageal cancer in high-risk patients, such as those with Barrett's esophagus.

Candidates. Fundoplication is recommended for patients whose condition includes one or more of the following:

• Esophagitis (inflamed esophagus).
• Symptoms that persist or are recurrent in spite of anti-reflux drug treatment.
• Strictures.
• Failure to gain or maintain weight (children).

Fundoplication has little benefit for patients with impaired stomach motility (an inability for the muscles to move spontaneously).

The Open Nissen Fundoplication Procedure. Until recently, most fundoplication procedures for GERD have been the 360° Nissen fundoplication. This is a called an open procedure because it requires wide surgical incisions.