Dr. Eisner Answers your GERD Questions: Should I Consider Surgery?
I have been suffering from GERD for years. Should I be considering surgery?
Patients that usually do best with surgical management of gastroesophageal reflux disease (GERD) are those that are totally dependent on medications to prevent recurrence of symptoms. It is also considered in patients that are non-compliant with medication, those that have complications such as strictures, and in those that do not respond to medical therapy. Unfortunately, patients that do not respond to medical therapy may not have good results with surgery either. Surgical treatment with fundoplication can be more cost effective than long term medical therapy.
While there are many types of fundoplication surgeries, Nissen is the most common. They all involve creating a functional lower esophageal sphincter the repair of a hiatal hernia if one is present. The [Nissen fundoplication](Reflux Surgery Part I: The Nissen Fundoplication) involves mobilization and wrapping of the fundus of the stomach completely around the lower esophagus. The surgeries are being done more commonly now as they are done laparoscopically, but complications are not unusual. The most common risks associated with fundoplications include bleeding or damage to structures such as the spleen, vagus nerves, esophagus or stomach. While these occur approximately 5% of the time, they can be very serious and life threatening when they do. Most patients stay in the hospital for 1-3 days after a laparoscopic fundoplication, and 3-5 days after an open procedure.
Studies show that long-term outcome is equivalent after open or laparoscopic procedures, and their effect on reflux symptoms is similar to that achieved with medical therapy. If surgery is decided on, it is important to select a physician that has performed large numbers of the surgery. You should check with your physician to see if surgery is an option for you.
I was considering surgery for my GERD symptoms, but have looked into Stretta. What is Stretta, and is it right for me?
Stretta is a procedure that is done endoscopically, in which high-frequency radio waves are delivered into the lower esophageal sphincter that connects the esophagus and the stomach. In many patients with gastroesophageal reflux disease, the lower esophageal sphincter is loose, allowing acid to freely flow into the esophagus. The high-frequency radio waves tighten the sphincter, keeping the acid in the stomach. Results have been good, with studies allowing patients being able to come off of their acid reflux medications, with minimal complications. You should check with your doctor to see if Stretta is a good treatment option for your reflux disease.
I have tried many different medications for my acid reflux, all of which lower acid. Are there other medication types available?
There are generally two arms to the medical treatment of acid reflux disease. One is to lower acid. This is accomplished with medications such as proton pump inhibitors and H2 receptor antagonists. The other treatment arm of acid reflux is aimed at facilitating gastric emptying. The thought process behind this is that if there is no acid left in the stomach, there will be nothing to reflux up into the esophagus. While medications used to increase gastric emptying have worked, they have not been extremely safe. Currently, the only FDA approved drug used to increase gastric emptying in patients with gastroesophageal reflux disease is Reglan. Reglan however, has the extremely serious potential side effect of tardive dyskinesia, abnormal involuntary movements, which can leave the patient with Parkinson-like symptoms. Its use is therefore not recommended long term. Patients that are treated with it need to be aware of the potential complications and need to be carefully followed.
Prior to Reglan, Propulsid was used in conjunction with acid-reducing agents to treat gastroesophageal reflux disease. Propulsid was taken off the market however, due to an increased incidence of sudden death related to an unusual cardia arrhythmia. The third drug used, motolin, or Domperidone, has been used for many years in Europe, but has not been approved in the United States. It is available in Canada with a prescription, and is used by United States physicians at times. You should check with your doctor to see if Reglan or Domperidone might be an appropriate drug for you.