Reflux Surgery Part I: The Nissen Fundoplication
After dealing with acid reflux in myself and two of my children I have encountered the question "what about surgery to fix the problem?" more times than I can remember. Obviously none of us wishes to go through surgery or put our child through it unless it is absolutely necessary. My girls have not met the indications for surgical repair but some of you may be facing the decision on whether to go ahead with surgery or continue with medical treatments.
Some of the indications for surgery in the treatment of acid reflux disease or GERD can be related to the inability to find relief with the medical treatments available. Failure is generally defined by the patient's heartburn symptoms and may also be due to regurgitation. There are only a small percentage of patients find that PPI's are unable to control the acid production. Patients who have chronic problems with aspirations, Barrett's or related issues may also be pointed the direction of surgical interventions (1). In infants severe failure to thrive may also indicate the need for surgical intervention.
The Nissen Fundoplication is the most frequently used surgery to treat chronic GERD. During this procedure the top of the stomach ("fundus") is wrapped around the esophagus and sutured into place. Similar procedures can also be done that are only a partial wrap. This tightens the area of the LES and prevents the backwashing of acid into the esophagus. Studies report that 89.5% of patients are symptom free after 10 years (2). The procedure can now be done as a laproscopy which can lessen the risk to the patient.
That is not to say that the Nissen Fundoplication is not with out its problems. It is thought that in approximately 5-10% of the cases the fundoplication can come undone and cause symptoms to return. Side effects may also include: dumping syndrome, scarring, trouble swallowing and "gas bloat syndrome" (2).
The Nissen Fundoplication should not be considered a "cure all" for every patient. Some patients continue to need PPI's to control the acid production. For those whose symptoms may be severe and unresponsive it can be a way to improve the quality of life. Each patient has to weigh the risks versus the benefits with their own doctor.
Tune back in for Part Two in this series where I will discuss two of the newer procedures: The EndoCinch and the Stretta System.