When should reflux surgery be considered?
If you have GERD symptoms, need acid-suppressive medication, and especially if you have ongoing GERD despite medication, you might be better off with an anti-reflux procedure. And today’s antireflux procedures are far better and less invasive than procedures of even 10 or 20 years ago. I’d like to review what these options are and why they are great options for many people with GERD. Not only do I specialize in minimally invasive treatment options for GERD; I’ve been a GERD patient and have had surgical treatment for GERD.
Acid-suppressive medications (e.g. omeprazole, Nexium, Dexilant) do not actually change the amount of reflux patients have – they just decrease the level of acidity in the reflux. If a person has, say, 50 reflux episodes per day and then takes an acid-suppressive medication, she will still have 50 reflux episodes per day – it just may burn less. Antireflux procedures treat the underlying cause of reflux, and reduce the number of gastric reflux episodes that occurs. Medication treats symptoms – surgery treats the cause. Which would you prefer?
Patients should think about what their goals are in having an antireflux procedure. Is it to reduce or completely eliminate taking acid suppressive medication? Is it to control symptoms that aren’t currently controlled by medication? How much am I willing to trade off risks and potential side effects of a surgical procedure to see an improvement in my GERD?
Surgical procedures to consider
I think any patient considering an antireflux procedure should be aware of, and may want to seek out a surgeon with expertise in, the LINX procedure, endoscopic therapies of TIF and Stretta, as well as partial fundoplication. A new device, EndoStim, will also soon be undergoing clinical trials. Now. let’s look at the various procedures available:
LINX Reflux Management System
LINX is fairly new procedure, and a bit revolutionary in the way that it treats reflux. Rather than surgically altering the stomach, we place a small implant around the lower esophageal sphincter (LES) that strengthens the sphincter and controls reflux, but still permits belching and vomiting. I think this procedure currently offers the best control of GERD symptoms, ability to stop antireflux medication, fast recovery, and low side effects.
Procedure: A small titanium implant is placed around the lower esophageal sphincter during a minimally invasive laparoscopic surgery. If present, a hiatal hernia would be repaired at the same time.
How it works: The device is bracelet of magnetic beads – it expands to allow food to pass, and holds the LES closed afterward.
Recovery: No hospital stay is required. Patients can return to non-strenuous activity and a relatively normal diet as tolerated within a few days.
Success rates: About 90% of patients find that their GERD symptoms are so well controlled by LINX that they can stop taking acid suppressive medications. Additionally most patients find they can belch or, if needed, vomit – something that can be a problem in some of the older antireflux procedures.
Side effects: LINX patients don’t report gas or bloating, though a small amount may have trouble with food sticking after swallowing and/or esophageal spasms.
Who is a good candidate for LINX?
Patients who have reflux symptoms that aren’t controlled by medication, or who don’t want to take acid-suppressive medication should consider the LINX procedure. What are
TIF (Transoral Incisionless Fundoplication) with EsophyX
TIF with EsophyX recreates the gastroesophageal valve using a special device placed into the stomach through the mouth (so there are no incisions). The upper portion of the stomach is folded against the lower esophagus and secured in place with fasteners, reestablishing a more normal configuration to the lower esophageal sphincter. Patients go home the same day and are often back at work within a few days to a week of surgery.
How successful is TIF?
About 70-80% of patients find that their GERD symptoms are controlled well enough by TIF that they can stop taking daily acid suppressive medications. Additionally most patients find they can belch or, if needed, vomit – something that can be a problem in some of the older antireflux procedures.
Who is a good candidate for TIF?
Similar to LINX, patients who have reflux symptoms that aren’t controlled by medication, or who don’t want to take acid-suppressive medication should consider the TIF procedure. The TIF procedure may not always be as effective as LINX. Problems with swallowing are even less common with TIF than with LINX.
What are the downsides to TIF?
Hiatal hernias over about 2 cm cannot be treated with the TIF procedure. (For patients with hernias larger than 2 cm I prefer a laparoscopic procedure such as the LINX). TIF is probably not the best procedure for patients with severe reflux or extensive Barrett’s esophagus, as it doesn’t control reflux as well as some of the other procedures. Durability of TIF has not been well studied, and some patients may require a second procedure due to recurrent reflux.
Stretta RF Ablation
Stretta is a minimally-invasive alternative to surgery or implants. It’s a good option for patients who are concerned about taking PPIs, but for whom the other surgical options seem too extreme of an option.
Procedure: Stretta is incision-free and takes less than an hour. Your surgeon will insert a device into your esophagus that delivers radiofrequency (or RF) waves to the LES. This thickens and improves muscle tissue, which helps prevent reflux.
Recovery: Patients go home the same day, and often don’t require any pain medication stronger than acetaminophen. You’ll be required to follow a soft food diet for two weeks following the procedure.
Success rates: Results do not last as long as with surgical procedures. 4 years post-procedure, 86% of patients no longer require medication. At 10 years, 64% are still off medication.
Side effects: Stretta has a low complication rate, and patients don’t report side effects like gas or bloating.
Laparoscopic Fundoplication involves folding (plicating) a certain portion of the stomach (the fundus) around the lower esophagus and securing it in place with sutures. A hiatal hernia, if present, is repaired at the same time.
Laparoscopic Nissen (Complete Fundoplication) is one of the most commonly-performed procedures for GERD, and has generally been considered the most effective at preventing reflux. The upper part of the stomach is folded all the way (360 degrees) around the lower esophagus and sutured in place. Another Option is Partial Fundoplication. Here, the stomach is only folded partway (180 to 270 degrees) around the esophagus. We typically perform this when the patient has fairly mild disease, as it controls symptoms extremely well in this setting. Although there is potential for gas and bloating after partial fundoplication, it tends not to be as severe as with a complete fundoplication. We have been performing partial fundoplications for over 20 years, and we do it in about half of our patients having a fundoplication.
Procedure: The surgery is performed laparoscopically. A hiatal hernia repair is almost always performed (even if not present beforehand) because of the dissection required to free up the stomach. The upper part of the stomach, called the fundus, is folded around the lower part of the esophagus. This creates a one-way flap valve that keeps stomach contents in the stomach.
Recovery: Most patients can go home the same day. In rare cases, a patient stays in the hospital overnight due to pain control. The first 3-4 weeks after the surgery, patients will need to follow a diet progression plan and avoid strenuous activity. Wait 4 weeks to return to manual labor work, 2-3 weeks for sedentary work.
Success rates: When performed in centers of expertise, at 5-10 years post-procedure, 85% to 90% of patients report excellent symptom control without needing daily medication. 5-7% of patients will have a reoperation at some point, typically because of recurrent reflux not able to be managed medically.
Side effects: While you are healing, you may experience difficulty swallowing as there will be swelling around your esophagus. This is usually resolved over time. A small number of patients (around 5 to 10%) notice they have to avoid certain consistency foods, like bread or steak, long term. Post-op, a small number of patients (around 5-10%) may suffer from “gas-bloat syndrome,” which occurs because the newly created flap valve may not easily allow swallowed air to escape from the stomach. Around 30% of patients report increased flatulence and up to 10% will lose the ability to belch or vomit. These side effects go away in some patients, but in others they may not. For patients with moderate to severe reflux disease these potential side effects are a reasonable trade-off and patient satisfaction is excellent.
Dr. Reginald C.W. Bell M.D., F.A.C.S. is a the founder of SurgOne Foregut Institute (SOFI), a reflux surgery center in Englewood, Colorado. He has had extensive experience performing minimally invasive procedures on the esophagus and stomach with over 20 years in practice.