Unlike acid suppressive medical therapy, the objective of the surgical and endoscopic treatment of GERD is to restore the integrity of the damaged LES to stop reflux. This consists of augmenting, repairing, or restoring the LES’ function. Thus, the direct cause of GERD is corrected permanently. This surgical alternative should reduce or eliminate symptoms and stop stomach contents from reaching the esophagus. If a post-operative pH study is performed, it may validate that all reflux has stopped. Without reflux, GERD symptoms due to reflux will cease as well. The cessation of reflux results in the elimination of the need for medications. However, if reflux is not completely eliminated, symptoms should still be reduced and medication requirements will be reduced. With each procedure, the desired outcome must be balanced with risks, side effects, and durability.
The “gold standard” to which all anti-reflux procedures are compared is the laparoscopic Nissen fundoplication (Nissen). This minimally invasive surgical procedure is performed under general anesthesia via several small incisions. A slender scope (laparoscope) is inserted into the abdomen that produces a high-resolution image on a monitor which the surgeon carefully observes as he performs the procedure. The procedure involves repairing the hiatal hernia (typically present) and recreates a functional valve by wrapping part of the stomach around the lower esophagus at the site of the LES. The procedure takes approximately 1-2 hours with an overnight stay in the hospital. Most people are back to light, “every day” activity within a week. A successful laparoscopic Nissen fundoplication stops the reflux approximately 80-85% of the time and typically 90% of all patients are satisfied with the procedure after 5 years. Side effects can include excess gas and bloating, as well as the inability to belch or vomit. The Nissen stops the reflux with a reliability above all other existing therapies.
LINX Reflux Management System
A new device, The Linx Reflux Management System, has recently been approved by the FDA. This procedure is performed using the same minimally invasive technique as the Nissen, however it is much less complex and performed on an outpatient basis. A specially designed “bracelet of magnetic beads” is placed loosely around the esophagus, augmenting the damaged LES. As food passes, the magnetic beads separate allowing the food to pass into the stomach and then close preventing reflux. The procedure takes approximately 30 minutes and patients return home the same day. Compared to the Nissen, the results are similar but side effects are minimal. Presently, this procedure is only available at select centers, but availability will expand rather quickly. This procedure is also reversible. RefluxMD has a list of the physicians approved to perform this surgery and we can recommend a center for you.
There are a multitude of procedures designed to repair the sphincter. They are performed orally (through the mouth) and are classified as endoscopic anti-reflux procedures. There are no abdominal incisions. Several of these have been introduced in recent years and RefluxMD will comment on them as clinical evidence is available.
Transoral Intraluminal Fundoplication
The transoral intraluminal fundoplication (TIF procedure), sometimes referred to as Esophyx is one such procedure that is available today. Under general anesthesia, a special endoscope is used to place small plastic fasteners which recreates the dysfunctional valve from the inside of the stomach. It has been available for several years and improves GERD symptoms in most patients. It is not as effective in stopping the reflux as the Nissen fundoplication, but improves symptoms and decreases medication requirements in most patients with few side effects. A similar procedure called Medigus was recently approved by the FDA.
Understanding each of the available surgical and endoscopic options for the treatment of GERD is difficult. Conflicting information and data exists about each and the information you receive may be confusing at times. RefluxMD suggests that you contact one of our expert Refluxologists for education. They will discuss the facts regarding each treatment alternative so that you can make an informed decision. If you elect a surgical alternative you should have the procedure performed by an expert who has performed many successful procedures.
Reviewed by: Dr. Dengler, RefluxMD Medical Director