Surgical treatment options for GERD

July 5, 2013 Ralph W. Aye, MD, FACS

Gastroesophageal reflux disease (GERD) is the most common disorder of the upper gastrointestinal track.  It's estimated that up to 40% of Americans take some form of anti-acid medication at least once a month, making it one of the most commonly used types of medication in the world. 

Heartburn is simply a burning sensation behind the breast bone, and is not necessarily from GERD.  It can be caused by a variety of other disorders, including heart disease, musculoskeletal disorders, and disorders of other parts of the gastrointestinal track, including the stomach, pancreas, gall bladder, liver, or intestine A simple way to differentiate GERD from heartburn is to take antacids or over the counter acid suppressants.  There are two classes of acid suppressants: H2 blockers like ranitidine/zantac; and proton pump inhibitors (PPIs) like prilosec/omeprazole.  If the symptom partially or completely responds, it is likely caused by stomach acid, particularly GERD.

How is GERD managed?

GERD is rarely life-threatening and can generally be managed symptomatically.  Some may need to take medication intermittently while others take it daily.  If you are having persistent daily symptoms for 5 years or more; symptoms which aren't responding to medication; or dysphagia (the sensation of food sticking) or aspiration symptoms (choking on stomach contents, particularly at night), you should talk to your health care provider about your symptoms.

It's estimated that 40% of those on acid suppressants have incomplete relief of symptoms, and some individuals have significant side effects from medications, limiting their use.   In addition, despite therapeutic doses, GERD can result in complications of bleeding, ulceration, stricture, or aspiration.  There are also increasing concerns about the long-term use of  PPIs including diminished  bone density, a higher rate of certain types of infection, and the temporal link between antisecretory medications and the frightening rise in the rate of cancer of the lower esophagus.   For any of these reasons, it may be appropriate to consider surgical repair.

What are the surgical options for GERD?

Surgery for GERD (Nissen, Hill, or Toupet fundoplication) is highly effective in experienced hands.  In a 25- year follow up of over 1000 patients undergoing open surgery, 93% rated results as good to excellent; only 23% had resumed medication1. Today, more than 99% of antireflux surgery can be done laparoscopically, with similar longer-term results but typically with only an overnight hospital stay and a quick recovery.  We have performed over 2500 laparoscopic repairs at Swedish  since 1991 and have been leaders in the evolution of the most effective techniques.

What are the risks of surgery for GERD?

Surgery is not without risk.  It carries a 0.2% mortality risk nationally as well as  the potential for serious complications.  There can be side effects, most of which are short term, but it may be difficult to burp after repair, leading to more flatulence, and vomiting may result in only "dry heaves".  This has led to the development of a magnetic ring called the LINX device, designed to prevent reflux by strengthening  the lower end of the esophagus to prevent reflux, while potentially  reducing side effects such as inability to burp.  At this time, Swedish is one of 20 national sites approved to place the LINX. 

A number of endoluminal procedures (done entirely through an endoscope without surgical incisions) have been attempted, most without much success.  The current available procedure is called Esophyx.  Results have been less than hoped for and we are not currently offering this approach. 

In summary, gastroesophageal reflux disease, or GERD, is common and usually easily managed medically.  Surgical procedures such as fundoplication or insertion of the new LINX device can be highly effective and durable in experienced hands, with high long-term satisfaction and an end of the need for antisecretory medications.

1.  Aye R, Rehse D, Blitz M, Kraemer S, Hill L.  The Hill Antireflux Repair at 5 Institutions over 25 Years.  Am J Surg (2011) 201, 597–602

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