What is acid reflux?

Surgical Treatment of Acid Reflux Disease

Antireflux surgery reduces GER by increasing basal LES pressure, decreasing episodes of transient LESRs, and inhibiting complete LESR. This is accomplished by reducing the hiatal hernia back into the abdomen and thereby restoring an adequate length of intra-abdominal sphincter, reconstructing the diaphragmatic hiatus, and reinforcing the LES. Before the explosion of laparoscopic surgery, the three most common operations were the Nissen fundoplication, the Belsey Mark IV repair, and the Hill posterior gastropexy repair. Since the advent of minimally invasive surgery, the two most popular procedures are the Nissen fundoplication and the Toupet partial fundoplication. The former is a superior operation with more long-term durability, but it has a higher frequency of postoperative dysphagia and gas bloat symptoms. Both are now routinely performed laparoscopically through the abdomen. The hospital stay is 1 to 2 days, and many patients return to normal activity in 7 to 10 days. Patients with more severe disease and a short esophagus manifested by a large nonreducible hernia, a tight stricture, or a long-segment Barrett esophagus require a Collis lengthening procedure creating a 3- to 5-cm neoesophagus, so the fundoplication can be placed in the abdomen under minimal tension.

The common indications for antireflux surgery have evolved with the availability of more powerful medications for treating GERD. In the PPI era, the resolution of symptoms on treatment helps to predicate the success of antireflux surgery for both classical and atypical symptoms. Antireflux surgery is a reasonable option in the following situations:

1. Healthy patients with GERD well controlled on PPIs who want alternative therapy because of drug expense, poor medication compliance, or a fear of unknown long-term side effects

2. Patients with atypical GERD symptoms responding to PPIs

3. Patients with volume regurgitation and aspiration symptoms not controlled on PPIs.

Patients recalcitrant to PPI therapy need to be approached cautiously with surgery because they may have another cause of their disorder (i.e., pill esophagitis, gastroparesis, functional heartburn).

Extensive physiological testing should be done before antireflux surgery is performed. All patients need endoscopy to exclude stricture, Barrett esophagus, and dysplasia. A barium esophagram can help define a nonreducible hernia, shortened esophagus, and poor esophageal motility. Esophageal manometry will identify ineffective esophageal peristalsis and previously misdiagnosed achalasia or scleroderma. Twenty-four hour pH testing is needed in all patients with nonerosive GERD or in those with esophagitis not responding to PPI therapy. Gastric analysis and gastric emptying studies may be indicated in selected patients. Careful testing will result in modification of the original operation or an alternative diagnosis in approximately 25% of patients.

Antireflux surgery relieves reflux symptoms and reduces the need for stricture dilation in more than 90% of patients, but Barrett esophagus rarely regresses, and the influence of surgery on the development of esophageal adenocarcinoma is controversial. Comparison studies have found antireflux surgery superior to lifestyle changes, antacids, and H 2RA and prokinetic therapy, but not PPI therapy, especially when dose titration is permitted. Mortality is rare (lesser than 1%) after antireflux surgery, but new postoperative complaints can occur in up to 25% of patients including dysphagia, gas bloat, diarrhea, and increased flatus. Most symptoms improve over 1 year, but persistent complaints suggest too tight a wrap, a displaced fundoplication, or inadvertent damage to the vagus nerve. Successful antireflux surgery, however, does not guarantee a permanent cure. The best surgical results are obtained by experienced surgeons in high-volume centers who report long-term symptom recurrence in only 10% to 15% of patients. However, most operations are performed by community or Veterans Affairs hospital surgeons. Here the results are not as good with studies finding relapse of esophagitis in 30% of patients and return to regular use of antireflux medications in 62% of patients 10 to 15 years after fundoplication. Potential factors contributing to these high relapse rates include inexperienced surgeons, low numbers of operations yearly per surgeon, and persistence of abdominal stressors (i.e., obesity, heavy isometric exercise or work) that gradually weaken the fundoplication. A suboptimal operation or severe symptom relapse may necessitate a second operation, which has less likelihood of a successful outcome. Because optimal medical therapy is available to all patients with GERD, the risk and benefits of both long-term medical treatment and antireflux surgery must be carefully discussed with patients, so they can take part in this important decision.