Surgery for Acid Reflux Disease
For those with severe GERD, antireflux surgery is an effective long term treatment. It is important to have a skilled surgeon. Negative factors about surgical treatment of acid reflux disease are: the dependence of the results of surgery on the expertise of the surgeon, the morbidity associated with the surgery, and the small but significant (about 0.5 percent) mortality associated with the surgery itself. Laparoscopic antireflux surgery is a major advance in treatment, because it achieves good control of reflux with a major reduction in the morbidity which is inherent in the traditional form of surgery. More research is needed into the long-term results of laparoscopic surgery.
Choosing the type of treatment
Deciding on medical or surgical treatment depends on the severity of the disease and the risks of antireflux surgery specific to the patient. This decision should take into account of the patient's age, both from the point of view of surgical risk and the length of time over which the patient will require treatment for GERD, the cost of effective medical ttreatment and naturally the preferences of the patient.
In the United States, good open reduction antireflux surgery becomes cost effective when compared with medical therapy after about ten years. But this does not take account of the mortality risk. The breakeven point is shorter with laparoscopic surgery and in those countries where surgical treatment is cheaper than the United States. Economic assessments also need to take into account the decreasing price of acid suppressing medication.
How does antireflux surgery work?
Antireflux surgery reduces episodes of acid reflux by increasing the basal lower esophageal pressure (LES), reducing episodes of transient lower esophageal sphincter relaxations (LESR's) and preventing or reducing complete LESR. This is achieved by reducing (pushing) the hiatus hernia back into the abdominal cavity and therefore restoring an adequate length of intra-abdominal sphincter, reconstructing the diaphragmatic hiatus (hole in the diaphragm), and reinforcing the LES.
The two most popular operations are the Nissen fundoplication (total 360 degree) and the Toupet partial fundoplication. The Nissen fundoplication is generally felt by specialists to be the superior operation. This is because the Nissen fundoplication has a better long-term durability. However it has a higher frequency of post operative dysphagia and gas bloat syndromes. These days both operations are now routinely performed laparoscopically through the abdomen. The stay in hospital after the operation is usually 1 to 2 days, and many patients return to normal activity within 7 to 10 days. Those patients who have more severe disease and a short esophagus manifested by a large non-reducible hernia, a tight stricture or a long segment Barrett esophagus need a Collis lengthening procedure creating a 3 to 5 new segment of oesophagus to enable the fundoplication to be placed in the abdominal cavity under minimal tension.
Other types of fundoplication include the Belsey fundoplication which involves a 270° anterior transthoracic fundoplication and the Dor fundoplication which involves an anterior 180-200 degree fundoplication.
A fundoplication operation involves wrapping the upper part of the stomach (the gastric fundus) around the lower end of the oesophagus. The gastric fundus is stitched in place, therefore reinforcing the closing function of the lower oesophageal sphincter. The oesophageal hiatus is also made narrower using sutures to prevent or treat an associated hiatus hernia. In a hiatus hernia the gastric fundus slides or rolled up through the enlarged oesophageal hiatus of the muscular diaphragm.
A Nissen fundoplication is also known as a complete fundoplication, because the gastric fundus is wrapped 360° all the way around the oesophagus. Surgery for achalasia usually involves a Dor (anterior 180-200 degrees) or Toupet (posterior 270 degrees) partial fundoplication, because this is less likely to aggravate the dysphagia that is typical of achalasia.
These procedures are now routinely performed laparoscopically and robotically often using the da Vinci Surgery System. If the acid reflux symptoms are complicated by the presence of delayed gastric emptying, then sometimes surgeons will operate on the pylorus (outflow tract) of the stomach carrying out a pyloroplasty to improve gastric emptying.
Since the advent of PPI medication, the resolution of symptoms on treatment helps to predict the success of antireflux surgery for both classical and atypical symptoms of GERD. Antireflux surgery is generally considered to be a reasonable option by specialists in the following situations:
- Healthy patients with GERD well-controlled on PPI's who want alternative treatment because of drug expense, poor medication compliance or a fear of unknown long-term side-effects with proton pump inhibitors.
- Patients with atypical GERD symptoms responding to proton pump inhibitors.
- Patients who have volume regurgitation and aspiration symptoms not controlled on PPI's.
- Patients who are not responding to PPI therapy need to be approached cautiously before having surgery because there may be another cause for their disorder. For example they may have gastroparesis, functional heartburn or pill esophagitis.
Extensive physiological testing needs to be carried out before anti-reflux surgery is performed. All patients should undergo Upper gastrointestinal endoscopy to exclude problems such as strictures, dysplasia and Barrett oesophagus. A barium oesophagram can help to delineate a shortened oesophagus, non-reducible hiatus hernia and poor esophageal motility. Esophageal manometry combined with impedance testing enables identification of ineffective esophageal peristalsis and previously missed diagnosed scleroderma or achalasia. In addition, 24-hour pH monitoring is required in all patients with non-erosive GERD or in those who have esophagitis that is not responding to proton pump inhibitor therapy. Gastric emptying studies and gastric analysis may be required in certain patients. Careful testing will result in modification of the original operation or an alternative diagnosis in roughly 25% of patients.
Antireflux surgery relieves acid reflux symptoms and reduces the requirement for stricture dilatation in more than 90% of patients. However it is important to note that Barrett oesophagus rarely regresses and there is not enough evidence, at present, to show that surgery reduces the risk of esophageal adenocarcinoma (cancer).
Medical research studies have shown that anti-reflux surgery is more effective than lifestyle changes, the use of antacids, and histamine2 receptor antagonist and prokinetic therapy. However antireflux surgery is not more effective than PPI treatment, particularly when dose titration is allowed.
Mortality, as mentioned above is rare (<1%) after antireflux surgery, , but new post surgical complaints may take place in up to 25% of patients. These complaints include: dysphagia, gas bloat, diarrhoea and increased flatus.
Research has shown that most symptoms improved over a year, but assistant problems 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 of acid reflux disease.
The best surgical results are obtained by experienced surgeons in high volume centres who report long-term symptom recurrence in only 10 to 15% of patients. In the United States, a specialists report that most operations are carried out by community or Veterans Affairs hospital surgeons.
Studies have shown that in the circumstances, unfortunately, the post-operative results are not as good. Medical studies have shown relapse of symptoms after two years in approximately 32% of patients, with about 7% requiring repeat surgery, and a return to regular use of antireflux medications in 62% of patients 10 to 15 years after fundoplication.
Gastroenterologists suggest that potential factors that contribute to these high relapse rates include: inexperienced surgeons, low numbers of operations performed annually per surgeon and persistence of abdominal stressors (e.g. obesity, heavy isometric exercise or work) that gradually weaken the fundoplication.
A severe symptom relapse or sub optimal operation may result in the need for a second operation, which has a less likelihood of a successful result. Because optimal medical therapy is available to all patients with GERD, the risks and benefits of both long-term medical treatment and antireflux surgery must be carefully discussed with patients to enable them to be involved and informed in this important decision.