Gastroesophageal reflux surgery

Definition

Gastroesophageal reflux surgery is typically performed in patients with serious gastroesophageal reflux disease that does not respond to drug therapy. Gastroesophageal reflux is classified as the symptoms produced by the inappropriate movement of stomach contents back up into the esophagus. Nissen fundoplication is the most common surgical approach in the correction of gastroesophageal reflux. The laparoscopic method of Nissen fundoplication is becoming the standard form of surgical correction.

Purpose

Gastroesophageal reflux surgery, including Nissen fundoplication and laparoscopic fundoplication, has two essential purposes: heartburn symptom relief and reduced backflow of stomach contents into the esophagus.

Heartburn symptom relief

Because Nissen fundoplication is considered surgery, it is usually considered as a treatment option only when drug treatment is only partially effective or ineffective. Nissen fundoplication is often used in patients with a particular anatomic abnormality called hiatal hernia that causes significant gastroesophageal reflux. In some cases, Nissen fundoplication is also used when the patient cannot or does not want to take reflux medication. Surgery is also more likely to be considered when it is obvious that the patient will need to take reflux drugs on a permanent basis. Reflux drugs, like virtually all drugs, may produce side effects, especially when taken over a period of years.

One of the biggest problems in diagnosing and controlling gastroesophageal reflux disease is that the severity of disease is not directly related to the presence or intensity of symptoms. There is also no consistent relationship between the severity of disease and the degree of tissue damage in the esophagus. When reflux occurs, stomach acid comes into contact with the cells lining the esophagus. This contact can produce a feeling of burning in the esophagus and is commonly called heartburn. Some of the other symptoms associated with this condition include:

• chest pain
• swallowing problems
• changes in vocal qualities

Reduced reflux

The reduction or elimination of reflux is as important, and sometimes more important, than the elimination of symptoms. This necessity leads to one of the most important points in gastroesophageal reflux disease. Long-term exposure to acid in the esophagus tends to produce changes in the cells of the esophagus. These changes are usually harmful and can result in very serious conditions, such as Barrett's esophagus and cancer of the esophagus. Because of this, all persons with gastroesophageal reflux disease symptoms need to be evaluated with a diagnostic instrument called an endoscope. An endoscope is a long, flexible tube with a camera on the end that is inserted down the throat and passed all the way down to the esophageal/stomach region.

All gastroesophageal reflux surgery, including Nissen fundoplication, attempts to restore the normal function of the lower esophageal sphincter (LES). Malfunction of the LES is the most common cause of gastroesophageal reflux disease. Typically, the LES opens during swallowing but closes quickly thereafter to prevent the reflux of acid back into the esophagus. Some patients have sufficient strength in the sphincter to prevent reflux, but the sphincter opens and closes at the wrong times. However, this is not the case in most individuals with gastroesophageal reflux disease. These individuals usually have insufficient sphincter strength. In a small number of cases, the muscles of the upper esophagus region are too weak and are not appropriately coordinated with the process of swallowing.

The development of heartburn does not necessarily suggest the presence of gastroesophageal reflux disease, which is a more serious condition. Gastroesophageal reflux disease is often defined as the occurrence of heartburn more than twice per week on a long-term basis. Gastroesophageal reflux disease can lead to more serious health consequences if left untreated. The primary symptoms of gastroesophageal reflux disease are chronic heartburn and acid regurgitation, or reflux. It is important to note that not all patients with gastroesophageal reflux disease have heartburn. Gastroesophageal reflux disease is most common in adults, but it can also occur in children.

The precise mechanism that causes gastroesophageal reflux disease is not entirely known. It is known that the presence of a hiatal hernia increases the likelihood that gastroesophageal reflux disease will develop. Other factors that are known to contribute to gastroesophageal reflux disease include:

• smoking
• alcohol ingestion
• obesity
• pregnancy

In a laparoscopic surgery to alleviate gastroesophageal reflux, the surgeon makes several incisions to gain access to the stomach and esophagus (A). Using the videoscope, the stomach is visualized (B), and the ligament connecting the stomach to the liver is divided (C). The upper part of the stomach is brought up around the base of the esophagus (D), and stitched into place (E). (

Illustration by GGS Inc.

)

The following foods and drinks are known to increase the production of stomach acid and the resulting reflux into the esophagus:

• caffeinated drinks
• high-fat foods
• garlic
• onions
• citrus fruits
• chocolate
• fried foods
• foods that contain tomatoes
• foods that contain mint
• spicy foods

Most patients take over-the-counter antacids initially to relieve the symptoms of acid reflux. If antacids do not help, the physician may prescribe drugs called H ₂ blockers, which can help those with mild-to-moderate disease. If these drugs are not effective, more powerful acid-inhibiting drugs called proton-pump inhibitors may be prescribed. If these drugs are not effective in controlling gastroesophageal reflux disease, then the patient may require surgery.

Demographics

It has been estimated that heartburn occurs in more than 60% of adults. About 20% of the population take antacids or over-the-counter H ₂ blockers at least once per week to relieve heartburn. In addition, about 80% of pregnant women have significant heartburn. Hiatal hernia is believed to develop in more than half of all persons over the age of 50 years. Hiatal hernia is present in about 70% of patients with gastroesophageal reflux disease, but the majority of patients with hiatal hernia do not have symptoms of gastroesophageal reflux disease. In addition, about 7-10% of the population has daily episodes of heartburn. It is these individuals who are likely to be classified as having gastroesophageal reflux disease.

Description

The most common type of gastroesophageal reflux surgery to correct gastroesophageal reflux disease is Nissen fundoplication. Nissen fundoplication is a specific technique that is used to help prevent the reflux of stomach contents back into the esophagus. When Nissen fundoplication is successful, symptoms and further damage to tissue in the esophagus are significantly reduced. Prior to Nissen fundoplication, open surgery was required to gain access to the lower esophageal region. This approach required a large external incision in the abdomen of the patient.

Fundoplication involves wrapping the upper region of the stomach around the lower esophageal sphincter to increase pressure on the LES. This procedure can be understood by visualizing a bun being wrapped around a hot dog. The wrapped portion is then sewn into place so that the lower part of the esophagus passes through a small hole in the stomach muscle. When the surgeon performs the fundoplication wrap, a large rubber dilator is usually placed inside the esophagus to reduce the likelihood of an overly tight wrap. The goal of this approach is to strengthen the sphincter; to repair a hiatal hernia, if present; and to prevent or significantly reduce acid reflux.

Fundoplication was greatly improved with the development of the laparoscope. The laparoscope is a long thin flexible instrument with a camera and tiny surgical tools on the end. Laparoscopic fundoplication (sometimes called "telescopic" or "keyhole" surgery) is performed under general anesthesia and usually includes the following steps:

• Several small incisions are created in the abdomen.
• The laparoscope is passed into the abdomen through one of the incisions. The other incisions are used to admit instruments to manipulate structures within the abdomen.
• The abdomen is inflated with carbon dioxide. The contents of the abdomen can now be viewed on a video monitor that receives its picture from the laparoscopic camera.
• The stomach is freed from its attachment to the spleen.
• An esophageal dilator is passed through the mouth into the esophagus. This dilator keeps the stomach from being wrapped too tightly around the esophagus.
• The portion of the esophagus in the abdomen is freed of its attachments.
• The top portion of the stomach (the fundus) is passed behind the esophagus, wrapped around it 360°, and sutured in place.
• If a hiatal hernia is present, the hiatus (the hole in the diaphragm through which the esophagus passes) is made smaller with one to three sutures so that it fits around the esophagus snugly. The sutures keep the fundoplication from protruding into the chest cavity.
• The laparoscope and instruments are removed and the incisions are closed.

Diagnosis/Preparation

The diagnosis of gastroesophageal reflux disease can be straightforward in cases where the patient has the classic symptoms of regurgitation, heartburn, and/or swallowing difficulties. Gastroesophageal reflux disease can be more difficult to diagnose when these classic symptoms are not present. Some of the less common symptoms associated with reflux disease include asthma, nausea, cough, hoarseness, and chest pain. Such symptoms as severe chest pain and weight loss may be an indication of disease more serious than gastroesophageal reflux disease.

The most accurate test for diagnosing gastroesophageal reflux disease is ambulatory pH monitoring. This is a test of the pH (a measurement of acids and bases) above the lower esophageal sphincter over a 24-hour period. Endoscopies can be used to diagnose such complications of gastroesophageal reflux disease, as esophagitis, Barrett's esophagus, and esophageal cancer, but only about 50% of patients with gastroesophageal reflux disease have changes that are evident using this diagnostic tool. Some physicians prescribe omeprazole, a proton-pump inhibiting drug, to persons suspected of having gastroesophageal reflux disease to see if the person improves over a period of several weeks.

Aftercare

Patients should be able to participate in light physical activity at home in the days following discharge from the hospital . In the days and weeks following surgery, anti-reflux medication should not be necessary. Pain following this surgery is usually mild, but some patients may need pain medication. Some patients are instructed to limit food intake to a liquid diet in the days following surgery. Over a period of days, they are advised to gradually add solid foods to their diet. Patients should ask the surgeon about the post-operative diet. Such normal activities, as lifting, work, driving, showering, and sexual intercourse can usually be resumed within a short period of time. If pain is more than mild and pain medication is not effective, then the surgeon should be consulted in a follow-up appointment.

The patient should call the doctor if any of the following symptoms develop:

• drainage from the incision region
• swallowing difficulties
• persistent cough
• shortness of breath
• chills
• persistent fever
• bleeding
• significant abdominal pain or swelling
• persistent nausea or vomiting

Risks

Risks or complications that have been associated with fundoplication include:

• heartburn recurrence
• swallowing difficulties caused by an overly tight wrap of the stomach on the esophagus
• failure of the wrap to stay in place so that the LES is no longer supported
• normal risks associated with major surgical procedures and the use of general anesthesia
• increased bloating and discomfort due to a decreased ability to expel excess gas

Complications, though rare, can occur during fundoplication. These complications can include injury to such surrounding tissues and organs, as the liver, esophagus, spleen, and stomach. One of the major drawbacks to fundoplication surgery, whether it is open or laparoscopic, is that the procedure is not reversible. In addition, some of the symptoms associated with complications are not always treatable. One study showed that about 10% to 20% of patients who receive fundoplication have a recurrence of gastroesophageal reflux disease symptoms or develop such other problems, as bloating, intestinal gas, vomiting, or swallowing problems following the surgery. In addition, some patients may develop altered bowel habits following the surgery.

Normal results

One research study found that fundoplication is successful in 50% to 90% of cases. This study found that successful surgery typically relieves the symptoms of gastroesophageal reflux disease and esophagus inflammation (esophagitis). The researchers in this study, however, provided no information on the long-term stability of the procedure. Fundoplication does not always eliminate the need for medication to control gastroesophageal reflux disease symptoms. A different study found that 62% of patients who received fundoplication continued to need medication to control reflux symptoms. However, these patients required less medication than before fundoplication.

Two studies demonstrated that laparoscopic fundoplication improved reflux symptoms in 76% and 98% of the treated populations, respectively. In an additional study, researchers evaluated 74 patients with reflux disease who received Nissen fundoplication after failure of medical therapy. The researchers concluded that 93.8% of the patients had complete resolution of symptoms and did not require anti-reflux medications approximately 14 months after fundoplication. Researchers have found that when fundoplication is successful, the resting pressure in the LES increases. This increase reflects a return to more normal LES functioning where the LES keeps stomach acid in the stomach through increased pressure.

Overall, studies have suggested that the vast majority of patients who receive laparoscopic reflux surgery have positive results. These patients are either symptom-free or have significant improvements in reflux symptoms. The laparoscopic approach has a few advantages over other forms of fundoplication. These advantages include:

• decreased postoperative pain
• more rapid return to work
• decreased hospital stay
• better cosmetic results

Morbidity and mortality rates

Mortality is extremely rare during or following fundoplication. Complications and side effects are not common following fundoplication, especially using the laparoscopic approach, and are usually mild. A review of 621 laparoscopic fundoplication procedures performed in Italy found no cases of mortality and complications in 7.3% of cases. The most serious complication was acute dysphagia (difficulty swallowing) that required a re-operation in 10 patients. In general, long-term complications resulting from this procedure are uncommon.

Alternatives

There are several variations of fundoplication that may be performed. In addition, laparoscopic fundoplication may require conversion to an open, or traditional, surgical fundoplication in a small percentage of cases. The most common alternative to fundoplication is simply a continuation of medical therapy. Typically, patients receive medication for a period prior to being evaluated for surgery. A review of nine studies found that omeprazole, a proton-pump inhibitor, was as effective as surgery. This same review, however, found that the other commonly used anti-reflux drugs, histamine H ₂ -antagonists, were not as effective as surgery.

Resources

books

Current Medical Diagnosis & Treatment. New York: McGraw-Hill, 2003.

Ferri, Fred F. Ferri's Clinical Advisor. St. Louis, MO: Mosby, 2001.

periodicals

Allgood, P. C., and M. Bachmann. "Medical or Surgical Treatment for Chronic Gastroesophageal Reflux: A Systematic Review of Published Effectiveness." European Journal of Surgery 166 (2000): 9.

Kahrilas, P. J. "Management of GERD: Medical vs. Surgical." Seminars in Gastrointestinal Disease 12 (2001): 3–15.

Scott, M., et al. "Gastroesophageal Reflux Disease: Diagnosis and Management." American Family Physician 59 (March 1, 1999): 1161–1172.

Society of American Gastrointestinal Endoscopic Surgeons. "Guidelines for Surgical Treatment of Gastroesophageal Reflux Disease (GERD)." Surgical Endoscopy 12 (1998): 186–188.

Spechler, S. J., et al. "Long-term Outcome of Medical and Surgical Therapies for Gastroesophageal Reflux Disease: Follow-Up of a Randomized Controlled Trial." Journal of the American Medical Association 285 (May 9, 2001): 2331–2338.

Triadafilopoulos, G., et al. "Radiofrequency Energy Delivery to the Gastroesophageal Junction for the Treatment of GERD." Gastrointestinal Endoscopy 53 (2001): 407–415.

Zaninotto, G., D. Molena, and E. Ancona. "A Prospective Multicenter Study on Laparoscopic Treatment of Gastroesophageal Reflux in Italy." Surgical Endoscopy 14 (2000): 282–288.

other

National Digestive Diseases Information Clearinghouse. Heartburn, Hiatal Hernia, and Gastroesophageal Reflux Disease (GERD). 2003.

Society of American Gastrointestinal Endoscopic Surgeons. Patient Information from Your Surgeon and SAGES. 1997.

Mark Mitchell, M.D., M.P.H., M.B.A.

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Fundoplication, including the laparoscopic approach, is generally performed by a specialist known as a gastroenterologist. A gastroenterologist is a medical doctor (M.D.) who has received additional training in the diseases of the gastrointestinal system. Gastroenterologists who perform laparoscopic fundoplications receive extensive training in general surgery and in the proper techniques involving the use of the laparoscope. If surgery is being considered, it is a good idea to find out how many laparoscopic fundoplications the surgeon performs on a yearly basis. Laparoscopic fundoplications are often performed in the specialized department of a general hospital, but they are also performed in specialized clinics or institutes for gastrointestinal disorders.

QUESTIONS TO ASK THE DOCTOR

Questions to ask the primary care physician:

• What are my alternatives?
• Is surgery the answer for me?
• Can you recommend a surgeon who performs the laparoscopic procedure?
• If surgery is appropriate for me, what are the next steps?

Questions to ask the surgeon:

• How many times have you performed Nissen or laparoscopic fundoplication?
• Are you a board-certified surgeon?
• What types of outcomes have you had?
• What are the most common side effects or complications?
• What should I do to prepare for surgery?
• What should I expect following the surgery?
• Can you refer me to one of your patients who has had this procedure?
• What type of diagnostic procedures are performed to determine if patients require surgery?
• Will I need to see another specialist for the diagnostic procedures?
• Do you use endoscopy, motility studies, and/ or pH studies for your pre-operative evaluation?