When to Refer Your Patient with GERD for Surgery
Gastro-esophageal reflux disease (GERD) is one of the most common diseases of the modern Western world, with symptoms affecting up to 50% of the population. A defective lower esophageal sphincter (LES) with or without a concomitant hiatal hernia has been identified as the underlying pathophysiologic mechanism. Although acid-reducing medications can provide relief by limiting gastric secretion, many patients continue to experience significant symptoms such as heartburn, acid brash, regurgitation, dysphagia, and nausea that can result in a tremendously decreased quality of life.
For those patients whose symptoms are not able to be effectively managed with medications, surgery can address the basis of the disease by recreating a “neovalve” to compensate for the incompetent sphincter. The most widely performed anti-reflux procedure is the Nissen fundoplication, consisting of a 360-degree wrap of the gastric fundus around the lower esophagus. This operation, developed originally by Dr. Rudolph Nissen (1896-1981) while practicing in Europe in 1956, consisted of a 6-cm-long wrap created around the distal esophagus with 4-5 interrupted stitches, some of which incorporated the anterior esophageal wall. The technique has been subsequently modified by many successors, but the underlying physiologic mechanism remains the same. Although the transabdominal Nissen fundoplication was proven to be highly effective in the treatment of GERD, the invasiveness of laparotomy in combination with the advent of new acid-reducing medications limited the use of surgery in reflux. With the emergence of laparoscopy in the 1990s, anti-reflux surgery found renewed interest, and laparoscopic Nissen fundoplication has now become the most commonly performed foregut operation in the United States.
Laparoscopic anti-reflux surgery has been demonstrated to be an effective and durable treatment option for GERD. Its effectiveness has been proven in patients whose symptoms are not adequately controlled by medications. Moreover, anti-reflux surgery is considered a safe, equivalent alternative even for patients controlled with acid-reducing medications. Current indications for anti-reflux surgery include:
For patients who are morbidly obese (BMI>35) with significant reflux, the option of bariatric surgery (rather than anti-reflux surgery) should be considered since the pathophysiology of GERD in obesity is at least, partially, related to increased intra-abdominal pressure. Proponents of this approach suggest that the weight reduction that accompanies bariatric surgery will decrease GERD in addition to providing the benefit that inheres as a result of the well-documented improvement of obesity-related co-morbidities such as diabetes, hypertension, and obstructive sleep apnea.
The ideal patient
Careful selection of patients is extremely important when offering surgery aimed to improve quality of life. In general, patients with the typical GERD symptoms and whom have good response to anti-secretory medications have been shown to have the best symptom response after fundoplication. Those patients with mainly atypical symptoms of GERD (such as cough, shortness of breath, or hoarseness) and those who have no or minimal response to medical therapy have a much less consistent response to surgery. Prior to any planned surgery, it is imperative to document the presence of pathologic reflux via endoscopy or with the use of pH monitoring if endoscopic evaluation is unrevealing. An evaluation of esophageal function is also very important as patients with poor esophageal motility may be better candidates for a partial wrap, or in some cases, surgery may be contraindicated. Likewise, in most cases, patients with severe gastroparesis should not be considered for anti-reflux surgery.
Recovery after surgery is usually minimal, with an average hospital stay of 1-2 days and return to usual activities within a short period of time. The decision to proceed to surgery is usually made in conjunction with the surgeon and the patient after discussing their goals for symptom control postoperatively. In the appropriate patients, significant improvement in quality of life and overall high satisfaction rates are reported.
For more information
UW Health offers information on surgical treatment options for Gastroesophageal Reflux Disease and other minimally invasive surgical procedures. To refer a patient, contact the General Surgery Clinic at UW Hospital at (608) 263-7502.