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Surgical Management

Surgical Management

Surgery

Surgery is an option when medicine and lifestyle changes fail to successfully manage the symp­toms and damage associated with GERD. The procedures utilized are designed to correct the mechanical/physical defect that allows reflux to occur. Some patients also choose surgery as a reasonable alternative to a lifetime of medical management and lifestyle restrictions that were detailed above.

Fundoplication is the standard surgical treatment for GERD. Usually a specific type of this proce­dure, called Nissen fundoplication, is performed. The Nissen fundoplication is considered the “gold standard” for controlling reflux and repairing hiatal hernias. It is the technique by which all other pro­cedures are judged. During the Nissen fundoplication, the hiatal hernia is repaired and the upper part of the stomach is wrapped around the LES to strengthen the sphincter, preventing acid reflux.

The Nissen fundoplication is typically performed with minimally invasive surgi­cal techniques (laparoscopic surgery). During a laparoscopic Nissen fundoplication small cameras and instruments are utilized to perform the repair through very small incisions. The small incisions greatly reduce the post-operative pain and allow for a much faster recovery.

When performed by experienced surgeons laparoscopic fundoplication is safe and effective in people of all ages, including infants. A “Robotic” Nissen Fundoplication is identical to a laparoscopic Nissen with respect to the actual operative steps. It may offer some advantage in some cases for the operating surgeon with respect to improved vision and dissection. Most people can leave the hospital after an overnight stay and return to work in 1 to 2 weeks.

More importantly, because the reflux is controlled, medications for GERD are usually no longer needed for most patients.

 

Endoscopic techniques have been developed in the past to attempt to control reflux. None have shown the efficacy of laparoscopic surgery at controlling reflux long term. However, in highly selected patients with mild disease and small hiatal hernias they can be very effective. The Trans-oral Incisionless Fundoplication or TIF procedure is a good example. It is often chosen by patients who find medical management unsatisfactory but feel that even a minimally invasive surgery is too big of a step for them. These procedures do not “burn any bridges” so a surgical fundoplication can be done at a later date if the incision less route doesn’t maintain durable results.

Magnetic Sphincter Augmentation utilizing the LINX procedure is one of the newest mechanisms for controlling reflux. This FDA approved device is implanted by the surgeon around the LES utilizing minimally invasive surgical technique that takes less than an hour to perform in most cases. The magnetic bracelet opens and closes to let food pass through but resists regurgitation of acid and gastric contents from below. Unlike a Nissen the repaired valve has the ability to relax, which allows belching and vomiting to occur if needed. Virginia Hospital Center became the first and only facility in Virginia and the DC Metro area approved to implant this device and we are currently a leading center for this procedure in the Eastern United States.

What are the long-term complications of GERD?

Chronic GERD that is untreated can cause serious complications. Inflammation of the esophagus from refluxed stomach acid can damage the lin­ing and cause bleeding or ulcers—also called esophagitis. Scars from tissue damage can lead to strictures—narrowing of the esophagus—that make swallowing difficult. Some people develop Barrett’s esophagus, in which cells in the esopha­geal lining take on an abnormal appearance. Over time, the cells can lead to esophageal cancer, which is often fatal. Even if a patient feels that surgery is not for them they should still pursue evaluation and proper diagnosis so that they can be managed in a way that reduces their risk of long-term complications. A physician should monitor people with GERD for studies have shown that GERD may worsen or contribute to asthma, chronic cough and pulmo­nary fibrosis.

  Points to Remember

  • Frequent heartburn, also called acid indiges­tion, is the most common symptom of GERD in adults. Anyone experiencing heartburn twice a week or more may have GERD.
  • You can have GERD without having heartburn. Your symptoms could include a dry cough, asthma symptoms, or trouble swallowing.
  • If you have been using antacids for more than 2 weeks, it is time to see your health care provider. Most doctors can treat GERD. Your health care provider may refer you to a gastro­enterologist, a doctor who treats diseases of the stomach and intestines.
  • Health care providers usually recommend lifestyle and dietary changes to relieve symptoms of GERD. Many people with GERD also need medications. Surgery is a treatment option when medical management fails or is too burdensome for the patient over time. It can be performed by specially trained surgeons and is associated with a brief hospitalization and a short recovery when laparoscopic techniques are used.

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