Anti-reflux surgery

Surgical therapy may be indicated in some patients with GERD. Since the advent of proton pump inhibitors (PPIs), surgical therapy has declined in its use as more effective medical therapy emerged. In addition, the risk of life-threatening side-effects from proton pump inhibitors is lower as compared to anti-reflux surgery. However, there are patients in whom surgical therapy is indicated. These patients usually have severe GERD, poorly controlled on standard dose or even high-dose proton pump inhibitors (although poor control on proton pump inhibitors may be a warning sign that anti-reflux surgery may also fail to control the patient's symptoms). They may be relatively young patients who are wary of continuing high doses of a medication long-term. In some instances, surgical treatment as a potential "cure" is more appealing than medical therapy to patients in whom medical therapy is successful in relieving symptoms.

Laparoscopic anti-reflux surgery has made surgery a much more desirable option than the open procedure (the abdomen cut open to expose the esophagus and stomach). The laparoscopic procedure can be performed through a telescope-like instrument called a laparoscope. Using this technique, there are only a few small incisions made and the hospital stay is one to two days. As with most surgical techniques to control GERD, the top part of the stomach (the hiatal hernia) is pulled back down into the abdomen so that there is no longer a hiatal hernia. The top part of the stomach is then wrapped around the bottom of the esophagus to reinforce the weak valve. A successful anti-reflux surgery leads to the disappearance of reflux symptoms and healing of erosive esophagitis with long-term effects.

Adapted from Eubanks TR: Hiatal hernia and GERD. In Sabiston's Textbook of Surgery, 16th ed, Philadelphia, WB Saunders, 2000.

Laparoscopic anti-reflux surgery has been in use for only about a decade and long-term results are not known. The disadvantages of this treatment are that; 1) the anti-reflux surgery can fail resulting in recurrent GERD. 2) Occasionally, the laparoscopic technique cannot be used in a patient and the surgeon must switch to the open procedure during the operation. 3) In some patients, dysphagia (problems swallowing) after the surgery can be significant and gas bloat can occur due to decreased ability to belch swallowed air, and 4) Even though laparoscopic surgery is usually safe, all surgical procedures carry with them a risk of injury or death. It is generally recommended that any surgery be performed only by a surgeon who is experienced in doing that particular surgery.

The advantage of anti-reflux surgery is that it can afford complete relief of heartburn symptoms without long-term use of medication. The argument can also be made that a successful anti-reflux surgery keeps bile as well as acid out of the esophagus, thus preventing reflux of any substance that could injure the esophagus and lead to the development of Barrett's esophagus or esophageal adenocarcinoma (cancer). Similarly, proton pump inhibitors also decrease both acid and bile reflux into the esophagus. Although there is a small body of surgical literature suggesting that anti-reflux surgery prevents the development of Barrett's esophagus in GERD patients and prevents the development of dysplasia and cancer in Barrett's esophagus, there are no large, convincing studies. As with the proton pump inhibitors, anti-reflux surgery is unsuccessful in controlling GE reflux in many patients who have a history of severe GERD, such as those who have Barrett's esophagus.

Descriptions of the various anti-reflux surgical techniques are beyond the scope of this site and should be discussed with the surgeon who will be performing the operation.