Surgery:

The standard surgical treatment for GERD is fundoplication. The goals of this procedure are to:

• Increase LES pressure and prevent acid backup (reflux)
• Repair a hiatal hernia

There are two primary approaches:

• Open Nissen fundoplication (the more invasive technique)
• Laparoscopic fundoplication

In general, the long-term benefits of these procedures are similar. Fundoplication relieves GERD-induced coughs and other respiratory symptoms in up to 85% of patients. (Its effect on asthma associated with GERD, however, is unclear.) It may enhance stomach emptying and improve peristalsis in about half of patients. (It may actually cause abnormal peristalsis in some patients, although in such cases the problem does not appear to be very significant.)

Fundoplication has some significant limitations and postoperative problems. For example, many patients still require anti-GERD medications or experience new symptoms (such as gas, bloating, and trouble swallowing). Most of these new symptoms occur more than a year after surgery. Fundoplication does not cure GERD, and evidence suggests that the procedure does not reduce the risk for esophageal cancer in high-risk patients, such as those with Barrett's esophagus. However, fundoplication has very good long-term results, especially when performed by an experienced surgeon, and few patients need to have a repeat procedure.

Candidates. Fundoplication is recommended for patients whose condition includes one or more of the following:

• Esophagitis (inflamed esophagus)
• Symptoms that persist or come back in spite of antireflux drug treatment
• Strictures
• Failure to gain or maintain weight (in children)

Fundoplication has little benefit for patients with impaired stomach motility (an inability of the muscles to move spontaneously).

The Open Nissen Fundoplication Procedure. Until recently, the 360° Nissen fundoplication was the fundoplication procedure most often used for GERD. This is called an open procedure because it requires wide surgical incisions.

• With this procedure, the physician wraps the upper part of the stomach (fundus) completely around the esophagus to form a collar-like structure.
• The collar places pressure on the LES and prevents stomach fluids from backing up into the esophagus.
• Open fundoplication requires a hospital stay of 6 - 10 days.

Laparoscopic Fundoplication. The standard invasive fundoplication procedure has been replaced in many cases by a less invasive procedure that uses laparoscopy. In the operation:

• Tiny incisions are made in the abdomen.
• Small instruments and a tiny camera are inserted into tubes, through which the surgeon can view the region.
• The surgeon creates a collar using the fundus, although the area to work with is smaller.

When performed by experienced surgeons, results are equal to those of standard open fundoplication, but with a faster recovery time.

Overall, laparoscopic fundoplication appears to be safe and effective in people of all ages, even babies. Five years after undergoing laparoscopic fundoplication for GERD, patients report a near normal quality of life, and say they are satisfied with their treatment choice. Laparoscopic surgery also has a low reoperation rate -- about 1%.

Laparoscopy is more difficult to perform in certain patients, including those who are obese, who have a short esophagus, or who have a history of previous surgery in the upper abdominal area. It may also be less successful in relieving atypical symptoms of GERD, including cough, abnormal chest pain, and choking. In about 8% of laparoscopies, it is necessary to convert to open surgery during the procedure because of unforeseen complications.

Other Variations. There are now different fundoplication procedures.

• Toupet fundoplication and Thal fundoplication use only a partial wrap. Partial fundoplication procedures may be more effective in patients with poor or no esophageal muscle movement. Those with normal muscle movement may do better with the full-circle wrap.
• Other procedures use a very short and "floppy" Nissen full wrap.

Many surgeons report that such limited fundoplications help patients start eating and get released from the hospital sooner, and they have a lower incidence of complications (trouble swallowing, gas bloating, and gagging) than the full Nissan fundoplication.

Postoperative Problems and Complications after Fundoplication. Problems after surgery can include a delay in intestinal functioning, causing bloating, gagging, and vomiting. These side effects usually go away in a few weeks. If symptoms last or start weeks or months after surgery, particularly if there is vomiting, surgical complications are likely. Complications include:

• An excessively wrapped fundus. This is fairly common and can cause difficulty swallowing (dysphagia), as well as gagging, gas, bloating, or an inability to burp. (A follow-up procedure that dilates the esophagus using an inflated balloon may help correct dysphagia, although it cannot treat other symptoms.)
• Bowel obstruction
• Wound infection
• Injury to nearby organs
• Respiratory complications, such as a collapsed lung. These are uncommon, particularly with laparoscopic fundoplication.
• Muscle spasms after swallowing food. This can cause intense pain, and patients may need to eat a liquid diet, sometimes for weeks. This is a rare complication in most patients, but the risk can be very high in children with brain and nervous system (neurologic) abnormalities. Such children are already at very high risk for GERD.

Reasons for Treatment Failure. Long-term failure rates after fundoplication are 30% after 5 years and 63% after 10 years. Hiatal herniation is the most common reason for surgical failure and the need for a repeat fundoplication. Other common reasons for reoperation include breakdown, slippage, and excessive tightness of the wrap. Surgeon experience can lessen complication risks. Some studies have reported that 3 - 6% of patients need repeat operations, usually because of continuing reflux symptoms and swallowing difficulty (dysphagia). Repeat surgery usually has good success, significantly reducing symptoms in about 70% of patients. However, these surgeries can also lead to greater complications, such as injury to the liver or spleen.

Surgical Treatments Using Endoscopy

A number of endoscopic treatments are being used or investigated for increasing LES pressure and preventing reflux, as well as for treating severe GERD and its complications. Researchers find that endoscopic therapies for GERD may relieve symptoms and reduce the need for antireflux medications, although they are not as effective as laparoscopic fundoplication. Endoscopic procedures are also being done along with fundoplication.

Transoral Flexible Endoscopic Suturing. Transoral flexible endoscopic suturing (sometimes referred to as Bard's procedure) uses a tiny device at the end of the endoscope that acts like a miniature sewing machine. It places stitches in two locations near the LES, which are then tied to tighten the valve and increase pressure. There is no incision and no need for general anesthesia.

Radiofrequency. Radiofrequency energy generated from the tip of a needle (sometimes called the Stretta procedure) heats and destroys tissue in problem spots in the LES. Either the resulting scar tissue strengthens the muscle, or the heat kills the nerves that caused the malfunction. Patients may experience some chest or stomach pain afterwards. Few serious side effects have been reported, although there have been reports of perforation, hemorrhage, and even death.

Dilation Procedures. Strictures (abnormally narrowed regions) may need to be dilated (opened) with endoscopy. Dilation may be performed by inflating a balloon in the passageway. About 30% of patients who need this procedure require a series of dilation treatments over a long period of time to fully open the passageway. Long-term use of PPIs may reduce the duration of treatments.