The term gastroesophageal reflux describes the movement (or reflux) of stomach contents back up into the esophagus, the muscular tube that extends from the neck to the abdomen and connects the back of the throat to the stomach. Also known as acid reflux.
Because the stomach manufactures acid as an aid to digestion, this phenomenon is often referred to as acid reflux. Most people experience acid reflux from time to time as heartburn, a burning sensation below the breast bone that occurs after eating or at night.
When the frequency of acid reflux is much greater than normal, or complications develop as a result of acid reflux, the condition is known as gastroesophageal reflux disease, or GERD.
Should GERD Be Treated?
Treatment is appropriate if GERD is severe. The aim of treatment is the relief of symptoms such as heartburn. Most drug treatments are not designed to stop reflux but instead focus on reducing stomach acid so that irritation of the esophagus is minimized.
The majority of people experience adequate relief with over-the-counter medications such as antacids or acid-suppression drugs.
How is GERD Treatment?
There are several components to the treatment of GERD. The first component consists of alterations in lifestyle. Most people benefit substantially from weight loss. Avoiding tight or restrictive clothing is also recommended. Avoiding eating for several hours before going to sleep at night helps to keep the stomach empty, reducing reflux.
Some people benefit from elevating the head of the bed 6″ to 8″ above the foot of the bed, allowing gravity to help prevent reflux episodes. Smoking cessation is important. Refrain from eating spicy and fatty foods, peppermint, caffeine, and chocolate. Seek the advice of your physician for help in eliminating medications that might promote reflux.
The second component of treatment is drug therapy. Most people get adequate relief from antacids or over-the-counter acid suppression medications.
If these fail to provide sufficient relief, prescription medications may be necessary to further suppress stomach acid production. Some patients also benefit from drugs that improve emptying of the esophagus and stomach.
The third component of treatment is modification of the valve between the esophagus and stomach. More than 95% of patients with GERD get sufficient relief from lifestyle changes and medical therapy and do not require such interventions.
When additional interventions are necessary, there are a variety of options to choose from. For patients without large hiatal hernias and who have mild to moderate reflux symptoms, there are endoscopic options for therapy.
These include stitching the esophagus and stomach to reinforce the valve, applying radiofrequency current to the valve to strengthen it, and injecting a bulking substance into the tissues of the valve to increase the valve pressure. All of these options are new, and the long-term results of such treatments have yet to be determined.
The other option for strengthening the valve is surgical therapy, which is a standard treatment for which long-term results are known and are very good. It is the best additional therapy for patients with severe symptoms and for patients who have a hiatal hernia.
Is Surgery Necessary?
Surgery is indicated for a small group of patients with GERD. The most common indication for surgery is the failure of medical therapy to adequately relieve symptoms of GERD. Some patients are unable to tolerate medical therapy due to side effects from the medications themselves.
Other patients experience complications of GERD such as scarring, bleeding, or respiratory symptoms that are sometimes best treated with an operation.
There is currently debate over whether young adults with significant GERD symptoms should be considered for surgery even if they obtain adequate relief from medical therapy.
What Can I Expect If Surgery is Recommended?
Most patients who are recommended to have surgery for GERD will have undergone an endoscopic examination of the esophagus prior to operation. Many will have also had an x-ray examination of the esophagus, a manometric pressure study, or an esophageal pH study, depending on their specific symptoms.
All operations for GERD should be considered major surgery even if the operations are safe and the risks they pose are small.
Most operations are performed using a laparoscopic approach under a general anesthetic. Four or five small punctures are made in the abdomen permitting insertion of a telescope for viewing and instruments to do the operation.
This can be accomplished in some patients on an outpatient basis or with just one overnight stay in the hospital. If laparoscopy is not feasible, the operation is performed through an open abdominal incision or an incision on the left side of the chest. These larger operations require a hospital stay of at least several days.
The aims of surgery for GERD are to correct any hernia which might exist and to wrap a portion of the stomach around the esophagus, thus creating a new valve mechanism to prevent reflux. If complications of GERD exist, such as scarring or ulcer formation, these are also corrected at the same time.
The likelihood of having a successful operation that relieves symptoms of GERD sufficiently so that no medications are necessary is about 95%.
Surgery Options for GERD
Acid reflux occurs when stomach acid flows backwards into the esophagus. This causes heartburn and other symptoms. Chronic or severe acid reflux is known as gastroesophageal reflux disease (GERD).
Mild or moderate reflux symptoms can often be relieved with diet and lifestyle changes. Over-the-counter and prescription medications can also help with symptom relief. Medications used to treat GERD include:
- H2 blockers
- proton pump inhibitors (PPIs)
Unfortunately, some people aren’t helped by lifestyle changes or medications. Surgery may be an option for those people. Surgery focuses on repairing or replacing the valve at the bottom of the esophagus that normally keeps acid from moving backward from the stomach.
This valve is called the lower esophageal sphincter (LES). A weak or damaged LES is what causes GERD.
Surgery may be recommended if you have serious GERD complications. For example, stomach acid can cause inflammation of the esophagus.
This may lead to bleeding or ulcers. Scars from tissue damage can constrict the esophagus and make swallowing difficult.
Untreated GERD can also develop into a condition called Barrett’s esophagus. This condition increases the risk of esophageal cancer. However, esophageal cancer is rare, even in people with Barrett’s.
There are several surgical options that may help to relieve GERD symptoms and manage complications. Surgery for GERD is usually a last resort.
Most doctors use it only when other treatments have failed to relieve symptoms. For some people, surgery is a better option than a lifetime of managing drugs and discomfort. Speak with your doctor for guidance on the best approach to manage your condition.
This is the standard surgical treatment for GERD. It tightens and reinforces the LES. The upper part of the stomach is wrapped around the outside of the lower esophagus to strengthen the sphincter.
Fundoplication can be performed as an open surgery. During an open surgery, the surgeon makes a long incision in your stomach to access the esophagus. It can also be performed as laparoscopic surgery. This type of surgery involves several smaller incisions.
Miniaturized instruments are used to make the process less invasive.
TIF (Transoral Incisionless Fundoplication)
This procedure is used when open fundoplication is not appropriate. It creates a barrier between the stomach and the esophagus. The barrier prevents reflux of stomach acid.
This procedure doesn’t require incisions. A device called an EsophyX is inserted through your mouth. It creates several folds at the base of the esophagus. The folds form a new valve.
This procedure is performed with an endoscope. This is a thin, flexible tube that can be threaded into your esophagus.
An electrode at the end of the tube heats your esophageal tissue and creates tiny cuts in it. The cuts form scar tissue in the esophagus. This blocks the nerves that respond to refluxed acid.
The scar tissue that forms also helps strengthen the surrounding muscles.
Bard EndoCinch System
This system also uses an endoscope. Stitches are made to form pleats in the LES. This strengthens the LES.
This surgery uses a special device called a Linx. It’s a ring of tiny magnetic titanium beads. When wrapped around the LES, the Linx strengthens the sphincter.
Because the beads are magnetized, they move together to keep the opening between the stomach and esophagus closed. Food can still pass through normally.