Surgical Options for GERD
Medication and lifestyle changes successfully control GERD in about 95% of people. When they don’t, surgery may be an option. Surgery may be preferable for young individuals who don’t like the prospect of taking a PPI for life. Other conditions that might warrant surgery are occasional cases of erosive esophagitis that do not improve with drug therapy, strictures that come back despite treatment, or pneumonia or recurrent respiratory problems due to acid reflux that don’t improve with drug therapy.
The goal of surgery is to tighten the LES. The operations are generally effective and may eliminate the need for all GERD medications.
The most common antireflux operation is the Nissen fundoplication. It is also known as a stomach wrap. This operation prevents stomach acid from surging upward into the esophagus. Partial fundoplication, in which the stomach is wrapped only partway around the esophagus, is another option.
Nissen fundoplication involves taking a portion of the top of the stomach and looping it around the lower end of the esophagus and the lower esophageal sphincter. This creates an artificial sphincter, sometimes called a pinch valve. The artificial sphincter prevents stomach acid from backing up into the esophagus. The wrap must be tight enough to prevent the acid from coming back up, but not so tight that food can’t enter and a satisfying belch can’t escape. In addition to curing heartburn and GERD-induced respiratory symptoms, the procedure may help the stomach empty and improve abnormal peristalsis in some people.
Over time, stomach wraps can loosen. When that happens, an individual may need to resume medications and, in a small number of cases, undergo surgery to redo the procedure. A study in the Journal of the American Medical Association found that 62% of people who had undergone the Nissen fundoplication procedure 10 years earlier were regularly using medications to control reflux.
An increasing number of surgeons are performing fundoplication as a laparoscopic (“keyhole”) procedure. Instead of making a large incision in the abdomen, a surgeon makes a few tiny incisions. Through these, special cameras and surgical instruments are inserted into the upper abdomen. People recover much faster from laparoscopy than from open surgery.
Endoscopic suturing and plicating systems
Endoscopic treatments are carried out via a tube placed down the throat rather than through an incision. They provide a middle-ground alternative to long-term acid-suppressing therapy and surgical intervention.
One endoscopic procedure, known as the Bard EndoCinch endoscopic suturing system, tightens the lower esophageal sphincter with stitches. The procedure uses a thin, flexible endoscope with a device that resembles a miniature sewing machine at its tip. The endoscope is inserted down the throat and into the esophagus. Once in place, it is used to place stitches on either side of the sphincter. The doctor then ties the stitches together to tighten the valve.
A similar technique is called plication. It uses an endoscope called a plicator to make a single, full-thickness pleat in the upper stomach, about 1 centimeter below the junction between the esophagus and the stomach. This pleat restructures and strengthens the antireflux barrier. Although long-term data are limited, one small study found that this approach continued to effectively reduce GERD symptoms and medication use three years after the procedure was performed.
About 90% of people are free of heartburn in the months following reflux surgery. But a follow-up study showed that within 10 to 13 years, many such individuals eventually needed to start taking heartburn medications again.
Radiofrequency catheter ablation
More than 10 years ago, the FDA approved a procedure known as endoscopic radiofrequency catheter ablation to treat acid reflux. Also known as the Stretta procedure, it involves applying controlled radiofrequency energy through an endoscope. The procedure, which takes about an hour, “zaps” the lower esophageal sphincter and the upper part of the stomach. This causes the lining of the lower esophagus to swell slightly. Afterward, the valve gradually tightens. This creates a more effective barrier between the esophagus and stomach. Individuals undergoing this procedure can expect to get back to their regular activities the next day.
The long term safety and effectiveness of the procedure are still being studied.
Medical innovators have long sought to quell GERD by injecting inert materials into the muscles lining the end of the esophagus. This would create a mechanical barrier that blocks reflux. Initial results with collagen and Teflon were not very encouraging, because particles sometimes moved away from the injection site or dissolved. In 2003, the FDA approved Enteryx, a liquid chemical polymer designed to be injected into the wall of the lower esophagus. The polymer solidified into a spongy material that helped prevent reflux by strengthening the muscle separating the lower esophagus from the stomach. However, Enteryx was pulled from the market in 2005 because of serious adverse effects, including death, which happened when Enteryx was unknowingly injected into structures surrounding the esophagus.
For the moment, injections are not being used to treat GERD.