The Surgery to Treat Gastroesophageal Reflux Disease
Gastroesophageal reflux disease (GERD) affects about 15% of the population and may be treated by surgery. The disorder produces bothersome symptoms, although in most cases they are mild. They also affect people’s quality of life.
Although medical treatment is usually effective, there are patients who could benefit greatly from surgery, especially those who have a low response to the traditional approach.
Surgical treatment isn’t the most requested option, nor is it the most indicated. However, it represents a valid alternative for a group of patients, as long as the evaluation of the clinical picture is complete and sufficient complementary studies are available.
Surgical treatment for GERD: When is it an option?
About 10% of all patients with gastroesophageal reflux disease undergo surgery. This figure is apparently low, but has several important explanations.
First, like any surgical procedure, it carries a risk that must be analyzed beforehand. For this reason, some physicians are reluctant to even mention it.
Another reason for the low number of GERD patients operated on is the severity of the disease. More than 70% of people with this disorder manifest mild symptoms. So it is unlikely that a physician will consider a surgical option.
Such a conservative attitude is almost always prudent.
On the other hand, many GERD patients self-medicate, so they do not get reliable professional advice. This is because the symptoms improve with the consumption of antacids or gastric protectors, which are marketed without professional prescription. Thus, in the face of momentary relief of reflux, consultation and evaluation of possible alternatives are neglected.
Indications for surgery in patients with gastroesophageal reflux disease
It’s important to note that, to date, studies propose surgery as an option only in specific cases of patients with GERD. Also, careful and individualized evaluation should always be the priority.
Indications for antireflux surgery include the following:
- Patients in whom, upon discontinuation of treatment, symptoms reappear. Or the need to increase the dosage of the pills repeatedly.
- Cases in which complications of GERD, such as esophagitis, ulcer or esophageal stricture, and Barrett’s esophagus, are found.
- People who do not wish to continue receiving medication chronically.
- Young people with frequent relapses.
- Presence of hiatal hernia.
It’s essential to know that, although in most cases, antireflux surgery seems to improve symptoms, some patients will continue to need medication after the procedure. An example is those whose symptoms appear when sleeping.
Recommended tests to opt for surgery
The diagnosis of GERD is clinical. That is, it takes into account the characteristic symptoms of the disease (heartburn, heartburn, regurgitation, belching, bulimia nervosa, halitosis, and even coughing).
Among the complementary explorations are the following:
- An evaluation of the esophageal function with a manometry
- Ambulatory pH measurement (pHmetry)
- Radiological studies
- An endoscopy
Similarly, some authors propose the diagnosis in cases in which anatomical changes characteristic of gastroesophageal reflux are found. These can only be evidenced by endoscopy and information from an esophageal mucosal biopsy.
It’s also a good idea to explore the presence of psychiatric illness, such as major depression, as the patient’s sense of satisfaction with the procedure may be diminished by this.
Important surgical considerations
Some patients with gastroesophageal reflux disease are not the best candidates for surgery. Therefore, information should be tailored to the individual conditions of each person, without generalizing.
Situations with lower surgical success rates include the following:
- Association of psychiatric conditions, such as bulimia nervosa and major depression.
- Cases with an improvement in esophageal mucosa alterations with medication.
- Patients with obesity, especially when it is severe.
- Results of a pHmetry within normal values.
- Presence of a severe motor disorder of the esophagus.
- People with atypical GERD symptoms.
What is surgery for gastroesophageal reflux disease?
Although various surgical techniques are available to manage GERD, the goal is to restore the normal functioning of the lower esophageal sphincter. The most commonly used surgery is fundoplication which can be performed either through the abdominal approach or through the thorax. Similarly, the surgeon can opt for an incision (laparotomy) or the use of laparoscopy.
Nissen and Toupet fundoplication
The two most frequently described techniques are fundoplications. Among these, the most commonly used and the one with the highest success rate is the Nissen fundoplication. In this technique, the surgeon attempts to create a valvular mechanism to control gastroesophageal reflux. For this reason, she or he uses the fundus of the stomach to encircle the esophagus in its entirety.
In the case of the Toupet fundoplication, the procedure does not create a complete ring. Thus, it’s appropriate for patients who have esophageal motility disorders in addition to GERD.
Other surgical options
There are other less-used techniques with lower success rates. In addition, some endoscopic procedures attempt to normalize lower esophageal sphincter function to avoid constant reflux.
These include the following:
- Endoscopic gastroplasty
- Radiofrequency ablation
- Injection of some substances
Minimally invasive techniques have been proposed for the management of GERD. They constitute a promising treatment option, such as a cardiac magnetic bracelet and electrical stimulation of the lower esophageal sphincter. However, we still need more studies to verify their efficacy.
What are the complications of antireflux surgery?
As in any other surgical procedure, there are risks that are inherent to all surgery and the use of anesthesia. Among them are risks of hemorrhage, thromboembolism, and infections.
However, in this case, there may be other complications depending on the approach and whether it’s done by laparotomy (open surgery) or by laparoscopy. Among the complications typical of these surgeries are the following:
- Air retention
- Esophageal or gastric perforation
- Pain when eating food (dysphagia)
- Mediastinal or subcutaneous emphysema
- Inability to vomit
- Hepatic or spleen injury
The advantages of surgery for gastroesophageal reflux disease
In conclusion, although antireflux surgery is a procedure that requires careful evaluation, it represents a valid treatment option for some patients. It’s important to highlight that the effectiveness of the approach is similar to that shown by medications. However, the surgical option has the additional advantage of not causing long-term adverse effects.
Similarly, surgery prevents esophageal lesions produced by the constant presence of gastric acid on the walls of the organ from evolving into other diseases that are more difficult to treat. This is the case of Barrett’s esophagus, with a specific risk of progressing to adenocarcinoma.It might interest you...