Achieving acid reflux relief with surgery

The frequency of heartburn is the main factor that should be considered in determining the best treatment. Heartburn may be infrequent, frequent or persistent. Infrequent bouts usually respond to lifestyle modifications and traditional OTC medications. Frequent heartburn is mostly relieved with proton pump inhibitors. On the other hand when heartburn is persistent the situation is different as it is considered a warning sign of acid reflux disease.
In view of the fact that the natural history of esophageal damage caused by acid reflux can involve rare and serious consequences, other treatment options should be seriously considered. Actually, surgery is being reserved for those who can develop serious complications.
But how can we select those who are more susceptible to complications?
1- By documenting the presence of visible changes in the appearance of the surface lining the esophagus.
2- By documenting that the cause of these changes is mostly attributable to acid reflux.
3- By documenting the association of lower esophageal sphincter motility functional disturbance.
These would be translated into Endoscopy, 24-hour esophageal acid monitoring and esophageal manometry respectively.
The aim of these procedures is to confirm the cause- effect relationship in the heartburn sufferer, and together with failure of medications to relieve symptoms (as revealed by the need for continuous drug treatment or of increasing doses of medication) would be an indication for surgery. Other factors related to failure of medical treatment include: non compliance with drug therapy, the financial burden of medications and the preference for surgery especially in young patients.
The purpose of surgery is to ensure the intra-abdominal location of the lower esophageal segment which has the lower esophageal sphincter at its lower end. That would keep it positioned where a positive (intra-abdominal) pressure is maintained.
The diaphragmatic opening through which the lower esophagus passes is also narrowed and the top part of the stomach (called fundus) is wrapped around the lower esophagus and sutured to itself to tighten lower esophageal end.

This operation is called Nissen Fundoplication and is considered the most effective and proven procedure.
Recently, innovative techniques have allowed surgeons to perform this operation laparoscopically. It takes about 90 minutes and improves symptoms in 90% of patients. The operation may reverse damage caused by acid reflux disease and patients may be able to stop medications completely. However, it has been reported that after 5 years some patients would require proton pump inhibitors to control symptoms.
The operation may also be associated with some complications as difficulty in swallowing, inability to vomit and failure to completely relieve reflux symptoms.
Patient selection is the key to effectiveness of this operation and should mainly be indicated on the basis of patient preference.
If Hiatal Hernia or frequent pulmonary aspiration is associated with acid reflux disease they add more indications for the operation and results are much improved.
Always consult your physician to determine if surgery is an appropriate option for you.