Surgery for Acid Reflux Relief

Indications of Antireflux Surgery
Antireflux surgery is indicated for the treatment of objectively documented, relatively severe GERD. Candidates for surgery include not only patients with erosive esophagitis, stricture, and Barrett's esophagus but also those without severe mucosal injury who are dependent on PPIs for symptom relief. Patients with atypical or respiratory symptoms who have a good response to intensive medical treatment are also candidates. The option of antireflux surgery should be given to all patients who have demonstrated the need for long-term medical therapy, particularly if escalating doses of PPIs are needed to control symptoms. Antireflux surgery may be the preferred option in patients younger than 50 years, those who are noncompliant with their drug regimen, those for whom medications are a financial burden, and those who favor a single intervention over long-term drug treatment. It may be the treatment of choice in patients who are at high risk of progression despite medical therapy. Although this population is not well defined, risk factors that predict progressive disease and a poor response to medical therapy include (a) nocturnal reflux on 24-hour esophageal pH study, (b) a structurally deficient LES, (c) mixed reflux of gastric and duodenal juice, and (d) mucosal injury at presentation.

Preoperative Evaluation
Successful antireflux surgery is largely defined by two objectives: the achievement of long-term relief of reflux symptoms and the absence of complications or complaints after the operation. In practice, achieving these two deceptively simple goals is difficult. Both are critically dependent on establishing that the symptoms for which the operation is performed are the result of excess esophageal exposure to gastric juice, as well as the proper performance of the appropriate antireflux procedure. Success can be expected in the vast majority of patients if these two criteria are met. The status of the LES is not as important a factor as in the days of open surgery. Patients with normal resting sphincters are often selected for antireflux surgery in the era of laparoscopic fundoplication. The outcome is not dependent on sphincter function.
There are four important goals of the diagnostic approach to patients suspected of having GERD and being considered for antireflux surgery.

Objective Documentation
The introduction of laparoscopic access, coupled with the growing recognition that surgery is a safe and durable treatment for GERD, has dramatically increased the number of patients being referred for laparoscopic fundoplication. The threshold for surgical referral is such that increasing numbers of patients without endoscopic esophagitis or other objective evidence of the presence of reflux are now considered candidates for laparoscopic antireflux surgery. These facts combine to underscore the importance of selecting patients for surgery who are likely to have a successful outcome. Although a Nissen fundoplication will reliably and reproducibly halt the return of gastroduodenal juice into the esophagus, little benefit is likely if the patient's symptoms are not caused by this specific pathophysiologic derangement. Thus, in large part, the anticipated success rate of laparoscopic fundoplication is directly proportional to the degree of certainty that GERD is the underlying cause of the patient's complaints.
Three factors predictive of a successful outcome following antireflux surgery have emerged . These are (a) an abnormal score on 24-hour esophageal pH monitoring; (b) the presence of typical symptoms of GERD, namely heartburn or regurgitation; and (c) symptomatic improvement in response to acid suppression therapy prior to surgery. It is immediately evident that each of these factors helps to establish that GERD is indeed the cause of the patient's symptoms and that they have little to do with the severity of the disease.

Endoscopic evaluation

Twenty-four hour ambulatory pH monitoring

Assessment of esophageal length

Radiographic evaluation

Assessment of esophageal body and gastric function

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.