Antireflux Surgery - Indications, Outcomes, and Complications

What Is Antireflux Surgery?

Antireflux surgery is necessary when the lower esophageal sphincter (LES), the muscle separating the stomach from the food pipe, fails to function properly. If it does not work correctly, the stomach acid backs up into the esophagus, causing acid reflux and heartburn. Surgery tightens this barrier and, in doing so, diminishes symptoms and prevents complications such as inflammation of the food pipe or Barrett's esophagus (a condition where long-term acid reflux causes a change in the cellular structure of the food pipe lining).

When Is Surgery Indicated for GERD?

Surgery for GERD is indicated when:

• Failure of medical therapy:

Reflux symptoms such as heartburn and regurgitation that continue even after maximum therapy with proton pump inhibitors (PPIs) at the appropriate dose and time.

• Medication intolerance or preference:

Patients who have severe side effects of prolonged use of acid-suppressive drugs, as well as patients who prefer a final surgical approach instead of lifelong pharmacologic management.

• Complications of GERD:

Surgery may be considered in those with complications related to reflux, like severe reflux esophagitis, peptic strictures, bleeding, or Barrett’s esophagus, in those at risk of progression, or in those with symptoms that are not responding to anti-reflux medication.

• Extra-esophageal manifestations:

Long-lasting cough, asthma, throat irritation, or aspiration pneumonia (lung infection) that can be associated with GERD and that is not resolved even after medical treatment.

• Quality of life impairment:

Daily discomfort can occur due to regurgitation (acid coming back up), difficulty swallowing, chest discomfort, or disturbed sleep that does not improve despite taking treatments.

What Does Heartburn Feel Like, and When Is Surgery Needed?

Stomach acid returning to the tube that connects the mouth to the stomach causes heartburn, a sensation that rises to the chest. Individuals may experience a burning sensation in the chest, and occasionally, a foul taste in the mouth may be noticed. Since heartburn does not produce visible external signs, it is characterized by a burning sensation inside, caused by acid irritation of the food pipe, rather than by any changes visible on the body.

A doctor may recommend surgery if medication and lifestyle modifications are ineffective. A popular procedure is the fundoplication. During this procedure, the upper portion of the stomach is wrapped around the lower portion of the swallowing tube to create a stronger barrier. This helps prevent stomach acid from refluxing up into the throat. A surgeon will advise on the best course of action and review the potential risks and advantages of the case before performing surgery.

What Are Acid Reflux Surgery Options?

There are many treatment options for acid reflux; however, the choice depends on the severity of the condition.

Here are some simple explanations for common surgery options:

• Fundoplication surgery involves wrapping the upper part of the stomach around the lower part of the swallowing tube (esophagus). It is like creating a stronger barrier to prevent stomach acid from going back up.

• The LINX device is a small ring of magnetic beads that is surgically placed around the bottom of the esophagus. It helps keep the esophageal sphincter (the valve between the esophagus and stomach) closed to prevent acid reflux.

• Another minimally invasive procedure, radiofrequency ablation, is used to strengthen the muscle at the base of the esophagus, thereby reducing acid reflux.

• Transoral incisionless fundoplication, or TIF, is an endoscopic technique in which a procedure is carried out in the mouth to recreate an anti-reflux valve.

• Recently, a truly innovative implant device has been designed to restore the physiological barrier against reflux by repositioning the stomach, rather than squeezing the esophagus. In recent trials, there have been outstanding results regarding symptom control and improvement in quality of life at the 5-year mark, with minimal use of antisecretory medication.

These surgeries aim to create a barrier or strengthen the muscles that keep stomach acid in the stomach and prevent it from flowing back up into the esophagus.

What Are the Preoperative Measures to Be Taken for Acid Reflux Surgery?

• A proper medical history should be taken, including questions about pregnancy and drug history.

• A blood test should be performed, including a complete blood count (CBC), electrolyte levels, and a liver function test.

• Esophageal manometry is a procedure to check the pressure in the esophagus. And pH monitoring should be done to check how much acid comes back to the esophagus.

• Upper endoscopy is a procedure that every patient with acid reflux should undergo to check for ulcers, scarring, etc., in the esophagus.

• X-ray of the esophagus.

• Before starting the surgery, the patient should discontinue taking medications such as Aspirin, Warfarin, Vitamin E, Ibuprofen, and other medicines that affect the blood coagulation process. This should be done a few days before surgery.

• On the day of surgery, patients must stop eating and drinking for a specified period before surgery.

What Are the Outcomes After Acid Reflux Surgery?

Excellent outcomes are possible after laparoscopic acid reflux surgery, both in the short term (one to five years) and in the long term (five to ten years). Some patients may experience temporary GERD symptoms after fundoplication surgery, such as bloating or difficulty swallowing, which usually improve over time.

What Are the Complications of Acid Reflux Surgery?

Common complications of surgery include bleeding, infection, and delayed wound healing.

Total fundoplication will result in mechanical obstruction, such as difficulty swallowing, and a slightly compressed food pathway through the esophagus into the stomach. The inability to vent air from the stomach makes it difficult to burp, causes more air to pass through the intestines, and leads to bloating and flatulence.

These effects are less pronounced in patients who have undergone partial fundoplication.

• Pneumothorax, where air escapes into the surrounding space of the lungs.

• Tears of the stitches.

• Perforation, making a hole in the esophagus and stomach.

What Are the Risks of Anti-Reflux Surgery?

Some common risks caused by anesthesia are:

• Reactions caused by the medications.

• Breathing issues.

• Infection.

• Bleeding and blood clots.

Risks caused by the surgery are:

• Damage may be caused to the esophagus, stomach, small intestine, or liver.

• Gas bloat is caused when too much air or food overfills the stomach, and the person is unable to relieve the pressure.

• Difficulty while swallowing.

• Recurrence of hiatal hernia (occurs in the upper portion of the stomach when the abdominal organs push into the chest through the diaphragm) or reflux.

Conclusion

Antireflux surgery could be an efficient alternative in dealing with GERD in situations where patients are not able to respond to medication or lifestyle modifications. However, owing to advancements in antireflux surgeries, such as fundoplication, LINX, or new ones like RefluxStop, patients can now easily alleviate their reflux problem. To determine the proper treatment course for managing reflux problems, it is advisable to consult a gastro health specialist online for guidance.

Key Takeaways

• The primary objective of antireflux surgery is to enhance the natural barrier between the stomach and esophagus, thereby preventing acid reflux.

• Surgery becomes an option for GERD in either of the following conditions: when it is uncontrolled with medications, leads to complications, or affects the quality of the patient’s life.

• Recent practices have shown excellent results, with trials demonstrating sustained symptom control for 5 to 10 years and reduced dependence on long-term acid-reducing agents.