Introduction:
Antireflux surgery (ARS) is an effective treatment for gastroesophageal reflux disease (GERD), refractory to medical management, in patients who have been on lifelong acid suppression and in those with side effects on medical management. GERD is when acidic gastric content is refluxed back into the esophagus. The success of antireflux surgery on GERD depends on multiple factors, like diagnosing GERD, choosing the patient, surgery, and care given post-operatively.
What Are the Causes of GERD?
The muscle present at the lower esophagus, called the lower esophageal sphincter, closes the esophagus to prevent the reflux of gastric content back into the esophagus. If this valve is weak, it thus causes reflux of gastric content.
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Overweight or obese.
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Delayed emptying of the stomach.
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Smoking and drinking alcohol (bad lifestyle habits).
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Certain medication.
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Diseases like rheumatoid arthritis and scleroderma.
What Is Antireflux Surgery?
Fundoplication is the most common procedure in this. If the patient has a Hiatal hernia, the doctor will first repair it, including securing the diaphragm gap to keep the stomach from ascending and swelling through the gap in the muscle wall. Some doctors will keep a mesh in that area to make it secure. The stomach's upper part is wrapped around the end of the esophagus with stitches.
This will create pressure at the esophagus's end, preventing stomach acid from flowing into the esophagus. Fundoplication is a procedure to reinforce the lower esophageal sphincter, thus rebuilding the barrier to prevent reflux from the stomach into the esophagus. The Nissen fundoplication is the main fundoplication used in GERD. Fundoplications have different types.
It includes,
1. Partial vs. Total Fundoplication
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Anterior (Dor) - Less postoperative dysphagia is its advantage. But the recurrence of symptoms will be there. Thus, multiple operations are required in the future.
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Toupet vs. Nissen Fundoplication - the main advantage of toupet fundoplication is that there is less chance of postoperative dysphagia. Still, in this procedure, the surgeon should be very careful about the wrap length, as it reflects the quality of reflux control.
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Open Repair - the surgeon will make a large incision in the belly, and a channel will be positioned into the stomach to keep the stomach wall in place. The tube is taken out in a week.
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Laparoscopic Repair - the surgeon makes a few small cuts in the stomach. A thin tube with a tiny camera is inserted into the stomach. A surgical instrument was inserted through another cut. The laparoscope is connected to a video monitoring device in the operating room. The surgeon will do the repair process by viewing through the video monitor in the operation room. The surgeon will change to an open procedure in case of any emergency or problem.
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Endoluminal Fundoplication - This is done without incision; in this procedure, an endoscope is passed through the mouth into the esophagus. Small clips are placed at the junction of the esophagus and stomach. This will prevent the flow of gastric content back into the esophagus.
Nowadays, minimally invasive procedures are preferred because they reduce the length of hospital stay, cause less pain, have small scars, and have a lower chance of wound infection and hernia.
Robotic Surgery in the Treatment of GERD - It is a safe and viable option. Robotic Nissen fundoplication is helpful as surgeons will have better vision, comfort, and autonomy. The disadvantage is that it takes longer and is expensive compared to laparoscopic surgeries.
When Is Surgery Indicated for GERD?
When there is a severe problem in the esophagus, like an ulcer, scarring, narrowing, or bleeding. Surgery is an alternative to lifelong medical therapy for patients with chronic reflux disease. Surgery is also done in patients who have established chronic reflux disease, and proton pump inhibitors or other antireflux therapy is not acting.
What Does Heartburn Look Like and Their Surgery?
Stomach acid returning to the tube that connects the mouth to the stomach causes heartburn, a sensation that rises to the chest. Individuals' chests may feel burning, and occasionally, people may notice a foul taste in their mouth. Since heartburn is primarily a sense or experience, it does not physically seem like anything. Seeing a doctor can help determine the cause and best course of action if an individual suffers from chronic heartburn.
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 aids in keeping 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?
When people have acid reflux, stomach acid can go up into the tube connecting the mouth to the stomach (the esophagus). If lifestyle changes and medications do not work well enough, a doctor might suggest surgery.
Here are some simple explanations for common surgery options:
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Fundoplication surgery involves wrapping the top part of your stomach around the bottom of the swallowing tube (esophagus). It is like creating a stronger barrier to prevent stomach acid from going back up.
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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.
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The stretta procedure involves using radiofrequency energy to strengthen the muscle at the bottom of the esophagus, helping to reduce acid reflux.
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These surgeries aim to make a barrier or strengthen the muscles to keep stomach acid where it belongs in the stomach and not flow back up into the esophagus.
What Are the Preoperative Measures to Be Taken for Acid Reflux Surgery?
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A proper medical history should be taken, and questions should be included regarding pregnancy and drug history.
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A blood test should be done, including a complete blood count (CBC), electrolytes, or liver test.
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Esophagus 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.
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Upper Endoscopy - is a procedure in which every patient with acid reflux should be checked to check for any ulcers, scarring, etc., in the esophagus.
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X-ray of the esophagus.
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Before starting the surgery, the patient should stop taking medications like Aspirin, Warfarin, Vitamin E, Ibuprofen, and other drugs that alter the blood coagulation process. It should be stopped a few days before surgery.
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On the day of surgery, a patient must stop eating and drinking for some time before surgery.
What Are the Outcomes After Acid Reflux Surgery?
There is an excellent outcome after laparoscopic acid reflux surgery. That is both in the short term, like one to five years, and the long term, like five to ten years. Heartburn and similar symptoms will be controlled after surgery.
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, like difficulty swallowing 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 intestine, and causes bloating and flatulence.
These effects are less affecting inpatients who underwent 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.
Conclusion:
Gastroesophageal reflux disease is the most common disease, with an increased prevalence. Continuous regurgitation of gastric acid content causes multiple symptoms in the patient, including heartburn, dysphagia, and cough. One complication associated with this is Barrett's esophagus, esophagitis, stricture, or adenocarcinoma.
Medicines are given to these patients, and lifestyle modification is done. Still, if it is found to be useless or any of the complications mentioned above occur, surgery is done to provide a long-term effect. The surgeon will decide the treatment procedure for each patient accordingly, and special care is taken for obese patients.
