Provides Freedom From Reflux for Selected Patients

Acid suppression remains the therapeutic mainstay for gastroesophageal reflux disease (GERD). Highly effective antireflux agents, particularly proton pump inhibitors, provide symptomatic control and esophageal healing for the vast majority of patients. Yet for a select population — individuals with severe reflux and those who are intolerant of or refractory to medications — antireflux surgery can relieve painful symptoms, prevent, and sometimes reverse esophageal damage as well as the laryngeal and pulmonary complications associated with GERD.

“Fundoplication is an option for patients whose symptoms impair their quality of life, such as those with GERD-related dysphagia that interferes with eating and individuals who have nocturnal regurgitation of acid or food, which can cause heartburn, chest pain, coughing, choking, and sleep disturbances,” says UAB’s Chief of the Section of Gastrointestinal Surgery Mary T. Hawn, MD. “Although there is no evidence fundoplication prevents esophageal malignancy, the procedure eliminates symptoms without the need for medications in 90% of carefully selected patients.”

Only 5% to 10% of patients have refractory or severe enough GERD to warrant surgical evaluation for fundoplication. “Because antireflux drugs are so effective, the diagnosis of GERD should be reconsidered in nonresponsive patients. We must also define anatomy with a barium swallow study and/or flexible endoscopy, which can reveal strictures and other abnormalities of the esophagus or stomach,” Hawn says.

Motility can assess esophageal function and a 24-hour pH probe can measure the amount of acid refluxed into the esophagus and determine if symptoms are associated with those acid reflux events.

When presurgical studies show patients are likely to benefit from antireflux surgery, Hawn typically performs a laparoscopic Nissen fundoplication (360º wrap). During the procedure the fundus of the stomach is completely wrapped around the esophagus to create a mechanical barrier against gastric refluxate. Hiatal hernias, which are common in patients with GERD, are repaired during the same procedure.

“Partial wraps are not as durable as complete fundoplication. Wraps in obese patients also tend to break down, and I advise these individuals to lose weight prior to surgery,” she says. “Weight loss may even cure reflux or bring symptoms under control.”

Recent data show laparoscopic fundoplication is effective and durable, with 90% of patients symptom free 10 years after surgery (Surg Endosc. 2006;20:159-165). Hawn says surgeons have experimented with general endoscopic therapies including radiofrequency ablation and injection of polymer fillers to strengthen the esophageal sphincter. These techniques have proven ineffective, providing minimal improvement in reflux control.

Up to 20% of patients develop new conditions after surgery — typically dysphagia and gas-bloat syndrome. “People with uncontrolled GERD often are willing to accept such complications rather than continue to suffer with chronic, painful reflux,” she says. “Physicians should consider fundoplication for patients with severe or medically refractory GERD. In addition, patients who have extra-esophageal symptoms such as hoarseness and coughing should undergo endoscopic evaluation to uncover conditions that could lead to GERD-related injuries.”

For more information:
Dr. Mary Hawn
1.800.UAB.MIST
mist@uabmc.edu