Surgical Solutions for Gastroesophageal Reflux Disease (GERD)
Understanding GERD:
GERD, or gastroesophageal reflux disease, stems from stomach acid irritation of the esophagus. Affecting a significant portion of US adults, occasional heartburn is manageable with lifestyle changes or over-the-counter antacids. However, chronic GERD can lead to severe complications, including Barrett's esophagus, increasing the risk of esophageal adenocarcinoma.
Causes of GERD:
The exact cause of GERD is not fully understood, but factors like lower esophageal sphincter (LES) dysfunction, hiatal hernia, or abdominal pressure may contribute. Some patient’s have Bile regurgitation where bile from duodenum regurgitates into the stomach and reaches the Esophagus. Bile is alkaline in nature. Bile instead of coagulating the protein, melts the protein away. When the LES fails to close tightly, stomach acid or regurgitated bile refluxes into the esophagus, causing the burning sensation and inflammation. Gastric emptying disorder or failed esophageal peristalsis can also lead to GERD.
Diagnosing Severe GERD:
Severe GERD requires objective documentation of gastroesophageal reflux before considering surgery. Flexible esophagoscopy, tissue biopsies during endoscopy, or the 24-hour esophageal pH test are common diagnostic steps. Barrett's esophagus diagnosed histologically from tissue biopsy is considered objective evidence of GERD.
Candidates for Anti-Reflux Surgery:
Consider anti-reflux surgery if:
Symptom control is inadequate despite high-dose medications.
Also Bile reflux doesn’t respond to Acid reducing therapy and motility agents like Reglan and erythromycin are used.
Medication side effects or complications like Barrett's esophagus are present.
Extra-esophageal manifestations such as asthma or chest pain occur.
Patients opt for surgery to avoid lifelong acid suppression medications or improve their quality of life.
Advantages of Surgical Treatment:
Studies strongly support surgery as an effective alternative to acid suppression medications. Long-term follow-up data reveal less acid exposure and increased LES pressure compared to medical therapy, leading to high patient satisfaction. Most patients can discontinue acid suppression medications post-surgery.
Surgery Options:
Laparoscopic Nissen Fundoplication: This gold standard approach involves a 360° reinforcement of the LES. Partial fundoplication like Dor and Toupet are alternatives. People with shortened esophagus benefit with Colis procedure where stomach is converted into Neo-Esophagus thus recreating the LES. Laparoscopic surgery offers advantages such as reduced post-operative pain, improved cosmetic appearance, shorter hospital stays, and faster recovery compared to open surgery.
Anti-Reflux Surgery for Morbidly Obese Patients:
Obesity increases the risk of GERD, and when surgery is indicated in morbidly obese patients, laparoscopic Roux-en-Y gastric bypass is preferred over fundoplication. This addresses GERD and obesity-related comorbidities, providing durable relief of reflux symptoms and improving overall quality of life.
Outcomes:
Studies with long-term follow-up demonstrate laparoscopic anti-reflux surgery's safety, effectiveness, and durability. Appropriately performed surgery significantly improves GERD symptoms and enhances overall quality of life.