Gastroesophageal reflux disease (GERD) develops from the regurgitation of stomach contents in the oesophagus, causing heartburn, sore throat and voice hoarseness.
Typically, first-line non-operative treatments for GERD include lifestyle changes such as maintaining healthy body weight and avoiding trigger foods (spicy food, fried food and citrus) and taking prescribed medications such as proton pump inhibitors. Anti-reflux procedures aim to prevent the recurrence of persistent inflammation in the oesophageal lining due to the increased flow of stomach acid. Surgery is an attempt to tighten the lower oesophageal sphincter (LES), a circular frame of muscle that functions as a valve. A healthy functioning LES opens and closes entirely to prevent the influx of stomach acid in the oesophagus. However, in patients with GERD, the LES doesn’t close all the way, which allows gastric contents to flow back into the oesophagus. Fortunately, anti-reflux operations are designed to strengthen and support the LES to reduce the risk of acid reflux. These types of anti-reflux surgeries can be done less invasively using a commonly performed technique called laparoscopy.
Less invasive gastroesophageal fundoplication is considered the gold standard operative treatment for GERD with positive outcomes. Surgical intervention is only initiated when the patient fails to respond favourably to medical therapy or develops worsening acid reflux symptoms.
Medical therapies for patients with GERD include proton pump inhibitors (PPIs) and antacids. However, various studies comparing non-operative treatment and surgical intervention for GERD have discovered that anti-reflux procedures are good alternatives to medical therapies, even for patients who respond favourably to pharmacologic therapy.
Studies have found that patients exhibit less acidic content after fundoplication and higher LES pressure than with medical management alone. Furthermore, the American Society for Gastrointestinal and Endoscopic Surgeons (SAGES) presented guidelines outlining the curative benefits of surgery for GERD, which has proven effective in over eighty per cent of cases (Moore et al., 2016). However, many patients still benefit from acid suppression drugs even after undergoing open or laparoscopic acid reflux surgery.
Despite benefiting from medical management, patients need to consider surgery should complications from GERD arise. These complications include Barrett’s oesophagus, a peptic stricture, enamel erosion, asthma, or chest pain. The SAGES guidelines stress the need for surgery when patients do not respond well to medications or their symptoms worsen. A large hiatus hernia is one of the primary reasons for GERD, in which case hernia repair needs to be carried out to address the underlying cause of the condition.
Recent studies have shown that prolonged use of PPIs may be associated with the following:
- High gastric pH
- Achlorhydria
Laparoscopic diaphragmatic hernia repair with fundoplication is recognised as a safe and effective procedure with complication rates of less than 5%. Some of the risks/complications associated with surgery include gas bloat syndrome, difficulty or pain when swallowing, recurrence of acid reflux and hiatus hernia.
Sources
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Jiang Y, Cui WX, Wang Y, Heng D, Tan JC, Lin L. Anti-reflux surgery vs medical treatment for gastroesophageal reflux disease: A meta-analysis. World J Meta-Anal 2015; 3(6): 284-294 [DOI: 10.13105/wjma.v3.i6.284]
Maureen Moore, Cheguevara Afaneh, Daniel Benhuri, Caroline Antonacci, Jonathan Abelson, and Rasa Zarnegar. Gastroesophageal reflux disease: A review of surgical decision making. 2016. World Journal of gastrointestinal surgery.
National Library of Medicine. Medline Plus. Anti-reflux surgery. 2021. https://medlineplus.gov/ency/article/002925.htm
Ryan D. Rosen, Ryan Winters. The National Library of Medicine. Physiology, Lower Esophageal Sphincter. 2022.
Stefanidis D, Hope WW, Kohn GP, Reardon PR, Richardson WS, Fanelli RD. Guidelines for surgical treatment of gastroesophageal reflux disease. Surg Endosc. 2010;24:2647–2669.