For most people, heartburn is a treatable symptom. Frequent heartburn may indicate acid reflux or gastroesophageal reflux disease, also known as GERD. When treatment doesn't work and heartburn is severe despite lifestyle changes, surgery may be an option. It may also be an option if GERD causes other medical problems. Minimally invasive procedures using endoscopy are also available to treat acid reflux.
When to Consider Surgery for GERD
The vast majority of people with GERD can control heartburn symptoms adequately without surgery. A few people, though, still have acid reflux symptoms even after treating them with medications, lifestyle, and diet changes. For these people, surgery helps.
Heartburn that doesn't go away despite maximum non-surgical treatment is the most common reason to consider surgery for GERD. Other situations where surgery may be an option include:
- Severe inflammation of the esophagus, called esophagitis.
- A narrowing, known as a stricture, of the esophagus that's not caused by cancer.
- Barrett's esophagus, which is a change in the cells of the esophagus because of acid reflux.
All surgical procedures carry risk. So generally, GERD surgery should be considered only after other treatment has not worked and tests suggest there's a good chance surgery will succeed.
Most people, if not everyone, considering surgery for GERD will first undergo endoscopy. Many will also have tests to check the muscle function of the esophagus. These tests can include esophageal manometry and esophageal motility studies.
Types of Surgery for GERD
The main surgery performed for persistent heartburn is called fundoplication. The surgery involves several steps:
- The surgeon first cuts into the abdomen. He or she will either make one large incision for open surgery or a few small incisions for laparoscopic surgery.
- In laparoscopic fundoplication, the surgeon operates from outside the body using tools inserted into the abdomen. During open fundoplication, he or she operates directly using his or her hands.
- The surgeon wraps the top part of the stomach around the lower part of the esophagus and sews it in place.
- This tightens the lower esophagus. That helps prevent acid from moving from the stomach into the esophagus and causing acid reflux.
In most cases, the top part of the stomach is wrapped all the way around the esophagus. People with other problems in the esophagus besides reflux may undergo a modified surgery with only a partial wrap.
Other types of surgery can also be done with a laparoscope. For example, a ring of titanium beads can be placed around the outside of the lower esophagus. It strengthens the valve between the esophagus and stomach while still allowing food and liquids to pass through.
Laparoscopic surgery requires a shorter recovery time with less pain than open surgery. Plus it leaves no large scar. When performed by an experienced surgeon, laparoscopic surgery works at least as well as traditional open surgery. In some cases, symptoms may return or develop and additional surgery may be needed.
Minimally Invasive (Endoscopic) Procedure for GERD
By using endoscopy, doctors can also treat GERD in the esophagus without an incision in the abdomen. Endoscopy for GERD uses a flexible tube that is placed through the mouth and into the esophagus and stomach. The tube contains a light and camera to visualize the inside of the body. Through the endoscope, doctors can also take tissue samples and perform procedures using other tools.
Minimally invasive endoscopic treatments for GERD involve:
Endoscopic procedure. A doctor operates with a limited set of small surgical tools at the tip of an endoscope. Using a procedure called the Esophyx system, the doctor tightly binds the end of the esophagus to the top of the stomach. With the EndoCinch system, stitches are placed in the lower esophagus to form pleats that strengthen the area.
Radiofrequency treatment. This is also known as the Stretta procedure. During endoscopy, high-energy waves are directed into the wall of the lower esophagus. The esophagus responds by producing small amounts of scar tissue. In most people, this reduces heartburn and other acid reflux symptoms. More than one radiofrequency treatment may be required to achieve a good result.
Endoscopic procedures are usually effective but are not as good as surgery at treating acid reflux, generally speaking. However, they offer the significant advantages of not requiring incisions, general anesthesia, or a hospital stay.
What to Expect After Surgery for GERD
Five or more years after fundoplication for acid reflux, 90% to 95% of people surveyed report feeling satisfied with their surgery and its results.
Surgery for acid reflux frequently does not eliminate all symptoms, however. Some people need to continue to take acid-suppressing medications after heartburn surgery to control the remaining symptoms. Nevertheless, they usually report satisfaction with their heartburn surgery results.
Surgery for acid reflux has low risks in general. Some risks of surgery include:
- Difficulty swallowing after the surgery
- A frequent feeling of bloating (gas bloat syndrome)
- The need for repeat surgery in up to 10% of people
- Wound infection
Before undergoing heartburn surgery, it's important to discuss these and other risks with your doctor.