Surgical Treatment for GERD
Hiatal Hernia repair
The esophagus is a complex muscular tubular organ with specialized lining that connects the mouth to the stomach. It transverse the diaphragm through an opening called the “hiatus”. The hiatus is located between 2 muscles on the diaphragm, the right and let crura muscles. Due to a variety of reasons, that opening can increase in diameter allowing the stomach to either slide up into the chest or to allow part of the stomach to migrate into the chest adjacent to the remaining stomach. To repair this defect, it is necessary to suture and approximate the crura muscles closer together. This can typically be easily performed by laparoscopic approach.
LINX lower esophageal sphincter augmentation.
The LINX is a small flexible ring with titanium beads with magnetic cores. It is placed by laparoscopy (tiny incisions in the abdomen) around the lower esophageal sphincter (LES). It sits comfortably around the LES assisting it in preventing gastric contents reflux into the esophagus.
It provides a slight higher pressure than the reflux pressure, keeping the contents in the stomach. However, its pressure is significantly lower than the pressure generated by the esophagus when liquids or food goes down, allowing the magnetic beads to open apart allowing it to pass through the LES and LINX. After the swallow goes through, the magnetic attraction closes it back comfortably around the LES.
- Initially done by means of a large incision in the abdomen or chest, now most of the procedures can be performed entirely by laparoscopy (tiny incisions in the abdomen).
- The stomach fundus is dissected free of surrounding structures and wrapped around the lower esophagus and upper stomach (FUNDOPLICATION )
- The Nissen fundoplication is a 360° wrap developed by Dr. Rudolph Nissen and first performed in 1955. It became popular in 1970 and has been used extensively by surgeons around the word. However there are other partial fundoplications such as the “Thal” fundoplication (anterior 270°); The “Dor” also anteriorly uses a less of a wrap normally between 180° to 200°. The “Lind” uses a posterior approach when a 300° wrap is performed. The “Toupet” also posterior uses a 270°. A thoracic approach with an incision between the ribs is used to perform the “Belsey” anterior 270° fundoplication.
- The Nissen Fundoplication is considered an effective and safe operation with mortality rate been reported less than 1%. Patients have been reported to remain free of reflux in 89.5% after 10 years. The wrap for different reasons can become undone years later in about 5-10% of the patients.
- The Nissen fundoplication can be associated with minor to significant side effects such as dysphagia (difficulty swallows), gas bloat syndrome, achalasia (dilation of the esophagus due to difficult passage of food through the LES area), and others.
- Patients may present with “gas bloat syndrome” with very difficult time belching or vomiting after the Nissen fundoplication with significant bloating. It is reported in about 41% of the patients. In rare occasions revisional surgery to partial wraps may be required.
Transoral Incisionless Fundoplication (TIF)
The procedure is performed using an endoscope, similar to the ones used to evaluate if a patient has gastritis, ulcers or any abnormalities by direct observation.
- The procedure attempts to recreate an anti-reflux valve and to improve the lower esophageal sphincter competence.
- The procedure provides short hospital stay, no visible scars and high patient satisfaction.
- It is performed under general anesthesia. The instrument is inserted though the mouth and advance through the esophagus into the stomach under examination by an endoscope. Parts of the stomach and esophagus are grasped and folds are created. Using medical fasteners, the folds are secured in place around the lower esophageal sphincter creating a tunnel that will prevent reflux.
- The procedure has been used outside of US. Over 5000 cases have been performed.
- Studies have demonstrated that TIF improves typical symptoms such as heartburn and regurgitation in 75-89% of patients. Eliminates atypical symptoms such as cough and hoarseness in 72-90% of patients. Patients stop taking daily anti-reflux medications in 90% of cases.
- The procedure has some disadvantages over other surgical procedures. It does not create a 360-degree valve as other fundoplications. It also cannot fix medium to large hiatal hernias. It is not as effective on patients with severe esophageal reflux or patients with big hiatal hernias. The vagus nerve cannot be identified from inside of the esophagus/stomach and therefore can be injured by one of the fasteners.
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