Is there a way to eliminate reflux?
Surgical treatments are available that can potentially eliminate GastroEsophageal Reflux Disease (GERD). These procedures involve strengthening the sphincter by wrapping the upper portion of the stomach (the "fundus") around the lower esophagus just above the point where it enters into the stomach.  The procedure is called a fundoplication, and these operations work by improving the function of the sphincter to stop acid and food from backing up into the esophagus. In most cases, they eliminate the need for heartburn medication and may significantly improve other GERD related symptoms.  

How are these procedures performed?
For many years fundoplications could only be performed by making a large incision in either the abdomen of the chest, but in the early 1990's minimally invasive laparoscopic surgery techniques were developed that makes it possible to eliminate the large incisions.  More recently an even less invasive option has been developed to perform the procedure entirely through the mouth using a highly sophisticated device called EsophyX.  This procedure is called a Transoral Incisionless Fundoplication, or TIF. (Click on Video link in the right side column of this page) 

How is the TIF procedure performed?
The newest innovation in Anti-Reflux surgery is the Transoral Incisionless Fundoplication (TIF). A video of this procedure is available in the right hand column of theis page.  Click on "Click to Play". 

The biggest advantage of the TIF procedure is that it requires no incisions.  It is performed using a device called EsophyX and a flexible endoscope.  The device is passed through the mouth along with a flexible endoscope, then working entirely from the inside of the stomach the upper stomach is wrapped three-quarters of the way around the lower esophagus, similar to the Toupet fundoplication.  







How well does the TIF procedure work? 
Early results of the TIF procedure appear quite promising and are similar to the laparoscopic Nissen fundoplication, but the long-term durability of this option has yet to be determined.  The TIF procedure is not recommended for anyone with a significant hiatal hernia.  If a hiatal hernia greater than 2 centimeters long is present, it must be repaired as part of any anti-reflux procedure.  So, for any patient with a hiatal hernia, the recommended treatment remains a laparoscopic operation.

How are laparoscopic operations done?
A small tube called a canula is inserted through a small incision in the upper abdomen, and the abdominal cavity is filled with carbon dioxide gas, much like inflating a balloon. The gas separates the internal organs from the abdominal wall creating space for the surgeon to look inside the abdomen. A long lighted tube called a laparoscope is attached to a miniature television camera and is used to view the inside of the abdomen on a high-resolution video monitor. Several additional cylinders are then inserted, which allow special laparoscopic instruments to be used to perform the operation. The surgeon exposes all the important anatomic structures in the area, including the diaphragm, the stomach, the esophagus, the liver, and the spleen. If there is a hiatal hernia, it is repaired followed by the stomach being wrapped around the lower one inch of the esophagus and sutured in place. 

There are two different types of laparoscopic stomach wraps used to treat GERD. The most common procedure is to wrap the stomach completely around the esophagus - a procedure called a Nissen Fundoplication. The other procedure, called a Toupet Fundoplication, is a stomach wrap that goes three-quarters of the way around the esophagus and is sutured to the diaphragm and the esophagus. Both of these procedures typically work quite well to control the symptoms of GERD.

Are there risks to having anti-reflux surgery?
The overall risk of laparoscopic anti-reflux surgery is actually quite low; however, there are a few, well-recognized potential complications associated with these operations. They include risks of:

Anesthesia: Since a general anesthetic is used (the patient is completely asleep), there are some risks associated with this type of anesthesia. These risks will vary from patient to patient, and will be discussed by the Anesthesiologist with each patient during a pre-operative visit.

Infection: Infections are very infrequent following laparoscopic surgery, but they can occur. Most often they occur just beneath the skin and are treated by simply opening the skin incision, allowing the wound to drain. More serious infections inside the abdomen may require re-operation to provide adequate drainage.

Bleeding: Significant bleeding may occur either during or after the operation. Numerous blood vessels are encountered during this type of operation and each is a potential bleeding site. The liver and spleen are located very near the esophagus and stomach, and either of these blood-filled organs can be the source of bleeding. 

Perforation: The word perforation means a hole occurring in the wall of an internal organ. During operations around the esophagus, it is possible for this somewhat fragile organ to be injured or even perforated. Such an injury can happen despite the surgeon's best efforts to avoid it. If a perforation of the esophagus or the stomach occurs, it would require more extensive surgery. While it may be possible to repair such an injury during the laparoscopic procedure, an open operation might be needed to solve the problem. 

Pneumothorax: Pneumothorax is the medical term for a collapsed lung. Because the operation involves working above the diaphragm in the chest, it is possible for the thin membrane around the lung to be penetrated. This would allow the lung to collapse and would likely require the placement of a temporary tube into the chest to expand the lung.

Treatment Failure: Although most patients find that their symptoms are significantly improved after laparoscopic anti-reflux surgery; a small percentage experience little or no relief. The reasons for such treatment failures are not always clear. In some cases, the procedure may work well initially, but fail later. These delayed failures are most often caused by overeating, extreme retching or vomiting, or heavy lifting. Failures are usually the result of the wrap coming lose, so if the operation was initially successful, it may be possible to treat recurrent GERD with a second operation. 

What should I expect after anti-reflux surgery?
Following any anti-reflux operation, most patients remain in the hospital overnight, and are discharged home the following morning. Perhaps the biggest change most patients notice is the fact that they can stop taking their heartburn medicine. Most patients are able to resume day to day activities, including light exercise and return to non-strenuous work within a week or two. However, it is advisable to avoid extremely heavy lifting, straining or strenuous exercise for several weeks to allow the operation to heal properly. You should check with your doctor before doing anything that requires you to strain or lift something heavy.

For the first few days after you return home, your diet should remain restricted to liquids only. Gradually you can advance your diet so that within a few weeks you should be able to eat virtually any of the foods you usually enjoy. Because part of the stomach is used to wrap around the esophagus, your stomach volume will be significantly less than normal. After eating only a small meal, you may feel quite full. The combination of a liquid diet and a smaller than normal stomach volume, will likely cause a temporary weight loss of 10 to 15 pounds. After a month or so, your stomach will gradually stretch out and allow for more normal sized meals. Occasional belching and even slight regurgitation of fluids are not uncommon after the operation. This is due to swelling in the lower esophagus that typically follows the surgery. These problems will gradually go away with time as the swelling resolves, but it is important to eat slowly, and follow the diet instructions.

Most patients are able to stop taking heartburn medicine immediately after the surgery, but if you are on other medications you should resume taking them the day after surgery. If the pills are large you may need to break them in two or crush them and take them with some pudding or ice cream or yogurt. 

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This page contains answers to many common questions about Surgical Treatments for Heartburn and Gastroesophageal Reflux in easy to understand language.  After reviewing this material you should be familiar with common medical terms related to these procedures and be able to discuss the subject with your doctor.