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Anti-reflux surgery

Definition

Anti-reflux surgery is surgery to correct a problem with the muscles at the bottom of the esophagus (the tube from your mouth to the stomach). Problems with these muscles allow gastroesophageal reflux disease (GERD) to happen.

This surgery can also repair a hiatal hernia.

Alternative Names

Fundoplication; Nissen fundoplication; Belsey (Mark IV) fundoplication; Toupet fundoplication; Thal fundoplication; Hiatal hernia repair; Endoluminal fundoplication

Description

GERD is a condition that causes food or stomach acid to come back up from your stomach into your esophagus. This is called reflux. It can cause heartburn and other uncomfortable symptoms. Reflux occurs if the muscles where the esophagus meets the stomach do not close tightly enough.

A hiatal hernia occurs when the natural opening in your diaphragm is too large. Your diaphragm is the muscle and tissue layer between your chest and belly. Your stomach may bulge through this large hole into your chest. This bulging is called a hiatal hernia. It may make GERD symptoms worse.

A procedure called fundoplication is the most common type of anti-reflux surgery. During this procedure, your surgeon will:

• First repair the hiatal hernia with stitches. The surgeon will tighten the opening in your diaphragm to keep your stomach from bulging through.
• Your surgeon will then use stitches to wrap the upper part of your stomach around the end of your esophagus. This creates pressure at the end of your esophagus and helps prevent stomach acid and food from flowing back up.

Surgery is done while you are under general anesthesia (asleep and pain-free). Surgery usually takes 2 to 3 hours.

Ways your doctor may do this surgery are:

• Open repair. Your surgeon will make an incision (cut) in your belly area (abdomen). Sometimes the surgeon will place a tube from your stomach through the abdominal wall to keep your stomach in place. This tube will be removed when you no longer need it.
• Laparoscopic repair: Your surgeon will make 3 to 5 small incisions in your belly. Your surgeon will insert a laparoscope (a thin, hollow tube with a tiny camera on the end) through one of these incisions and other tools through the other incisions. The laparoscope is connected to a video monitor in the operating room that allows your surgeon to see inside your belly and do the repair. The surgeon may need to switch to an open procedure if there is bleeding, a lot of scar tissue from earlier surgeries, or the patient is very overweight.

Endoluminal fundoplication is a new procedure that uses a special camera called an endoscope. The tube is passed down through your mouth and into your esophagus. Your doctor will place small clips on the inside where the esophagus meets the stomach. These clips help prevent food or stomach acid from coming back. An endoscope is similar to a laparoscope. This procedure is done to help prevent reflux.

Why the Procedure Is Performed

Your doctor may suggest surgery when:

• You have symptoms of heartburn that get better when you use medicines, but you do not want to continue taking these medicines. Symptoms of heartburn are burning in the stomach that you may also feel in your throat or chest, burping or gas bubbles, or have trouble swallowing food or fluids.
• Part of your stomach is getting stuck in your chest or is twisting around itself. This is called a para-esophageal hernia.
• You have reflux disease and another related, serious problem. Some of these problems are strictures (a narrowing of your esophagus), ulcers in your esophagus, and bleeding in your esophagus.
• You have reflux disease and aspiration pneumonia (a lung infection caused by inhaling contents of the stomach into the lungs), a chronic cough, or hoarseness.

Risks

Risks for any anesthesia are:

• Reactions to medicines
• Breathing problems, including pneumonia
• Heart problems

Risks for any surgery are:

• Bleeding
• Infection

Risks for this surgery are:

• Gas bloat, which makes it hard to burp or throw up. It also causes bloating after meals. These symptoms slowly get better for most people.
• Pain and difficulty when you swallow, for some people. This is called dysphagia. For most people, this goes away in the first 3 months after surgery.
• Damage to the stomach, esophagus, liver, or small intestine. This is very rare.
• Respiratory complications, such as a collapsed lung. This is also rare.
• Recurrence of the hiatal hernia

Before the Procedure

Your doctor may ask you to have these tests:

• Blood tests (complete blood count, electrolytes, or liver tests)
• Upper endoscopy. Almost all people who have this procedure have already had this test. If you have not, you will need to.
• Other tests, such as manometry (to measure gases) or pH monitoring (to see how much stomach acid is in your esophagus).

Always tell your doctor or nurse if:

• You could be pregnant
• You are taking any drugs, supplements, or herbs you bought without a prescription

During the week before your surgery:

• You may be asked to stop taking aspirin, ibuprofen (Advil, Motrin), vitamin E, clopidogrel (Plavix), warfarin (Coumadin), and any other drugs or supplements that affect blood clotting several days to a week before surgery.
• Ask your doctor which drugs you should still take on the day of your surgery.

On the day of your surgery:

• Do not eat or drink anything after midnight the night before your surgery.
• Take your drugs your doctor told you to take with a small sip of water.
• Shower the night before or the morning of your surgery.
• Your doctor or nurse will tell you when to arrive at the hospital.

After the Procedure

Patients who have laparoscopic surgery usually spend 1 to 3 days in hospital. Those who have open surgery may spend 2 to 6 days in the hospital after the procedure.

Most patients go back to work 2 to 3 weeks after laparoscopic surgery and 4 to 6 weeks after open surgery.

Outlook (Prognosis)

Anti-reflux surgery repair is a safe operation. Heartburn and other symptoms should improve after surgery. But you may still need to take drugs for your heartburn after surgery.

Some people will need another operation in the future to treat new reflux symptoms or swallowing problems. This may happen if the stomach was wrapped around the esophagus too tightly, the wrap loosens, or a new hiatal hernia develops.

References

Brant K. Oelschlager BK, Eubanks TR, Pellegrini CA. Hiatal Hernia and Gastroesophageal Reflux Disease. In: Townsend: Sabiston Textbook of Surgery, 18th ed. Philadelphia, PA:WB Saunders; 2007:chap 42.

Kahrilas PJ, Shaheen NJ, Vaezi MF, Hiltz SW, Black E, Modlin IM. American Gastroenterological Association Medical Position Statement on the management of gastroesophageal reflux disease. Gastroenterology. 2008;135:1383-1391.

Wilson JF. In The Clinic: Gastroesophageal Reflux Disease. Ann Intern Med. 2008;149(3):ITC2-1-15.

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