Is It Acid Reflux… When It’s Time for Surgery

For some patients with GERD (acid reflux), even maximum dosages of medication aren’t entirely effective. Although heartburn may subside, patients may continue to experience chronic cough, hoarseness, or a variety of other symptoms. Others may find mediations effective but simply don’t want to take them long-term. What can these patients do to find relief?

The Nissen fundoplication, a surgical procedure, may be an option, says general surgeon Patrick M. McEnaney, MD, of UMass Memorial General Surgery at Milford. During this procedure, Dr. McEnaney wraps the upper portion of the stomach around the base of the esophagus (the long, muscular tube that connects your throat to your stomach). Doing so strengthens the lower esophageal sphincter—a ring of muscle that normally prevents reflux of gastric contents into the esophagus. “When people have GERD, one of the main contributors is that the lower esophageal sphincter is too relaxed,” Dr. McEnaney explains. “This allows the gastric contents, which are often acidic, to ride up the esophagus and cause discomfort. When we perform the Nissen fundoplication, what we are essentially doing is reconstructing and tightening the lower esophageal sphincter.”

Nissen fundoplication not only relieves symptoms of acid reflux, but it can also help prevent future complications—even for patients whose acid reflux symptoms are mostly well managed by medications. Oftentimes, these patients are unaware of the long-term effects of GERD. Dr. McEnaney often sees patients with chronic cough who aren’t aware of the neutralized gastric fluid and bile that is irritating their vocal cords. “There is data to suggest that even the bile reflux alone may be responsible for some changes that can occur in the lower esophagus that can be a risk factor for the development of esophageal cancer,” he says.

Patients planning to undergo the Nissen fundoplication receive thorough and careful evaluations prior to surgery. In particular, esophageal manometry—a test that measures the strength and coordination of the contractions of the esophagus—helps Dr. McEnaney determine whether he will wrap the stomach either fully or partially around the base of the esophagus. If esophageal contractions are normal and coordinated, he usually performs a full wrap because the esophagus will likely be able to continue to push food into the stomach, as intended. If contractions are weak and uncoordinated, he usually performs a partial wrap. The tightness of the wrap is extremely important. It must be tight enough to prevent reflux, but not so tight that it causes postoperative dysphagia (discomfort with eating) as the esophagus tries to propel food through the wrap and into the stomach, Dr. McEnaney explains.

Although Nissen fundoplication is highly effective at treating GERD, it’s more frequently performed to treat GERD in conjunction with a hernia, both of which usually occur together, explains Dr. McEnaney. When patients have both GERD and a hernia, he repairs the hernia, inserts permanent stitches to close the large opening in the diaphragm through which the stomach and any other organs have moved, and then wraps the stomach around the esophagus. “One of the reasons why we actually perform the wrap is to create some bulk to make it harder for the hernia to reoccur,” he says.

The good news is that recovery time for patients who undergo Nissen fundoplication is relatively quick. Patients who undergo the procedure strictly to treat GERD often stay only one night in the hospital. Patients who need a hernia repair in addition to the Nissen fundoplication procedure may stay in the hospital for two nights, depending on the complexity of the hernia and the patient’s ability to tolerate foods after surgery.

Short- and long-term dietary restrictions are the most significant change to which patients must adjust, says Dr. McEnaney. “I often spend a lot of time with patients talking about how their diets will change. Because of the wrap, it means the food is going to have a harder time entering the stomach,” he says.

Following surgery, patients move through a graduated program of incorporating various foods. After six weeks, they can eat most foods; however, they must chew and eat very slowly for the rest of their lives. In some cases, patients may need to go back on anti-reflux medication; however, they usually take much smaller and less frequent dosages compared to what they were taking preoperatively, states Dr. McEnaney. Even when this does happen, the benefits of surgery are generally far better than the alternative.

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