Anti-reflux surgery
Fundoplication; Nissen fundoplication; Belsey (Mark IV) fundoplication; Toupet fundoplication; Thal fundoplication; Hiatal hernia repair; Endoluminal fundoplication; Gastroesophageal reflux - surgery; GERD - surgery; Reflux - surgery; Hiatal hernia - surgery
Anti-reflux surgery is a treatment for acid reflux, also known as GERD (gastroesophageal reflux disease). GERD is a condition in which food or stomach acid comes back up from your stomach into the esophagus. The esophagus is the tube from your mouth to the stomach.
Reflux often occurs if the muscles where the esophagus meets the stomach do not close tightly enough. A hiatal hernia can make GERD symptoms worse. It occurs when the stomach bulges through this opening into your chest.
Symptoms of reflux or heartburn are burning in the stomach that you may also feel in your throat or chest, burping or gas bubbles, or trouble swallowing food or fluids.
The esophagus runs through the diaphragm to the stomach. It functions to carry food from the mouth to the stomach. The esophagus passes through the diaphragm just before it meets the stomach, through an opening called the esophageal hiatus.
This X-ray shows the upper portion of the stomach protruding through the diaphragm (hiatal hernia).
Do you feel a burning in your chest not long after you eat or lie down? If so, you may have Gastroesophageal reflux disease, or GERD. When we swallow food, it travels down our esophagus into the stomach, where it's greeted by a rush of Hydrochloric acid in the stomach to begin digestion. This acid is so powerful, it could eat the paint right off your car! Fortunately, there's a band of muscle between the stomach and the esophagus - called the Lower Esophageal Sphincter or L-E-S, that clamps down to prevent the stomach contents from moving or refluxing upward and burning the lining of the esophagus. If that band of muscle does not adequately clamp down, this backwash causes the irritation and burning that's known as heartburn or GERD. Maintaining good tight L-E-S muscle tone is the key to preventing this condition. Causes of GERD include being overweight, smoking, and drinking too much alcohol. Certain foods, like chocolate and peppermint and if you're a woman, pregnancy can bring on GERD. To determine if you have GERD, your doctor may request an upper endoscopy exam to look into your esophagus and stomach to diagnose reflux. Other tests can measure the acid and amount of pressure in your esophagus, or if you have blood in your stool. If you do have GERD, lifestyle changes can help. First, avoid foods that cause problems for you and avoid eating large meals. If you're a little on the heavy side, try to lose some weight. Since most GERD symptoms are experienced lying down in bed, let gravity help. Elevating the head of your bed 4 to 6 inches using blocks of wood may help. If symptoms continue, see your doctor or a Gastroenterologist for evaluation and an upper endoscopy exam. Your doctor may suggest you take over-the-counter antacids or may prescribe stronger medications. Call your doctor if you are bleeding, feel like you are choking, have trouble-swallowing, or experience sudden weight loss. The good news is most people who have GERD do not need surgery. For the worst cases, surgeons may perform a laparoscopic procedure to tighten a weak L-E-S muscle. If you have occasional heartburn, antacid tablets can be used as needed. However! If you're having heartburn more than 3 to 4 times a week, see your doctor & take the prescribed medication to prevent this condition.
You've just finished eating a double chili dog, when it hits. That burning, belching feeling, like your dinner has taken a detour back up your throat. You've got heartburn, also known as gastroesophageal reflux disease or GERD, for short. When heartburn becomes a frequent, unwelcome visitor and you're tired of taking medicine to treat it, your doctor may recommend surgery. Normally when you eat, food passes down this tube, called the esophagus. It crosses your diaphragm and enters your stomach through a hole. Sometimes the muscles where your esophagus and stomach meet don't close tightly enough, and this weakness allows acids from your stomach to back up into your esophagus, causing heartburn. The hole in your diaphragm may also be too big, letting part of your stomach slip into an opening in your chest. That's called a hiatal hernia, and it can make your heartburn symptoms even worse. If you don't want to take heartburn medicine anymore, or if you're dealing with complications like ulcers or bleeding in your esophagus, your doctor may recommend surgery to fix your hiatal hernia. Usually the surgery you'll have is called fundoplication. Fundoplication is done while you're under general anesthesia, which means that you'll be asleep and you won't feel any pain. Before your surgery, your doctor will ask you to stop taking drugs like aspirin or warfarin, which makes it harder for your blood to clot. Also, you shouldn't eat or drink anything after midnight the night before your surgery. If you have open surgery, the surgeon will make one large cut in your belly area. With laparoscopic surgery, there are more cuts, but they're much smaller. The surgeon will use a thin tube with a camera attached to see through these tiny holes and perform the surgery. A newer form of the procedure passes a special camera down your mouth into your esophagus. Whatever way the surgery is done, the goal is to close your hiatal hernia with stitches and tighten the opening in your diaphragm to keep your stomach from poking through. The surgeon will also wrap the upper part of your stomach around the end of your esophagus so that acids from your stomach can't back up into your esophagus. Just like any procedure, hiatal hernia surgery can have risks. You might have bleeding, an infection, breathing problems, bloating, or pain when you swallow. Call your doctor for any symptoms that bother you or don't go away. Expect to stay in the hospital for about 4 to 6 days, and then spend a month to 6 weeks recovering at home with the open surgical procedure. Laparoscopic surgery will shorten your hospital stay to 1 to 3 days, and you'll be back on your feet and at work in just 2 to 3 weeks. Anti-reflux surgery is safe, and it works. After your surgery, you should have fewer problems with heartburn. But if that burning feeling creeps back up again, you might need to have a repeat surgery. To avoid another procedure, take your heartburn medicine if you need it. Oh, and take it easy on those chili dogs!
Description
The most common procedure of this type is called fundoplication. In this surgery, your surgeon will:
- First repair the hiatal hernia, if one is present. This involves tightening the opening in your diaphragm with stitches to keep your stomach from bulging upward through the opening in the muscle wall. Some surgeons place a piece of mesh in the repaired area to make it more secure.
- Wrap the upper part of your stomach around the end of your esophagus with stitches. The stitches create pressure at the end of your esophagus, which helps prevent stomach acid and food from flowing up from the stomach into the esophagus.
Surgery is done while you are under general anesthesia, so you are asleep and pain-free. Surgery most often takes 2 to 3 hours. Your surgeon may choose from different techniques.
OPEN REPAIR
- Your surgeon will make 1 large surgical cut in your belly.
- A tube may be inserted into your stomach through the abdomen to keep the stomach wall in place. This tube will be taken out in about a week.
LAPAROSCOPIC REPAIR
- Your surgeon will make 3 to 5 small cuts in your belly. A thin tube with a tiny camera on the end is inserted through one of these cuts.
- Surgical tools are inserted through the other cuts. The laparoscope is connected to a video monitor in the operating room.
- Your surgeon does the repair while viewing the inside of your belly on the monitor.
- The surgeon may need to switch to an open procedure in case of problems.
ENDOLUMINAL FUNDOPLICATION
- This is a new procedure that can be done without making cuts. A special camera on a flexible tool (endoscope) is passed down through your mouth and into your esophagus.
- Using this tool, the doctor will put small clips in place at the point where the esophagus meets the stomach. These clips help prevent food or stomach acid from backing up.
Why the Procedure Is Performed
Before surgery is considered, your health care provider will have you try:
- Medicines such as H2 blockers or PPIs (proton pump inhibitors)
- Lifestyle changes
Surgery to treat your heartburn or reflux symptoms may be recommended when:
- Your symptoms do not get much better when you use medicines.
- You do not want to keep taking these medicines.
- You have more severe problems in your esophagus, such as scarring or narrowing, ulcers, or bleeding.
- You have reflux disease that is causing aspiration pneumonia, a chronic cough, or hoarseness.
Anti-reflux surgery is also used to treat a problem where part of your stomach is getting stuck in your chest or is twisted. This is called a para-esophageal hernia.
Risks
Risks of any anesthesia and surgery in general are:
- Reactions to medicines
- Breathing problems
- Bleeding, blood clots, or infections
Risks of this surgery are:
- Damage to the stomach, esophagus, liver, or small intestine. This is very rare.
- Gas bloat. This is when the stomach overfills with air or food and you are unable to relieve the pressure by burping or vomiting. These symptoms slowly get better for most people.
- Pain and difficulty when you swallow. This is called dysphagia. In most people, this goes away during the first 3 months after surgery.
- Return of the hiatal hernia or reflux.
Before the Procedure
You may need the following tests:
- Blood tests (complete blood count, electrolytes, or liver tests).
- Esophageal manometry (to measure pressures in the esophagus) or pH monitoring (to see how much stomach acid is coming back into your esophagus).
- Upper endoscopy. Almost all people who have this anti-reflux surgery have already had this test. If you have not had this test, you will need to do it.
- X-rays of the esophagus.
Always tell your provider if:
- You could be pregnant.
- You are taking any drugs, or supplements or herbs you bought without a prescription.
Before your surgery:
- You may need 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 before surgery. Ask your surgeon what you should do.
- Ask your provider which drugs you should still take on the day of your surgery.
On the day of your surgery:
- Follow your provider's instructions about when to stop eating and drinking.
- Take the drugs your doctor told you to take with a small sip of water.
- Follow instructions for showering before surgery.
Your provider will tell you when to arrive at the hospital. Be sure to arrive on time.
After the Procedure
Most people who have laparoscopic surgery can leave the hospital within 1 to 3 days after the procedure. You may need a hospital stay of 2 to 6 days if you have open surgery. Most people can return to normal activities in 4 to 6 weeks.
Outlook (Prognosis)
Heartburn and other symptoms should improve after surgery. Some people still need to take drugs for heartburn after surgery.
You may need another surgery in the future if you develop 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
Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2013;108(3):308-328. PMID: 23419381
Mazer LM, Azagury DE. Surgical management of gastroesophageal reflux disease. In: Cameron AM, Cameron JL, eds. Current Surgical Therapy. 13th ed. Philadelphia, PA: Elsevier; 2020:8-15.
Richter JE, Vaezi MF. Gastroesophageal reflux disease. In: Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger and Fordtran's Gastrointestinal and Liver Disease. 11th ed. Philadelphia, PA: Elsevier; 2021:chap 46.
Yates RB, Oelschlager BK, Pellegrini CA. Gastroesophageal reflux disease and hiatal hernia. In: Townsend CM Jr, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 21st ed. Philadelphia, PA: Elsevier; 2022:chap 43.
Version Info
Last reviewed on: 11/6/2021
Reviewed by: Debra G. Wechter, MD, FACS, General Surgery Practice Specializing in Breast Cancer, Virginia Mason Medical Center, Seattle, WA. Also reviewed by David Zieve, MD, MHA, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.
