Gastroesophageal reflux disease, or GERD, goes far beyond occasional heartburn. For those suffering, the effects range from inability to eat spice to not sleeping at night. When the antacid tablets aren’t doing the trick, is surgery the next step?
Emily Speer, MD, General Surgeon and Foregut Surgeon at Intermountain Health, is known by patients as the ‘GERD nerd’. She provided valuable insight into the disease, and when it's time to consider GERD surgery over other options.
What is GERD, and how does it work?
GERD is a chronic condition with symptoms like persistent heartburn, food regurgitation, chest pain, and difficulty swallowing. It can be debilitating, and significantly impact daily life.
It’s diagnosed through a combination of clinical evaluation, symptom assessment, and medical tests. One of the key methods to diagnose GERD is pH testing, which measures the amount of acid reflux in the esophagus.
According to Dr. Speer, the cause is often in your ‘pump, valve, reservoir’ mechanism.
- Pump: Your esophagus pumps food from your mouth down into your stomach.
- Valve: Your gastroesophageal reflux valve, at the bottom of your esophagus, helps prevent acid reflux coming up from the stomach.
- Reservoir: The stomach acts as a reservoir of food and acid and empties things out into your intestines.
When these gastrointestinal functions are not acting as they should, uncomfortable GERD symptoms arise. “Those three pieces of the puzzle are the main things that can go awry and often need to be fixed during surgery,” said Dr. Speer.
What are the treatments for GERD?
When facing a GERD diagnosis, you can review potential treatments with your doctor. They typically boil down to three areas:
- Lifestyle/behavior changes: This is typically the first line of defense, and includes approaches like quitting smoking, avoiding trigger foods, managing weight, and cognitive behavioral therapy.
- Medication: GERD medication can range from short-term relief to long-term medicative approaches. Over-the-counter antacids provide short-term acid reflux relief. Longer-term relief may include H2 blockers or proton pump inhibitors (PPIs) that block acid production.
- Surgery: In cases where lifestyle changes and medication are not controlling symptoms or patients desire not to take antacids, surgical options, like fundoplication or LINX placement, may be considered to provide long-term relief.
“For patients that have very mild acid reflux, popping a little medication once in a while is not a big deal,” said Dr. Speer. “But oftentimes patients that see us are on daily antacid medication and want to have true symptom relief.”
What types of GERD surgery are there?
Because there can be a variety of GERD causes, the surgery types vary. These surgical interventions aim to strengthen the lower esophageal sphincter (LES) or reconstruct the anatomy to prevent rising stomach acid. Most surgical candidates can expect a variation of these procedures:
- Fundoplication: This surgical procedure involves wrapping the top of the stomach around the lower esophagus to reinforce the LES and prevent reflux.
- LINX device placement: A LINX device is a magnetic ring that goes around the LES and helps prevent reflux while allowing food to pass.
- Hiatal hernia surgery: Hiatal hernia is when the top of your stomach pops up above your diaphragm, impacting your reflux valve. Surgery to correct this includes pulling the stomach back down, tightening the diaphragm, and reconstructing the reflux valve.
What should I expect for GERD surgery?
Before GERD surgery: After you decide on surgical intervention, your doctor will order any pre-surgical assessments. This might include blood tests, X-rays, esophageal function tests, and endoscopies.
Once your health is cleared for your surgery, you can also expect detailed prep instructions from your surgeon. These instructions depend on your surgery type, and might involve medication adjustments and nutritional prep.
After GERD surgery: Your surgeon will provide a recovery plan involving dietary restrictions and activity limitations. It’s important to follow these instructions for healthy recovery.
Surgical outcomes vary, but fellowship-trained surgeons with frequent foregut operation experience tend to have better outcomes. According to Dr. Speer, when fundoplication is done correctly, patients can expect an over 90% chance of reflux going away.
“What you can expect after surgery is to actually be able to lie flat in bed, to be able to bend over without choking on reflux, to eat spicy food, to get off your antacid medication,” said Dr. Speer.
Should I get GERD surgery?
According to Dr. Speer, there are three things that make patients the best GERD surgery candidates.
- Diagnosis: It may seem obvious, but the best candidates have an official diagnosis of GERD. This can be identified through pH testing.
- Symptoms: Surgical candidates should have typical symptoms, like heartburn and reflux. There are less common symptoms too, so mention potentially related effects to your doctor.
- PPI responsiveness: As we mentioned above, PPIs are medications that target GERD symptoms. If patients find some relief with PPIs, even if it’s not complete relief, it’s more likely their symptoms can be surgically resolved.
Discussing all medical options with an experienced foregut doctor, like Dr. Speer, are crucial. Different people have different priorities, and GERD surgery may not be for everyone.
“Patient collaboration is super, super important,” said Dr. Speer. “I try to always give patients all of their possible options, and spell out what those options look like, so they can make the best-informed decision for themselves.”