Surgery to Treat Reflux

by , last modified on 5/22/21.

Reflux at its simplest definition is when stomach contents regurgitate up towards the mouth. If the reflux reaches the throat level, it can cause a multitude of symptoms that a patient may not necessarily consider to be associated with reflux. More often, a patient may erroneously assume their throat symptoms are due to infection or post-nasal drainage.

Reflux that reaches the throat area or higher is known as laryngopharyngeal reflux or LPR.

Assuming all medications and non-surgical interventions have been tried and failed and workup confirms the presence of laryngopharyngeal reflux, surgery may be required to resolve a patient's persistent throat problems. Surgery is also the definitive management of non-acid reflux.

Reflux Surgery

The surgery, regardless of the approach, attempts to tighten the valve between the stomach and esophagus. This tightening procedure is accomplished either by magnetic breads (linx system) or a maneuver known as a stomach wrap (fundoplication) which is analogous to cinching a belt to make an opening smaller.

Image modified from Wikipedia

There are 4 different flavors of reflux surgery.

Open approach where one long incision is created over the belly... this approach is hardly ever performed anymore and will not be discussed further.
Laparoscopic Nissen Fundoplication: This approach uses tiny cameras and instruments inserted through multiple small incisions over the belly. There is a variation of the Nissen Fundoplication called the Toupet Fundoplication which is meant for patients with both reflux and ineffective esophageal motility.
LINX Reflux Management System: Uses magnetic beads to replicate the normal opening and closing of the stomach valve. Addresses many of the shortcomings of fundoplication surgery including inability to vomit and burp. Company Info here.
Trans-Oral Incisionless Procedures: This approach uses NO incisions over the belly. Rather, all instruments are introduced through the mouth and directed towards where the valve is located.

If a hiatal hernia is present, this would also be repaired at the same time. Keep in mind that trans-oral incisionless procedures can not address hiatal hernias effectively.

Laparoscopic Nissen Fundoplication

LINX Reflux Management System

Trans-Oral Incisionless Procedures

There are currently three different devices using different methods to perform valve tightening: Stretta, Esophyx, and SRS. The videos shown below illustrate Esophyx and Stretta. Although these methods require no incisions, it is felt that these procedures have less "durability" in that over time, reflux symptoms may unfortunately recur at a higher rate compard to LINX and formal Nissen fundoplications.

Most general surgeons know how to perform a standard laparoscopic nissen fundoplication. However, only a few are familiar with how to perform the incisionless or LINX methods.

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Workup Prior to Surgery

A patient must try non-surgical medical interventions first including:

  • Stress Reduction: Stress increases risk of GERD and LPR by stimulating acid production in your stomach.
  • Drink alkaline water (pH>8)
  • Avoid the following foods
    • Spicy, acidic and tomato-based foods like Mexican or Italian food.
    • Acidic fruit juices such as orange juice, grapefruit juice, cranberry juice, etc..
    • Fast foods and other fatty foods.
    • Caffeinated beverages (coffee, tea, soft drinks) and chocolate.
    • Alcohol
  • Adjust your meals:
    • Do not gorge yourself at mealtime
    • Eat sensibly (moderate amount of food)
    • Eat meals several hours before bedtime
    • Avoid bedtime snacks
    • Do not exercise immediately after eating
    • Lose weight! Being overweight can dramatically increase reflux.
    • Elevate the head of your entire bed 4-6 inches by placing books, bricks, or a block of wood under the legs of the bed to achieve a 20 degrees or more slant.
    • Avoid tight belts and other restrictive clothing.
    • Stop smoking! Smoking dramatically increases reflux.

Recent research suggests specifically that a modified Mediterranean diet helps as much as medications in resolving LPR [more info].

If these conservative measures do not adequately address LPR, there are medications one can take. Such medications include proton pump inhibitors like Prilosec, Nexium, or Prevacid (which are over-the-counter) as well as protonix, aciphex, etc as well as H2-blockers like zantac, pepcid, axid, etc. Be aware that these medications typically only work for acid reflux. If you are suffering from non-acidic reflux, alginate therapy is typically required. Alginate therapy includes RefluxRaft, Reflux Gourmet, Gaviscon Advance, and Refluxly.

At a certain point, tests may be obtained to further evaluate a patient's reflux and is required prior to surgical consideration. Alginate therapy is also preferred over proton pump inhibitors and H2-blockers, even for acid reflux, if long-term medical management is required.

Barium Swallow
24 hour multichannel pH and impedance testing
• Manometry

Watch Video of How a 24 hour pH and Impedance Testing is Performed

nexium prilosec prevacid gaviscon advance pepcid

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