Fundoplication Surgery for Chronic Acid Reflux / GERD

When a patient complains of significant or uncontrolled acid reflux, we start with a thorough medical work up. If the patient has not taken any steps to curb their acid reflux, we start with conservative therapy such as lifestyle changes in the form of losing weight, eating healthy and exercising. If lifestyle change fails to improve the symptoms of acid reflux and we suspect chronic acid reflux or GERD, medical treatment may be effective. This can be in the form of antacids – medications that neutralize acid in the stomach or proton pump inhibitors (PPIs) that prevent the stomach from producing acid in the first place. Of course, medical treatment does come with drawbacks including significant side effects in a number of patients.

Since it is most often the Lower Esophageal Sphincter, or LES, that malfunctions to cause reflux, the definitive treatment is putting pressure on the LES to reinforce it. This re-creates the one-way valve to stop acid from coming back up into the esophagus. For several decades, the most effective treatment was surgical, in the form of a fundoplication. While other procedures such as the LINX Reflux Management System have shown excellent promise as a less invasive alternative, a fundoplication is still the primary course of treatment in certain cases such as a very large hiatal hernia or a paraesophageal hiatal hernia.

How does a fundoplication work?

The fundoplication is performed in a minimally invasive manner, using four or five small incisions in the abdomen versus the large incisions traditionally used in open surgery. This reduces the risk of an incisional hernia and helps the patient recover more quickly with lower risk of infection and other postoperative complications.

First, the upper, outer part of the stomach known as the fundus is wrapped around the lower esophageal sphincter, at the base of the esophagus. This wrap is then stitched to form a permanent bond. If a hiatal hernia is present, it will be repaired at the same time.

There are several fundoplication’s available today. A Nissen fundoplication is a full, 360° wrap around the esophagus. While it offers the best long-term potential for reflux management, it also creates the most potential risks and considerations after surgery. More recently the Toupet 270° wrap and Dor 200° wrap have been used with great success and fewer postoperative limitations.

The procedure typically takes about an hour to perform, and patients will remain under general anesthesia for that time. A hospital stay will be required – approximately 1 to 2 nights depending on the patient’s general health. Immediately after surgery, patients will be on a limited diet until their stomach heals.

Results of the fundoplication

Most patients, up to 90%, report very good to excellent improvement or complete resolution of their acid reflux after receiving a fundoplication.

Risks and considerations of the fundoplication

Fundoplication is major abdominal operation and comes with inherent risks including the possibility of infection, pain and blood loss, which can in extremely rare cases be life threatening. However, the fundoplication also has a number of procedure-specific risks that we will detail below. Please speak to your surgeon during consultation to understand the degree to which these risks may apply to you.

• Gas bloat syndrome is common after fundoplication because of the added pressure around the LES. This is worse with the Nissen fundoplication and somewhat mitigated with partial wraps. When gas accumulates in the stomach, it becomes very hard to expel in the form of belching and can be quite painful. Eventually the gas dissipates.
• For similar reasons as above, vomiting is painful and sometimes impossible. Over time, as the stomach adapts to its new function, vomiting may become easier, but remains uncomfortable
• Failure of the plication is possible if the sutures do not keep the stomach wrapped properly. While this is not a serious complication, it will eliminate the effectiveness of the acid reflux fighting procedure. A revisional surgical procedure may be necessary

Has the LINX Reflux Management System made the fundoplication obsolete?

Surgical Association of Mobile offers the LINX Reflux Management System, an implanted medical device that loops around the LES and offers pressure similar to the fundoplication but without many of the risks. While the LINX system is very effective, it may not be appropriate for those with very large hiatal hernias or those with paraesophageal hiatal hernias. Patients who are experiencing new or worsened acid reflux after a gastric sleeve for weight loss will not be able to have a fundoplication and the LINX system may be more appropriate.

Contact our office to schedule consultation with one of our surgeons to learn more about whether a fundoplication, LINX, or lifestyle and medical treatment may be best to address your chronic acid reflux.