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Reflux and Hiatal and Paraesophageal Treatment Options //
Robotic Anti-reflux Surgery |
Anti-reflux surgery is commonly performed to repair the lower esophageal valve and close the hernia defect if one is present. This procedure which is selected based on specific characteristics of all the tests performed to establish a diagnosis entails wrapping a small amount of your own stomach around the esophagus to reinforce the valve and prevent reflux. This does not typically reduce your intake and most patients will continue to tolerate the same amount of food after surgery. However, for 3-4 weeks we have you on a specific diet plan to avoid having issues with the valve. As such some patients have noted some weight loss up to 25lbs after surgery which will usually return unless you attempt to keep it off.
The surgical procedure typically takes 1 1/2 to 2 hours to complete and the majority of patients go home on a liquid diet the same day. We typically recommend stopping and anti-reflux medications after surgery as these should no longer be indicated. We routinely perform this procedure robotically through 5 very small abdominal incisions. There are no restrictions on activity or lifting after surgery. We also do not make recommendations on when you should go back to work. However, we advise you use common sense and listen to your body.
The majority of patients after surgery have no return of symptoms even while they are off their reflux medications and no longer need to follow the reflux diet. Therefore, you can indulge a little. We continue to encourage however a healthy lifestyle and diet plan.
Most patients who have this procedure continue to not require medications for reflux at 10 years.
Most patients with heartburn, chest-pain, and regurgitation of food will no longer have these issues on a routine basis after the procedure. However, like any regular person that overeats you can have occasional heartburn. This is normal but should not be routine.
Atypical symptoms of reflux are harder to predict outcomes after surgery. These include throat clearing, hoarseness, asthma, sinusitis among others. We are more than happy to discuss the response of these to surgery and sometimes the testing methods may guide us in optimizing the recommendations. The reason patients may get a partial response is related to the symptom and potentially irreversible damage versus multifactorial nature of the problem.
NISSEN FUNDOPLICATION: (Fig 1)
This is the standard procedure that has been typically advocated for most patients. This involved a 360 degree wrap to avoid reflux. This is a loose wrap.
Of course, there are pros and cons to every procedure. These are shown in the table.
Therefore, if you are concerned about these symptoms we will perform other procedures to avoid these issues. Especially if you have bloating already.
TOUPET FUNDOPLICATION: (Fig 2)
This is a partial wrap (270 degree) and as such is aimed at reducing these complications. The wrap is tolerated well and has similar outcomes to the full wrap.
HILL FUNDOPLICATION: (Fig 3)
This procedure does not require a true wrap but enhancing the muscle fibers of the stomach to support the Sphincter to prevent reflux similar to how it was supposed to be designed.
25 year data on this has recently shown similar outcomes (over 85% of patients continue not to take medications) and has a lower risk of side effects.
This barely anatomically changes the structure of your stomach and esophagus.
Fig 1
Fig 2
Fig 3
Robotic Partial Wrap Video
Robotic LINX |
The LINX procedure is similar to the more conventional Anti-reflux surgery. Similar to the conventional approach this is performed robotically and we still need to fix a hiatal hernia if present. However, instead of using a small part of your stomach to strengthen your valve we would use a magnetic ring.
This procedure which is selected based on specific characteristics of all the tests performed to establish a diagnosis.
This does not typically reduce your intake and most patients will continue to tolerate the same amount of food after surgery. However, for 3-4 weeks we have you on a specific diet plan to avoid having issues with the valve. But because we need you to "exercise" the magnetic valve we do start you on regular food soon after surgery. This may feel uncomfortable at first but typically improves with time. Some patients have noted some weight loss up to 15lbs after surgery which will usually return unless you attempt to keep it off.
The surgical procedure typically takes 1 to 1 1/2 hours to complete and the majority of patients go home on the same day. We typically recommend stopping and anti-reflux medications after surgery as these should no longer be indicated. We routinely perform this procedure robotically through 5 very small abdominal incisions. There are no restrictions on activity or lifting after surgery. We also do not make recommendations on when you should go back to work. However, we advise you use common sense and listen to your body.
The majority of patients after surgery have no return of symptoms even while they are off their reflux medications and no longer need to follow the reflux diet. Therefore, you can indulge a little. We continue to encourage however a healthy lifestyle and diet plan.
There is no significant long-term data on this device but compared to the conventional anti-reflux procedure there is less bloating based on most current studies. There is however more difficulty with swallowing early on that does typically resolve.
This procedure is our recommended procedure in the setting of prior sleeve gastrectomy for weight loss.
Endoscopic Reflux Procedures |
Endoscopic Anti-reflux procedures are designed for specific patients and are part of the discussion of best approach. The TIF procedure (Transoral Incisionless Fundoplication) has the best outcome of all endoscopic anti-reflux procedures. This is performed through the mouth without incisions and we use a special device to reconstruct the valve between the esophagus and the stomach.
This procedure is ideal for patients who have reflux and no longer want to take medications or perform lifestyle modifications.
There are certain situations that this procedure will not work. Data on all anti-reflux procedures in the setting of hiatal hernia fail to show improvement if the hernia is NOT REPAIRED. The drawback of the TIF procedure or any other endoscopic procedure is the failure to fix hiatal hernias and in this group of patients the failure rate is very high. Even without a hiatal hernia the failure rate can be up to 70% at one year with patients requiring medications again to manage symptoms. However, symptom management should be improved.
As such our typical algorithm is to recommend the robotic anti-reflux procedure as to most effective with over 10 year data with 85% cure rates, followed by the LINX and lastly the TIF procedure for patients who are not candidates for the more effective options.
c-TIF Robotic and Endoscopic Reflux Procedures |
Extensive focus on reflux and hiatal and paraesophageal hernia surgery has shown the diaphragm closure contributes 80% to the repair and the wrap only 20%. To improve the effectiveness of endoscopic procedures in collaboration with our advanced interventional gastroenterologists the surgeons work to create a combined procedure involving repair of the hiatal or paraesophageal hernia robotically and the gastroenterologist endoscopically perform a wrap.
The goal is to create a robust reflux barrier and reduce the side effects including bloating and difficulty swallowing.
Medication |
There are a variety of medications for the management of reflux. These range from over the counter medications to prescription medications. These medications should be taken under careful monitoring of a trained specialist as there maybe side effects to long term use of these medications and correct diagnostic workup should be performed to ensure you are on the right medications and are on it for the right reasons.
The 4 main types of medications which are all antacids work by different mechanisms to block the acid excretion of your stomach or neutralize it.
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Tums/Rolaids: These medications work by neutralizing the acid by using an ingredient that work quickly on the acid secreted into the stomach. These medications have minimal side effects and are good for occasional symptoms usually with heavy meals. Typically, most patients take these medications knowing they will have symptoms or soon after having symptoms.
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Zantac and H2 blockers: These medications block the release of acid into your stomach and take slightly longer to work but last longer. Therefore, they are ideal for patients with some underlying daily symptoms that are mild. They do block acid production and side effect profiles are slightly worse than Tums and Rolaids.
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Proton Pump Inhibitors (PPI's): This is the major drug group used to treat symptomatic reflux. Drugs in this group include Omeprazole, Nexium, Dexilant, Prilosec among others. These drugs have been associated with bone loss, cardiovascular issues, and potentially mental acuity changes.
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Carafate, Gaviscon: These drugs work by coating the stomach and esophagus and are given prior to meals for onset of action. They do require and acidic environment for activation. Although Gaviscon is over the counter Carafate requires a prescription and due to having Aluminum can only be used for a brief period.