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Anti-reflux surgery

Definition

Anti-reflux surgery is a treatment for acid reflux or GERD, a problem in which food or stomach acid come 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

Alternative Names

Fundoplication; Nissen fundoplication; Belsey (Mark IV) fundoplication; Toupet fundoplication; Thal fundoplication; Hiatal hernia repair; Endoluminal fundoplication

Description

The most common procedure of this type is called fundoplication. In this surgery, your surgeon will:

  • First repair the hiatal hernia, if 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 that helps prevent stomach acid and food from flowing up into the esophagus.

Surgery is done while you are under general anesthesia so you are asleep and pain-free. Surgery usually 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 you’re 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.
  • Other surgical tools are inserted through the other cuts. he 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 the 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 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 doctor will have you try:

Your doctor may suggest surgery to treat your heartburn or reflux symptoms 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, and 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 are:

Risks of this surgery are:

  • Breathing complications, such as a collapsed lung. This is rare.
  • 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 doctor or nurse if:

  • You could be pregnant
  • You are taking any drugs, and even supplements, or herbs you bought without a prescription

Before your surgery:

  • You 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 to a week before surgery.
  • Ask your doctor which drugs you should still take on the day of your surgery.

On the day of your surgery:

  • Do not eat or drink anything after midnight the night before your surgery.
  • Take the drugs your doctor told you to take with a small sip of water.
  • Shower the night before or the morning of your surgery.

Your doctor or nurse will tell you when to arrive at the hospital.

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 patients go back to work 2 to 3 weeks.

Outlook (Prognosis)

Anti-reflux surgery is a safe operation. 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

Petersen RP, Pellegrini CA, Oelschlager BK. Hiatal hernia and gastroesophageal reflux disease. In: Townsend CM Jr, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 19th ed. Philadelphia, Pa: Saunders Elsevier; 2012:chap 42.

Falk GW, Katzka DA. Diseases of the esophagus. In: Goldman L, Schafer AI, eds. Cecil Medicine. 24th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 140.

Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2013;108:308-328.

Wilson JF. In the clinic: gastroesophageal reflux disease. Ann Intern Med. 2008;149(3):ITC2-1-ITC2-15.


Review Date: 8/15/2013
Reviewed By: Joshua Kunin, MD, Consulting Colorectal Surgeon, Zichron Yaakov, Israel. Also reviewed by David Zieve, MD, MHA, Bethanne Black, and the A.D.A.M. Editorial team.
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