Gastroesophageal Reflux Disease (GERD)
Minimally Invasive Surgical and Endoscopic Treatments
Common Symptoms: Heartburn, Regurgitation and Dysphagia
Approximately 10 to 20 percent of people in the United States have the most common symptoms of gastroesophageal reflux disease (GERD): heartburn, regurgitation, and dysphagia. (Less common symptoms include bronchospasm, laryngitis, chronic cough, chest pain, and others.)
Symptoms are considered clinically significant if they occur in a mild form two or more days per week, or in a moderate to severe form more than one day per week.
A presumptive diagnosis of GERD can be made based on clinical presentation; however and before surgical or endoscopic treatments testing with upper endoscopy, esophageal manometry or 24h ambulatory pH monitoring is usually necessary. These tests will look for commonly associated esophageal mucosal damage such as esophagitis, ulcers, strictures, Barrett’s esophagus, hiatal hernias; study the status of the lower esophageal sphincter (LES) and esophageal body and provide objective documentation of abnormal reflux of gastric contents into the esophagus.
Medical definition of GERD:
“Symptoms of Esophageal Mucosal damage that is produced by abnormal reflux of gastric contents into the esophagus” 1
Medical Management and When to Consider Surgery
For patients with mild GERD, symptoms may improve by losing weight, changing diet, and/or taking antacids, H2 blockers, or proton pump inhibitors.
However, surgical treatment may be recommended when:
- Medication doesn’t completely relieve symptoms that are known to be caused by reflux;
- A patient does not want or cannot take medications long-term due to presence or fear of short term and possible long –term side effects; or
- In addition to reflux, a patient has asthma, hoarseness, or cough that does not improve with medication.
- It is also an option for those who do not wish to stay on medications permanently in order to control their symptoms
Minimally Invasive Endoscopic and Surgical Options
The type of therapy chosen is tailored to individual patient characteristics such as age, presence of a hiatal hernia, how well the esophagus works and others. The minimally invasive endoscopic and surgical treatment options for patients with well-established GERD are:
||Laparoscopic Anti-reflux Surgery (LAR).
This is the most common surgical treatment for GERD. The surgeon creates a new anti-reflux valve around the lower esophageal sphincter using the fundus of the stomach. Different types of fundoplication are available such as the Nissen, Toupet or Dor fundoplications LAR allows food and drink to enter the stomach, but prevents stomach contents from flowing back up into the esophagus. LAR surgery requires five to six small incisions (5-12 millimeters) in the abdomen. The type of fundoplication is determined on an individual basis.
Technical Steps and Images of the different fundoplications:
There are five key technical steps of LARS:
- Complete crural dissection with identification and preservation of both anterior and posterior vagus nerve and reduction/excision of hiatal hernia sac if present, PICTURE
- Circumferential dissection of the esophagus and posterior mediastinum to obtain adequate abdominal esophageal length (3 cm), PICTURE
- Crural closure, PICTURE
- Mobilization of gastric fundus with division of short gastric vessels, and PICTURE
- Fundoplication (Nissen, Toupet and Dor Fundoplication) PICTURE1, PICTURE2, PICTURE3, VIDEO OF A LNF
||LINX® Reflux Management System.
LINX® Reflux Management System.
The LINX® system is for patients with GERD and without large hiatal hernias or severe mucosal damage. The LINX® system is a small ring of interlinked titanium beads with magnetic cores (FIGURE LINX 2) that surgeons implant laparoscopically (FIGURE LINX 4, 5, 6, 7 and video). After implantation, the beads bolster the existing structure of the lower esophageal sphincter (LES) and prevent reflux (VIDEO LINX® Animation). During swallowing, the beads relax, so food passes through the esophagus to the stomach and also allow patients to belch or vomit if necessary. This is an FDA cleared procedure.
Follow this link to watch a Video of a LINX device being implanted (LINX® Animation).
In a recent study with 5-Year results the LINX Procedure showed to be a Beneficial Treatment for Gastroesophageal Reflux Disease: (Clin Gastroenterol Hepatol. 2015 Jun 2. pii: S1542-3565(15)00763-6. doi: 10.1016/j.cgh.2015.05.028. [Epub ahead of print]
Long-Term Outcomes of Patients Receiving a Magnetic Sphincter Augmentation Device for Gastroesophageal Reflux.
Ganz RA1, Edmundowicz SA2, Taiganides PA3, Lipham JC4, Smith CD5, DeVault KR6, Horgan S7, Jacobsen G7, Luketich JD8, Smith CC9, Schlack-Haerer SC10, Kothari SN11, Dunst CM12, Watson TJ13, Peters J14, Oelschlager BK15, Perry KA16, Melvin S16, Bemelman WA17, Smout AJ18, Dunn D19.)
- 85 percent of patients remained free from dependence on daily GERD medication.
- Bothersome regurgitation, a debilitating symptom of GERD, was eliminated in 99 percent of patients.
- Bothersome heartburn, was significantly reduced from 89% at baseline to 11.9% at five years.
- Patients reported a significant improvement in their quality of life.
For additional information you can access the LINX Manufacturer Website at http://www.linxforlife.com
||Endoscopic Stretta Therapy®
The Endoscopic Stretta Therapy is a purely endoscopic treatment also for patients with GERD and without large hiatal hernias or severe mucosal damage. It uses a trans-oral Stretta catheter system (FIGURE http://www.mederi-inc.com/uploads/ST_MKT_Catheter_Illustration.jpg ) to apply low-power (5 Watts) radiofrequency energy to generates low temperatures (65°C to 85°C) during a series of 14 one-minute cycles which remodel the lower esophageal sphincter (LES) muscle and gastric cardia (FIGURE http://www.mederi-inc.com/uploads/ST_MKT_HowStrettaWorks.jpg). This is also an FDA cleared procedure Stretta. Clinical studies demonstrate that Stretta RF treatment results in significant reductions in tissue compliance and transient LES relaxations, as well as increased LES wall thickness due to muscle growth. Stretta is typically performed on an outpatient basis with conscious sedation.
Follow this link to watch a Video of a Stretta Procedure animation http://www.mederi-inc.com/uploads/ST_MKT_STRETTA60sec_-_Wi-Fi.m4v .
For a Stretta Patient Brochure please visit (http://www.mederi-inc.com/uploads/ST_MKT_173-5506B_patientbrochure.pdf)
For additional information you can access the Stretta Manufacturer Website at http://www.stretta-therapy.com/
Share Your Insights
Do you have additional knowledge, experience, or questions on this topic? We’d love to hear from you—please send us a message [link to email] with your feedback!
For More Information
For more information about the diagnosis and treatment of GERD, or contact our surgery team at (804)827-0045
- DeVault KR, Castell DO, American College of G. Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease. Am J Gastroenterol 2005;100:190-200.