Patients who are unresponsive to PPI treatment may be recommended to undergo acid reflux surgery, a procedure that aims to mechanically tighten the lower esophageal sphincter. (1) Over the years, several acid reflux surgery methods have been developed from traditional dissection to endoscopic implants, but none promise complete success. An esophageal manometry should be performed prior to considering acid reflux surgery to confirm acid reflux and LES incompetency. (2) A barium esophagram should also be performed to evaluate your anatomy and rule out any other possible causes, (3)
Laparoscopic Nissen Fundoplication, invented by Dr. Rudolph Nissen in 1936, who famously operated on Albert Einstein and saved his life, remains the gold standard for acid reflux surgery. (4) In a fundoplication, the top part of the stomach called the fundus, is dissected and separated from surrounding tissue, then stretched and wrapped 360 degrees around the lower esophagus. The fundus is then sutured to itself effectively creating an anti-reflux barrier.
Recovery for a fundoplication takes 4-6 weeks and about 80-95% of patients experience relief from heartburn.(4) Patient satisfaction with the surgery is generally pretty high, at about 90%. (5) (6) (7) Most patients who got surgery are happy that they got it.
Nissen Surgery Risks and Complications
Nissen surgery risks and complications include esophageal perforation, nerve damage, and serious bleeding. Reported side effects after surgery include trouble swallowing, bloating, nausea, diarrhea, flatulence, and recurrent heartburn and inability to vomit.(1) (8). Though the Nissen Fundoplication surgery is regarded as effective most of the time, it is not always successful.
A 10 year follow up study done in a Veteran’s Affairs Hospital found 62% of patients who had a fundoplication ended up back on reflux medications. (9). One 11 year follow up study reported 30% of Nissen patients were still on anti-reflux medication. (10) A 20 year follow-up study reported 43% of it’s subjects on PPIs. (7)
LPR patients, patients who have extra-esophageal symptoms, and patients who do not respond to aggressive PPI therapy should not opt for a Nissen Fundoplication.
Research shows acid reflux surgery does not improve the symptoms of LPR patients, patients with extra-esophageal symptoms, and patients who are unresponsive to medication. (11) (12) One study reported fewer than 50% of post-surgery patients experienced complete relief from extra-esophageal reflux symptoms. (12)
A Nissen Fundoplication is a serious procedure that dissects tissue and manipulates stomach tissue. The surgery may be permanent and irreversible as a fundoplication takedown tends to be difficult and risky due to the morphing of the stomach.
You should know for sure that you suffer from acid reflux before considering surgery. A highly skilled surgeon with considerable experience is strongly recommended for a Nissen fundoplication due to the life-altering repercussions of a failed or incorrect surgery. (13)
The Stretta Procedure
The Stretta procedure is a minimally invasive acid reflux surgery that aims to restructure the LES with radiofrequency energy. This procedure is conducted by inserting a catheter with an inflatable balloon at the end and passing it through the mouth to the LES where the balloon is inflated with air and four needles around the balloon are extended into the LES and lower esophagus.
Low temperatures of radiofrequency energy between 65 to 85 degrees Celcius are administered to the tissue for one minute, the catheter is rotated 45 degrees, and radiofrequency energy is again administered to the LES creating a ring of eight lesions. (4)
The entire process is repeated to create four rings of lesions. The catheter is then pushed further down the stomach to create two more rings of lesions. This process is thought to reshape the LES and lower esophagus, making it tighter to prevent acid reflux/LPR. (1) (8) The Stretta procedure lasts up to 10 years and is repeatable. (8)
Stretta Success Rate
Overall, the Stretta Procedure appears successful in 67% of patients. (4) Another study found 72% of its patients achieved normal symptom scores with the Stretta procedure. (3) Roughly, 56% of Stretta patients are able to discontinue PPI medication, leaving 44% still medication dependent. (14) (15) (16) (17)
Linx is a relatively new method of acid reflux surgery that was approved by the FDA in 2012. (4) Linx is performed with a small flexible band of magnetic titanium beads that are implanted into the stomach and wrapped around the lower esophagus sphincter to prevent acid reflux/LPR.
The procedure is similar to a Nissen Fundoplication in that the surgeon must cut through layers of stomach tissue and then cut a hole behind the esophagus.
The Linx system is designed to open when food or liquid is passed through the LES. As soon as the contents pass through, the magnetic beads reengage and tighten the LES again. (4)
The Linx procedure has advantages over the Nissen Fundoplication as patients can immediately eat solid foods after surgery. Most patients are able to burp and vomit if needed, things that Nissen patients often struggle to do. (8)
Linx Risks and Complications
Though Linx was initially promising, the results have proven mediocre at best. One of the largest trials of the surgery published in the New England Journal of Medicine reported that at 1 year only 64% of patients achieved resolution of their symptoms or a greater than 50% reduction of symptoms.
Even after surgery 93 out of 100 patients were apparently still taking PPIs. The study noted the daily dose of PPIs for these patients was reduced by at least 50%; which seems to defeat the purpose of the surgery in the first place.
The number of patients with esophagitis, however, decreased from 40% to 12% in the first year and further decreased in the second year. (8)
The most frequently reported side effect of Linx is dysphagia, a condition that makes it hard to swallow food. In the previously noted study of 100 patients who underwent the Linx procedure, 68% of patients experienced dysphagia postoperatively in the first year and 11% experienced dysphagia after 4 years. (8)
People with a Linx implant also cannot have MRI scans. MRI machines generate dangerously strong magnetic fields capable of disturbing a Linx implant and damaging the stomach and esophagus. (4) In 2005, a New York Times article reported an MRI accident that caused a woman’s aneurysm clip to dislodge from her brain. Newer Linx devices may be less susceptible to magnetic manipulation, but caution should still be taken.
Muse is a less popular reflux surgery that is performed by stretching 2-3 sections of the upper stomach towards the esophagus and stapling the sections to the esophagus in order to narrow the lower esophageal sphincter.
This process is completed with an endoscopic tool inserted through the mouth that peeks into a section of the stomach and pins it against the lower esophagus. (8) Anvil screws are then drilled through the stomach and esophagus to engage with a cartridge on the other side. Both tissues are finally compressed, the staples are “fired” in, and then the screws are removed.
This process is repeated 2-3 times to create a new semi-circle valve. The results of the Muse procedure aren’t too promising. One study found out of 66 patients who went through Muse only 64.6% were able to stop PPI medication. 35.4% of patients remained on PPIs after surgery.(8)
Another study found 83.8% of Muse patients remained off of daily PPI medication at 6 months and 69.4% at 4 years. (18)
A weight loss surgery called a sleeve gastrectomy is known to cause GERD. The procedure reduces the size of the stomach to that of a banana and has serious effects on the LES. In some cases, it can cause airway reflux. (19)
A transoral fundoplication (TIF) is an incision-less surgery that stretches portions of the upper stomach down and fastens them together to create a tube-shaped valve.
This procedure is done with an endoscopic tool that is inserted through the mouth and passed to the stomach where a segment of the top stomach is pinched, pulled down, and clamped in the device mold. The mold is then rotated to form a circular valve and screws are fired into the tissue to secure it.
Like the Muse procedure, this process is repeated until a circular valve is made. The results for transoral fundoplication are even more disappointing.
A study found 36% of its patients did not achieve satisfactory symptom relief after surgery. There appeared to be no difference between patients who took PPIs and patients who got surgery. (1) pH levels of patients improved but still fell short of being normal.
The most recent study done in 2016 revealed that 6 months after surgery only 67% of patients experienced relief from regurgitation, leaving 33% still suffering from regurgitation. (20) Side effects of the surgery include bloating, dysphagia, and excessive flatulence.
Failure of Anti-reflux surgery
Acid reflux surgery may alleviate typical acid reflux symptoms like heartburn for some people but as a whole, it seems to be ineffective for treating patients unresponsive to PPI medication and/or patients with extraesophageal symptoms like LPR and hoarseness. (21) (22)
Patients unresponsive to PPIs may have other conditions unrelated to GERD that are causing extraesophageal symptoms. (12) Reflux surgery for such patients is not recommended.
The significant failure rate of anti-reflux surgery raises some serious questions about our current understanding of what causes GERD/LPR symptoms.
If a loose or faulty LES is the cause, why do a significant number of patients still suffer symptoms even after surgery?
The mystery deepens when you consider that even healthy individuals experience GERD/LPR and can have up to 25-30 LES relaxations per day when burping and seem to be unaffected by it. (23)