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
Listen in as Michael McAllister, DO, General Surgeon, explains the damages of ongoing reflux and how anti-reflux surgery might be the treatment for you.
Selected Podcast
GERD and Antireflux Surgery
Featured Speaker:
Learn more about Michael McAllister, DO
Michael McAllister, DO
Michael McAllister, DO is a General Surgeon with Aspirus Keweenaw Hospital.Learn more about Michael McAllister, DO
Transcription:
GERD and Antireflux Surgery
Melanie Cole (Host): If you suffer from moderate to severe heartburn, referred to as gastroesophageal reflux disease or GERD, and you’ve tried other medicational interventions, your surgeon may have recommended laparoscopic anti-reflux surgery to treat the condition. My guest today is Dr. Michael McAllister. He’s a general surgeon with Aspirus Keweenaw Hospital. Welcome to the show, Dr. McAllister. Let’s start by giving a working definition of GERD for the listeners.
Dr. Michael McAllister (Guest): Gastroesophageal reflux disease -- or more commonly known as heartburn – has to do typically with a malfunction of the natural barrier to things coming up from the stomach and making their way back into the esophagus. We call that the gastroesophageal junction, and the ligaments and muscles around it. When somebody is having problems with heartburn or reflux, that can relate to a symptomatic hiatal hernia, which is to say that the top of the stomach and GE-Junction has slipped above the breathing muscle, or just malfunction of the ligaments around the hookup between the esophagus and the stomach.
Melanie: If somebody does suffer from heartburn or GERD, what are some of the first lines of defense that you would say that they usually try before they come and consider surgery?
Dr. McAllister: If a person is suffering from heartburn, it’s important that we first exclude a bacterial infection called H. Pylori as a cause for the complaint because that’s something that people can suffer with for many, many years. It’s also a risk factor for gastric cancer, so when we find that it’s typically very easily treated with the right medication. If somebody’s symptoms are not being caused by that infection, we typically start with a low-dose acid-lowering medication such as an H2-blocker or proton pump inhibitor. If that doesn’t help things, we’ll gradually increase the dose and see if that works better for them.
Melanie: If patients don’t respond well to lifestyle changes or medications or if they don’t – if medications are becoming too much of a strain on them, then when do you recommend surgery? And tell us about some of the anti-reflux surgery available out there.
Dr. McAllister: If someone’s having severe symptoms of heartburn or reflux, more than once a week, typically we’d want to move forward with an upper scope to clarify where the reflux is coming from. Again, it can relate to a bad hiatal hernia, and we’d also want to look for gastritis and ulcer disease because that can sometimes play a contributing role. As you hinted to before, lifestyle modifications are probably one of the most important things that we can start with respect to treatment of heartburn and reflux. The key ones that we tend to focus on are alcohol intake, nicotine intake, and to a degree, obesity. After we’ve gotten the upper scope out of the way that can help us plan what and if there is anything that we can do to help a patient surgically.
Laparoscopic Nissen Fundoplication is an option for certain patients with heartburn refractory to medication management and lifestyle changes, and as you also mentioned, people who are unable to or unwilling to take their daily acid medication. What we’re offering at Aspirus right now, is probably the next step forward from laparoscopic Nissen fundoplication. There was an explosion of all kinds of different devices for what they called natural orifice surgery in the early 2000s. One of those devices was the TIF or the Transoral Incisionless Fundoplication. There were a bunch of other similar things that came out around the same time, and the TIF is the one that has really shown that it is effective and safe with respect to management of reflux in certain people. Not everybody is a candidate for it, but the TIF has certain advantages when compared to Nissen fundoplication. A Nissen tends to result in a tighter wrap or a tighter valve than the TIF would. There’s a decent incidence of side effects after a Nissen fundoplication. Specifically, about 65% of patients with a Nissen will complain of some sort of gas bloating type symptoms after a year. Almost all of those patients will resolve their symptoms within a few months, but for the ones that continue to have problems, those problems can be quite bad for them. The advantage of the TIF is that it’s a gentler procedure. We can use it on older, more frail individuals who might not be a candidate for a more invasive surgery. The incidence of gas bloat and those kinds of symptoms is very close to none. The data has shown that it’s effective and safe for the treatment of reflux disease, specifically. Anywhere from 70 to 90% of patients will have an almost complete resolution of their symptoms at one year. That again depends on whose data set that you look at. The newer data sets reflect numbers closer to the 90th percentile, and that is what our numbers are starting to pan out here at Aspirus Keweenaw and Iron River.
Melanie: If you perform the TIF, is this something that’s now permanent? Are there some long-term studies that show that this isn’t something that’s going to come back or have to be redone?
Dr. McAllister: The TIF has been around for somewhere close to ten years or so, and we have now six-year, long-term data that again reflects a cure rate of somewhere around 90%. Sometimes, as with anything, we can do – we may have to go back and do a revision, but that is quite infrequent. The beauty of the TIF procedure is that the revision, when it needs to be done, can be done endoscopically typically, or with a gastroscope without the need for a more invasive surgery. For patients who have a large hiatal hernia, over 2 centimeters or so, we can sometimes combine a surgical repair of a hiatal hernia with the TIF procedure. With any kind of reflux or anti-reflux surgery, it’s very important to get the hookup of the esophagus to the stomach below the breathing muscle. If part of the primary problem is a hiatal hernia, we need to do something about that, and that would involve a laparoscopic hiatal hernia repair, which is something that we’re also offering at Aspirus Iron River.
Melanie: If somebody’s had the Nissen or the TIF, then do they have to – is there still medicational management that goes on? Are they done with their medications? What lifestyle modifications or changes would you like them to be aware of post-procedure?
Dr. McAllister: Part of going through an anti-reflux procedure or a surgery of any kind is to have the right goals in mind. Not everybody is going to be able to come off all of their acid-suppression medications. There are some people for whom we consider going from twice daily to once daily or less frequently, or sometimes only when they’re having symptoms acid medication administration is considered to be a reasonable goal. Most patients that we see tend to come off their medications altogether, but yes, there are some that may still need medications for symptomatic relief, especially if they eat the wrong thing. The most important thing with respect to lifestyle modifications is to again, avoid nicotine, alcohol, and if you are someone who suffers from obesity, to do your best to lose weight and stay at a healthy weight.
Melanie: And what would you like them to know about your team at Aspirus Keweenaw, and if they’re considering gastroesophageal reflux surgery, what would you really like to tell them? Wrap it up for us, Dr. McAllister.
Dr. McAllister: The anti-reflux program that we’re offering right now is being offered in concert with Aspirus Iron River. Dr. Fanous over there has a similar interest in these kinds of treatments and procedures as I do and he’s done a tremendous amount of work setting up a streamlined, efficient process, and really a program for diagnosing and treating gastroesophageal reflux disease. We’re in the process of bringing that same formula here to Aspirus Keweenaw. At some point in the next four or five months we should be able to offer the whole process from start to finish right here, but the main point is that now, we have a way to treat this kind of a problem definitively and surgically in people who have persistent symptoms or who are unable, for whatever reason, to take medication.
Melanie: Thank you, so much, Dr. McAllister, for being with us today. You’re listening to Aspirus Health Talk, and for more information, you can go to Aspirus.org, that’s Aspirus.org. This is Melanie Cole. Thanks, so much for listening.
GERD and Antireflux Surgery
Melanie Cole (Host): If you suffer from moderate to severe heartburn, referred to as gastroesophageal reflux disease or GERD, and you’ve tried other medicational interventions, your surgeon may have recommended laparoscopic anti-reflux surgery to treat the condition. My guest today is Dr. Michael McAllister. He’s a general surgeon with Aspirus Keweenaw Hospital. Welcome to the show, Dr. McAllister. Let’s start by giving a working definition of GERD for the listeners.
Dr. Michael McAllister (Guest): Gastroesophageal reflux disease -- or more commonly known as heartburn – has to do typically with a malfunction of the natural barrier to things coming up from the stomach and making their way back into the esophagus. We call that the gastroesophageal junction, and the ligaments and muscles around it. When somebody is having problems with heartburn or reflux, that can relate to a symptomatic hiatal hernia, which is to say that the top of the stomach and GE-Junction has slipped above the breathing muscle, or just malfunction of the ligaments around the hookup between the esophagus and the stomach.
Melanie: If somebody does suffer from heartburn or GERD, what are some of the first lines of defense that you would say that they usually try before they come and consider surgery?
Dr. McAllister: If a person is suffering from heartburn, it’s important that we first exclude a bacterial infection called H. Pylori as a cause for the complaint because that’s something that people can suffer with for many, many years. It’s also a risk factor for gastric cancer, so when we find that it’s typically very easily treated with the right medication. If somebody’s symptoms are not being caused by that infection, we typically start with a low-dose acid-lowering medication such as an H2-blocker or proton pump inhibitor. If that doesn’t help things, we’ll gradually increase the dose and see if that works better for them.
Melanie: If patients don’t respond well to lifestyle changes or medications or if they don’t – if medications are becoming too much of a strain on them, then when do you recommend surgery? And tell us about some of the anti-reflux surgery available out there.
Dr. McAllister: If someone’s having severe symptoms of heartburn or reflux, more than once a week, typically we’d want to move forward with an upper scope to clarify where the reflux is coming from. Again, it can relate to a bad hiatal hernia, and we’d also want to look for gastritis and ulcer disease because that can sometimes play a contributing role. As you hinted to before, lifestyle modifications are probably one of the most important things that we can start with respect to treatment of heartburn and reflux. The key ones that we tend to focus on are alcohol intake, nicotine intake, and to a degree, obesity. After we’ve gotten the upper scope out of the way that can help us plan what and if there is anything that we can do to help a patient surgically.
Laparoscopic Nissen Fundoplication is an option for certain patients with heartburn refractory to medication management and lifestyle changes, and as you also mentioned, people who are unable to or unwilling to take their daily acid medication. What we’re offering at Aspirus right now, is probably the next step forward from laparoscopic Nissen fundoplication. There was an explosion of all kinds of different devices for what they called natural orifice surgery in the early 2000s. One of those devices was the TIF or the Transoral Incisionless Fundoplication. There were a bunch of other similar things that came out around the same time, and the TIF is the one that has really shown that it is effective and safe with respect to management of reflux in certain people. Not everybody is a candidate for it, but the TIF has certain advantages when compared to Nissen fundoplication. A Nissen tends to result in a tighter wrap or a tighter valve than the TIF would. There’s a decent incidence of side effects after a Nissen fundoplication. Specifically, about 65% of patients with a Nissen will complain of some sort of gas bloating type symptoms after a year. Almost all of those patients will resolve their symptoms within a few months, but for the ones that continue to have problems, those problems can be quite bad for them. The advantage of the TIF is that it’s a gentler procedure. We can use it on older, more frail individuals who might not be a candidate for a more invasive surgery. The incidence of gas bloat and those kinds of symptoms is very close to none. The data has shown that it’s effective and safe for the treatment of reflux disease, specifically. Anywhere from 70 to 90% of patients will have an almost complete resolution of their symptoms at one year. That again depends on whose data set that you look at. The newer data sets reflect numbers closer to the 90th percentile, and that is what our numbers are starting to pan out here at Aspirus Keweenaw and Iron River.
Melanie: If you perform the TIF, is this something that’s now permanent? Are there some long-term studies that show that this isn’t something that’s going to come back or have to be redone?
Dr. McAllister: The TIF has been around for somewhere close to ten years or so, and we have now six-year, long-term data that again reflects a cure rate of somewhere around 90%. Sometimes, as with anything, we can do – we may have to go back and do a revision, but that is quite infrequent. The beauty of the TIF procedure is that the revision, when it needs to be done, can be done endoscopically typically, or with a gastroscope without the need for a more invasive surgery. For patients who have a large hiatal hernia, over 2 centimeters or so, we can sometimes combine a surgical repair of a hiatal hernia with the TIF procedure. With any kind of reflux or anti-reflux surgery, it’s very important to get the hookup of the esophagus to the stomach below the breathing muscle. If part of the primary problem is a hiatal hernia, we need to do something about that, and that would involve a laparoscopic hiatal hernia repair, which is something that we’re also offering at Aspirus Iron River.
Melanie: If somebody’s had the Nissen or the TIF, then do they have to – is there still medicational management that goes on? Are they done with their medications? What lifestyle modifications or changes would you like them to be aware of post-procedure?
Dr. McAllister: Part of going through an anti-reflux procedure or a surgery of any kind is to have the right goals in mind. Not everybody is going to be able to come off all of their acid-suppression medications. There are some people for whom we consider going from twice daily to once daily or less frequently, or sometimes only when they’re having symptoms acid medication administration is considered to be a reasonable goal. Most patients that we see tend to come off their medications altogether, but yes, there are some that may still need medications for symptomatic relief, especially if they eat the wrong thing. The most important thing with respect to lifestyle modifications is to again, avoid nicotine, alcohol, and if you are someone who suffers from obesity, to do your best to lose weight and stay at a healthy weight.
Melanie: And what would you like them to know about your team at Aspirus Keweenaw, and if they’re considering gastroesophageal reflux surgery, what would you really like to tell them? Wrap it up for us, Dr. McAllister.
Dr. McAllister: The anti-reflux program that we’re offering right now is being offered in concert with Aspirus Iron River. Dr. Fanous over there has a similar interest in these kinds of treatments and procedures as I do and he’s done a tremendous amount of work setting up a streamlined, efficient process, and really a program for diagnosing and treating gastroesophageal reflux disease. We’re in the process of bringing that same formula here to Aspirus Keweenaw. At some point in the next four or five months we should be able to offer the whole process from start to finish right here, but the main point is that now, we have a way to treat this kind of a problem definitively and surgically in people who have persistent symptoms or who are unable, for whatever reason, to take medication.
Melanie: Thank you, so much, Dr. McAllister, for being with us today. You’re listening to Aspirus Health Talk, and for more information, you can go to Aspirus.org, that’s Aspirus.org. This is Melanie Cole. Thanks, so much for listening.