Surgical management of GORD: Is anti-reflux surgery right for you?

Gastro-oesophageal reflux disease (GORD) is a relatively common condition in which acid leaking from the stomach can cause unpleasant symptoms such as heartburn, nausea or vomiting. Although these symptoms can be well managed with medication in some patients, others are unable to resolve their symptoms and may opt for surgical treatment. In this expert guide, highly esteemed consultant general, upper gastrointestinal and trauma surgeon Professor Mansoor Khan details how GORD can be managed with medication and when surgery is indicated. The leading specialist also offer expert insight on which factors make a patient a good candidate for anti-reflux surgery.

How is GORD managed?

Gastro-oesophageal reflux disease (GORD) is a common condition that affects approximately ten to twenty per cent of the western world although some estimates suggest that this could be as high as forty per cent. Management of GORD is varied and there are differing consensus statements as to the optimum treatment. Historically, GORD was considered to be secondary to a hiatus hernia, however, not all patients with reflux have a hiatus hernia, and operations which were designed to correct this deformity were often ineffective at treating reflux oesophagitis.

Current treatment includes lifestyle modifications and the use of proton pump inhibitors (PPIs), a type of medication, which has revolutionised the management of reflux. However, these therapies are often ineffective in severe disease and surgery offers an alternative. A Cochrane Collaborative meta-analysis comparing surgical treatment (laparoscopic fundoplication) and the use of medication reported that surgery was superior to medical therapy, with significantly better quality of life (as measured by the SF36 questionnaire).

When is surgery indicated?

The main aim of modern surgery, the fundoplication or the LINX procedure, is to prevent gastric contents refluxing into the oesophagus by recreating the natural effect of the lower oesophageal sphincter. There are numerous indications for fundoplication surgery, including:

• Failure of medical therapy
• Need for prolonged medical therapy and complications of long-term medical therapy
• Complications of reflux disease, including Barrett’s oesophagus or stricture
• Patient preference i.e. those who do not want to undergo long term treatment by medication
• Hiatus hernia with/without volume reflux
• Recurrent symptoms and signs of reflux after surgery
• Extra-oesophageal manifestation i.e. respiratory complications caused by reflux, dysphonia, globus, cough, choking, postnasal drip and sore throat
• Lung transplant patients

When is this type of surgery not advised?

There are two main contraindications to consider when contemplating anti-reflux surgery. Patients who are unfit to have general anaesthesia should not be offered anti-reflux surgery. This is due to the unacceptably high risk of severe cardiovascular complications. The second contraindication relates to patients who have reflux-related symptoms but no clear-cut reflux. These patients tend not to have gastro-oesophageal reflux, but a different disease (e.g. functional heartburn), so anti-reflux surgery will not help them.

What types of patients typically undergo anti-reflux surgery?

Anti-reflux surgery is in the main, performed in three distinct sets of patients. The first group represents the majority of patients who will undergo an anti-reflux operation and have established signs and symptoms of chronic reflux disease (including Barrett’s oesophagus or stricture), and do not wish to continue with life-long medical therapy and request anti-reflux surgery.

The second groups of patients who undergo anti-reflux surgery are those with well-established gastro-oesophageal reflux disease who are not achieving symptomatic control with PPI therapy. This group includes patients who have volume reflux, significant regurgitation, or who regularly aspirate (breathe in fluid into the lungs) during the night.

The third group of patients are those that present and have symptoms associated with extra-oesophageal manifestation of reflux disease, which include respiratory complications of reflux disease. Laparoscopic fundoplication is still considered the gold standard treatment for moderate to severe gastro-oesophageal reflux disease, with the LINX procedure gaining increasing popularity as a validated alternative. However, there is now an increasing tendency in many centres to utilise surgery at earlier stages of the disease. Extensive debates have concluded that continuing with medical therapy does not correct the underlying motor abnormalities that exist in the upper gastrointestinal tract, but that of acid suppression.

In addition to this, medication may not provide adequate control of volume reflux, nocturnal symptoms and retro-sternal (behind the breastbone) pain. The choice is often left to patients; individuals with effective medication-controlled reflux are now given the option to continue with life-long medication or undergo a potentially definitive procedure i.e. surgery. However, emphasis must be placed on the potential undesirable effects that can occur as a result of operative intervention when allowing patients to make an informed choice.

The following is the proposed algorithm for the surgical management of patients with GORD:

Professor Khan is one of the UK’s leading specialists in the surgical management of GORD. If you are seeking treatment for the condition and wish to book a consultation with Professor Khan, you can do by visiting his Top Doctors profile.