GERD has a broad spectrum of symptoms, including classic heartburn — a painful feeling in your throat or chest from the backup of stomach acid into your esophagus, along with stomach pain, chest pain, coughing, muscle spasms in the esophagus, and shortness of breath. “In most patients with GERD, the lower esophageal sphincter — the valve between the stomach and the esophagus (food tube) isn’t working properly,” says Paresh Shah, MD, the director of general surgery at New York University’s Langone Health in New York City. The lower esophageal sphincter should function like a one-way valve. It opens when you’re swallowing food, then closes again. In people with GERD, the valve stays open or is loose. As a result, fluid in the stomach can go back up into the esophagus. Ongoing reflux can damage the lining of the esophagus. In severe cases, it can cause ulcers and bleeding, or lead to Barrett’s esophagus, according to the NIDDK. With the condition, tissue similar to the lining of the intestine replaces tissue in the esophagus. Barrett’s esophagus is associated with an increased risk of esophageal cancer. “Most people with GERD are fairly well managed with occasional medication and lifestyle changes, such as stopping smoking and losing weight,” says Dr. Shah. Surgery may be just what the doctor orders, however, if your symptoms don’t improve with daily medication or if you develop severe esophagitis (your esophagus becomes irritated, swollen, or inflamed) or another reflux complication. Here are four surgical procedures for GERD that may help you feel better fast.
Fundoplication: Providing GERD Relief by Altering Your Anatomy
What it is: With laparoscopic surgery (tiny incisions), fundoplication uses your stomach to reinforce the lower esophageal sphincter — the valve at the end of your esophagus. “We use the stomach to augment the function of the valve,” Shah says. Using an endoscope (a flexible lighted tube), the surgeon gathers and sutures (sews) the stomach tissue closest to the esophagus around the lower esophagus and lower esophageal sphincter. The goal is to increase the pressure at the valve to reduce acid reflux. Upside: “Fundoplication is considered the gold standard because it’s the surgery we’ve been doing the longest,” Shah says. Downside: Because fundoplication involves the stomach, it can have complications such as the inability to burp or vomit. Over time, the sutured tissue can stretch and some symptoms can return. But many patients remain symptom free for five years or more, Shah says. Best candidates for fundoplication: People with GERD who also have a hiatal hernia (when a part of the stomach moves up into the chest area); Barrett’s esophagus; esophagitis; or poor motility (movement of food and liquids through the esophagus)
TIF 2.0: The Inside Version of Fundoplication
What it is: Transoral incisionless fundoplication, or TIF 2.0, uses a special endoscope to place internal stitches in your lower esophagus to reinforce the valve between the esophagus and the stomach. “TIF 2.0 replicates what we’re trying to do with fundoplication but from the inside,” Shah says. The laparoscopic surgery requires general anesthesia and takes roughly an hour to 90 minutes. Most patients go home the same day. “They feel symptom relief immediately,” Shah says of his patients. Upside: TIF 2.0 is less invasive than fundoplication and is less disruptive to your anatomy. “It doesn’t burn any bridges for you,” Shah says. “If you get a TIF but it doesn’t work well enough, you can still get a fundoplication.” A study published in April 2018 in Surgical Innovations known as the TEMPO Trial, involving 63 patients with GERD, found TIF 2.0 to be safe, durable, and cost-effective after five years. “You may have breakthrough symptoms every now and then and occasionally need medication. But most patients can get off their meds completely,” Shah says. Downside: “TIF 2.0 helps patients who have reflux and heartburn symptoms more than regurgitative symptoms,” Shah says. Similarly to fundoplication, the tissue surgically reinforcing the esophageal valve can stretch over time, causing symptoms to return. “The biggest risk is that it’s not effective enough for long enough,” Shah says. Best candidates for TIF 2.0. TIF 2.0 may be a good option if you have mild esophagitis and normal motility (your esophagus works well and contracts properly). TIF isn’t recommended for people with severe esophagitis, Barrett’s esophagus, or those with a hiatal hernia greater than 2 centimeters in size.
LINX: Treating GERD With Rare Earth Magnets
What it is: LINX surgery places a band of rare earth magnets at the lower end of the esophagus. The magnetic implant comes in different sizes. “We measure and calibrate it for each individual patient,” Shah says. “Its job is to increase the opening force of the valve. It makes it harder for the esophagus to open.” Food can still pass through normally. LINX takes just 30 to 40 minutes in the operating room. Patients typically go home the same day. “They can start eating normally right away,” Shah says. LINX doesn’t set off metal detectors at airports. You can go through security without a problem. Upside: Unlike fundoplication or TIF 2.0, “LINX is not going to deteriorate over time,” Shah says. Downside: LINX is a permanent implant that is designed to be left in forever. “Some patients aren’t comfortable with the idea of getting implants into their body,” Shah says. Another issue? LINX magnets interfere with magnetic resonance imaging. If you routinely need MRIs, LINX is not for you. Best candidates for LINX: Someone who doesn’t routinely need an MRI; people without severe esophagitis; absence of a large hiatal hernia; and those who respond partially to daily medication generally do the best with LINX, Shah says. To qualify for fundoplication, TIF or LINX, patients with GERD typically undergo four tests: endoscopy (examining your esophagus with a lighted tube); an upper GI series or barium swallow (an X-ray); a pH study, which assesses the acidity and quantity of the reflux; and manometry, which determines how well the esophagus pushes food down. “We want to make sure what we’re dealing with is truly a valve dysfunction,” Shah says. After you’ve been diagnosed with GERD, you may have two or three of these surgical options to choose from. As of May 2018, fundoplication is the only one covered by most health insurance plans, but check your policy to be sure. “We’re making headway to get more payers to cover TIF and LINX, but it’s a very slow process,” Shah says. The out-of-pocket cost for TIF or LINX is $8,000 to $12,000.
