GERD (Heartburn) Surgery: Everything You Need to Know

In the United States, symptoms of gastroesophageal reflux disease (GERD) are common. However, up to 40% of people don’t find relief from their heartburn with one of the most frequently used medications, proton pump inhibitors.

Surgery for GERD can be effective, both for those who do and those who don’t find that medications work for them. The most common type of surgery that is done to treat GERD is called Nissen fundoplication. Other types of procedures may be used in certain circumstances.

This article will describe the different types of surgery for GERD, their purpose, how to prepare, what happens on the day of surgery, and what to expect in recovery.

What Is GERD Surgery?

When the ring of muscles at the bottom of the esophagus, the lower esophageal sphincter (LES), is weakened, it can lead to symptoms of GERD. Common symptoms can include:

• Chest pain
• Difficulty swallowing
• Heartburn (a burning sensation in the chest)
• Regurgitation (gastric juice or food backing up into the throat)
• Feeling as though something is stuck in the throat
  

Even though most people do better with medications, some people may decide they’d rather have acid reflux surgery. Some of the reasons to have surgery for GERD include:

• A hiatal hernia (the upper part of the stomach bulges through the diaphragm)
• Being unable to take GERD medications
• Having symptoms even when taking medications
• Not wanting to take medications long term

There are different types of surgery for GERD.

Fundoplication

The goal of GERD surgery is to strengthen the LES. During a fundoplication operation, a portion of the upper stomach, which is called the fundus, is removed.

That piece of tissue is then wrapped around the LES, either fully or partially, so the muscles of the LES are better supported. This helps prevent food and liquids from coming back up the stomach and into the throat.

The most commonly used surgery for GERD is called a Nissen fundoplication, in which the removed portion of the upper stomach is fully wrapped around the outside of the LES, reinforcing the LES.

A Nissen fundoplication surgery can be done laparoscopically or with open surgery.

GERD surgery may be done laparoscopically or with open surgery. Laparoscopic is usually preferred because it has some advantages over open surgery. With laparoscopic, there could be:

• A quicker return to normal activities and work
• A shorter stay in the hospital
• Smaller scars
• Less pain after the surgery

In some cases, the laparoscopic technique might not be a possibility. Sometimes this decision is made before the surgery starts; other times, the decision to change from laparoscopic to open is made after the surgery begins.

Some of the reasons that might lead to using an open surgery instead of a minimally invasive one are:

• Obesity
• Scar tissue in the abdomen
• Too much bleeding during the operation
  

Transoral Incisionless Fundoplication (TIF)

This procedure might be used when other surgical techniques are not appropriate. It is less invasive than surgery because there are no incisions with this type of fundoplication. Instead, the esophagus is accessed with a device called an EsophyX, which is inserted into the mouth and down into the throat. 

TIF involves folding the tissue at the end of the esophagus near the stomach to create a new valve, which helps prevent the contents of the stomach and gastric juices from backing up into the esophagus and causing symptoms of GERD.

Stretta Procedure

This less invasive procedure is completed using an endoscope—a flexible tube with a light on the end that is designed to go through the mouth and down into the esophagus. With the use of the endoscope, treatment can be delivered into the upper digestive tract.

For this procedure, a special electrode that heats up is on the end of the endoscope. Radiofrequency energy is applied to the end of the esophagus, creating cuts that heal and form scar tissue.

This has two effects—it reinforces the muscles, and it blocks the nerves that react to acid backing up into the esophagus.

The procedure takes about an hour and is done on an outpatient basis.

After 10 years, most patients who had this procedure were able to use less medication to manage their GERD. However, the cost may not be covered by some insurance carriers.

Bard EndoCinch System Procedure

Another procedure uses an endoscope and a device called the Bard EndoCinch system. This procedure may also be called endoluminal gastroplication.

The endoscope is inserted into the esophagus, and the device on the end of it puts two stitches in the LES. The stitches are put together and tied to create a pleat that bolsters the LES.

This procedure is done less frequently, and the cost may not be covered by some insurance carriers.

It is less invasive than surgery because it doesn’t require any incisions, and recovery may be quicker. However, it is a newer procedure.

One study showed that about 44% of patients needed retreatment and 80% eventually needed medications to manage their GERD.

Linx Surgery

The linx is a ring of magnetic titanium beads which are wrapped around the LES during surgery to bolster it. The beads help keep the LES closed and prevent food from moving back up into the esophagus because they are magnetized.

This procedure is used less often to treat GERD than fundoplication surgery. Approved for use in 2012, it’s a less invasive option, and recovery time may be quicker. The cost may not be covered by some insurance carriers.

Contraindications

There are relatively few reasons that a procedure for GERD can’t be used. The two main reasons that a person would not be a good candidate are because they have been diagnosed with Barrett’s esophagus with precancerous cells or esophageal cancer.

Esophageal cancer is rare. Some of the risk factors include smoking, excessive drinking, obesity, and having GERD or Barrett’s esophagus.

Barrett’s esophagus (sometimes also called Barrett’s mucosa) is also rare. In this condition, the cells in the lining of the esophagus have changes, and there is an increased risk of cancer. It is associated with GERD, although there may not be any symptoms.

Other factors may be considered, such as overall health and any other pre-existing conditions.

Potential Risks

Any procedure carries risks. The surgical team will help you weigh the risks of a procedure to make the best decision. Some of the risks of having surgery or a procedure for GERD include:

• An adverse reaction to anesthesia
• Bleeding
• Infections
• Injury to the esophagus

Check with your healthcare team about any risks that may be specific to you. 

Purpose of GERD Surgery

One of the main reasons for GERD surgery is to improve quality of life by reducing the symptoms. Some people don’t feel better even after trying medications. Others may not want to take medications for long periods of time and would prefer to try to reduce the symptoms through the use of a procedure.

A procedure to strengthen the LES is also done to prevent complications or manage complications that have already occurred. While GERD is not a fatal condition, it could lead to more serious complications. Many of the potential complications are rare and only occur after years of symptoms.

Some of the complications of longstanding GERD that may be avoided with treatment include:

• Aspiration (inhaling secretions and contents from the digestive tract into the lungs)
• Aspiration pneumonia (lung infection due to aspiration)
• Bleeding
• Esophageal adenocarcinoma (cancer)
• Esophageal rupture
• Lung transplant rejection
  

Before having surgery for GERD, some tests may be needed. An accurate diagnosis of GERD is the first important step. There will also be questions to answer about symptoms and personal medical history, and a physical exam will be done.

It may also be necessary to ensure that there are no other problems with the esophagus before having surgery for GERD. This may mean that some tests are done to look at the muscles or the lining of the esophagus. 

Some of the tests that might be done to confirm a diagnosis of GERD and rule out other conditions include:

• Barium swallow
• Esophageal manometry
• pH monitoring
• Upper endoscopy (EGD)

How to Prepare

A few standard tests may be done in the days leading up to surgery. Some of these are to ensure that the heart and lungs are healthy and that there are no problems with other conditions like anemia. These tests might include: 

• Chest X-ray
• Complete blood count (CBC)
• Blood chemistry panel
• Electrocardiogram (EKG)

Location

Surgery or endoscopic procedures for GERD may be done in a hospital or an endoscopy center. Laparoscopic or open surgery procedures may be done in an operating room in a hospital. The less invasive procedures may be done in an outpatient clinic or endoscopy center. 

What to Wear

Patients will want to wear comfortable clothing that is easy to take off and put on. It’s a good idea to leave items like jewelry and watches at home. If expected to stay in the hospital for a few days, a change of clothes or two might be helpful.

Before the surgery, patients will change into a surgical gown. While in the hospital or the endoscopy center, the hospital gown will usually be worn until there’s no longer a need for an IV and/or it’s time to go home.

Food and Drink

It’s usually recommended that patients not eat or drink anything after midnight the night before the procedure. There may also be other dietary guidelines given in the weeks or days leading up to surgery. Those instructions will be given by the doctor or surgical center.

Medications

Certain medications and supplements may need to be stopped before surgery. One of the reasons some medications are stopped is because they may cause a risk of bleeding during surgery. The surgeon will give a list of medications which might include:

• Anti-inflammatory medications (such as ibuprofen)
• Aspirin
• Blood thinners (such as warfarin)
• Vitamin E
• St. John’s wort
  

During your pre-surgery visits, tell the medical team about all medications and supplements you are taking.

What to Bring

It will be necessary to bring identification and health insurance information on the day of the surgery. Information about past medical history may also be helpful, as there are often questions about medications, previous surgeries, or the date of a last menstrual period before surgery.

If expected to stay in the hospital for a few days, other comforts might be desired, such as a cell phone and charger, headphones, socks and slippers, and a book or activity to pass the time. 

Patients will not be allowed to drive themselves home. In many hospitals or surgical centers, patients must have a friend or relative to drive them home. Patients won’t be discharged to a taxi or rideshare service.

Pre-Op Lifestyle Changes

Preparing for a return home, such as arranging for help with meals and household tasks, will help ease recovery.

Patients who smoke will be advised to quit prior to the procedure.

What to Expect on the Day of Surgery

Before the Surgery

After arriving and checking in, patients will change into a hospital gown and be given an IV which will be used to deliver fluids and medications before and during the surgery. Temperature, blood pressure, and other vital signs are also taken.

During the Surgery/Procedure

Patients will be wheeled into surgery on a hospital bed. Staff will double-check some things with the patient such as name, birth date, and the type of surgery being done. Anesthetic will be given through the IV to put patients to sleep during the procedure.

Surgeries may take several hours to complete. Endoscopic procedures may take about an hour.

After the Surgery/Procedure

Patients will wake up in a recovery area after the procedure is complete. If staying in the hospital, patients will be transferred to a room when they are awake and vital signs are stable. If going home, patients are discharged after they are awake, their vitals are stable, and they are able to get dressed.

Recovery

The recovery time will depend on the type of surgery done and if it is laparoscopic or open.

After laparoscopic surgery, patients will get back to regular activities, usually in a few weeks. For open surgery, the recovery time will be longer. It may take anywhere from four to six weeks to get back to everyday activities.

It’s usually recommended that patients start to add activities back into their day slowly. At first, it’s important to avoid heavy lifting or strenuous exercise. More specific guidelines on activities will be given at discharge.

Healing

Any surgical wound(s) may require some attention in the first days after the procedure. Care should be taken in making sure an incision remains clean and that no inflammation or infection is starting. Patients should call their doctor if the surgical site becomes red or oozes, or if they have a temperature over 101 F.

There may be a need to have a liquid diet for several days or longer after surgery. If this goes well, the diet will be progressed to a full liquid diet and then to soft foods.

Detailed instructions on recommended foods should be given at the time of discharge. Carbonated drinks and foods that might easily clump up in the esophagus should be avoided. All foods should be chewed carefully.

Coping With Recovery

Many patients are able to stop their acid reflux medications after surgery. There will be a follow-up appointment with the doctor, usually about two weeks after the procedure. Pain medication may be prescribed for the recovery period. Walking, as tolerated, is usually recommended as a good activity to help aid in recovery.

Long-Term Care

Most people are able to cut back or stop their GERD medications after surgery. Symptoms after eating or at night should also be lessened. If symptoms return, patients should get in touch with their doctor to discuss the next steps.

Possible Future Surgeries

In some cases, the surgery may need to be done again, although this is not common. 

Lifestyle Adjustments

Most patients will return to regular activities and diet after their surgery, and there usually aren’t any long-term effects.

Summary

There are several types of surgery to address GERD, with the goal of reducing symptoms and the need for medications. Nissen fundoplication is the most common. It can be done as an open surgery or as a minimally invasive laparoscopic surgery.

Depending on the type of surgery, it might be done as a day surgery or require a short hospital stay. You may have to be on a liquid diet for a period of time after the surgery as you recover and heal.

A Word From Verywell

Patients have several choices when it comes to surgery for GERD. With a healthcare team that includes shared decision-making, patients can choose the best possible procedure for them. This includes not only the surgery itself, but also recovery time and cost.

With successful surgery, you may have fewer symptoms of GERD and be able to reduce medications. This can improve your quality of life and prevent the complications that can arise from long-term GERD.