GERD Surgery: Everything You Need to Know

Laparotomy: the process of peritoneal incision

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In This Article

Surgical treatment of gastroesophageal reflux disease (GERD) involves strategies to tighten the lower esophageal sphincter (LES) and prevent stomach fluid from entering the esophagus. Fundoplication is one common procedure, but there are others, with approaches that range from minimally invasive to open surgery. Surgery is an option for refractory GERD—that is, cases that do not improve with more modest treatments.

The procedure that's best for you depends on your medical condition and any structural issues affecting your digestive system.

What Is GERD Surgery?

Operations that treat GERD differ in terms of how they are done, but are all interventions that narrow the LES—a muscle located at the opening between the esophagus and the stomach.

The surgery leaves an opening wide enough for food that's in the esophagus to enter the stomach while keeping the contents of the stomach from backing up into the esophagus. Surgery also allows your LES to open when you need to vomit or burp. 

You might also have surgical treatment of a stomach ulcer at the same time as your GERD surgery, if needed.

Techniques used to narrow the LES in GERD surgery include:

  • Fundoplication: This is a common surgical treatment for GERD in which the upper part of the stomach is wrapped around the lower esophageal sphincter (LES). This surgery strengthens the sphincter to prevent acid reflux. There are several types of fundoplication—including partial fundoplication, total fundoplication, anterior fundoplication, Nissen fundoplication, and Toupet fundoplication.
  • Plication: This involves the placement of sutures around the LES to tighten the muscle.
  • Radiofrequency: This is a procedure in which heat is applied to the LES to create lesions that narrow the opening.
  • Magnetic sphincter augmentation: This technique involves wrapping a magnetic device (often called a LINX system) around the LES to hold it tight. A few different magnetic devices are available for this purpose.

To gain access to the LES, your doctor will choose between these surgical methods:

  • Endoscopy, which involves a camera-equipped surgical device placed into the mouth to access the LES
  • Laparoscopy, in which video assistance is used to manipulate surgical tools placed through small abdominal incisions (considered minimally invasive)
  • Open laparotomy, with a large abdominal incision and direct visibility of the stomach and esophagus during surgery
Procedure Typical Surgical Approach
Fundoplication  Open laparotomy or laparoscopy
Plication Endoscopy
Radiofrequency Endoscopy
Magnetic sphincter augmentation Laparoscopy or endoscopy

All of these require pain control. For an open laparotomy or laparoscopic surgery, you would be medically put to sleep with general anesthesia. You would have intravenous (IV, in a vein) sedation during an endoscopic GERD surgery.

An overnight hospital stay is necessary for an open laparotomy or laparaoscopy, but you might be able to go home on the same day as your surgery if you have an endoscopic GERD procedure.

Contraindications

These procedures aren't right for everyone. A major medical problem can predispose you to surgical complications, potentially making GERD surgery more risky than beneficial. And severe esophageal disease might mean that GERD surgery could be ineffective or impossible.

  • General health issues: You could have difficulty recovering or a high risk of serious postoperative complications if you have issues like cardiovascular disease, a bleeding disorder, or severe respiratory disease.
  • Esophageal problems: If you have a history of esophageal surgery, achalasia (a motility problem of the esophagus), or esophageal varices (abnormal blood vessels in the esophagus), GERD surgery can be harmful to you.

Potential Risks

GERD surgery can cause complications related to general anesthesia or IV sedation. In addition, these procedures may cause immediate post-operative surgical complications or lasting esophageal problems.

Complications from GERD surgery may include:

  • Bleeding in the days after surgery, which may cause anemia, low blood pressure, or shock
  • An injury to the esophagus or stomach
  • Bowel obstruction due to inflammation or bleeding
  • A post-operative infection
  • Dysphagia (trouble swallowing) for weeks or months after surgery, or permanently

These complications can lead to a medical emergency within a week after surgery. You may need to have urgent medical or surgical treatment for the management of such a postoperative complication.

If you develop persistent dysphagia, you may need swallowing therapy to help you optimize your swallowing function.

And sometimes abdominal surgery leads to adhesions, which are post-surgical scars that can cause problems several years after surgery, ranging from cramping to life-threatening gastrointestinal obstruction.

Purpose of GERD Surgery

The weakening of the LES that occurs with GERD allows acidic stomach fluid to backflow into the esophagus. This irritates the inner lining of the esophagus, causing issues such as heartburn, abdominal discomfort, hematemesis (vomiting blood), esophageal ulcers, Barrett's esophagus, and weight loss. GERD is also associated with an increased risk of esophageal cancer.

Clearly, management of the condition is important. Non-interventional options are typically sufficient in helping manage the condition. But you might be a candidate for surgery if they are not and your doctor determines that tightening the opening between your esophagus and stomach is what is needed to prevent stomach fluid from entering your esophagus and relieve your symptoms. This applies to cases stemming from risk factors like smoking, obesity, and heavy alcohol intake, but also those caused by congenital issues.

You will first need to try lifestyle changes (e.g., reducing alcohol intake, smoking cessation) to see if you experience any improvement.

lifestyle GERD treatments
Illustration by Jessica Olah, Verywell

In many cases, an over-the-counter or prescription antacid is also recommended.

H2 blockers like Pepcid AC (famotidine) and proton-pump inhibitors (PPIs) like Prilosec (omeprazole) suppress gastric acid secretion, and each has features that can help guide treatment planning.

Your doctor will recommend a specific medication based on your symptom pattern and potential interactions with other medications you take (if applicable).

April 1, 2020 Update: The Food and Drug Administration (FDA) announced the recall of all medications containing the ingredient ranitidine, known by the brand name Zantac. The FDA also advised against taking OTC forms of ranitidine, and for patients taking prescription ranitidine to speak with their healthcare provider about other treatment options before stopping the medication.

If these recommendations are diligently followed and fail, surgery may be explored. This will involve diagnostic testing to evaluate the action of the LES muscle, as well as the pH of the fluid in your lower esophagus.

How to Prepare

Before your surgery, you will have a number of imaging tests that will be used in surgical planning. Pre-operative planning tests may include an abdominal computerized tomography (CT) scan, an abdominal ultrasound, or a diagnostic endoscopy.

You will also have standard pre-surgical testing, like a complete blood count (CBC) and a blood chemistry panel. Abnormalities like anemia or imbalanced blood electrolyte levels would need to be corrected before your surgery.

Your anesthesia pre-operative testing will include an electrocardiogram (EKG) and a chest X-ray.

Because bleeding ulcers are common with GERD, you might need to have your own blood collected and stored about a week before your surgery in case you need a blood transfusion during your procedure.

Location

A laparotomy or laparoscopy would be done in an operating room that's located in a hospital or surgical center. An endoscopic surgery would be done in an operating room or a procedural suite.

What to Wear

You can wear anything comfortable to your surgery appointment. You will wear a hospital gown during your procedure.

You should have something loose and comfortable to wear on your way home. If you are having a laparotomy, opt for an oversized shirt or one that buttons in the front so that you can access your surgical drain (if one is placed).

Food and Drink

You will have to abstain from food and drink after midnight the night before your surgery.

Medications

You will likely need to reduce or stop taking blood thinners and anti-inflammatory medications for several days prior to your surgery. In the days before your procedure, you may also need to adjust the dose of a diabetes medication or steroids that you regularly take.

Your doctor will also give you specific instructions with respect to any medications that you take for the treatment of your GERD.

What to Bring

When you go to your surgery appointment, you will need to have your personal identification, insurance information, and a form of payment for any portion of the cost that you might be responsible for.

Additionally, you should make sure someone can drive you home when you are discharged.

Pre-Op Lifestyle Changes

Before your surgery, you will need to avoid habits that worsen the effects of GERD so that any existing damage to the lower part of your esophagus has a chance to heal. For example, you should avoid spicy or acidic foods, cut down on alcohol, and stop smoking.

What to Expect on the Day of Surgery

When you go in for your surgery appointment, you will need to register and sign a consent form. You may have same-day blood tests, including a CBC and chemistry panel. If these tests show that you have an acute problem like anemia, you might still have your procedure, but your surgical team will prepare for the possibility that you may need a blood transfusion.

Shortly before your procedure, you will go to a pre-operative area where you will change into a hospital gown and have an IV placed in your hand or arm. You will have your temperature, pulse, blood pressure, and oxygen level checked.

Before the Surgery

Your anesthesia will be started, and what that entails depends on the type of procedure you are having:

  • Anesthesia for endoscopy: You will receive anesthetic medication in your IV to make you drowsy and relaxed. You will also have anesthetic medication sprayed in your mouth and throat to ease discomfort when the endoscope is advanced down into your esophagus and stomach.
  • Anesthesia for GERD surgery with an abdominal incision: If you are having a laparoscopic surgery or an open laparotomy, medication that induces general anesthesia will be injected in your IV for pain control. With general anesthesia, you won't be able to move or feel anything, and the medication will also put you to sleep. A breathing tube will be placed in your throat to assist you with breathing during your surgery.

If you will have a surgical incision, your abdomen will be covered with a surgical drape with the operating area left exposed. The skin in the incision area will be cleansed with an antiseptic solution before your surgery starts.

During the Surgery

The first step in your GERD surgery is gaining access to your LES.

For an endoscopic procedure, your doctor will place an endoscope in your mouth and ask you to swallow. The endoscope will be advanced down to your LES. You won't be able to feel this process and you might fall asleep. Your surgical team will be able to see the structures of your esophagus and stomach on a monitor.

If you are having one or more incisions, your surgeon will cut into the skin of your abdomen and then the peritoneal covering that encloses your gastrointestinal organs. With laparoscopic surgery, your surgeon will insert a camera to see the structures on a monitor; with an open laparotomy, your surgeon will directly see the structures that need repair.

Once your surgeon has access to your LES, next steps may include:

  • Placing sutures near your LES to make it tighter
  • Application of radiofrequency heat with a laser to narrow your LES
  • Pulling up the top portion of your stomach over your LES and stitching it to tighten the opening
  • Placing a magnetic device outside your LES to narrow the opening

If you are also having an ulcer repair, this may be done at the same time. Issues such as excessive bleeding will be controlled during surgery, and a blood transfusion may be administered if necessary.

With major abdominal surgeries, inflammation and fluid may be problematic and can increase the risk of postoperative gastrointestinal obstruction. If this possibility is anticipated, your surgeon may place a surgical drain in your abdominal cavity and extend the tube to the outside of your body so inflammatory fluid doesn't accumulate.

Once your laparotomy or laparoscopy is complete, you will have sutures to close any areas of peritoneum or skin that were cut for access, and your wound will be bandaged.

If you had endoscopic surgery, the endoscope will be removed when your procedure is done. You won't need any additional sutures besides those that may have been placed internally to narrow the LES.

Your anesthesia medication will be stopped. If you have a breathing tube, it will be removed and your anesthesia team will ensure that you are breathing on your own before you leave the operating room to go to the recovery area.

After the Surgery

As you are recovering, your medical team will check on you. You might receive pain medication if needed. You will also have your pulse, blood pressure, and oxygen level monitored as you are waking up.

Your length of stay and degree of post-operative monitoring is guided by your type of surgery. For example, if you had an endoscopic procedure with a few sutures placed near your LES, you might be able to go home within a few hours. If you had an open procedure with a large incision, you will likely stay in the hospital for one or more days. In any case, know that your stay may be longer if your surgery did not go as planned and/or recovery is not as expected.

When you are given the green light to go home, you will receive instructions about eating and drinking, physical activity, and wound and drain care (if applicable). Additionally, you will have a follow-up appointment scheduled, and your doctor will tell you signs of complications to look out for.

Recovery

Your post-operative recovery time should be shorter if you had less-extensive surgery or an endoscopic procedure, but it may be longer if you had a more extensive procedure/large incision.

You will have post-operative appointments in which you might need sutures or a drain removed, as well as wound care. Be sure to keep up with these visits as advised by your doctor.

Complications can occur with any type of procedure and tend to be more common if you have medical conditions or if you've had previous abdominal procedures. It's important that you get medical attention if you develop any signs of complications, including:

  • Fever
  • Abdominal pain
  • Constipation
  • Diarrhea
  • Vomiting
  • Hematemesis
  • Blood in the stool
  • Lightheadedness, dizziness, or passing out

After the recovery phase is over, you should notice an improvement in your symptoms. You might still need to maintain dietary adjustments and lifestyle habits that don't exacerbate your GERD. For example, your doctor may advise that you avoid smoking and drinking alcohol permanently so you won't have a recurrence.

Healing

You will have to keep your wound and drain clean if you have them.

You will also need to slowly advance your diet after GERD surgery. You might be able to resume your normal way of eating after a week if you had minor GERD surgery, or it may take several months if you had a fundoplication with an ulcer repair.

Your doctor will advise you accordingly. Generally, you will advance from one of these to the next.

  1. Clear fluids (like water and apple juice)
  2. Heartier fluids (like broth)
  3. Soft foods (e.g., apple sauce, mashed potatoes)
  4. Foods you need to chew

You might be able to advance your diet as tolerated if you had an endoscopic procedure, or this might need to be done on a schedule specified by your surgeon if you had an incision.

Coping With Recovery

While you are recovering, you may be instructed to avoid physical exertion for several weeks. Your surgeon will give you specific directions about advancing your activity.

Be sure to follow them, and don't advance just because you feel ready. Physical activity can cause sutures to break or may dislodge a surgical drain.

You can benefit from having someone help you with everyday tasks like doing the laundry and lifting grocery bags during this time.

Long-Term Care

You shouldn't need any specific long-term medical care as a result of GERD surgery. However, if you had certain types of magnetic devices placed, you might not be able to have a diagnostic MRI in the future. Make sure that current and future healthcare providers are aware of this.

Possible Future Surgeries

Generally, GERD surgery is a one-time procedure, without a need for any follow-up procedures. However, surgery may be necessary for the treatment of post-surgical obstruction caused by adhesions.

If you need another type of surgery for treatment of a different condition at some time in the future, be sure to tell your doctor about your GERD surgery. Your incisions and surgical restructuring can affect surgical planning for other abdominal procedures.

Lifestyle Adjustments

If you are prone to GERD, you will likely be advised to avoid the foods and habits that exacerbate the condition. Not only will you need to stay away from problematic foods and drinks, but you will also be advised to maintain habits like eating slowly and staying upright for an hour or so after eating and drinking.

Additionally, you might need to take medication that is used to manage gastrointestinal irritation and ulcers. Your doctor will work with you on creating a plan to prevent a recurrence of GERD.

2:04

Avoid These Things If You Have GERD

A Word From Verywell

Most of the time, surgery is not part of the treatment plan for GERD. But refractory GERD with severe effects may require surgical intervention. After surgery, it's important to maintain lifestyle habits that help prevent a recurrence of GERD.

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