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Surgical Options for Reflux

G. Kevin Gillian, MD, FACS, is Medical Director of the Virginia Hospital Center Physician Group-Hernia & Heartburn Institute, and Medical Director of the Heartburn Center at Virginia Hospital Center. He has a B.S. from Duke University and received his medical degree from University of Missouri-Columbia School of Medicine. Residency at Western Pennsylvania Hospital was followed by a fellowship in advanced laparascopic surgery at the Minimally Invasive Surgical Training Institute, and he teaches and lectures throughout the world. He is a Fellow of the American College of Surgeons, secretary-treasurer of the American Society of General Surgery, and member of the Society of Laparoendoscopic Surgery and other professional societies.

Medications have a place in treating gastroesophageal reflux disease (GERD), but
G. Kevin Gillian, MD, FACS, Virginia Hospital Center Physician Group–Hernia & Heartburn Institute, and Medical Director of the Heartburn Center at Virginia Hospital Center, warns against overreliance on them for several reasons.
Of greatest concern is that since 1980, reflux-induced adenocarcinoma of the esophagus has multiplied for men and women in all age groups. “It’s a rare cancer, but the numbers are going in the wrong direction,” he said.
“A lot of people are masking symptoms and continuing to reflux,” he said, referring to the approximately 20 million people who use proton pump inhibitors (PPIs). PPIs neutralize acid, but bile and other digestive enzymes continue to reflux up to the esophagus from the stomach. The sphincter mechanism remains dysfunctional and a hiatal hernia may continue to cause pain.

Is It Reflux?

Dr. Gillian noted reflux-type symptoms sometimes mask other conditions, such as gallbladder stones or angina, or reflux is not actually occurring. In these cases, PPIs, antacids, and other GERD medications are ineffective, no matter the amount or frequency of dosage.
Two diagnostics are used: (1) esophageal function testing, and (2) 24-hour pH testing to record how much liquid refluxes up from the stomach. Dr. Gillian says these tests have shown that some patients do not have the condition for which they have been medicating (some self-medicating) for years.

Three Options

If GERD is confirmed and an endoscopy shows no underlying issues, surgery can be considered. Dr. Gillian performs three surgical procedures that deal with sphincter dysfunction.
Nissen fundoplication, the gold standard, augments and restores the sphincter mechanism through a laparascopic procedure that alters the natural anatomy of the stomach.
Less invasive but appropriate only for a subset of patients is Transoral Incisionless Fundoplication (TIF). An EsophyX device, inserted through the mouth, reconstructs the reflux valve.
In the last year, the LINX system has become available: A flexible band of magnets, enclosed by titanium beads, is placed around the lower esophagus to augment the physiologic sphincter. Side effects are less marked than after Nissen, but the control of GERD that surgery offers is maintained.

Threshold for Surgery

As with all elective surgery, some people cannot or do not want to be candidates. Others have such a large hiatal hernia that Nissen is their most viable option. However, Dr. Gillian suggested a broader range of people, especially younger patients who might otherwise face decades of daily medication, be informed about surgery, especially with LINX as an option. “It’s a quality of life issue and also a potential to reduce a cancer risk going forward,” he said.

Preventing Reflux by Augmenting the Sphincter

The LINX device is implanted around the esophagus just above the stomach. A band of magnetized titanium beads creates a dynamic valve that allows food to descend and can expand to allow for swallowing or belching, but resists opening to typical gastric reflux. Dr. Gillian was the first and, as of this writing, only surgeon in Washington, DC, and Virginia performing LINX surgery, and Virginia Hospital Center is one of about 50 sites nationwide where the device can be implanted.

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