When Does Acid Reflux Require Surgery, Not Just Medication?

Acid Reflux (GERD) Can Cause More Than Heartburn

Interviewer: Often, people think of acid reflux as something you just live with. Maybe you pop a pill, and you just move on with life. But for some, it gets so bad that medication stops being enough; it starts impacting your life, and then the conversation shifts to surgical options.

And today I'm talking with Dr. Eric Volckmann. He's a director of the University of Utah Health Bariatric Surgery Program. He's also a specialist in minimally invasive procedures for GERD and hiatal hernias. And today I'm going to learn more about when reflux becomes a surgical problem, and what that surgery actually looks like.

First of all, I wanted to say, I think I have acid reflux, and it took me a long time to kind of realize that I did. And really, it wasn't until I was told, "You might have acid reflux," because it was weird symptoms. It was like a stuffy nose and coughing. I didn't really think that I had that burning feeling in my throat.

Then I just started taking some medications, right? And after a couple of weeks, I ran out, and when I stopped, I'm like, "Oh, boy, I do have that tightness in my esophagus and that burning in my throat." That was pretty crazy to me. Is that kind of common?

Dr. Volckmann: Most patients start out with symptoms of heartburn, kind of burning pain behind the chest. We'll normally start with medications. A lot of them are over-the-counter now. Prilosec, which the generic name is omeprazole, and Nexium, which is esomeprazole. But people can also experience extra esophageal symptoms. They can sometimes get a hoarse voice, cough, and runny nose. Those can all be associated with it. As it gets more severe, patients can get aspiration; sometimes can't lie flat at night.

The initial symptoms tend to be heartburn. And fortunately, I don't have much heartburn, but I've had it a couple times, and it's pretty uncomfortable. The times I did have it, it's pretty miserable.

Interviewer: So this is going to seem like a silly question, I think, but are GERD and acid reflux the same thing?

Dr. Volckmann: Yes.

Interviewer: It is? Okay. Because I googled it, and it said, actually, GERD is just a more intense acid reflux.

Dr. Volckmann: Well, GERD stands for gastroesophageal reflux disease. And so most of that is acid reflux. Without getting into the weeds, it is possible to have reflux that's non-acid. But the majority of patients out there with normal intact stomachs, when they have reflux, it's going to be acid reflux.

Medication Reduces Acid but Does Not Stop Reflux

Interviewer: So really, the heart of this conversation that I want to have with you is for somebody who has GERD or acid reflux, and maybe they've tried some things; you generally recommend lifestyle changes, medication, and that's not working, when does surgery actually become part of the conversation?

Dr. Volckmann: So the medications we have do a great job of controlling the acidity in the stomach. The most common ones are called proton pump inhibitors, or PPIs, meaning that they keep the stomach from secreting hydrogen or acid ions.

And so while those medications can decrease the acidity of what's refluxing into the esophagus and take away the caustic injury, the burning, they don't take away the reflux.

So as reflux gets more severe, it gets more voluminous. You have more reflux coming into the esophagus. And so people start having problems related to that, things like cough, hoarse voice. In severe cases, patients can aspirate and get aspiration pneumonia or just wake up choking, getting to the point where they can't lie flat at night, having to sleep with a wedge. So those would be things we can see.

Patients will sometimes describe leaning over and having reflux come out of their nose or even mouth, those kinds of things. It gets to be sort of large volume.

Most patients with reflux have some degree of a hiatal hernia. And as they get bigger, patients can progress. If you have a larger hiatal hernia, what we would call a paraesophageal hernia where several centimeters of the stomach are above the diaphragm, patients can then start to have difficulty swallowing solid foods and get obstructive symptoms and regurgitation with that as well.

So there's sort of a spectrum. But when reflux gets severe, it's more related to the volume that we see rather than uncontrolled heartburn. Because the medications do a really good job of taking care of the sensation that patients experience.

Interviewer: All right. So if medications are working, great. But there could be a time in my life, because I have acid reflux or GERD, that medications just aren't getting the job done anymore. The volume becomes so much that the medications just aren't doing it.

Dr. Volckmann: Correct.

Persistent Symptoms of GERD May Signal the Need for Surgery

Interviewer: So if those symptoms start coming back, getting worse, that sort of thing, that's when the surgery conversation becomes real. You're going to go in and fix mechanically what's going on?

Dr. Volckmann: Yeah, that's exactly what happens. Surgery provides a mechanical barrier to the reflux. When we do these procedures, we often tighten the diaphragm around the esophagus. And then we take the top part of the stomach, that's called the fundus of the stomach, and we partially or completely wrap it around the esophagus to augment the pressure of the lower esophageal sphincter, and that can help prevent patients from having reflux. So it provides a mechanical barrier.

And there are multiple different procedures that allow us to do that. The most common ones are minimally invasive procedures, either laparoscopic or robotic, which from a patient's perspective is about the same thing.

They're called either a Nissen fundoplication or a Toupet fundoplication. Those are the two most commonly performed laparoscopic or robotic anti-reflux procedures, where we wrap the stomach either partially or completely around the lower esophagus, and make sure that the lower esophagus, where the lower esophageal sphincter is located, is below the diaphragm and within the abdominal cavity.

Recovery After GERD Surgery

Interviewer: When people hear surgery, even if it's laparoscopic, sometimes they think, "Oh, boy, this is a little scary. The recovery is a consideration. Is there risk?" What does reflux surgery look like today, now that you can actually do laparoscopic and robotic procedures?

Dr. Volckmann: They all fall under the umbrella of minimally invasive surgery. Anything that ends with a "scopy" means that we're using a scope, and "laparo" refers to abdominal. So laparoscopy is using a scope and small, narrow instruments, generally about five millimeters.

And so when I do this surgery, I'll use a total of five small incisions. Most of them are about the width of a pencil, and one may be about the width of an index finger to do the surgery.

Patients normally come in in the morning; they spend the night and go home the following day.

For any anti-reflux procedure or any procedure on the stomach, we generally have patients on a liquid diet after surgery for a couple of weeks.

The pain is quite well controlled. It's very similar to, say, having your gallbladder removed or your appendix removed. As a matter of fact, the incisions hurt not so much from this procedure. It's more that patients often feel the stitches that we sometimes have to put in the diaphragm. The diaphragm is an innervated muscle, so you can feel pain from stitches in the diaphragm.

But it's very well tolerated. It's not uncommon that we do these on older patients, sometimes patients in their 70s and 80s, and they're up cruising around saying, "When can I go home?"

GERD Surgery Can Be an Option for Patients Who Want to Avoid Lifelong Medication

All surgeries have risks, although this is pretty well managed from a risk perspective and really well tolerated, which also goes for indications for surgery. It's not just patients where the volume of the reflux is so great that the medications aren't working, but some patients don't tolerate the medications or don't want to be on a medication for the rest of their life. So that's another indication for surgery, although most insurers do want to see that patients have tried medical therapy prior to proceeding to surgery.

And even though I'm a surgeon and I enjoy operating, if you can avoid an operation, it's always a good thing. And so if it were me, I would want to go the route of medication first, but surgery works great when you need it.

Anti-Reflux Surgery Has High Success Rates in the Right Patients

Interviewer: When somebody's getting a surgical procedure for any sort of a condition, they kind of want some assurances that, "Hey, Doc, is this thing going to work? What's your confidence level that this is actually going to solve the problem that I'm having?"

When you do a workup with a patient, what is your confidence level that surgery will take care of the issue that they're complaining about?

Dr. Volckmann: Oh, when we do surgery, I feel really good that we're going to improve a patient's reflux. Hopefully, we'll take it all the way away. There are some circumstances where patients might continue to have a low-grade amount of reflux, but normally it should take it all the way away.

If your reflux is to the point where you are needing surgery, we would normally want to do a workup first. And so that includes an upper endoscopy or an EGD where we sedate you and look at your esophagus, your stomach, your duodenum. We can assess to see if you have a hiatal hernia, see if you have any inflammatory changes of the esophagus that could be precancerous that we'd need to worry about.

We also want to make sure that your esophagus functions normally. There are some conditions where the esophagus doesn't contract normally, and patients can experience the feelings of reflux, but really they're not clearing any reflux that refluxes into their esophagus.

So we all have reflux throughout the day, but most of us, our esophagus will push it back down into our stomach and clear our esophagus. So if your esophagus doesn't function normally, or say your lower esophageal sphincter doesn't relax normally, you can experience reflux, and that's a whole different ballgame in terms of how that works.

The other thing that we often want to have is pH testing or acidity testing just to confirm the presence of reflux.

So those three things: an EGD, esophageal function testing, also called esophageal manometry, and pH testing. If those studies confirm the presence of reflux . . . And sometimes you can avoid pH testing if you see inflammation of the esophagus that's consistent with reflux. If you have those findings, I feel really good that if we do surgery, we're going to improve your reflux and those things will get better.

Most Side Effects Are Temporary and Manageable

Surgery is not without risks, though. When we do the surgery, we do have to mobilize the esophagus from the diaphragm, and so that can predispose some patients to getting a hiatal hernia, and the repair can break with time. Ideally, we want it to last for life, but that is a possibility.

Any surgery, there's a risk of injury to surrounding organs, things like the liver, the spleen, but also to the organs that we're directly operating on, the esophagus, stomach.

Fortunately, if something like that were to happen, we normally would recognize and be able to repair it, and it shouldn't set patients back. But that also is . . . we're talking about risks that are much less than 1%. So sort of standard postoperative things that we can see as well.

Operating at altitude like we are here in Utah, patients sometimes can have low oxygen levels at night, and so a fair number of patients will need to go home on oxygen just at night when they're sleeping. So we always prepare patients for that.

But generally, when we're seeing patients in clinic, they're pretty miserable with their reflux, and so they're ready for surgery.

Interviewer: So that oxygen, is that then a lifetime thing, or is that just a during-a-recovery thing?

Dr. Volckmann: It's just temporary. Because we are operating in the upper abdomen, you have some incisions, and the body tends to take shallower breaths. So it would only normally be a week or two.

And it is an altitude-related phenomenon, so we definitely see that here in Utah, but training at sea level, that's not something that we would ever see.

Interviewer: What I'm hearing is if you're having a conversation with your doctor, it sounds like the diagnostic tools are pretty good at determining if that's indeed the problem. And it sounds like then the surgery is pretty good at taking care of the problem almost entirely, if not giving significant sort of relief to the patient. Is that correct?

Dr. Volckmann: Yes, that's correct. There are some things with the surgery. We do want patients to avoid vomiting after surgery because that can disrupt our repair. We would prefer for patients not to vomit ever, so we often send patients home with some anti-nausea medications.

And as I mentioned, we do have patients on a liquid diet for a couple of weeks, and that's because there's going to be some swelling where we did the operation, and we want that to settle down before patients start putting solid food across where we reinforced the lower esophageal sphincter to prevent patients from having reflux.

Interviewer: It also sounds like any of the side effects that might occur are solvable. It's something you can address.

Dr. Volckmann: Absolutely, yeah. Hopefully, those things don't occur, but if they do, they're certainly things that we can troubleshoot.

Partial and Complete Fundoplications Treat Reflux Differently

Interviewer: How does a patient usually land on one option versus another when it comes to surgery? How do you figure out which one's best for them?

Dr. Volckmann: When it comes to gastric fundoplications, I normally lean towards the 270-degree wrap called a Toupet fundoplication. Not like the toupee on your head, but Dr. Toupet.

Interviewer: Thank you for clarifying. I wasn't taking the procedure very seriously until you mentioned that.

Dr. Volckmann: Yeah, and that's a 270-degree wrap. The other very commonly performed one is a 360-degree wrap, or a Nissen. That's Nissen, not Nissan.

And I would say the tides have shifted away from the full wrap more towards the partial wrap over the last couple of decades because, after surgery, patients have an easier time being able to belch with the Toupet fundoplication and less problems with difficulty swallowing. So they can eat all food consistencies, and that's a big deal to patients. When patients have problems swallowing, we call that dysphagia. I don't want my patients to ever have that.

There are some other surgical options out there. Magnetic sphincter augmentation, that can sometimes have difficulty with insurance coverage. That's where we place a ring of magnets around the lower esophageal sphincter. It still requires surgery. Historically, foreign bodies around the lower esophagus or on the GI tract have not worked out well, but it's been around for a little while now, and it seems to work pretty well. It has a similar risk profile to a fundoplication.

For a long time, people have tried different endoscopic anti-reflux procedures, although in my experience and opinion, the laparoscopic procedures still work best.

You had asked about laparoscopy versus robotic surgery. Robotic surgery also uses a camera and long, narrow instruments. Some surgeons are more comfortable with a robot; some are more comfortable laparoscopically, which has been around a little longer, but the outcomes should be the same in capable hands.

Surgeon Experience Can Influence Outcomes

Interviewer: And as a patient is considering one option versus the other, say they're in their provider's office, and they're having this conversation, what are the kinds of questions that they might want to ask as the provider is going through the different options? It sounds like maybe "What is the risk? What is the reward?"

Dr. Volckmann: I think any time you're having a surgery performed, a really good question for the provider is, "How many of these procedures do you do? How much experience do you have in this procedure?"

If you come to the University of Utah, you'll probably be seen by myself or one of my three partners, and we all have subspecialty training in surgery on the stomach and esophagus.

I do several of these procedures a week. They all do several a week as well, and so we do large numbers of it. We also have a lot of experience seeing patients who've had surgery elsewhere and have had an issue that needs to be addressed.

I've described the surgery pretty simply, and the concept is simple, but like most things, there's a lot of nuance. And like most procedures, the more you do of it, the better you get. And so going to someone with a lot of experience and a lot of understanding of gastroesophageal pathology, not just reflux, but other things that can cause those kinds of symptoms, ends up being really important.

So I would say going to a specialist for this type of procedure, especially. I mean, if I were going to be having anti-reflux surgery, I'd want to go to someone who does a lot of the procedures and is knowledgeable of gastroesophageal surgery.

I think a lot of the other questions have to do with, "Am I a candidate?" And it really comes down to, "What symptoms are you having?" If your symptoms are pretty bad and they're not controlled by medication, then I'd go ahead with it. They generally don't go away, and they tend to progress over time.

Most things that we talk about in medicine are "When are the risks of the intervention outweighed by the benefits?" And so when the benefits of the surgery start outweighing the risks, which are pretty well managed, then I think it's reasonable to go ahead with surgery at that point.

Body Weight Can Affect the Best Surgical Option

Interviewer: I guess I was asking some of the questions you might want to ask a provider, like, "What's your level of confidence that this is going to take care of my issue? What do I need to know about the recovery process? How well will it take care of my issue? Is it going to make it go away, or is it going to just be a reduction, like 80% of my symptoms will go away?" I think those are probably some good questions to ask too.

Dr. Volckmann: Yeah, for sure. As I mentioned, most patients with reflux have some degree of a hiatal hernia. That's a hernia where the lower esophagus and the proximal stomach can move up above the diaphragm and either be fixed or sometimes just move up and down throughout the course of the day.

And so long term, what we worry about is that hiatal hernia that we have to close coming back. It's more rare with this procedure that the wrap of the stomach actually fails, although it can happen. It's just probably more common that the stomach will herniate above the diaphragm, and that is something that can be weight-related as well.

And so as far as candidacy goes for these procedures and having good healing, ideally we're doing these procedures on patients who aren't smoking, because if you're smoking, your tissue integrity goes down and your healing is not as good.

Gastric Bypass May Be the Better Choice for Patients With Obesity

And also, it's important to be at a healthy body weight. As patients' body weight gets up above, say, a body mass index of 35 . . . And body mass index is a ratio of your weight to your height, kilograms per meter squared. Normally, you can find a calculator online and just plug in your height and your weight, and it'll tell you what your BMI is. But a body mass index of 35, that's where patients start having Class 1 obesity.

When you're getting into those weights, patients will normally be better served by having a gastric bypass rather than anti-reflux surgery. The weight loss that patients will experience will decrease the pressure on the stomach, and so that lessens reflux. Also, there's less acid in the little gastric pouch we make. So, overall, it is an amazing procedure for reflux.

So if I have a patient who's considering having weight loss surgery, which is also part of my practice, and we do a gastric bypass and they have reflux, they wake up the next day after surgery, and they're like, "Oh, man, I slept the whole night, and I had no reflux. It was great."

Interviewer: Oh, man.

Dr. Volckmann: We probably see with that procedure even less postoperative issues than we would ever see with the other procedures. However, it comes with some caveats. If you have any kind of weight loss surgery, you have to take vitamins and minerals for the rest of your life. There are certain foods you can't eat. Your portion size is restricted to about a cup. With a gastric bypass, you can't take nonsteroidal anti-inflammatory drugs, things like ibuprofen, Aleve, or steroids, and smoking can cause ulcers.

There's a lot that goes along with having a gastric bypass, which is really helpful for all kinds of weight-related medical problems, but someone probably with a normal body weight and just has reflux doesn't want to say, "Hey, sign me up for a gastric bypass." They'd much rather have a more appropriate procedure for their weight.

The Right Procedure Depends on Symptoms and Overall Health

Interviewer: So the gastric bypass surgery might be a good solution for somebody who's overweight and has not been able to lose weight, and it would also get rid of their reflux. Maybe not such a great solution if you don't want to have to do some of the lifestyle changes afterwards. Maybe losing some weight and then getting a standard acid reflux operation might be an option that a patient would consider, it sounds like.

Dr. Volckmann: Correct. So if somebody comes into my office and they've got pretty bad acid reflux, but they also have sleep apnea, they've got diabetes, or they've got high blood pressure, on multiple medications, and hyperlipidemia, all these weight-related medical problems, then it's sort of a no-brainer to go with a gastric bypass.

Also, a patient who is struggling with their weight and maybe has issues with their stomach emptying, they have gastroparesis, with a bypass, we're kind of bypassing, as the name would . . .

Interviewer: Imply. Right.

Dr. Volckmann: Yes. It would bypass the lower stomach. So problems with stomach emptying, gastroparesis, and delayed gastric emptying are really mitigated by a gastric bypass as well.

So a lot of benefits, but really it's ideal for the patient who needs weight loss to improve other medical problems in addition to reflux.

A Surgical Consultation Helps Determine the Best Treatment Plan

Interviewer: So for somebody listening right now and they're considering . . . they're like, "Maybe surgery is the next step," and they're on the fence, or they don't know what the next thing they should do to bring it up with their doctor, what's your advice?

Dr. Volckmann: Patients can always come in for a consultation. That's part of what we do. It is helpful when they've had some of their testing beforehand, things like an upper endoscopy or esophageal manometry. That's going to have to be done before we entertain surgery anyway.

However, it really comes down to patients who the medications aren't cutting it anymore, or they don't want to be on medications for the rest of their life. So when I see patients, I'm looking to see, "Can they lie flat at night? Are they having regurgitation? Are they having extra esophageal symptoms that we talked about, cough, hoarse voice, congestion, those types of things?"

For a patient who has reflux and is pretty well controlled with a medication, or very well controlled, I would normally tell them, "I would hold off on surgery for now and have it if any of those symptoms occur." That's what I would want if it were me, but there are patients who opt to have surgery before a medication.

We're happy to see patients from their primary providers, gastroenterology. We're always happy to answer questions. That's part of our job as surgeons, is really identifying who are appropriate candidates for surgery, not just doing the procedures.

Sometimes I'll run into people in the hospital or on the street, or hear from someone who knows me and is a family friend of someone who had surgery. They'll say, "So-and-so is doing so great. They said their reflux is just gone," or, "Hey, Doc, my reflux is gone. I sleep so well. I no longer have any heartburn."

Recently, I just saw a young man who the medications were controlling his reflux well. He no longer had heartburn, but he would feel stuff coming up into the back of his throat when he was being active and exercising. He was a young kid, and it was really interfering with his life. And so when you see someone back in clinic, and those things are all better and gone, it makes you feel good. It's really rewarding.