Surgery

Sutures Reduce Side Effects

Rhode Island Hospital became the first hospital to simplify surgery for gastroesophageal reflux disease by eliminating the need to tie knots to close sutures. The technology, called the AxyaWeld Laparoscopic Sonic J™ System, uses ultrasonic energy to weld sutures together.

The new technology was first used by former hospital president and surgeon Joseph Amaral, MD. The surgery usually requires4 to 7sutures. Considerable skill is needed to tie each knot during minimally invasive surgery; on average it takes three minutes to tie a knot. The new technology, says Amaral, "simplifies the complicated process and results in a strong knot."

The suture welding technology, which can be used in open as well as minimally invasive procedures, also eliminates the knot bundle.

"Overall the process saves time and reduces stress for the surgeon with a result that is equal to or better than conventional knot tying in terms of the knot strength." Amaral says.

When Is Surgery Necessary?

Surgical correction of GERD is recommended in the following cases:

Continued pain or symptoms despite maximum medical therapy
The presence of Barrett's esophagus
Recurrent stricture formation on medical therapy
Recurrent bleeding or ulcer formation on maximum medical therapy
Continued regurgitation despite elimination of heartburn with medications
Need for lifelong therapy with medications, especially in a young person
Poor compliance with medications or patient desire not to take medications

Which Works Better-Medicine or Surgery?

All studies that have examined this question in a randomized, prospective manner, have found that surgery is at least equal to medical therapy with regard to symptom resolution and elimination of esophagitis. These studies have also documented a high rate of relapse if the medications are stopped in the medical treatment group. In most studies, the results are numerically better (but not statistically better) in the surgical group than in the medical group. Unfortunately, by the time these studies are complete, new drugs become available which confuse the issue. However, surgery is at least as effective as proton pump inhibitors in the treatment of GERD.

Why Doesn't Everyone with GERD have Surgery?

About 25% of patients with GERD will get better once their lifestyles are changed, and will no longer need medication. An additional 25% to 50% will have symptoms, but will only require occasional use of medicines or low dose, constant medication. Only about 25% of people with GERD will have severe symptoms and fall into the categories noted above. Surgery has complications, side effects that may last from months to a lifetime and a definite failure rate associated with it.

Surgery Side Effects and Failure Rate

Side effects of anti-reflux surgery are related to the creation of a valve at the lower esophageal sphincter where none previously existed.

These may include:

Difficult, painful swallowing that may last up to three months, but is usually gone in 4 to 6 weeks. It may be associated with pain in the shoulder as well. Although liquids usually go down without any difficulty, some people may experience problems with them.
Getting "full" easily since there is less stomach to hold food and liquids. Even a few bites can give the sensation of being full. This takes a few months to resolve in almost all patients. Meal size should be normal by six months. If a person eats less and gets full quickly, it stands to reason he or she will lose weight. Following anti-reflux surgery, patients can expect to lose 10 to 20 pounds. This resolves in a few months.
The inability to vomit because the valve stops the regurgitation of material from the stomach into the esophagus. Should a patient get food poisoning, get the flu, or drink too much alcohol, he or she will feel sicker longer than others and may have more epigastric abdominal pain. This shouldn't cause harm. Medications can be prescribed during this time.
The inability to belch. Although we try to make the wrap loose enough that patients can belch a little, those loud, roaring sounds from the pit of the stomach will be gone forever. If one ingests a lot of carbonation, such as in beer or a soft drink, he or she may experience a prolonged bloated sensation and even some epigastric discomfort until the gas passes from the stomach to the intestine.
More flatus (gas) than before the operation. Air that is swallowed and carbonation that is ingested must now be passed via flatus. Although this can be annoying at times, most people gradually accommodate this and don't find it problematic.

Failure Rate

The failure rate for anti-reflux surgery performed by surgeons with experience in the procedure and in the management of patients with GERD, is about 10% at 10 years. These results are from studies involving anti-reflux procedures performed with the conventional abdominal incision. Although 10-year follow-up studies with the laparoscopic approach are not yet possible, five year follow-up results with the laparoscopic approach are similar to those observed with the open approach.

If the Operation Fails

If reflux returns after an anti-reflux procedure, the procedure can be performed again or medications can be used. Complete evaluation to document the presence of reflux and to determine the causes of the reflux is necessary. The re-operation procedures can be performed either laparoscopically or open. However, the feasibility of doing the second procedure laparoscopically is less than when the procedure is done for the first time.

What Is the Chance the Operation Can't be Done Laparoscopically?

Overall, the likelihood that a procedure can be done laparoscopically the first time is greater than 95%. While obesity, a large liver or a very large hernia makes the procedure more difficult, it is usually some unforeseen problem that makes it necessary to convert to an open procedure. Therefore, it is impossible to predict who will need conversion to an open procedure, although the chance is less than 1% for our patients.

Complications During Surgery

Intra-operative complications during this surgery are unusual, but as with any operative procedure, they can occur. These can be related to the laparoscopy, to the operative procedure itself or to pre-existing illnesses in the patient.

Possible complications:

Bleeding is very unusual with these procedures. Blood banking is not routinely practiced preoperatively. Only one patient has required transfusion in over 250 such operations.
The most common intra-operative complication has little relevance under most circumstances. During the dissection of the esophagus and reduction of a hiatal hernia, a hole can be made in the lining of the thoracic cavity, the pleura. When this occurs, gas in the abdomen for laparoscopy enters the chest cavity. This may make ventilation a little more difficult during the operation, but it is still without risk.
Perforation of the stomach or esophagus can occur from the instruments used, from the dilating tube used to measure the esophagus during the procedure or because the tissues are very weak. Fortunately, this can almost always be repaired during the laparoscopic procedure by switching to an open procedure without any side effects.
The spleen is at risk of bleeding during the procedure because of its location. In our experience, no patient has required removal of the spleen (splenectomy) because injuries are usually small and the bleeding is easily stopped.

What are the Post-operative Complications of this Surgery?

Complications following this operation are also unusual. Less than 5% of patients will have a significant complication. Complications are usually related to a delayed perforation of the stomach, which results days after the operation. The instruments used can be traumatic to the tissues at times and lead to crushing of the stomach where it is grasped. The area may later tear and create a small, painful hole or perforation. This can almost always be fixed laparoscopically, via another operation. This complication rarely occurs, because measures are taken to prevent it.