New, less-invasive technique treats stubborn acid reflux disease.

The problem might begin with a burning sensation that starts behind the breastbone and radiates to the neck and throat. In addition to this pain, known as heartburn, there may be nausea, regurgitation, bad breath and tooth decay. These are some of the telltale symptoms of a common condition known as gastroesophageal reflux disease, or GERD.

The term gastroesophageal refers to the stomach (gastro) and the esophagus, or food pipe. The esophagus empties into the stomach through a circular band of muscle called the lower esophageal sphincter (LES). If the LES does not open and close properly, digestive acids from the stomach can flow back into the esophagus and cause symptoms.

“When this backflow of stomach acids happens persistently, the condition is diagnosed as GERD,” notes David A. Napoliello, MD, who is board certified by the American Board of Surgery and is a Fellow of the American College of Surgeons. “Over time, GERD can damage the esophagus and lead to serious complications.”

Among these complications are esophagitis, or inflammation of the esophagus; and stricture, a narrowing of the esophagus due to scar tissue from acid erosion. Another complication is the formation of ulcers in the esophagus, and yet another is the development of precancerous changes in the tissue, a condition called Barrett’s esophagus.

Being obese or pregnant, smoking, overeating, eating late at night; eating certain foods, such as fried or fatty foods; drinking alcohol or coffee, and taking certain medications, including aspirin, can all be contributing factors in the weakening of the LES and the development of GERD. Another factor associated with GERD is hiatal hernia.

“There is a natural space in the diaphragm, which is the thin muscle wall that separates the chest cavity from the abdomen, that allows the esophagus to pass through to the stomach. It’s called the hiatus,” explains Dr. Napoliello. “The hiatus can become abnormally large from actions such as years of coughing or straining. The stomach can inappropriately slip upward into the chest cavity though that enlarged hiatus. That is a hiatal hernia.

“The normal position of the stomach is a major force in reflux management. When the stomach and its connection to the esophagus are in the wrong anatomical position, the proper food depositing mechanism is broken. This contributes significantly to the heartburn and regurgitation associated with GERD.”

With GERD and hiatal hernia, people can experience all of the usual symptoms of GERD and also suffer additional symptoms attributed to hiatal hernia. These can include difficulty swallowing and respiratory issues such as chronic coughing and asthma-like symptoms.

Combined Repair

People can have GERD without having a hiatal hernia and a hiatal hernia without having GERD, but in most instances, people with hiatal hernia also have GERD. They generally co-exist. In some cases of simple hiatal hernia, there may be no symptoms, but symptomatic patients are treated with medication or surgery, relates Dr. Napoliello.

“There is a type of hiatal hernia called a paraesophageal hiatal hernia that is dangerous because with it the stomach can get constricted and its blood supply can get cut off,” he informs. “With that type of hiatal hernia, surgery is indicated upon diagnosis.”

When surgery for GERD with hiatal hernia is warranted, Dr. Napoliello can typically treat both conditions during one surgical session. He performs most of these combined procedures as laparoscopic surgeries with the patients under general anesthesia. Laparoscopic surgery is a minimally invasive technique that uses thin instruments and a camera inserted into the abdomen through tiny incisions. The surgeons view the esophagus, hiatal hernia and surrounding tissue on a video screen.

Fortunately, Dr. Napoliello has expertise in surgically treating GERD with hiatal hernia. He is a specially trained reflux surgeon who completed a fellowship in minimally invasive and advanced laparoscopic surgery at the world-famous Mayo Clinic.

“During the combined GERD/hiatal hernia surgery, we begin by repairing the hiatal hernia,” observes Dr. Napoliello. “That involves first putting the stomach back into its appropriate position. Then we sew the defect in the diaphragm closed with or without the use of a biologic mesh patch. After that, we pursue the anti-reflux procedure.

“There has been classically one type of anti-reflux surgery, called Nissen fundoplication, during which the surgeon wraps the upper portion of the stomach around the esophagus. This adds pressure to the LES and lower end of the esophagus. This procedure, although tried and tested, has some rare pitfalls that would favor a simpler intervention.”

Now, however, there is a new option for GERD treatment that is less invasive and proving to be equal, if not more effective than fundoplication in reducing GERD symptoms. This technique uses a reflux-preventing device called the LINX Reflux Management System.

Repair Techniques

The LINX system is a drug-free treatment for patients who continue to experience significant GERD symptoms despite conservative treatments such as lifestyle changes and acid-suppressing medications. The LINX procedure is considerably less invasive than fundoplication because it doesn’t require any surgical changes to the anatomy.

“The LINX device is a small, flexible, circular band of interlinked magnetic beads made of titanium,” describes Dr. Napoliello. “The device is placed around the base of the esophagus, and it essentially acts as a new, artificial lower esophageal sphincter.

“The beads in the device form a strong magnetic bond, which holds this artificial LES tightly closed. When patients swallow, the movement of food passing through the lower part of the esophagus breaks that bond and allows food to pass from the esophagus into the stomach. After that, the magnetic bond quickly reforms, which resists gastric pressures and prevents acids from flowing backward.”

Surgery to install a LINX Reflux Management System can be done as an outpatient procedure or with an overnight stay in the hospital. A standalone LINX procedure takes about one hour to perform. When done as a GERD/hiatal hernia repair, surgery time is slightly longer, about an hour and a half. The LINX device can be removed or replaced if necessary.

“The LINX device was developed by pioneers in reflux surgery and studied for more than ten years,” reports Dr. Napoliello. “It is a safer choice for people whose GERD has not responded to medications, and surgery is the next step in treatment.”

The LINX technique is also a good option for those who are concerned about the risks and side effects of long-term medication use to manage their GERD symptoms, adds the doctor.

“There have been reports recently questioning the standard medical management of GERD, especially the use of proton pump inhibitors,” states Dr. Napoliello. Proton pump inhibitors are a group of medications that stop production of a protein in the stomach that is necessary for acid secretion.

“These medications have been linked to decreased calcium and magnesium, stomach tumors, blood clots and even the development of dementia. Patients who have concerns about these risks now have a new answer for treatment of their GERD. It is the less invasive surgery using the LINX device.

“The LINX Reflux Management System is a simpler, more readily reversible option that can provide significant GERD relief. The LINX procedure is excellent for GERD, especially for GERD in combination with hiatal hernia.”