Gastroesophageal reflux disease (GERD) is a complex condition that can greatly diminish quality of life and increase the risk of serious diseases, such as esophageal cancer. Northern Dutchess Hospital marshals the full spectrum of nonsurgical and surgical solutions to address GERD. These include the latest advance in treatment: the LINX Reflux Management System.
Brian Binetti, MD, Medical Director of Metabolic and Bariatric Surgery for Health Quest Medical Practice
Approximately 20 to 25 percent of the patients Brian Binetti, MD, general surgeon on the medical staff of Northern Dutchess Hospital, treats have GERD. This statistic is reflective of the general population. The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) estimates that 20 percent of Americans have GERD, a condition that develops when stomach acid refluxes into the esophagus, causing a range of symptoms and complications.
Exploring the Causes and Signs of GERD
Dr. Binetti considers GERD a primarily anatomical problem. The condition develops due to abnormalities and related dysfunction affecting components of the esophagogastric junction, which includes the lower esophageal sphincter, crural diaphragm, angle of His — the angle at which the esophagus and stomach meet — and the gastroesophageal flap valve.
Lower esophageal sphincter dysfunction occurs when the sphincter is either too weak to close fully or relaxes when it should contract. In both cases, the sphincter remains open, which allows stomach contents to reflux into the esophagus. Taking certain medications, smoking and factors that increase intra-abdominal pressure, such as pregnancy or obesity, can raise a patient’s risk of lower esophageal reflux dysfunction, according to the NIDDK.
Hiatal hernia, which occurs when the upper part of the stomach bulges through the hiatus and into the chest, can also contribute to reflux by putting pressure on the lower esophageal sphincter, weakening it over time and compromising the crural diaphragm, which acts as a second barrier to reflux and helps to reinforce the lower esophageal sphincter. It is important to note, however, that not all patients with a hiatal hernia develop GERD.
Signs that warrant an evaluation for the condition may vary depending on reflux severity. Symptoms can range from heartburn and indigestion to chest pain, dysphagia, frequent regurgitation, bad breath, weight loss, nausea and vomiting. In severe cases, GERD can lead to inflammation or narrowing of the esophagus and irritate the lungs, resulting in symptoms such as chronic cough, laryngitis, asthma and chest congestion.
“It’s a spectrum — some patients may have symptoms occasionally or respond to dietary changes or exercise,” Dr. Binetti says. “Others take medication twice a day and use additional medication at night for breakthrough reflux and still have symptoms. Of the patients who are on proton pump inhibitors, 35 to 40 percent still have symptoms that affect quality of life.”
Left unaddressed, GERD can cause serious complications. The American Society for Gastrointestinal Endoscopy estimates that 10 to 15 percent of patients who have GERD develop Barrett’s esophagus, a condition characterized by cellular changes in the esophageal lining that raise the risk of developing adenocarcinoma of the esophagus. Patients with Barrett’s esophagus require disease-specific follow-up in addition to GERD treatment. The American College of Gastroenterology recommends follow-up endoscopy to monitor Barrett’s esophagus with no dysplasia every three to five years. Patients with Barrett’s esophagus and low- or high-grade dysplasia may require treatment, such as radiofrequency ablation.
Making the Diagnosis
The GERD workup begins with an evaluation and review of patients’ symptoms and medical history. Depending on the results of this exam, Northern Dutchess Hospital physicians may perform additional diagnostic testing, such as an upper gastrointestinal series, endoscopy, esophageal manometry or esophageal pH testing.
Dr. Binetti reviewing swallowing patterns in a patient who recently underwent esophageal manometry testing
Ambulatory esophageal pH testing is considered the gold standard for GERD diagnosis. During the test, a nurse inserts a catheter containing a pH sensor into the esophagus transnasally and monitors the pH content within the distal portion of the esophagus for a period of time, usually 24 hours. Throughout the test, patients are asked to keep a food journal to assess potential food-related triggers, including the timing of meals.
To perform esophageal manometry, a nurse passes a catheter containing a high-resolution manometry camera through the esophagus and into the stomach transnasally. The goal of the test is to evaluate the function of the esophagogastric junction.
A diagnostic imaging test, the upper GI series allows physicians to look for gastrointestinal abnormalities, such as hiatal hernia or esophageal stricture. Finally, upper endoscopy with or without biopsy may be performed to look at the inside of the mouth, esophagus and stomach. This test is usually performed if a patient has severe symptoms or physicians suspect the patient has esophagitis or Barrett’s esophagus.
The Northern Dutchess Hospital team emphasizes conservative care and typically starts with the least invasive diagnostic test. Additional testing that requires sedation, such as endoscopy, is subsequently performed as needed.
Surgery is not the only solution. Initial GERD treatment typically involves dietary changes and exercise, according to Dr. Binetti.
Dr. Binetti reviews surgical treatment options with a patient who suffers from gastroesophageal reflux disease
“Specifically, with diet, we advise patients to avoid eating too late at night or too close to the time before bed to give their stomach a chance to clear out before sleep,” he says. “Avoiding spicy and fatty foods, cigarettes, and alcohol, and putting blocks beneath the bedframe to create a downward slant that elevates the head above the feet is also helpful. If patients don’t respond to those first-line therapies, the next step is medication therapy, which usually involves taking a proton pump inhibitor once a day and goes up from there.”
Proton pump inhibitors are considered the most effective currently available medications for acid-related diseases, according to a review published in BMC Medicine. These drugs suppress the amount of acid produced by the stomach and are used to treat a variety of conditions, including GERD, esophagitis and peptic ulcer disease. Indications for proton pump inhibitor therapy in patients with GERD include short-term dosing of eight to 12 weeks to treat erosive esophagitis and long-term, on-demand or continuous therapy to manage symptoms, according to the BMC Medicine article. Other medications that may be useful in treating GERD include antacids, H2 receptor antagonists and promotility agents.
If patients don’t respond to conservative strategies, surgery to correct the underlying anatomical abnormality contributing to reflux may be necessary. Dr. Binetti commonly partners with gastroenterologists to determine the appropriate treatment plan for patients with GERD. He considers appropriate surgical candidates to be patients whose symptoms continue to significantly affect quality of life despite treatment and those who are concerned about taking medications long term to control symptoms.
An Advanced Surgical Solution
Many with GERD continue to suffer when nonsurgical treatments, such as dietary changes and medications, fail or cause side effects.
“Options are out there for patients whose current gastroesophageal reflux disease treatments are not improving their quality of life. Patients don’t have to suffer — we can do a more extensive workup, find the problem and treat it effectively,” Dr. Binetti says.
However, lack of awareness about the operations available to treat GERD may prevent physicians from considering surgery as an alternative for their patients.
“Unfortunately, only a small percentage of patients with GERD are currently offered surgery,” Dr. Binetti says. “I’d like to treat more patients who are on medication and continue to have a poor quality of life, but at this time, I probably end up treating only the more extreme cases within that demographic — patients whose primary care physicians and gastroenterologists have tried everything possible and still can’t make them feel better.”
Dr. Binetti hopes availability of the LINX Reflux Management System will reverse this trend. Unlike fundoplication, which alters patients’ anatomy, the implantable LINX Reflux Management System helps maintain a physiologically normal reflux barrier.
The implantable LINX Reflux Management System
Northern Dutchess Hospital is currently the only hospital in the Mid-Hudson and Lower-Hudson Valley to offer the LINX Reflux Management System, which is designed for patients who have abnormally high levels of acid in their esophagus as identified by esophageal pH testing and who wish to avoid continuous acid suppression therapy with proton pump inhibitors. The device consists of a quarter-size ring that is implanted around the outside of the lower esophageal sphincter and can be tailored to each patient’s anatomy.
“The ring is composed of magnetic beads,” Dr. Binetti explains. “The magnet is enclosed in titanium, and each bead is connected with a titanium wire to the bead next to it. Each magnet in each bead sticks to only the magnet to the right or left of it, so magnets stay close to each other at rest. As patients eat, the force of the esophagus pops the magnets open and food passes into the stomach.”
Dr. Binetti implants the ring using a robot-assisted approach. To perform the surgery, he identifies the area of the esophagogastric junction, where the lower esophageal sphincter is located, and dissects that area free. He then finds the vagus nerve, which runs parallel to the esophagus, and creates a small window between the nerve and the esophagus. Using a special device, Dr. Binetti measures each patient’s esophagus individually so he knows what size LINX device to use. He then places the LINX device around the esophagus and clasps the links between the magnetic beads together.
“Once that clasp locks, it cannot be separated,” Dr. Binetti says.
Following placement of the device, patients typically spend one night in the hospital, and recovery time after discharge is usually short. Many patients are ambulatory with minimal pain and able to eat a regular diet immediately after surgery. Because the device provides a more physiologically normal reflux barrier, patients can also experience other gastrointestinal functions, such as belching or vomiting, in a more natural way.
In addition, even though the LINX device contains magnets, patients can undergo an MRI or pass through airport security without incident in virtually all cases.
“In extremely rare instances, an MRI machine is so strong it can depolarize the magnets,” Dr. Binetti says. “However, 99 percent of MRI machines have a magnetic strength that won’t affect the magnets.”
Studies have found that the LINX Reflux Management System is a safe, effective alternative to proton pump inhibitor use. A 2016 review published in Clinical Gastroenterology and Hepatology reported data obtained at five-year follow-up appointments. It found that 85 percent of patients no longer needed daily reflux medication, 88 percent experienced relief from heartburn, and 99 percent no longer had regurgitation after placement of the LINX Reflux Management System.
“Options are out there for patients whose current gastroesophageal reflux disease treatments are not improving their quality of life. Patients don’t have to suffer — we can do a more extensive workup, find the problem and treat it effectively.”
— Brian Binetti, MD, general surgeon on the medical staff of Northern Dutchess Hospital
Updates in Anti-reflux Surgery
The LINX Reflux Management System is one of several surgeries Dr. Binetti performs to treat GERD. He also performs gastric fundoplication, hiatal hernia repair and transoral incisionless fundoplication.
Dr. Binetti discusses the surgical plan for a patient with anesthesiologist Michael Moses, MD.
The goal of fundoplication is to reinforce the strength of the lower esophageal sphincter and improve the anatomy and function of the gastroesophageal flap valve mechanism and esophagogastric junction overall. During the procedure, physicians use tissue from the patient’s stomach to restore pressure on the distal esophagus, which helps reinforce the lower esophageal sphincter and prevents stomach contents from refluxing into the esophagus.
“We essentially wrap the upper part of the patient’s stomach around the lower part of the esophagus,” Dr. Binetti says. “That helps recreate the tightness and the gastroesophageal flap valve.”
If necessary, physicians perform a hiatal hernia repair at the same time as the gastric fundoplication procedure. Following gastric fundoplication, patients typically spend one night in the hospital and are able to return to their usual activities within two to three weeks. Because the procedure creates a supernormal tightness, according to Dr. Binetti, patients eat a modified diet consisting of liquid and soft foods for three months after surgery. They may also experience symptoms associated with the tightness, such as dysphagia, or discomfort because they cannot burp or vomit as easily.
Physicians first performed gastric fundoplication in the 1950s through one large incision in the chest. The procedure has evolved through the years, and today, Dr. Binetti performs gastric fundoplication with or without hiatal hernia repair through several small incisions using the da Vinci Xi Surgical System — the latest-generation surgical robot.
“Robotic gastric fundoplication promotes faster healing with less pain and shorter hospital stays,” Dr. Binetti says. “There’s less risk of infection and hernia. It’s a much better-tolerated procedure than when it’s performed through a non-minimally invasive approach. Specific to the robot, the control of instrumentation and the visualization we get with the 3-D camera provide a superior experience while doing dissections during the procedure.”
In the modern era of minimally invasive surgery, approximately 85 to 90 percent of patients are able to stop taking medication to manage reflux within five years of gastric fundoplication, according to Dr. Binetti.
Adrienne Bolten, the registered dietitian for gastroesophageal reflux disease patients, reviews postoperative dietary restrictions with a patient.
Physicians perform transoral incisionless fundoplication (TIF) using the EsophyX device. The procedure achieves the same goal — creating a tighter, more functional esophagogastric junction and lower esophageal sphincter — as gastric fundoplication. However, TIF requires no incisions. Physicians use an endoscope to thread the EsophyX device through the patient’s mouth, throat and esophagus into the stomach, and the upper portion of the stomach is partially wrapped around the esophagus and secured with fasteners.
Using this approach, physicians can also repair hiatal hernias less than 2 centimeters in size and perform repeat procedures in patients who have had fundoplication in the past. To repair larger hiatal hernias, physicians perform laparoscopic gastric fundoplication.
Outcomes show TIF has a low rate of serious complications and can be effective in resolving regurgitation and heartburn that persists despite medical therapy, according to a 2016 review published in Current Opinion in Gastroenterology. Five-year follow-up data from the TEMPO trial, published in 2018 in Surgical Innovation, supports the conclusions of the literature review. The study found that TIF resolved regurgitation in 86 percent of patients at five years and atypical symptoms, such as chronic cough and asthma, in 80 percent of patients. In addition, only 34 percent of patients were still taking proton pump inhibitors at the five-year follow-up mark.
Like gastric fundoplication, TIF alters the anatomy and results in supernormal tightness that may lead to side effects, such as dysphagia and the inability to belch or vomit easily. Following TIF, patients also follow a modified liquid and solid diet for a prescribed period of time, similar to the recovery following gastric fundoplication.
“Previously, patients would have had to travel to a bigger medical center to access this level of care. However, all of these surgical options are available locally at Northern Dutchess Hospital, which provides not only high-quality care but also a friendlier and intimate environment.”
— Brian Binetti, MD, general surgeon on the medical staff of Northern Dutchess Hospital
Identifying the Right Procedure for Each Patient
TIF, gastric fundoplication and the LINX Reflux Management System each have specific advantages and disadvantages. TIF and gastric fundoplication, for example, irreversibly alter a patient’s anatomy, whereas the LINX Reflux Management System introduces a device into patients’ bodies. All three procedures, however, can improve patients’ quality of life and reduce or eliminate the need for long-term medical management. While the presence of a hiatal hernia can influence whether or not patients are appropriate candidates for the LINX Reflux Management System or TIF procedure, Dr. Binetti believes patients can, in large part, choose the type of procedure they prefer.
From left, Mary Valentino, RN, Metabolic and Bariatric surgical nurse; Mae Antonio, RN, Bariatric and GERD Coordinator; Dr. Binetti; and Bolten
“To a significant extent, this is a discussion to be had with patients about what they hope to achieve,” he says. “Do patients want something supernormal? Or something that’s more physiologically normal? I review what all the options entail and help guide their decision-making process.”
For more information about the services in place to address GERD at Northern Dutchess Hospital, visit healthquest.org, select “Northern Dutchess Hospital” and choose “Gastroesophageal Reflux Disease.”