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Gastroesophageal Reflux Disease (GERD) is a common condition that affects millions of individuals, both children and adults, and accounts for roughly 75% of all esophageal disorders worldwide. With pharmaceutical advancements, this disease has largely been treated with medications, such as acid blockers, obviating the need for more aggressive surgical intervention. Unfortunately, most patients with GERD require strict adherence to their medications, and many become immediately symptomatic after missing even a single dose. Another complaint that patients have is the need for lifelong medical therapy, often started at a very young age. Recent studies, however, have re-energized the premise that surgical anti-reflux techniques, now performed with a minimally invasive approach, are as effective as or better than the latest medical therapy.

The main symptom of GERD in adults is frequent heartburn, also called acid indigestion, a burning-type pain in the lower part of the mid-chest, behind the breast bone, and in the mid-abdomen. Most children under 12 years, and some adults, have GERD without heartburn.¹ These patients can present with atypical symptoms, such as nausea, vomiting, postprandial fullness, and chest pain. Furthermore, respiratory symptoms such as choking, hoarseness, chronic cough, wheezing, asthma and recurrent pneumonia can be primarily due to GERD.²

The basic pathophysiological abnormality associated with this condition is the loss of the physical barrier to reflux, otherwise known as a functional lower esophageal sphincter. The presence of a hiatal hernia has also been associated with the pathogenesis of GERD. Studies have shown that reflux is seen more often in patients with non-reducing hiatal hernias versus normal subjects. Recent investigations have discovered that the presence of chemicals other than gastric acid, such as bile salts from the duodenum, not only contribute to, but actually accentuate the damage. The idea that the combination of gastric and duodenal juice is more noxious to the esophageal mucosa than gastric acid alone may explain the repeated observation that 25% of patients develop recurrent and progressive damage despite medical therapy. Complications due to the damage inflicted by repeated episodes of esophageal exposure include esophagitis, stricture, Barrett’s esophagus (intestinal metaplasia), and eventually cancer.

PCP’s and gastroenterologists currently treat patients with proton pump inhibitors, also known as acid blockers. In patients, however, who reflux a combination of gastric and duodenal juice, acid suppression therapy may give relief of symptoms, while still allowing mucosal damage to occur.³ Furthermore, there is evidence which shows that up to 80% of medically treated patients with Barrett’s esophagus continue to have abnormal acid exposure. Therefore, is reasonable to conclude that anti-reflux surgery produces more measurable and consistent results than medical therapy alone.⁴

Before proceeding to surgery, several studies confirm a patient’s candidacy. These include upper endoscopy, 24 hr pH monitoring, esophageal manometry, and contrast imaging. The data derived from these studies not only objectively confirms GERD, but also determine an individual’s likelihood of having a successful long-term outcome after anti-reflux surgery.

With the advancements in surgical technology, which have formed the foundation of minimally invasive techniques, the laparoscopic Nissen fundoplication has been established as the standard of care for anti-reflux surgery. This procedure aims at correcting the fundamental abnormalities associated with GERD. Laparoscopic techniques, using 5 small incisions, allow surgeons to perform a 360° wrap of the gastric fundus around the lower esophagus, therefore reinforcing the weakened sphincter mechanism. Often, reduction and repair of a hiatal hernia is performed simultaneously, and patients are typically able to be discharged on the first post-operative day. Due to the lack of a large incision, individuals have documented significantly lower post-operative pain, an earlier return to normal daily activity, and an overall higher degree of satisfaction. ⁵

Studies show that up to 85% of patients were free of symptoms 5-8 years after fundoplication, indicating that laparoscopic surgery provides a durable benefit in the vast majority of patients. ⁶ Clinical research has also shown that anti-reflux surgery not only halts the progression of intestinal metaplasia, but often leads to regression of Barrett’s esophagus and low grade dysplasia. ⁷ Finally, university based investigations have also shown that the Nissen wrap is equally safe for both younger individuals and those over the age of 65. ⁸

The need for lifelong medical therapy aimed at treating a diagnosis often made at a young age, the immediate return of symptoms that frequently occur upon missing even one dose, and the ability to perform the procedure in a minimally invasive fashion, make the laparoscopic Nissen fundoplication an attractive option for those individuals diagnosed with gastroesophageal reflux disease. At Dr. Phillips Surgical Associates, we have the capability of evaluating each patient’s candidacy for anti-reflux surgery, the training to perform it safely and effectively, and the office and hospital staff to make your experience a warm and pleasant one.


1 National Digestive Diseases Information Clearinghouse
2 Schwartz’s Principles of Surgery
3 Schwartz’s Principles of Surgery
4 Schwartz’s Principles of Surgery
5 Cir Esp. 2005 Jan;77(1):31-5.
6 Bull Acad Natl Med. 2005 Oct;189(7):1519-25.
7 Am J Surg. 2004 Jul; 188(1): 27-33.
8 Arch Surg. 2006 Mar;141(3):289-92.


Enrique M. Sta.Ana V, M.D., a board certified general surgeon with specialty training in advanced laparoscopic surgery, is a new member of Dr. Phillips Surgical Associates. Dr. Sta.Ana obtained his medical degree at the Marshall University School of Medicine. He completed his general surgical training at St. Elizabeth’s Medical Center in Boston, MA, and furthered his training via a fellowship in Minimally Invasive Surgery at the University of Massachusetts. He is a member of the American College of Surgeons, the American Medical Association, the Society of Laparoendoscopic Surgeons, and the Society of Gastrointestinal and Endoscopic Surgeons. Dr. Sta.Ana is dedicated to the various facets of general surgery in which minimally invasive techniques have made a significant impact.

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