A 40-year-old patient from Houston, Texas presented to Houston Heartburn and Reflux Center with persistent acid reflux related symptoms following a novel anti-reflux procedure. Patient has been struggling with severe acid reflux related symptoms like heartburn and food regurgitation for many years. He had poor symptom control with daily Dexilant and strict dietary habits. He underwent a new procedure for acid reflux called Bicorn, in Germany. Procedure was performed through tiny incisions and recovery was fast. Surgery consisted of standard hiatal hernia repair, but instead of a Nissen fundoplication, the angle of His was reconstructed using couple of sutures. The angle of His is an angulation present on the left side of esophagus as it joins the stomach. This angulation contributes to the anti-reflux barrier. As acid reflux develops, and hiatal hernia starts to form, the angle of His gets progressively obliterated. Phrenoesophageal membrane and right diaphragm crus are also part of the anti-reflux barrier anatomy. The phrenoesophageal membrane anchors lower esophagus sphincter to breathing muscle. The right crus creates a tunnel like hiatal opening that separates the intra-abdominal esophagus from the chest cavity. Both structures are stretched and thinned out as acid reflux progresses and hiatal hernia grows.
Restoring the angle of His, surgically (BICORN procedure) or endoscopically (TIF, GERD-X), short of doing a Nissen fundoplication is not enough to stop acid reflux. The anti-reflux barrier is not just an anatomical structure. Rather, it is a complex physiologic barrier that relies on esophageal motility, lower esophagus sphincter function and gastric motility. Lower esophagus sphincter function is probably the most important factor in preventing acid reflux. Transient lower esophageal sphincter relaxation, TLESR, as opposed to basal lower esophagus sphincter pressure, is the most common mechanism for reflux in both normal and GERD patients. Neither TLESR events are increased, nor is basal lower esophagus sphincter pressure decreased in acid reflux patients. Rather, GERD patient TLESR events are more likely associated with acid reflux leading to increased esophageal acid exposure. TLESR events are controlled by electric impulses generated in various parts of the stomach and possibly esophagus. TLESR dysregulation leading to GERD is not fully understood. However, any procedure or medication that reverses TLESR dysregulation is most likely to control GERD.
Several studies have shown that Nissen fundoplication surgery reduces TLESR events as well as the likelihood of acid reflux during TLESR leading to effective acid reflux control. BICORN procedure and hiatal hernia repair by itself without a wrap do not alter the physiology of the anti-reflux barrier leading to poor acid reflux control.
A properly performed hiatal hernia repair and Nissen fundoplication is currently the only anti-reflux procedure that addresses both anatomy and physiology of anti-reflux barrier. It is crucial, however, to find an expert acid reflux specialist to manage your acid reflux disease. Not all Nissen fundoplication surgeries are created equal.
If you struggle with acid reflux give us a call at 832-945-8717