Gastroesophageal reflux surgery - anti-reflux surgery

What is Gastroesophageal Reflux Disease?

Also known as GORD, it is a condition that results from the acid in the stomach splashing back up into the oesophagus (gullet). When the sensitive lining of the oesophagus is exposed to stomach acid, burning pain (heartburn) may result. Gastroesophageal reflux surgery or anti-reflux surgery corrects this.

The symptoms may include:

  • Heartburn: a burning feeling in the upper abdomen. It can travel through the chest and into the throat and neck. It is believed to be caused by acid irritating the oesophagus.
  • Regurgitation: a warm salty, bitter taste in the mouth. It occurs when stomach contents flow back into the mouth, often when belching. Sometimes food may physically regurgitate to the mouth.
  • Chest pain: pain in the chest reflecting spasm in the oesophagus. It can be caused by the acid returning to the oesophagus and can mimic a heart attack.
  • Hoarseness: this can develop if the acid and/or stomach contents reach the mouth and throat.
  • Choking/Wheezing: may occur at night when stomach contents may enter the lungs.
  • In severe cases of GORD, patients may experience difficulty in swallowing, painful swallowing or bleeding from the oesophagus. The presence of high level of gastric acid in the lower oesophagus may lead to chronic dry cough.
  • Atypical symptoms: Nausea, bad breath, cough and difficulty in swallowing.

The likely causes of these symptoms are:

  • A weak lower oesophageal sphincter that acts as a valve to the stomach. This valve normally remains closed until swallowing forces it open and then closes. With GORD, this sphincter (valve) may be weak and acid splashes back into the oesophagus.
  • Hiatus Hernia: This occurs when part of the stomach bulges up through the diaphragm and into the chest. It has been suggested that a hiatus hernia can prevent the sphincter from working properly. Hiatus hernia is common in the population but not everybody with hiatus hernia will suffer from GORD.
  • Other factors that may contribute to GORD are fatty foods, smoking, chocolate, caffeine, alcohol, obesity and pregnancy.

How does gastroesophageal reflux surgery work?

The first part of the gastroesophageal reflux surgery or anti-reflux surgery operation will entail reducing the herniated stomach and bringing the lower part of the oesophagus into the abdomen. The widened hiatus in the diaphragm, where the oesophagus passes through, will be narrowed to prevent future herniation.

The second part of the gastroesophageal reflux surgery operation is called Nissen 360° Fundoplication. Basically this means creating a new valve, by wrapping the upper part of the stomach around the lower end of the oesophagus, to prevent abnormal reflux. This is the standard operation which can be done via keyhole surgery.

The gastroesophageal reflux surgery procedure is performed under general anaesthetic. A needle is passed through the abdominal wall and gas is introduced to distend the abdomen. At least five small incisions are made to allow the instruments and camera to be passed into the abdominal cavity to perform the operation.

During the operation, the wide opening of the diaphragm is narrowed by stitches (repair of the hiatus hernia), and the lower end of the oesophagus is pulled down and secured in the abdomen by a wrap of the stomach around the lower oesophagus.

There are a small percentage of patients who cannot have the operation performed laparoscopically, due to the huge size of hernia or anatomical difficulties. It may therefore be necessary for the surgeon to convert to the open method. Occasionally it will be advisable not to perform the full wrap and a partial wrap is constructed.

What are the benefits of this surgery?

This operation is offered to patients with symptomatic gastroesophageal reflux disease, who have not benefited from non-surgical treatments or are unable to take life-long medications. The aim of this operation is to relieve symptoms and to improve quality of life.

How safe is the treatment?

The complication rate has reduced dramatically since the laparoscopic approach has been adopted.

Potential problems

General problems associated with anaesthetics will be eliminated at your pre-assessment visit. The anaesthetist will explain the procedure to you beforehand and any questions you have can be discussed at this point.

Complications such as deep vein thrombosis, internal bleeding or bleeding from the skin wounds and infection, may rarely occur, and can be treated as required. Damage to the internal organs, chest infection and bruising is a possibility.

Specific complications

The following are potential short-term complications that may arise shortly after the operation.

  • Dysphagia: meaning difficulty in swallowing. This can occur for a few days, weeks or months after surgery. It is believed that the swelling around the area in the stomach and oesophagus causes discomfort when swallowing food. Time is required before the newly created valve will adapt to function normally. If swallowing is difficult due to tightness of the wrap, you may need further surgery to loosen the wrap, provided the gullet motility is normal.
  • Difficulty bringing up wind: may occur with consequent gas bloating and excessive passing of flatus. Cramping may occur as a result. This is not uncommon and will resolve with time.
  • Early satiety: meaning feeling full very quickly. This is because the stomach is a little smaller. This may cause an initial weight loss but over time the stomach adjusts to accommodate a normal meal. It is very important not to gain any excess weight after surgery.
  • Wrap migration: means upward or downward displacement of the wrap. This is very rare and will require further surgery.
  • Recurrent symptoms: of heart burn or regurgitation may occur in up to 10% of cases. There may be a variety of causes or sometimes no cause is found. These symptoms will be investigated and the appropriate advice will be given which may entail revisional surgery.

Long-term problems

Laparoscopic antireflux is successful in 85-90% of cases. 10-15% of cases will have recurrent symptoms within 10 years after the operation. It is unlikely for recurrent symptoms to appear after 10 years.

Sometimes, especially with large hiatus hernia, reflux symptoms may improve dramatically, but do not disappear completely and the patient may require occasional medication.

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