Gastroesophageal reflux surgery (anti-reflux surgery)

What is Gastroesophageal Reflux Disease?

Also known as GORD, gastroesophageal reflux disease 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 can correct this. Long-standing GORD can lead to pre-cancerous changes in the gullet, called Barrett’s oesophagus.

Symptoms can include:

• Heartburn: a burning feeling in the upper abdomen. It can travel through the chest and into the throat and neck and 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: this 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 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 involves 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 gastroesophageal reflux surgery 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.

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 size of hernia or anatomical difficulties. So it may be necessary for the surgeon to convert to an open method. Occasionally it will be advisable not to perform the full wrap. If this is the case, a partial wrap is constructed.

What are the benefits of this surgery?

This operation is offered to patients with symptomatic gastroesophageal reflux disease where their symptoms haven’t improved from non-surgical treatments or are unable to take life-long medications. The aim of this surgery is to relieve the patient’s symptoms and to improve their quality of life.

What are the risks or complications?

The rate of complications has reduced since the laparoscopic approach has been adopted. General potential problems associated with anaesthetics will be discussed 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. These include:

• Dysphagia: meaning difficulty in swallowing. This can occur for a few days, weeks or months after surgery. It’s 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: this may occur with consequent gas bloating and excessive passing of flatus. Cramping may occur as a result however this is not uncommon and should resolve with time.
• Early satiety: meaning feeling full very quickly. This is because the stomach is a little smaller and may cause an initial weight loss, however over time the stomach adjusts to accommodate a normal meal. It’s very important not to gain any excess weight after surgery.
• Wrap migration: meaning upward or downward displacement of the wrap. This is very rare and will require further surgery.
• Recurrent symptoms: heartburn 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 can be investigated and appropriate advice given, which may include revision surgery.

Long-term problems

Laparoscopic anti-reflux is successful in 85-90% of cases. However, 10-15% of cases will have recurrent symptoms within 10 years after the operation. It’s 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.

Other available treatments

There are some other treatments that can help to reduce GORD symptoms. These include:

Stretta

An alternative to traditional surgical anti-reflux options, Stretta is a minimally invasive endoscopic procedure that is performed to treat symptoms of GORD using radiofrequency (RF) energy. The aim of the procedure is to reduce and resolve the symptoms associated with reflux. It can also remove the need for medication in certain patients. Stretta is performed under general anaesthetic and is a day case procedure. In the weeks following treatment, there should be an improvement in barrier function and less episodes of reflux.

LINX® Reflux Management System

The LINX® System offers another treatment option instead of traditional anti-reflux surgery. LINX® is designed to treat the symptoms and problems associated with gastro-oesophageal reflux disease.

The LINX® System consists of small flexible titanium beads that have magnetic cores. It is the magnetic attraction between the beads that helps the lower oesophageal sphincter to resist opening to gastric pressures. This can prevent reflux from the stomach spilling up into the oesophagus. The force of swallowing temporarily breaks the magnetic bond to let food and liquid pass into the stomach. Magnetic attraction is designed to close the lower oesophageal sphincter straight after swallowing. LINX® is typically performed as a day case and takes approximately 45-60 minutes.