Studies have shown that 7% of the American population suffer from daily heartburn and indigestion.Normally there are mechanisms that allow solids and liquids to pass down from the oesophagus into the stomach and prevent a reverse flow from the stomach to the oesophagus. There are multiple factors, which in combination prevent any reflux across the gastroesophageal junction. These mechanisms are the lower oesophageal sphincter pressure, length of intra-abdominal oesophagus, angle of His and folds of the gastroesophageal junction. In the case of gastroesophageal reflux one or a combination of these mechanisms are disturbed. The most common reason for the failure is the development of a hiatus hernia.
The majority of patients with reflux disease complain of heartburn. However, gastroesophageal reflux can result in a variety of symptoms some of which are not always apparent.
Patients may have
- heartburn and acid taste in back of throat
- dysphagia(difficulty in swallowing)
- water brash (excessive salivation giving a feeling of excessive liquid in the mouth)
- minor food regurgitation and vomiting
- dyspepsia (abdominal fullness and belching)
- upper abdominal and lower chest discomfort
- chronic coughing
- chest pain
- aspiration into the lung
- teeth discolouration
Management of GORD
The majority of patients have minor reflux symptoms, which are usually controlled by dietary modification and/or simple medications.
- Avoiding fatty, spicy and large meals.
- Reducing body weight
- Stopping smoking
- Sleeping with head raised to reduce acid reflux
These are alkaline liquids or tablets that neutralise acids in the stomach such as Rennies, Gaviscon. These medications can be bought over the counter or given as a prescription and on their own are only effective for minor reflux disease. In severe reflux disease cases they are usually used in combination with others
Acid Separation Medicines
- H2 Blockers (Histamine Receptor Blockers). These medications supress the acid secretion in the stomach by blocking the histamine receptor. Commonly used H2 Blockers are Cimtidine (Tagamet) and Ranitidine (Zantac).
- Proton Pump Inhibitors (PPI). These are very powerful acid suppressing medications. Commonly used ones are Omeprazole (Lozec) and Lansoprazole. They are very effective in controlling the majority of symptoms for many patients and the patient may be required to take them for long periods.
However Lifestyle modifications and the use of Medications do not help all patients. Significant proportions of patients suffer from severe disease and continue to experience symptoms even when they are on continuous medications. Surgical treatment offers a possibility of a cure for these patients.
When is surgery considered?
People with severe, chronic oesophageal reflux might need surgery to correct the problem if their symptoms are not relieved through other medical treatments. If left untreated, chronic gastro-oesophageal reflux can cause complications such as oesophagitis, oesophageal ulcers, bleeding, or scarring of the oesophagus.
Patients to be considered for surgery are as follows:
- Patients who do not respond to medical treatment.
- Patients requiring increasing doses of PPI.
- Young patients with long-term need for aggressive medical therapy.
- Patients who do not wish to undergo long-term medical therapy because of the inconvenience or fear of side effects.
- Patients who have severe erosive disease and are likely to require long-term high dose treatment.
- Patients with large hiatus hernia.
- Patients who develop severe complications of GORD, despite medical therapy, like oesophageal stricture, ulceration, Barrett’s oesophagus.
- Patients with progressively worsening extra-oesophageal symptoms, despite regular use of PPI.
It is important that patients with severe gastro-oesophageal reflux disease should be offered a choice of surgery to get relief of their symptoms. Nowadays this surgery can be undertaken laparoscopically with minimal morbidity and patients have good 5 and 10 year results.
The standard surgical treatment for GORD is Laparoscopic Nissen fundoplication. Laparoscopic anti-reflux surgery is a minimally-invasive procedure that corrects gastro-oesophageal reflux by reducing the hiatal hernia, reconstructing the oesophageal hiatus and reinforcing the lower oesophageal sphincter using the construction of a valve like mechanism by means of a partial 275 degree or a complete 360 degree Fundoplication3. This is an extremely effective operation and cures the problem of reflux instantly. The operation is done by keyhole technique.
Patients go home in one or two days. At the time of discharge patients eat a soft and sloppy diet and it takes few weeks to return to normal eating. The main side effects of the operation are difficulty of swallowing certain foods like bread and meat, and abdominal bloating. These settle within a few months in the majority of patients and only 5% of patients may have longterm problems of varying severity.
Frequently Asked Questions
Who can have this operation?
Anyone who is suffering from severe reflux disease that is affecting their quality of life and has not been able to be control it in spite of being on full medical treatment. Also those who are unable to take medication due to side effects.
Is the operation done by Keyhole?
Yes, the majority of patients are operated on using the Keyhole technique. In my own practice 99% of patients have Keyhole Surgery.
How long will I be in hospital?
The majority of patients would stay in the hospital after their operation for one or two nights. At the time of discharge the patient will have seen the dietician who will give advice about the dietary intake during the post-op recovery.
Will there be a lot of pain after the operation?
There will be a relative amount of pain and discomfort after the operation however you will be given painkillers that will control the pain very effectively to ensure your discomfort is reduced. The majority of patients are up and about with minimal pain with in a few days of the operation and usually stop taking pain relief by the end of the week.
How long before my diet can return to normal?
The dietician will give you advice regarding your diet in the recovery period. This usually consists of a soft and liquid diet in the first few weeks that gradually returns to normal diet at around 6 weeks in most cases.
How long will it be before I can drive again?
The patient is usually advised not to drive within the first week. If pain and discomfort is not a problem within the second week of post-op then you should be able to drive. Long distance and prolonged driving should be avoided during the first few weeks.
When can I return to work?
In most cases you should be able to return to work with in 4 weeks after the procedure unless the work requires heavy lifting and strenuous activity, in those situations a slow return to work is advised and heavy lifting should be avoided for 6-8 weeks.
Would I still need to take medication for reflux?
No the operation is there to provide a cure to your reflux problem and you will be advised to stop taking medication soon after your operation.