What is Acid Reflux?
Acid reflux is a common condition than affects around 40% of the adult population in Western societies. It is due to acid content (often combined with bile) refluxing back into the oesophagous and typically causing heartburn, lower to mid-chest pain, burping and food regurgitation. Sometimes, patients may also complain of change of voice, swallowing or breathing difficulty, nausea, sore throat, night-time coughing or recurrent chest infection.
This disorder is also called gastro-oesophageal reflux disease (GORD) and is caused by a weakness of the circular lower oesophageal sphincter (LOS). The LOS is normally situated below the diaphragm and acts like a valve preventing stomach content from moving back into the oesophagous. In a condition called hiatal hernia (HH) the LOS is progressively displaced upwards into the chest, as the stomach bulges through a hole in the diaphragm. With time the HH increases in size thus exacerbating reflux symptoms, as the LOS becomes unable to fulfill its role as an anti-reflux flap valve mechanism. Additionally, certain factors such as obesity, pregnancy, smoking, alcohol, or food (chocolate, garlic, caffeine, spicy food, citrus) may impair even further its function thus aggravating GORD.
How is GORD diagnosed?
Clinical symptoms are quite typical of GORD and often no further test is initially required before treating patients with antacid medication [proton pump inhibitor (PPI), H2 antagonist]. Additional tests are generally performed to assess the severity and possible complications of GORD, or prior to surgery.
- Barium swallow
- Oesophageal manometry
- Abdominal/Chest CT-scan
- 24 hour pH-testing
How is GORD treated?
- Most patients can be successfully treated by the combination of dietary and lifestyle measures (stop smoking, decrease caffeine and alcohol intake, weight loss, small meals and no meals within 2 hours from bedtime, raise head of bed) as well as antacid medications
- Anti-reflux surgery may become an option when GORD persists or worsen despite adequate conservative measures and optimal antacid medications
Who needs anti-reflux surgery?
- Patients with severe symptomatic GORD despite optimal treatment
- Patients with large paraoesophageal HH
- Young patients who need lifelong PPI treatment
- Non-compliance or serious adverse event associated with PPI
- Patient choice
- Laparoscopic (keyhole) fundoplication is the operation of choice where all or part of the stomach is wrapped around the end of the oesophagous and LOS, and sutured in place
How is anti-reflux surgery performed?
- The procedure is performed under general anasthaesia and the patient stays in hospital 24-48 hours.
- Preference is to perform the procedure via 5 small skin incisions in the upper part of the abdomen.
- The aim of this procedure is to safely reduce the entire stomach and lower part of the oesophagous (LOS) back into the abdominal cavity, to tighten with sutures the hole in the diaphragm through which the oesophagous passes, and to create an anti-reflux mechanism with the upper part of the stomach (fundus) that is sutured around the lower oesophagous.
- The wrap (or fundoplication) can be complete (360o; Nissen fundoplication) or partial (270o Toupet fundoplication, or 180o Dor fundoplication)
- Prof Berney’s preference is to offer a partial fundoplication to his patients as it reduces the risk of post-operative complication.
- In the presence of a large paraoesophageal HH the hernia sac is dissected out from the chest and totally excised. Furthermore, the diaphragmatic repair is reinforced with placement of a prosthetic mesh that is fixed with fibrin glue.
- Once the repair is satisfactory, a small drain (plastic tube) is left overnight to ensure that no blood collects in the abdomen.
- The patient may start drinking only few hours after surgery and will be discharged home on a soft (puree) diet for 1-2 weeks.
- Once discharged home, the small waterproof dressings covering the wounds can be safely removed 5 days later and there is no need to remove the stiches as they spontaneously dissolve within few weeks.
- Follow-up appointment is made for 2 weeks after surgery.