Anti-Reflux

Acid heartburn (or gastro-oesophageal reflux disease) is a common condition and most of us have suffered from it at some stage of our lives. However, for some people it can be a real nuisance with severe discomfort during the day and night.

Most of the time heartburn can be controlled with simple medication that works well. However, for some people the medication doesn’t completely control their symptoms or they may not want to be dependent on tablets for the rest of their lives. Keyhole surgery to prevent acid reflux may be an option and the commonest operation is a laparoscopic fundoplication.

This is performed through keyhole surgery and requires a one, or sometimes two, night stay in hospital. Most people are able to return to driving after one week and return to work after two weeks.

The operation works well for about 90% of people who can stop their anti-acid medication completely.

The operation is not appropriate for everyone and it may be necessary for you to have further investigations before deciding if the surgery is likely to help.

Q. What is gastro-oesophageal reflux disease (GORD)?

A. There is a thickening of the muscle layer at the lower end of the oesophagus (lower oesophageal sphincter) which acts as a valve. It relaxes to allow swallowed food and liquid to pass into the stomach but then contracts when the bolus of food has passed through. If this is not working properly then acid from the stomach can reflux back into the oesophagus. This may be felt as heartburn. Many of us will suffer from heartburn at some stage and it is usually quickly relieved with antacid medication. For some people it occurs frequently and is persistent. Many people take medication, such as a proton-pump inhibitor or PPI, that neutralises the acid in the stomach and controls their heartburn. These are very good tablets that work well in most people.

In some people the reflux symptoms can be more severe; their heartburn is worse when they lay down or bend over, they can wake in the night with a choking sensation or they get significant acid erosion of their teeth

Q. What is a laparoscopic fundoplication?

A. A laparoscopic fundoplication is a 'keyhole' surgery operation to treat gastro-oesophageal reflux disease (GORD). The operation involves wrapping the top of the stomach around the lower end of the oesophagus to create a one-way valve into the stomach. This allows food and liquids to pass into the stomach but prevents acid from refluxing back into the oesophagus causing heartburn.

Q. Who should have this operation?

A. The operation is normally offered to patients with quite severe or troublesome acid reflux that is not fully controlled by anti-acid medication. It is also a good option for younger patients who don't want to take long-term medication for their heartburn. Most patients will have had, or will need to have, an endoscopy to look for evidence of inflammation of the lower oesophagus (oesophagitis) due to acid reflux. If the endoscopy is not conclusive then further investigations, such as a barium swallow or oesophageal studies, may be required to ensure the operation is appropriate.

Q. What does the operation involve?

A. The operation is performed under a general anaesthetic and takes about 90 minutes. Five small incisions (cuts) are made in the upper abdomen to allow me to insert a camera and instruments through the tummy wall to perform the operation. At the end of the procedure these incisions are closed with invisible, dissolvable stitches.

Q. Will there be pain?

A. You must expect some pain after any abdominal operation. This may be in the upper tummy where the incisions are or in the left shoulder-tip. You will be given painkillers, which you should take regularly for about 5 days.

Q. What are the risks of the operation?

A. A laparoscopic fundoplication is a safe and straightforward procedure for the vast majority of people. Over 90% of people have an improvement in their acid reflux symptoms and may come of their medication completely. However, no operation is completely without risk and there are some points you need to be aware of:

It is possible that I may not be able to perform the operation through keyhole surgery because of inflammation, bleeding or unusual anatomy. In this situation I would proceed immediately to an ‘open’ operation which involves a 20cm scar in the upper abdomen, a longer stay in hospital (4-5 days) and a longer recovery at home afterwards (6-8 weeks).
About 1 in 10 people will get gas bloat, which is difficulty in belching and upper abdominal discomfort particularly if they eat too quickly or drink fizzy drinks.
About 1 in 10 people notice an increase in flatulence after this operation.
About 1 in 20 people will have persistent dysphagia (difficulty swallowing) with certain foods and rarely we have to reoperate to loosen the wrap if it is too tight.

Q. What can I expect to do after the operation?

You should gradually resume your normal activities, as you feel able.
You can shower, bathe and get the wounds wet after 24 hours.
Don’t soak for too long and gently dab the wounds dry for a few days.
Most people return to work within two weeks of surgery depending on your job.
You can drive as soon as you are safe to do so and for most people this is about 7-10 days after surgery.

Q. Do I need to alter my diet after the operation?

A. In the first few weeks after surgery there will be swelling at the lower end of the oesophagus. This means bulkier foods - typically bread, meat, rice and pasta - may get stuck on swallowing and cause some temporary discomfort. This can last up to 8 weeks after the operation so you may want to stick to a softer or sloppier diet during this time. Remember to chew your food well and eat slowly. Many patient feel full up quite quickly after a laparoscopic fundoplication. You may not be able to eat all the food on your plate and, for this reason, many people will lose weight after this operation.

Q. What should I look out for after the operation?

A. You should contact the ward where you had the operation or my secretary if you develop:

a persistent temperature (>38ºC)
worsening abdominal pain
worsening difficulty swallowing

If you don’t get a response from them then you may need to contact your GP. You shouldn’t need to see your GP routinely.