Gastroesophageal reflux and antireflux surgery 

Heartburn, Gastro-oesophageal Reflux and antirefluxsurgery surgery explained

What is reflux?

When you have something to eat or drink, it passes down the oesophagus (gullet) into the stomach. The flow of traffic should definitely be one-way. However, reflux occurs when whatever happens to be in your stomach travels in the wrong direction back up into the oesophagus. Unlike vomiting, which is quite a violent activity, reflux mostly occurs without us being aware that it is happening.


Why does reflux happen?

There is a ring of muscle around the lower end of the oesophagus which is there to stop reflux. When we eat or drink, the muscle relaxes but it then tightens up when we have finished. If the muscular ring gets too slack, reflux can occur.


Does reflux always cause symptoms?

Certainly not. Almost all of us have a little reflux from time to time, but we just don’t know that it’s happening. However, if reflux happens more often than normal, this may well lead to symptoms developing.


What symptoms might I expect?

The most frequent symptom is heartburn which is a burning sensation in the chest. Run your hand down your breastbone. Heartburn is often most noticed at the lowest end of the bone and the discomfort rises upwards to an extent that varies from individual to individual. Sometimes the burning feeling can reach all the way up to the throat. Heartburn often seems worse after rich meals, citrus fruits, hot beverages or alcohol. Occasionally it can be felt deeply within the chest – almost within the back. Some patients notice reflux when some of the contents of their stomach ‘repeat’ by coming back up the oesophagus as far as the throat or even the mouth. A few patients notice discomfort or pain as they swallow. It is quite common for these symptoms to be worse at night or at other times when patients lie down.


What is oesophagitis?

Sometimes, even in people who have quite marked symptoms, the oesophagus may look entirely normal. However, some patients can develop oesophagitis. Whenever you see a medical term ending in -itis, this indicates inflammation. When inflammation occurs, this suggests that there is damage to that part of the body. Quite simply, oesophagitis means that there is inflammation within the oesophagus. The lining of the inflamed oesophagus looks red and sore. If the inflammation is severe, ulcers can form. Much the commonest cause of oesophagitis is reflux of acid from the stomach.


How does reflux cause oesophagitis?

The stomach makes acid which helps start off digestion by mixing with whatever we have to eat or drink. The acid is very strong so if it refluxes in sufficient quantities and often enough, it will begin to cause damage to the lining of the oesophagus. At first the lining may just appear rather more red than normal. Later on the lining of the oesophagus may begin to wear away and, in severe cases, an ulcer may form.


Why am I getting reflux?

In many cases we just do not know why the muscular ring that prevents reflux is not working properly. Some people do seem prone to getting reflux – especially those who smoke, drink excess alcohol, women during pregnancy or those who put on weight. Wearing tight clothes, stooping or bending forwards and eating rich, fatty foods all seem to increase the tendency to reflux. There are individuals who seem to lead healthy lives and have none of the above ‘risk factors’ yet experience troublesome symptoms. It is quite common for people to develop symptoms as a result of reflux when there are no signs of oesophagitis. Doctors believe that, in such cases, the lining of the oesophagus is unusually sensitive to reflux of acid.


Will I need tests?

A doctor may diagnose reflux just by listening carefully when you describe your symptoms and may treat you without the need for any tests. If they are not sure however or if the treatment does not work well, it is probable that they will arrange investigations.


What tests can I expect?

The first investigation that doctors usually perform if they suspect you might have reflux oesophagitis is endoscopy. This involves passing a thin, flexible tube through the mouth and down into your oesophagus. The doctor will be able to get a really good look at your oesophagus and stomach and check whether there are signs of inflammation. Although it sounds unpleasant, your doctor will take care to explain how the discomfort of the procedure will be minimised. Although not used routinely, some specialists will choose to measure the amount of acid you are refluxing. This can be done by measuring the amount of acid in your oesophagus over  a 24 hour period using a very narrow tube passed through the nose.


 And if I do not fancy having an endoscopy?

No-one is going to make you have tests although it is reasonable for the doctor to explain why it is important that you should do so. An alternative to an endoscopy is the barium meal test which will show up your oesophagus and stomach on x-ray. It does give less information than endoscopy but is good at showing up whether you have a hiatus hernia or whether your oesophagus is narrowed for any reason. It is worthwhile knowing that up to half of all patients with symptoms that suggest they have reflux turn out to have only mild inflammation or an oesophagus that looks quite normal.


Does it matter if I have a hiatus hernia?

The short answer is … not much. Instead of staying entirely in the belly as it should do, it is possible for part of the stomach to slide upwards into the chest. It does this by pushing itself through a hole (called the hiatus) in the diaphragm muscle. The hernia itself rarely causes any symptoms but it does seem to make reflux more likely. Do note (1) that hiatus hernia is very common, (2) that you can certainly have reflux without one, (3) that many people who have one do not get reflux. The importance of having a hiatus hernia can certainly be overrated.


So what is the best treatment for reflux symptoms?

Because the severity of the condition varies from being just an occasional nuisance for some people while others are quite seriously troubled, so the intensity of treatment varies from one individual to another. There may well be changes in your lifestyle that you can make to help. There are also medicines – either bought over the counter or prescribed by your doctor – that can help your symptoms. There is no simple ‘cure’.


How can I help myself?

Your symptoms are likely to lessen if you take measures to reduce the amount of reflux that you have. It is a bad idea to eat large, rich meals – especially late in the evening. Eat little but more often if necessary. If you are carrying extra pounds, losing weight is usually very helpful. If you indulge, cut down on alcohol and stop smoking. Do eat early enough in the evening so as to avoid going to bed with a full stomach. It may help to prop up the head of the bed. Try to avoid bending forward or wearing tight clothes as this can put extra pressure on your tummy. There are a variety of useful medicines that you can buy. Many contain antacids which neutralize the acid in your stomach. Ask your doctor for advice about medicines that help reflux symptoms.


Will I need treatment forever?

Many people find their symptoms improve greatly if they change their lifestyle to reduce reflux. Others may need to take medicines from time to time if their symptoms return. Some just cannot manage without taking drug treatment most of the time. It is very reassuring that taking extremely safe. There is a small number of people for whom drug treatment is not suitable for one reason or another. In such cases, surgery is definitely an option.


Is reflux oesophagitis ever serious?

For most people with the condition, reflux is just a nuisance and little more than that. In a few people, especially where there is severe inflammation of the oesophagus, there is a risk of complications which can include internal bleeding and narrowing of the gullet. If you are worried about these complications, it is best to have a chat with your doctor.


How is GERD treated?

GERD is generally treated in three progressive steps:

1. Life style changes

In many cases, changing diet and taking over-the-counter antacids can reduce how often and how harsh your symptoms are. Losing weight, reducing or eliminating smoking and alcohol consumption, and altering eating and sleeping patterns can also help.

2. Drug therapy

If symptoms persist after these life style changes, drug therapy may be required. Antacids neutralize stomach acids and over-the-counter medications reduce the amount of stomach acid produced. Both may be effective in relieving symptoms. Prescription drugs may be more effective in healing irritation of the esophagus and relieving symptoms. This therapy needs to be discussed with your surgeon.

3. Surgery

Patients who do not respond well to lifestyle changes or medications or those who continually require medications to control their symptoms, will have to live with their condition or may undergo a surgical procedure. Surgery is very effective in treating GERD.

There are procedures being tried, known as Intraluminal Endoscopic Procedures, which are alternatives to laparoscopic and open surgery. You will need to discuss with your surgeon and physician whether you are a candidate for any of these procedures.


What are the advantages of the laparoscopic method?

The advantage of the laparoscopic approach is that it usually provides:

  • reduced postoperative pain
  • shorter hospital stay
  • a faster return to work
  • improved cosmetic result.


Are you a candiate for the laparoscopic method?

Although laparoscopic anti-reflux surgery has many benefits, it may not be appropriate for some patients. Obtain a thorough medical evaluation by a surgeon qualified in laparoscopic anti-reflux surgery in consultation with your primary care physician or Gastroenterologist to find out if the technique is appropriate for you.


What to expect before laparoscopic anti-reflux surgery:

  • After your surgeon reviews with you the potential risks and benefits of the operation, you will need to provide written consent for surgery.
  • Preoperative preparation includes blood work, medical evaluation, chest x-ray and an EKG depending on your age and medical condition.
  • Your surgeon may request that you completely empty your colon and cleanse your intestines prior to surgery. You may be requested to drink clear liquids, only, for one or several days prior to surgery.
  • It is recommended that you shower the night before or morning of the operation.
  • After midnight the night before the operation, you should not eat or drink anything except medications that your surgeon has told you are permissible to take with a sip of water the morning of surgery.
  • Drugs such as aspirin, blood thinners, anti-inflammatory medications (arthritis medications) and Vitamin E will need to be stopped temporarily for several days to a week prior to surgery.
  • Diet medication or St. John’s Wort should not be used for the two weeks prior to surgery.
  • Quit smoking and arrange for any help you may need at home.


What to expect the day of surgery:

  • You usually arrive at the hospital the morning of the operation.
  • A qualified medical staff member will place a small needle/catheter in your vein to dispense medication during surgery.
  • Often pre-operative medications are necessary.
  • You will be under general anesthesia – asleep – during the operation which may last several hours.
  • Following the operation you will be sent to the recovery room until you are fully awake.
  • Most patients stay in the hospital the night of surgery and may require additional days in the hospital.


How is laparoscopic anti-reflux surgery performed?

  • Laparoscopic anti-reflux surgery (commonly referred to as Laparoscopic Nissen Fundoplication) involves reinforcing the “valve” between the esophagus and the stomach by wrapping the upper portion of the stomach around the lowest portion of the esophagus – much the way a bun wraps around a hot dog.
  • In a laparoscopic procedure, surgeons use small incisions (1/4 to 1/2 inch) to enter the abdomen through cannulas (narrow tube-like instruments). The laparoscope, which is connected to a tiny video camera, is inserted through the small incision, giving the surgeon a magnified view of the patient’s internal organs on a television screen.
  • The entire operation is performed “inside” after the abdomen is expanded by inflating gas into it.



What happens if the operation cannot be performed or completed by the laparoscopic method?

In a small number of patients the laparoscopic method is not feasible because of the inability to visualize or handle the organs effectively. Factors that may increase the possibility of converting to the “open” procedure may include obesity, a history of prior abdominal surgery causing dense scar tissue, or bleeding problems during the operation. The decision to perform the open procedure is a judgment decision made by your surgeon either before or during the actual operation. When the surgeon feels that it is safest to convert the laparoscopic procedure to an open one, this is not a complication, but rather sound surgical judgment. The decision to convert to an open procedure is strictly based on patient safety.


What should i expect after surgery?

  • Patients are encouraged to engage in light activity while at home after surgery.
  • Post operative pain is generally mild although some patients may require prescription pain medication.
  • Anti-reflux medication is usually not required after surgery.
  • Some surgeons modify patients diet after surgery beginning with liquids followed by gradual advance to solid foods. You should ask your surgeon about dietary restrictions immediately after the operation.
  • You will probably be able to get back to your normal activities within a short amount of time. These activities include showering, driving, walking up stairs, lifting, working and engaging in sexual intercourse.
  • Call and schedule a follow-up appointment within 2 weeks after your operation.


Are there side effects to this operation?

Studies have shown that the vast majority of patients who undergo the procedure are either symptom-free or have significant improvement in their GERD symptoms.


Long-term side effects to this procedure are generally uncommon.

  • Some patients develop temporary difficulty swallowing immediately after the operation. This usually resolves within one to three months after surgery.
  • Occasionally, patients may require a procedure to stretch the esophagus (endoscopic dilation) or rarely re-operation.
  • The ability to belch and or vomit may be limited following this procedure. Some patients report stomach bloating.
  • Rarely, some patients report no improvement in their symptoms.


What complications can occur?

Although the operation is considered safe, complications may occur as they may occur with any operation.

Complications may include but are not limited to:

  • adverse reaction to general anesthesia
  • bleeding
  • injury to the esophagus, spleen, stomach or internal organs
  • infection of the wound, abdomen, or blood.
  • other less common complications may also occur.


Your surgeon may wish to discuss these with you. (S)He will also help you decide if the risks of laparoscopic anti-reflux surgery are less than non-operative management.

When to call your doctor

Be sure to call your physician or surgeon if you develop any of the following:

  • Persistent fever over 101 degrees F (39 C)
  • Bleeding
  • Increasing abdominal swelling
  • Pain that is not relieved by your medications
  • Persistent nausea or vomiting
  • Chills
  • Persistent cough or shortness of breath
  • Purulent drainage (pus) from any incision
  • Redness surrounding any of your incisions that is worsening or getting bigger
  • You are unable to eat or drink liquids



About the Author: drkalhan