Surgery for Gastric Reflux Disease
Gastro Oesophageal Reflux Disease (GORD)
Gastro-Oesophageal Reflux Disease (GORD) is a common condition where the acid fluid of the stomach intermittently “refluxes” up in to the oesophagus through the Lower-Oesophageal Sphincter (LOS). GORD, is a chronic disease, which occurs when the lower oesophageal sphincter does not close properly allowing stomach contents to leak back or regurgitate into the oesophagus.
When refluxed stomach acid touches the lining of the oesophagus, it causes a burning sensation in the chest or throat called heartburn.
Anyone including infants, children and pregnant women can have GORD.
Common Symptoms of Reflux:
- Heartburn or reflux
- Altered taste, sense of fluid in the mouth when bending over or sleeping
- Coughing especially at night, and can be severe and debilitating.
- Asthma and repeated lung infections
- Difficulty in swallowing
- Hiatal hernia- hiatal hernia occurs when the upper part of the stomach is above the diaphragm, the muscle wall that separates the stomach from the chest.
- Alcohol use
- Medical History
- Response to Omeprazole PPI Drugs
- Barium Swallow Radiograph
Uses x rays to help spot abnormalities such as a hiatal hernia and severe inflammation of the oesophagus
Also known as Gastroscopy this allows assessment of the food pipe, stomach and the upper part of small bowel.
Oesophageal pH study
An Oesophageal pH study is regarded as the gold standard for quantifying the extent of reflux.
Hiatus hernia surgery is a distortion of the stomach at the diaphragm and is associated with GORD. Most people with GORD achieve good symptom control by taking acid relieving medication. Sometimes the medication fails to do this properly, the patient does not like taking medication or frequently forgets and has only poor symptom control, or the fluid enters the mouth and so the medication only solves part of the problem. In all these situations, anti-reflux surgery can be considered. Barrett’s Oesophagus is a condition where there is an increased risk of developing oesophageal cancer. This risk is mitigated somewhat by this surgery
Once the diagnosis of gastroesophageal reflux disease is reliably made it can be treated. The progression of the disease will often exceed the ability of the PPI to control the symptoms of GERD. Patients will often return several times to their prescribing physicians for the persistent symptoms and complaints. Physicians will titrate to a higher dose and frequency of the medications and emphasize a strict regimen. But with continued use of PPIs, the symptoms will often return as the disease progresses. At this point, PPIs will no longer control the symptoms and surgery is indicated to stop the gastroesophageal reflux.
Surgery is indicated for patients that have failed management with medications (such as PPIs), have desire to no longer take medications, or have a hiatal hernia. The knowledge of the physiological changes with regard to GORD has been studied extensively and surgical treatments have improved. The steps to repair gastroesophageal reflux disease with surgery are at the discretion of the surgeon. Examples include:
Hiatal hernia repair
- Five small (5 to 15mm) incisions are made in the wall of the abdomen and instruments introduced through them. The inside of the abdomen can then be visualised and the upper stomach separated from the surrounding structures. If a hiatus hernia is present, then this is repaired by repositioning the stomach below the diaphragm and narrowing the gap in the diaphragm by either suturing it or using mesh.
- For a Nissen Fundoplication the stomach is wrapped 360° around the LOS and sutured in place. Larger hernias may require additional measures. Sometimes a modified operation is required where only 180° or 270° of the LOS is wrapped by the fundus.
With a Hiatus hernia, the stomach has protruded through an enlarged gap in the diaphragm and this effectively weakens the barrier between stomach and oesophagus and acid freely swishes up in to the oesophagus. When the volume of fluid is, large this creates “volume reflux”, which is not responsive to medication.
This is a procedure that has evolved over the last 40 years. The ability of the surgeon to tailor the fundoplication to the patient’s needs have improved greatly. There is a preoperative workup that needs to be undertaken for the surgeon to determine the best fundoplication for the patient.
There are a variety of fundoplications available, but most commonly discussed are partial fundoplications and complete fundoplications (often called a Nissen fundoplication). Partial fundoplications are created to help accommodate patients with poor esophageal function. The fundoplication does not create a new lower esophageal sphincter or provide a new valve. It simply prevents the effacement of the walls of the esophagus with increased pressure and reestablishes the natural reflux barrier by restoring some of the features of the angle at which the esophagus enters the stomach.