Gastro-Esophageal Reflux Disease and Fundoplication

What is gastro-oesophageal reflux and why do I get reflux?

Gastro-oesophageal reflux is a condition where acidic stomach contents flow upwards in the gullet. The gullet or Esophagus is a muscular tube that passes through the chest and enters the abdomen through a small hole or Esophageal Hiatus in the diaphragm (a muscle partition between chest and abdomen, at the level of lower rib cage). At its junction with the stomach, Esophagus has a one-way valve formed by a ring of muscle. This valve or Lower Esophageal Sphincter (LES) permits food and liquid to go down but largely stops acidic stomach contents from coming back up into the gullet. If the LES mal-functions and stays more relaxed than usual or for longer periods, reflux can happen. Same thing happens when you develop a hiatus hernia where a part of whole of the stomach moves into the chest through the diaphragmatic opening. A hiatus hernia often prevents the LES from functioning properly, causing reflux.

What are the effects of reflux?

Gastro-esophageal reflux (GER) causes chest discomfort of varying degrees and often results in vomiting. This mostly happens after a major meal, when the stomach is full, and the patient lies flat. Persisting GER may lead to a number of temporary or permanent changes like ulcers, strictures, and Barrett’s changes in the lower Esophagus. Additionally, a small proportion of Barrett’s Esophagus can turn into Cancer of Esophagus over next several years.

Is a Hiatus hernia dangerous?

Many people have small hiatus hernias which are asymptomatic or result in minimal reflux. If this reflux is well controlled by lifestyle changes and medications, nothing more needs to be done. However, some hiatus hernias can grow big, and present with a variety of symptoms, ranging from reflux resistant to medicines, vomiting of food, inability to eat, early satiety, loss of weight, blood loss, anaemia. The large hiatus hernias, especially those involving the entire stomach can cause obstruction of food and result in vomiting. Rarely, the herniated stomach can twist and lose its blood supply. This last condition can be life threatening and requires emergency intervention.

What are the common symptoms of Gastro-Esophageal Reflux (GER)?

Symptoms range from burning sensation in the chest / back of the throat, mostly when patients lie flat to bringing up of acidic fluid (volume reflux), especially when they bend forwards, resulting in a choking sensation or actual vomiting. These symptoms can be very distressing and in its severe form are often confused with symptoms of heart attack. Patients with GER can also get non-specific symptoms like chronic cough, hoarse voice, recurrent chest infections, worsening of asthma and tooth decay. Of course, all these symptoms could also arise from other diseases, hence a proper assessment by one or multiple specialists is necessary.

What is the treatment of Gastro-Esophageal Reflux?

Initial management involves dietary and lifestyle adjustment, recommended by your doctor or specialist with or without medications to reduce acid secretion from your stomach. If the medical management fails to relieve symptoms, you will need to see an upper gastrointestinal (GI) surgeon who will run a range of specialist investigations like Upper GI Endoscopy, Barium Swallow, 24-hour pH and Esophageal manometry. If these tests confirm significant GER, your surgeon may offer you Anti-Reflux Surgery. GER associated with high Body Mass Index (BMI) over 35 and significant central obesity (circumference at the level of umbilicus, more than 120 cm in men and 110 cm in women) is best dealt by weight loss in the initial instance. Your specialist will be able to advice you on this.

What is Anti-Reflux Surgery?

The commonest types of anti-reflux operations are Fundoplication and LINX. If a hiatus hernia exists, the surgeon repairs this during the same procedure. Fundoplication involves wrapping the upper part of the stomach (Fundus) around the lower Esophagus to re-enforce the one-way valve at LES. Depending on the degree of wrap, they are named Nissen’s (360o), Toupet’s (270o) or Dor’s (180o anterior) Fundoplication. Till date, there is poor evidence to choose one variety of fundoplication over the other. Your surgeon will have their own preference which he/she will discuss with you prior to surgery. LINX involves using a ring with magnetic beads around the lower Esophagus, instead of the wrap. Both these procedures are deemed safe and recommended by NICE guidelines.

What is Fundoplication operation?

What are the risks?

Do I need to change my diet after operation?

Fundoplication operation is a key-hole surgery (laparoscopic procedure). In 2% cases, based on intra-operative findings, the surgeon may opt to convert the operation to open procedure through an upper midline or upper abdominal transverse scar. Hence patients are consented for both open and laparoscopic procedures at the outset. The intended benefits are relief from existing symptoms. Risks include bleeding, infection, pain, incisional hernia, thromboembolism, general anaesthetic complications, injury to the intra-abdominal organs, recurrence of symptoms and need for further or repeat operations (re-do surgery).

Some patients will find it slightly difficult to swallow after the surgery. Hence, it is recommended to stay on liquid to soft diet for few weeks after the operation and gradually introduce solids in the diet. Patients struggle mostly with bread and meat. Hence, it is prudent to avoid these for few weeks till swallowing eases. The swallowing difficulty is expected to get better with time. This length of time and severity of symptoms may vary between patients. Additionally, some patients will find it difficult to burp after the surgery. A standard low risk of death (0.1%) related to surgery or anaesthetic complication is also quoted routinely with this operation.

What do you expect during your surgery?

Before your operation, your surgeon will see you in a clinic and talk to you about the relevant benefits and risks. You will be offered an information leaflet or online resources. If you have any questions, we will try and answer them to the best of our capabilities any time prior to your operation. If you agree to proceed with the surgery, you will be given an appointment. On the day of operation, you will be fasting for at least 6 hours before the scheduled time of your operation. You will arrive to the hospital with an overnight bag. You will be assigned your bed. The operation normally lasts about three hours, following which you will be back in your bed. If the operation goes as planned, you should be fit for discharge early next day morning. However, if you feel well enough, you can go home on the same day. Your discharge will be nurse-led. You will need pain killers after your surgery and should be able to stop anti-reflux medications straightway. The sutures placed are usually dissolvable. You will receive a discharge letter specifying your post-operative diet and follow-up plan, when you leave the hospital. You will be expected to refrain from driving for at least 24 hours after a general anaesthetic and may need a week after your operation, to be on light activities only.

Is there a Registry for Hiatal operations?

Yes, a registry for hiatal operations has been introduced in 2021 by the British Benign Upper Gastrointestinal Surgical Society (BBUGSS) and Association of Upper Gastrointestinal Surgeons (AUGIS). It is called National Hiatal Surgery Registry (NHSR). Prior to your operation, your surgeon will inform you about this registry. With your consent, details about you (your NHS number, email address and phone number) and details of your surgery will be entered and stored in NHSR database. The NHSR will monitor you for a period of 5 years after the operation. The registry’s contact with you will be kept to a minimum and very limited, about once a year. The NHSR exists to define, improve and maintain the quality of care when receiving surgical treatment for your condition in the NHS and the independent healthcare sector. Hiatal surgical procedures are commonly performed and are highly successful operations that bring many patients great relief from their symptoms. The registry helps ensure this is the case for all patients currently and the future. The NHSR thus helps patients by the following ways:

• Surgeons define exactly what they are trying to achieve for you.

• It will help highlight to you as the patient what outcome you will expect from your surgery

• Improve patient safety by recording problems that might occur.

• Give hospitals and surgeons feedback about their performance to help them improve patient care.

• Help surgeons decide if the treatment they are providing you is as good as other hospitals and take steps to correct that if required.

Is there a possibility that my operation is best performed in an NHS hospital?

Prior to booking patients for anti-reflux surgery or hiatus hernia repair, clinicians routinely take multiple clinical factors into account. Depending on their assessment, some patients are better suited for an NHS hospital with adequate intensive care facilities. Although this assessment is best done through a detailed consultation with your specialist(s), some of these factors are as follows, but are not limited to:

1. Patients with a higher body weight (BMI more than 35).

2. Patients with significant pre-existing medical conditions, especially related to heart and lungs.

3. Patients who had previous independent abdominal operations, especially above the level of bellybutton, which can cause intra-abdominal adhesions.

4. Patients who have a very big hiatus hernia or had previous anti-reflux surgery.