Anti-reflux surgery

Acid reflux symptoms are extremely common, with approximately 40 per cent of the population affected at some point in their lifetime. Why certain people are more prone to acid reflux is not always clear. Some may have what is called a hiatus hernia – which is a condition where the top of the stomach can slip into the chest allowing acid and stomach contents to enter the oesophagus. Other people may be prone to hyperacidity (the production of too much stomach acid) or have a very acid-sensitive oesophagus.

Normally, the first investigation recommended for acid reflux will be an upper GI endoscopy or OGD (oesophago-gastro-duodenoscopy).

This is a camera test – normally performed using local anaesthetic throat spray and sometimes light sedation – which examines the oesophagus, stomach and duodenum. It is a fairly quick (about five minutes) and painless procedure that allows direct visualisation of the upper GI tract to examine for signs of inflammation, ulcers or any evidence of a hiatus hernia.

If surgery is something that is being considered, we then normally recommend proceeding with more specific acid studies called oesophageal physiology tests.

These tests are performed by our specialist upper GI physiologists based at the Royal Berkshire Hospital. They involve the positioning of a small tube into the oesophagus (down through the nose) and allow measurements to be taken of the pressures in the oesophagus and the valve at the bottom of the oesophagus. The tests also monitor acid levels in the oesophagus over a 24-hour period.

The results allow the surgeon to give an accurate prediction of whether an operation would likely to be of benefit.

Basic changes in the diet such as the avoidance of substances that irritate the oesophagus – for example: alcohol, spicy foods or acidy foods – may help to relieve symptoms. The avoidance of foods that relax the valve between the stomach and the oesophagus – for example: fatty foods or caffeine –¬ may also help.
Being overweight and smoking are also risk factors for acid reflux.

Treatment with simple antacids, such as Gaviscon and Rennie, may help to relieve the symptoms of reflux. Progression onto specific acid-blocking medication such as ranitidine (H2 antagonist) or omeprazole (proton pump inhibitor) may also help.

However, for many people these treatments are not enough and surgery may offer some benefit.

The principles of anti-reflux surgery are to repair the hiatus hernia (if present) and tighten the junction between the oesophagus and stomach to prevent acid from refluxing up again.

This is generally performed laparoscopically under general anaesthetic. A one-night stay in hospital would be required.

During the procedure, some sutures are placed across the hiatus (diaphragm muscles around the lower oesophagus/upper stomach) to narrow the opening between the abdominal and chest cavity. This prevents the stomach from re-herniating into the chest.

The final part of the operation is to wrap the top of the stomach around itself to reinforce the valve in the lower oesophagus. This wrap may be either a full 360-degree wrap (Nissen’s procedure) or a partial wrap (commonly 180 degrees or 270 degrees). The standard procedure is a 360-degree wrap.

One of the side effects of tightening the valve at the lower oesophagus can be difficulty in swallowing (dysphagia). For the first few weeks after surgery, all patients are advised to be on a soft or sloppy diet until swelling from the operation has settled. By about four to six weeks after the procedure most people are back to eating normal solids, although a minority of people may still struggle to eat large chunks of meat and sometimes bread.

Rarely, if the valve is too tight, an endoscopic procedure to stretch it is required (dilatation) and even more rarely a second operation to undo the wrap may be necessary.

Some people suffer from trapped gas/wind within the stomach during the first few weeks post-operatively, which may cause some discomfort (gas-bloat syndrome) but this normally settles over time.

Diarrhoea can sometimes occur post-operatively and, rarely, symptoms may worsen in people who already have irritable bowel syndrome.

When patients are selected for surgery based on their symptoms and oesophageal physiology studies, about 90 per cent of patients experience good relief of reflux symptoms post-operatively.

Up to 10-20 per cent of patients may develop some recurrent reflux symptoms but the vast majority of patients are able to come off all of their anti-reflux medication.

Obesity is a risk factor for failure of standard anti-reflux (fundoplication) surgery.

In patients with morbid obesity (BMI >40) a gastric bypass (laparoscopic, Roux-en-Y gastric bypass) procedure may offer the best form of acid reflux control and the patient will also benefit from the consequential weight loss that occurs.

Gastric bypass surgery results in the complete diversion of the acid-producing part of the stomach from the oesophagus.

On occasion, it may also be performed in patients of normal weight in which standard anti-reflux procedures have failed or who suffer from severe acid-related duodenal inflammation or ulceration.