• Why acid reflux occurs
• Symptoms
• Complications of acid reflux
• View balloon dilation of an oesophageal stricture
• Barrett’s oesophagus
• Screening of Barrett’s oesophagus
• Investigations
• Treatment options
• Keyhole surgery for acid reflux
• What Does the Operation Involve?
• After the operation
• Eating after Keyhole Surgery for Acid Reflux
• Patient Story

Why acid reflux occurs

Under normal circumstances the contents of the stomach are acid and the contents of the gullet are neutral or alkaline. Occasionally during belching, for example, small amounts of acid may pass from the stomach into the gullet. Acid in the gullet should be present less than 4% of the time.

In the normal person when food is swallowed, muscles of the gullet (oesophagus) propel the food towards the stomach. A control muscle, the lower oesophageal sphincter (LOS) relaxes allowing passage of the food into the stomach. The LOS then contracts preventing regurgitation of acid or food into the gullet. In patients with gastro oesophageal reflux disease (GORD) the lower oesophageal sphincter is ineffective in controlling reflux of acid.

Normal Lower oesophageal sphincter (LOS)

Open LOS at endoscopy

Gastric prolapse through LOS endoscopy

Acid and bile are present in the gullet and attack the lining eventually leading to inflammation and ulceration. Some patients develop a low LOS pressure at an early age and may have a familial tendency to the disease. In others a viral illness, pregnancy, over weight , smoking or excessive alcohol may all play a part.

Symptoms

The most common symptoms are of heartburn, upper abdominal and lower chest pain, regurgitation, difficulty in swallowing, acid brash, excessive belching, nausea, vomiting and occasional night time coughing or wheezing. Poor teeth and sinus problems have also been linked to acid reflux.

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What are the Complications of acid reflux?

1. Hiatus hernia. Prolonged acid reflux can lead to oesophageal spasm and shortening. Under these circumstances it is thought that the stomach can be pulled up into the chest through the hiatus in the diaphragm. A so called hiatus hernia. Not all patients with acid reflux have a hiatus hernia.
   
2. Oesophagitis. Inflammation of the lining of the gullet, which can develop into ulceration, that is loss of the lining of gullet and occasionally bleeding.
   
3. Stricturing. If inflammation is severe then following ulceration fibrosis can occur in the gullet leading to a narrowing or stricture. View balloon dilation of an oesophageal stricture
4. Barrett’s Oesophagus. Following prolonged acid exposure, oesophagitis and ulceration the lining of the gullet can be replaced by a more acid resistant stomach type mucosa so called columnar lined or Barrett’s oesophagus. This may be associated with development of pre cancerous and cancerous change in only a small percentage of patients.

   Barrett’s Oesophagus

   Oesophageal cancer

Investigations

Gastroscopy otherwise known as Endoscopy or OGD allows the surgeon to view the lining of the gullet, take biopsies, do dilations of strictures and assess the position of the lower oesophageal sphincter and the size of the hiatus hernia if present.This test can be done as a day case under local anaesthetic throat spray or mild sedation if required.
Some patients with acid reflux can have a normal looking oesophagus especially if they have been on acid suppressive medication. Thus patients with typical symptoms of acid reflux but a normal Endoscopy require further tests before corrective surgery can be discussed. The best test for Endoscopy negatives patents is the 24 hour pH test.

24 Hour pH test. Patients with pathological acid reflux have acid in the gullet for more than 4% of the time (normal pH test). The pH test is done as an out patient. A fine probe is placed in the gullet above the lower oesophageal sphincter and pH is measured over 24 hours and recorded on a belt held box. Symptoms can be recorded by pressing a button and may coincide with a reflux episode. It is important that the patient has stopped medication for 2 weeks before the test as some drug effects last that long. Patients with pure bile reflux will have a normal acid test.

Manometry. Manometry measures the pressure and relaxation of the lower oesophageal sphincter. Manometry also measures gullet contraction. The test allows identification of the position of the LOS which is important in placing the pH probe. Manometry is usually done before the pH probe is place. It is important to do this test for patients with difficulty in swallowing or who feel food sticking. A rare condition called Achalasia of the Cardia whose main symptom is difficulty in swallowing can be picked up by this test. This condition requires a different treatment to acid reflux.

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Treatments options

1. Conservative measures. Patients will benefit from the cessation of smoking and excess alcohol consumption. Occasionally a relatively low fat diet and weight loss may be beneficial but these have not been found to have a major impact in the majority of patients.
2. Drug Treatment. Proton Pump Inhibitors. The most effective acid suppressant drugs are Proton Pump Initiators, for example, Omeprazol (Losec) and Zoton (Lansoprazole). These are generally effective in turning off the stomach acid production. They may have side effects such as diarrhoea, joint inflammation and abdominal pain. H2 Antagonists such as Ranitidine have largely been superseded by Proton Pump Inhibitors.

   Rafting agents, which float on the top of the stomach such as Gaviscon, may be beneficial in patients with mild disease.

   Pro Kinetic Agents designed to tone up the muscle of the gullet have little place in the treatment of GORD and the most effective of these drugs Cisapride has been removed from the market because of heart toxicity.

Keyhole surgery for acid reflux

Keyhole surgery for gastro oesophageal reflux disease (GORD) is a safe and effective treatment with generally a high level of patient satisfaction. Very many studies including large numbers of patients have consistently shown levels of satisfaction of over 90%. Keyhole surgery has almost completely superseded open surgery and has the advantages of very small incision giving rise to little pain, early discharge from hospital, few wound complications and early return to normal activity.

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What Does the Operation Involve?

The operation is done under general anaesthetic. The abdominal cavity is accessed through five small abdominal punctures between ½ and 1cm. The hiatus hernia is repaired and the upper part of the stomach (fundus) is wrapped around the lower oesophageal sphincter reinforcing its action. A mucosal swirl is created below the lower oesophageal sphincter, which acts as a one-way flap valve preventing the reflux of acid into the gullet.(Photo endoscopic view of fundoplication) The operation is very effective in preventing acid reflux which is abolished in over 95% of patients.
View a laparoscopic fundoplication

After the Operation

In-patient Stay. Most patients are discharged the day following surgery although some stay an extra day. Patients can return to work within 7-10 days after that if well motivated.

Eating After Key Hole Surgery. Most patients would experience some difficulty in swallowing solid food immediately after surgery. This can persist from between 7-12 weeks. Difficulty in swallowing solid food is the result of bruising and swelling around the lower gullet following surgery. In addition the muscles of the gullet need to retrain to propel food through the newly reconstituted lower oesophageal sphincter. A graded programme of increased solidity of food will be given. Most patients tolerate this period of rehabilitation without difficulty.
Eating after Keyhole Surgery for Acid Reflux

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What Complications Can Occur at Surgery?

In centres performing large numbers of these procedures on a routine basis surgical complications are unusual. As with any operation keyhole there is a small chance of needing an open operation, which should occur in less than 2% of cases. Patients will be selected for a general level of fitness and it is not suggested that this procedure should be performed for patients with severe coincidental heart or lung problems. You may wish to ask your own surgeon about his personal record for post-operative complications and conversion to open operation.

Symptomatic Improvement after Gastro Oesophageal Reflux Surgery

Symptoms, which are most effectively treated by this surgery, are those of heartburn, upper abdominal and chest pain and regurgitation and vomiting. Patients with difficulty in swallowing before the operation may find that this is improved provided causes other than reflux have been excluded before surgery. Upper abdominal bloating and nighttime cough and wheeze are also improved if related to reflux.

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Symptoms that May Develop after Such Surgery

The inability to belch and vomit following surgery may be appreciated in a proportion of patients. Patients who swallow air may pass this as flatus rather than belching. This generally reduces over time as patients adapt their behaviour. Swallowing air can be associated with acid reflux as the patient tries to clear acid or food from the gullet. In addition, a small proportion of patients will experience some minor difficulty in swallowing in the longer term. This is generally felt to be acceptable as an alternative to pre operative symptoms. Symptoms related to irritable bowel syndrome will not be affected by the surgery and increased flatulence and diarrhoea may be appreciated by some patients in this category.

Which Patients May Benefit from Key Hole Surgery for GORD

Three categories of patients may benefit from this type of surgery.

1. Patients for whom medical treatment is incompletely effective. These will include patients with bile or volume reflux for whom acid suppressant medication will not be relevant to their condition. Patients with the most severe disease complicated by Barrett’s oesophagus or structuring require special consideration and individual assessment.
2. Patients experiencing side effects of medical therapy such as diarrhoea and abdominal pain.
3. Patients for whom their intractable symptoms require long term medical treatment who wish to deal with the underlying problem and discontinue medication. There is undoubtedly a cost benefit to surgery in many of these patients.