|
SURGERY FOR GASTRIC REFLUX - a patient's guide
Dr Ross Roberts - Surgeon, The Oxford Clinic
Overview
Gastroesophageal reflux is a very common condition that
ranges in severity from mild occasional attacks of heartburn
to more severe complications such as ulceration and narrowing
(stricturing) of the oesophagus. In the normal situation
acid and food is confined to the stomach by a high-pressure
area of the oesophagus called the lower oesophageal sphincter.
This sphincter prevents regurgitation back into the oesophagus
when bending, straining or lying down. (Figure 1) In some
people this sphincter is weakened. Often this weakness is
associated with protrusion of the stomach through a defect
in the diaphragm called a hiatal hernia (figure 2). The
final result is reflux of stomach content into the oesophagus
causing discomfort and damage to the lining of the oesophagus.
This problem is made worse by certain foods and drinks,
being overweight and eating before lying down.
Treatment options include dietary changes, weight loss
and medications to reduce stomach acid or increase muscle
contraction in the oesophagus and stomach. For the majority,
these measures are adequate to control their symptoms. There
are, however, those who either have persistent symptoms
despite medications or prefer not to take tablets long term.
Surgical treatment should be considered for these people.
Surgical options:
The aim of surgery is to permanently control the reflux
of acid from the stomach into the oesophagus by strengthening
the lower oesophageal sphincter. Three main steps achieve
this: 1) the stomach is repositioned in its normal location
below the diaphragm. 2) The defect in the diaphragm is closed.
3) A portion of the stomach is used to encircle the lower
oesophagus to strengthen the lower oesophageal sphincter
(Fundal wrap).
Traditionally this operation was performed using a large
abdominal incision. While this approach was usually successful,
the pain caused by the incision, meant that patients spent
up to a week in hospital and were unable to work for at
least six weeks.
Modern technology has made it possible to perform this
same operation without the large incision using a video
camera called a laparoscope. In most cases five small incisions
are used. Two of these are 10 mm in size and three are 5
mm in size. All the operating is done through these small
cuts. The result of this less invasive surgery is that patients
are able to return home after only one or two nights in
hospital and are often back at work within a week. This
new approach is called a "Laparoscopic Nissen Fundoplication"
and is becoming increasingly popular for long term control
of gastroesophageal reflux.
Who is suitable for anti-reflux surgery?
Before surgery is advised it is very important that the
diagnosis is confirmed beyond doubt. Making the diagnosis
usually requires viewing the oesophagus and stomach by gastroscopy
(a flexible video camera), taking samples of the oesophageal
lining and excluding other causes of chest pain such as
heart disease or spasm of the oesophagus. Sometimes it is
necessary to use special tests such as oesophageal pH (acid)
testing where an electrode is positioned in the lower oesophagus
for a full day and the severity of reflux is measured.
Surgery is usually only recommended if medications have
already been tried and are not effective or a preference
to avoid medications is indicated.
Who is not suitable for surgery?
If there is any doubt about the diagnosis then surgery
should be deferred. People who are medically unfit due to
a major illness such as heart disease are not normally considered
for surgery. Previous extensive surgery around the oesophagus
or stomach makes surgery more hazardous. Certain disorders
such as spasm of the oesophagus can cause swallowing difficulties
after surgery. The most accurate way to diagnose these disorders
is a test called "oesophageal manometry" which measures
the pressures in the oesophagus while swallowing. People
who have these disorders are not usually operated on but
can often benefit from appropriate medication.
What symptoms are likely to improve with surgery?
The most symptoms most likely to improve after surgery
are heartburn, regurgitation and coughing when lying down.
Other symptoms which may improve are asthma, abdominal bloating
and difficulty in swallowing.
What are the side effects of surgery?
Following surgery most patients experience a temporary
difficulty in swallowing solids foods caused by increased
pressure in the lower oesophagus. Normally this improves
within two weeks and is managed by avoiding troublesome
foods (see below). Occasionally this sensation can persist
and rarely it is necessary to stretch (dilate) the oesophagus
to overcome this problem. As the operation makes the lower
oesophageal sphincter airtight some people complain of difficulty
in belching and vomiting after surgery. Often this improves
with time. The most frequent side effect described is increased
flatulence or wind following surgery. This occurs because
air is not belched up as easily and people who have gastroesophageal
reflux habitually swallow frequently to clear acid from
the oesophagus. A temporary problem experienced by most
patients is shoulder pain for a few days caused by irritation
of the diaphragm.
What are the risks of surgery?
Any operation, no matter how small, carries certain risks
related to the anaesthetic needed such as heart and lung
problems. With modern techniques these risks are now very
low. The specific risks of laparoscopic anti-reflux surgery
include injury to the oesophagus, stomach, spleen, colon
and vagus nerves. Other risks include bleeding, wound infection
and formation of blood clots (thrombosis) in the veins in
the legs. The experience of the surgeon is the biggest factor
in reducing these risks and in good centres the risk should
be low.
Does the operation always succeed?
The success rate for well-selected patients is over 90%
in controlling reflux symptoms but occasionally it is necessary
for patients to continue taking medications as some reflux
persists.
What activities can I perform following surgery?
The small skin incisions heal rapidly but the diaphragm
repair takes a few weeks to heal. Most people can return
to a desk job within one or two weeks but should avoid heavy
lifting or straining for at least six weeks. Patients are
encouraged to walk actively after surgery to prevent leg
clots.
What should I eat and drink after the operation?
Most people can manage to drink liquids the day after
surgery. On the second day after surgery soft food can normally
be eaten. For two weeks after the operation solid food should
be avoided if possible. After this time it is usually possible
to eat a normal diet.
General eating instructions:
Eat small regular meals
Eat slowly and chew food well
Avoid large meals and fried food
Do not smoke or drink alcohol before meals
Drink small amounts with meals and regularly in between
meals
If certain foods cause difficulty - avoid them
Foods that are likely to cause problems:
Meat - especially red meat and chicken
Fresh bread
Carbonated (fizzy) drinks
Fibrous vegetables
Fruit (especially the skin)
Nuts and seeds
Cooked cheese
Bananas
Suggested foods:
Pureed food
Soups
Yoghurt or jelly
Eggs
Custard or ice cream
Mashed potato
Soft fish
|
