Surgery for reflux disease
Information for patients from General Surgery
You have been given this leaflet as you suffer from “heartburn”, also known as gastro-oesophageal reflux disease (GORD). This condition can be treated using keyhole surgery, called laparoscopic anti-reflux surgery. This leaflet will explain the following.
What gastro-oesophageal reflux disease (GORD) is
What your treatment options are
What alternatives there are to surgery
What the benefits and risks are to having surgery
What happens during and after surgery
What to expect if you choose to have laparoscopic anti-reflux surgery
What will happen if you cannot have laparoscopic surgery
We hope this leaflet answers some of the questions you may have. If you have any further questions or concerns, please speak to your surgeon.
What is gastro-oesophageal reflux disease (GORD)?
Heartburn is a burning feeling in the chest caused by stomach acid travelling up towards the throat (acid reflux). If it keeps happening, it may be called gastro-oesophageal reflux disease (GORD).
What are the symptoms of GORD?
Heartburn is described as a harsh, burning feeling in the area behind the breast bone or just below the neck. The feeling may radiate up the chest and into the throat and neck. Many adults in the UK have this uncomfortable, burning sensation at least once a month.
Other symptoms may include the following.
Vomiting
Difficulty swallowing
Discomfort behind the breast bone and between the shoulder blades
Regurgitation (food coming up into the mouth)
Loosing blood due to inflammation, causing anaemia.
Uncommon symptoms can include the following.
Wheezing
Chronic (long-term) coughing
Coughing at night
Recurrent chest infections
Waking up from sleep with a choking sensation
A change of voice
Choking sensation
In extreme cases, there can even be damage to the teeth (for example loss of teeth) and poor gums.
What causes GORD?
When you eat, food travels from your mouth to your stomach through a tube called the oesophagus (gullet).
At the lower end of your oesophagus is a small ring of muscle called the lower oesophageal sphincter (LOS).
The LOS acts like a one-way valve, allowing food to pass through to your stomach.
Normally, the LOS closes immediately after swallowing to prevent a back-up of stomach juices, which have a high acid content.
GORD happens when the LOS does not work properly, allowing acid to flow back and burn your lower oesophagus. This irritates and inflames your oesophagus. It can cause heartburn and may damage your oesophagus over time.
Some people are born with a weak lower oesophageal sphincter. However, for others the following may cause their LOS to relax, causing reflux or the back flow of acid.
Fatty and spicy food
Caffeine (regular coffee or tea)
Certain types of medication
Tight clothing
Smoking
Drinking alcohol
Vigorous exercise, changes in body position (bending over or lying down), or lifting very heavy weights
Increasing body weight
Hiatus hernia is due to a weakness in the diaphragm, which allows part of the stomach to enter the chest cavity. Many patients who suffer from GORD, while also have a hiatus hernia. However, hiatus hernia may not always cause the symptoms of heartburn.
How is GORD treated? Are there alternatives to surgery?
GORD is generally treated in three steps.
Lifestyle changes
For many patients, the following lifestyle changes can reduce the harsh symptoms of GORD.
Changing your diet, for example avoiding fatty and spicy foods, and caffeinated drinks.
Losing weight.
Stopping or reducing smoking and the amount of alcohol you drink.
Changing sleeping patterns and eating times. For example, not going to bed immediately after eating and leaving a gap of at least 3 hours can also help.
Keeping the head end of the bed elevated (raised).
Taking over-the-counter antacids.
Drug therapy
If your symptoms continue despite these lifestyle changes, you may need drug therapy. Over-the-counter antacids neutralise stomach acids. There are also prescription drugs that reduce the amount of stomach acid produced. Both may be useful in relieving your symptoms. Prescription drugs may help to heal the irritation of the oesophagus caused by the acid and relieve symptoms. Prescription drugs include H2-antagonists (ranitidine) or proton pump inhibitors (omeprazole, pantoprazole, esomeprazole). Your doctor or gastroenterologist will discuss your options with you.
8 in 10 patient's symptoms are relieved through lifestyle changes and drug therapy. However, these treatments address the effect not the cause.
Surgery
A small number of patients will not see any improvements from making lifestyle changes or using drug therapy. These patients continually need drugs to control their symptoms and may benefit from surgery.
Surgery works well in treating GORD. This surgery uses keyhole techniques, that avoid large abdominal incisions (cuts). Surgery addresses the cause and treats the effect of the disease as well.
We will not offer surgery to people with a BMI (body mass index) higher than 35. The success of surgery starts to fall for patients with a BMI of over 30.
What is laparoscopic anti-reflux surgery?
Laparoscopic surgery means keyhole surgery. It allows a surgeon to use small cuts and a camera for procedures inside the tummy or pelvis.
Laparoscopic anti-reflux surgery involves the following.
Recreating the abdominal length of the oesophagus (gullet).
Repairing the hiatus hernia with stitches. If you have a large defect, we often reinforce the area with mesh after stitching; to improve the outcome. This mesh is biological and not synthetic, so as your body remodels over time the mesh will disappear.
Reinforcing the “valve” between the oesophagus and the stomach. Your surgeon will wrap the upper part of your stomach around the lowest part of your oesophagus. This is best described as ‘cuddling’ the gullet with the stomach (see diagram).
What are the expected results of laparoscopic anti-reflux surgery?
Studies show that most patients who have this procedure are either:
symptom free; or
have significant improvement in their GORD symptoms following surgery.
What are the benefits of laparoscopic surgery?
The advantages of the laparoscopic surgery compared to open surgery include:
reduced pain after surgery
shorter hospital stays (1 to 2 days)
a faster return to work (1 month)
improved cosmetic result (small scars)
What are the risks of laparoscopic anti-reflux surgery?
There are risks with any general anaesthetic procedure, but life-threatening complications are rare. More information on anaesthetic risks is available in the You and Your Anaesthetic leaflet.
Rare complications during the operation may include the following.
A bad reaction to the general anaesthetic.
Bleeding.
Injury to the oesophagus, spleen, stomach, pleura (lining of the lung), liver, and lungs.
Injury to the vagus nerve, resulting in poor gastric function. If this happens you may need further surgery to widen your gastric outlet.
Complications after surgery may include the following.
Infection of the wound, abdomen, chest, or blood.
Rare complications include deep vein thrombosis (DVT). DVT is clots in the leg veins that can spread to the lung, and cause difficulties with breathing.
Your surgeon and their team will review you regularly after surgery and take steps to minimise these risks. These steps include:
being given prophylactic antibiotics and blood thinning injections
wearing special stockings to prevent leg vein clots
receiving chest physiotherapy
What happens if I cannot have laparoscopic surgery?
For 1 in 25 patients, laparoscopic surgery is not possible or safe. This is mainly because the surgeon is not able to see or handle the organs effectively. If this happens, you will be referred for open rather than laparoscopic surgery. Open surgery means cutting the skin and tissues, so the surgeon can clearly see the structures or organs involved. Having open rather than laparoscopic surgery is not a complication. Your surgeon has made a sound clinical judgement.
The following may increase your chances of changing from laparoscopic to open surgery.
Obesity (excess body fat)
A history of previous abdominal surgery, which has caused dense scar tissue or adhesions
A very large left lobe of the liver
Bleeding problems during surgery
What happens before laparoscopic anti-reflux surgery?
You will have a medical examination to check that you can have laparoscopic surgery. You may be referred for one or more of the following tests.
X-rays / CT scan
Barium studies
pH and manometry study (measuring the pressure and acid level in the gullet, using a fine tube through the nose down to the gullet)
An endoscopy (a telescope test through the mouth, looking at the gullet and stomach)
Blood tests
After this examination, your surgeon will discuss with you whether this operation may help your symptoms. They will also discuss the risks and benefits, and help you decide whether to continue with drug therapy or to have surgery.
How can I prepare for my surgery?
While you wait for your surgery date, you can start preparing for your operation. Research shows that fitter patients, who are able to improve their health and activity levels before surgery, recover more quickly. Taking an active role in planning and preparing for your operation will help you:
feel in control;
leave hospital sooner; and
get back to normal more quickly.
To help with this, you may be contacted by a member of the One You Kent (OYK) team. OYK work in the community, and help patients improve their general health. This includes help and advice on:
Stopping smoking
Losing weight
Getting more exercise
More information can be found on the following web sites.
One You Kent (Kent Community Health)
Fitter Better Sooner Toolkit (Royal College of Anaesthetists)
Are there any side effects to this surgery?
Long-term side effects to this procedure are generally uncommon (less than one in 25 patients).
Some patients develop temporary swallowing difficulties immediately after their surgery, due to inflammation in the area. This usually stops within 1 to 3 months following surgery. A sloppy diet may be needed during this time. Avoid bread and beef for 8 weeks, as they are lumpy and can block the gullet causing retching. This can cause the operation to fail.
After surgery you will feel full more quickly. Eat little and often, rather than large meals.
You may also lose weight, even up to 6 to 10 kilograms. If this happens, you may need a simple procedure called endoscopic dilation, to expand your oesophagus. Surgery is repeated in less than 1 in 100 patients.
Your ability to belch and / or vomit may be limited following this procedure.
Some patients complain of stomach bloating. It is best to avoid fizzy drinks (for life).
All patients pass more wind (flatulence).
Some patients report very little improvement in their symptoms (less than 1 in 20). Every operation has a failure rate. One in 8 to 10 patients will have recurrence of their symptoms within 5 years.
The diaphragm moves on average 20 to 30,000 times per day. The stitches used are permanent, but the muscles can still stretch which is the reason symptoms can recur in a small number of cases. If the symptoms do recur, you may need further surgery. You will discuss this with your surgeon.
When can I drive again?
Please arrange for someone to take you home after your surgery and stay with you overnight. Do not drive for 2 weeks following your surgery.
When can I return to work?
Most people can return to work after 2 weeks. This can vary from person to person. If you need longer off work, please ask your GP for an extended leave.
What if I have any questions or concerns?
If you have any queries, please speak to your surgeon.
Ask 3 Questions
There may be choices to make about your healthcare. Before making any decisions, make sure you get the answers to these three questions:
What are my choices?
What is good and bad about each choice?
How do I get support to help me make a decision that is right for me?
Your healthcare team needs you to tell them what is important to you. It’s all about shared decision making.
What do you think of this leaflet?
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Patient Voice Team
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