Surgical Conditions

Gastro Oesophageal Reflux Disease (GORD)

The oesophagus carries food from the mouth to the stomach. The lower oesophageal sphincter is a ring of muscle at the bottom of the oesophagus that acts like a valve between the oesophagus and stomach.

Gastro Oesophageal reflux disease, or GORD, is a chronic disease that occurs when the lower oesophageal sphincter does not close properly and stomach contents leak back, or reflux, into the oesophagus.

When refluxed stomach acid touches the lining of the oesophagus, it causes a burning sensation in the chest or throat called heartburn. The fluid may even be tasted in the back of the mouth, and this is called acid indigestion. Occasional heartburn is common but does not necessarily mean one has GORD. Heartburn that occurs more than twice a week may be considered GORD, and it can eventually lead to more serious health problems.

Anyone, including infants, children, and pregnant women, can have GORD.

Symptoms

The main symptoms are persistent heartburn and acid regurgitation. Some people have GORD without heartburn. Instead, they experience pain in the chest, hoarseness in the morning, or trouble swallowing. You may feel like you have food stuck in your throat or like you are choking or your throat is tight. GORD can also cause a dry cough and bad breath.

The most frequent symptoms of GORD are so common that they may not be associated with a disease. Self-diagnosis can lead to mistreatment. Consultation with a physician is essential to proper diagnosis and treatment of GORD.

Causes

• Hiatal hernia- occurs when the upper part of the stomach is above the diaphragm, the muscle wall that separates the stomach from the chest.
• Alcohol use
• Obesity
• Pregnancy
• Smoking

Also, certain food and drinks are associated with reflux

Diagnoses

1. Medical history
2. Response to acid lowering medication
3. Endoscopy

Treatment

Conservative treatment

• Life style modification
  • Lose weight
  • Avoid alcohol, caffeine etc
• Medications including antacids, H2 receptor blockers, Proton Pump inhibitors

Surgical treatment

There are various indications to consider surgical treatment for reflux

• Complicated GORD
• Stricture
• Barrett’s Oesophagus
• Respiratory Complications
• Hiatus Hernia
• Inadequate response to Medical Treatment
• Volume reflux
• To avoid requiring long term medication

Laparoscopic Fundoplication

Fundoplication can be a very effective surgical procedure to correct reflux. This procedure involves wrapping the upper portion of the stomach around the junction between the oesophagus and stomach to reinforce the strength of the lower oesophageal sphincter. Until recently, the procedure required a large abdominal incision. A hospital stay of 5-7 days was usually required, and the time to full recovery and return to work was measured in weeks.

Laparoscopic Fundoplication is a minimally invasive approach that involves specialized video equipment and instruments that allow a surgeon to perform the procedure through five tiny incisions, most of which are less than a half-centimetre in size. This surgery is performed under general anaesthesia. One advantage of this method is a brief hospitalization. Most of the time it will require only 2-3 days in hospital. Other advantages include less pain (less of a need for pain medication), fewer and smaller scars, and a shorter recovery time.

Advantages

Whilst medications may lower the acid content of the stomach they don’t stop the stomach contents refluxing into the oesophagus. Fundoplication improves the function of the gastro-oesophageal junction stopping all contents from refluxing into the oesophagus.

A hiatus hernia is known to predispose to reflux and is repaired during the operation by closing the defect in the diaphragm.

Fundoplication is successful 85-90% of patients in stopping acid reflux. The remainder are often better with medication that prior to the surgery.

The majority of patients are able to cease their acid lowering medication. Surgery is more cost-effective than many years of medication.

Side Effects

Dysphagia – or difficulty swallowing can be caused if the stomach wrap is too tight or the oesophageal swallowing reflex is too weak. Some patients require testing of the oesophagus called manometry and if there is poor swallowing fundoplication should be avoided.

Gas-Bloat & Flatulence – A more effective reflux barrier stops belching of gas from the stomach. Consequently it passes through the bowel and can cause bloating and increased flatulence. Patients with irritable bowel syndrome or motility disorders should avoid fundoplication.

Studies show that these side effects can be minimised by performing a partial wrap rather than wrapping the stomach completely around the oesophagus (Nissen or 360 degree fundoplication) whilst effective reflux control is maintained.

Mr Krishna Epari rountinely performs a partial (Anterior 180 degree) fundoplication to minimise the risk of side effects whilst achieving good control of reflux symptoms.