- What is reflux?
- Natural history of reflux
- Investigations for reflux
- Complications of reflux
- Treatment options for reflux
- Which treatment is appropriate?
- Surgical option for reflux: why consider it?
- Relevant investigations prior to surgery
- Open vs. laparoscopic surgery for reflux
- Laparoscopic anti-reflux surgery:
- Nissen fundoplication
- Nissen-Rossetti fundoplication
- Toupet fundoplication
- Anterior fundoplication
- Operation and recovery
- Side effects of anti reflux surgery
- Long term results of anti reflux surgery
- Reasons for failure of anti reflux surgery
- Andrew Bowker’s Experience with laparoscopic anti reflux surgery
What is reflux?
Gastro-oesophageal reflux occurs when stomach acid spills back up into the oesophagus. It is the result of a faulty valve mechanism between the stomach and oesophagus. The lining of the oesophagus is different from the stomach lining and is not built to handle acid. Reflux typically causes rising retrosternal (behind the breastbone) burning discomfort or pain – “heartburn”. This can extend up into the neck and mouth, at times accompanied by volume reflux of stomach contents into the mouth – “waterbrash”. Reflux can be aggravated by mechanical and dietary factors – excess weight, lying down, bending over, alcohol, caffeine, fats, spices, smoking.
Natural history of reflux
Reflux is a very common complaint; up to 30% of the population experience it on a monthly basis. However, for most it is a minor event and treatment is not sought. Many recognise it as a form of punishment for a night of alcoholic and dietary indiscretion, resorting to simple over-the-counter antacid preparations to settle the complaint. In others, it can become a condition that dominates much of their daily (and nightly) life, resulting in severe activity and dietary restrictions. Once reflux is experienced on a frequent basis, it rarely settles spontaneously. Usually it persists, slowly worsening, often over a period of years.
Investigations for reflux
Investigations are not always necessary. Often the doctor prescribes regular acid suppressing medication on basis of history alone. However, if symptoms are severe, or have been present for many years, endoscopy/gastroscopy is the investigation of choice. This involves the passage of a narrow flexible telescope down the throat so that the lining of the oesophagus and stomach can be directly visualised. Typically there is evidence of acid damage to the lining of the oesophagus – oesophagitis, ulceration – just above the junction with the stomach, which is the site of maximal acid exposure when reflux occurs.
Complications of reflux
Because more effective medical treatment is now readily available, complications from chronic gastro-oesophageal reflux are less frequently encountered than previously. The initial endoscopic study typically identifies evidence of oesophagitis in the form of erythema (reddening of the oesophageal lining) and ulceration. This is due to excessive exposure of the distal oesophagus to acid and can ultimately result in scarring and narrowing (stricturing) of the oesophagus. Strictures cause food to stick en route to the stomach, a symptom known as dysphagia (difficulty swallowing). This may need to be treated with dilatation, forcibly stretching the narrowed segment, as well as instituting more effective therapy. Fortunately, with the widespread use of Proton Pump Inhibitor medications (see below in Treatment Options), stricture formation is now a rare occurrence. If the patient has already been on treatment prior to endoscopy, there may be no abnormalities to see, as inflammation and ulceration typically heals within a month or so of taking a proton pump inhibitor medication.
In some people, chronic acid exposure causes a change in the cells lining the distal oesophagus, Barrett change, which is a precancerous state. The risk of progression to invasive cancer is not great, but when the change is identified, the area needs to be kept under endoscopic surveillance, so that if there is any evidence of progression towards actual cancer on biopsies, early surgical treatment can be implemented, with a high likelihood of cure. Once Barrett change is established, effective medical or surgical treatment of the reflux condition which caused it does not reduce the risk of progression, so surveillance needs to be maintained.
Reflux of material up the oesophagus can also trigger respiratory problems, such as coughing and choking, wheezing and asthma. Coughing paroxysms can be particularly persistent and distressing in some cases. Often there is a nocturnal bias to such symptoms, patients complaining of waking suddenly, coughing and choking due to refluxed material. Irritation of the throat and vocal chords can cause voice hoarseness. Rarely, acid reflux into the mouth can damage tooth enamel.
Treatment options for reflux
Dietary: certain dietary items tend to worsen reflux symptoms. The most commonly implicated are rich or spicy food, acidic foods, alcohol and caffeine. Avoidance of these can help control symptoms.
Physical: changes in posture encourage reflux. Lying down or bending over, particularly soon after a meal, commonly induces flow of acid up out of the stomach into the oesophagus, rather like tea is tipped out of the teapot. Controlling the timing of such activities helps, e.g. eating the evening meal early and retiring to bed late. Elevation of the head of the bed on blocks some 10-14cm can be of great help for nocturnal symptoms.
Medical: most people self-medicate with over-the-counter antacids such as Quickeeze and Tums. Gaviscon is a more sophisticated antacid. These days H2 antagonist acid suppressing agents such as ranitidine (zantac), cimetidine (tagamet) and pepcidine (pepcidine) are usually bypassed in favour of proton pump inhibitors (PPI’s) omeprazole (losec), pantoprazole (somac) and lanzoprazole (zoton), which effectively turn off acid production in the stomach. PPI’s are usually so very effective that all symptoms are abolished and postural and dietary restrictions can be abandoned. This total or near-total lack of acid does not seem to pose problems with digestion. Stomach acid does have a sterilising function but, although some initial breakdown of food occurs in the stomach, the majority of digestion takes place in the very alkaline environment of the small intestine. Initially there were some theoretical concerns about the lack of gastric acid creating an environment where gastric (stomach) cancer might more likely occur, but these fears have not been realised, despite the medication being in widespread use for 20 or more years now.
Endoscopic: recently there has been some progress with endoscopic anti-reflux procedures for those who do not wish to take medication long term, or where non-surgical control is suboptimal. The place of such procedures is not yet established. They are not likely to be as effective as surgery in those with severe symptoms or significant volume reflux of gastric contents up the oesophagus.
Surgical: surgery aims to create a new valve at the junction between the oesophagus and the stomach. It is not first-line treatment, but tends to be reserved for those who have more severe symptoms which are not adequately controlled by lifestyle and medical means. However, there is also a large group of usually younger sufferers who object to the need to constantly take medication on a long term basis, and seek surgery as a means of becoming symptom and medication free.
Which treatment is appropriate?
Most people who experience reflux symptoms can control them very effectively with medications. Often all that is needed is an occasional antacid. Those who have more troublesome symptoms are frequently prescribed proton pump inhibitors (PPI’s) as the first line regular treatment, rather than progressing through H2 antagonists (cimetidine, ranitidine, pepcidine, etc), which were the mainstay of reflux treatment until PPI’s became established and more freely available. Many are very happy to remain on these medical treatment options on a long term basis, and it appears safe to do so.
Surgery is an option when medical treatment becomes less effective, or if volume reflux is a problem despite good control of acidic heartburn. There is also a group who have troublesome respiratory symptoms (cough, wheeze, choking) which are only partially controlled by medication and postural measures. Occasionally side effects are experienced with PPI’s, such as headaches, gastrointestinal disturbances (most frequently diarrhoea) and rashes, but generally it is a very well targeted medication.
There is a large group of reflux sufferers, frequently in the younger age groups, who resent the fact that they are committed to having to take the medication on a long term basis. They look to surgery as a means of providing good control of symptoms without need for medication or lifestyle restrictions. Surgery is never mandatory; it is a lifestyle option, but one which can make a major positive impact on lifestyle.
Surgical option for reflux: why consider it?
Side effects from medication e.g. rashes, gastrointestinal disturbances (diarrhoea), headaches.
Incomplete control of symptoms by non-surgical means, particularly persistent volume reflux.
Complications from reflux: respiratory (cough, wheezing, choking), oesophageal (Barrett change, stricturing)
Desire to be free of medication requirements and lifestyle restrictions.
Relevant investigations prior to surgery
History: symptoms consistent with gastrooesophageal reflux.
Gastroscopy: findings supportive of reflux, such as ulceration, stricture formation, Barrett change. The first two are likely to disappear after a few weeks of proton pump inhibitor (omeprazole, pantoprazole,lansoprazole) therapy.
Barium swallow: not mandatory, but an option for demonstrating free reflux when it is occurring. It is a means of quantifying the size and position of any hiatus hernia associated with the reflux. It also provides a reasonable assessment of oesophageal motility (the effectiveness of the oesophageal muscular swallowing function.)
24 hour pH study: this is usually reserved for those in whom the diagnosis of reflux is in doubt. There may be atypical features to the story, or a minimal or absent response to optimal medical treatment. It provides an objective measure of whether reflux is occurring, but is not absolute in the information that it provides. It involves placement of a coated wire in the oesophagus such that sensors in the wire can detect degrees of acidity at points above the oesophago-gastric junction. These changes are recorded over a 24 hour period by a small device which is worn by the subject. Activities and symptoms are diarised and at the end of the study period the wire is withdrawn and the data downloaded so the changes in oesophageal acidity can be correlated with symptoms and compared to the “normal” population. It is a useful adjunct to patient assessment, particularly where there is doubt about whether reflux is the primary problem or not. Usually such assessment is made on the basis of patient history, any positive findings on endoscopy and response to proton pump inhibitor therapy. In fact, response to PPI’s is a good predictor of pH study results, meaning that this moderately invasive and uncomfortable study is rarely required.
Oesophageal manometry: manometry looks in more detail at the oesophageal swallowing mechanism than does a barium swallow. A coated sensor wire is positioned in the oesophagus and pressure sensors along its length record the force of the muscular contraction as the oesophagus propels food down into the stomach. Information gathered during a series of dry and wet swallows is collected and then printed out by the computer to give an objective measure of oesophageal function. It was hoped that this information would allow surgeons to tailor the type of anti-reflux operation to the individual, and therefore minimise the risk of significant difficulties swallowing postoperatively. Unfortunately this has not proved to be the case, but it does identify those with major swallowing disorders such as achalasia, a rare condition where there is a lack of coordinated oesophageal muscular contraction compounded by lack of relaxation of the oesophago-gastric sphincter. In this situation swallowing is driven largely by gravity, and creation of a more effective sphincter surgically would compound swallowing difficulties. Usually clues to this condition are present in the patient’s history, but they can be clouded by reflux-like symptoms.
Open vs. laparoscopic surgery for reflux
Laparoscopic operations that are performed for reflux are the same as those that are done “open”, through a traditional large muscle-cutting incision. However, the difference in recovery between open and laparoscopic approaches is probably greater with this type of surgery than any other operations that are now done laparoscopically. Access to the junction between the oesophagus and the stomach is not easy with open surgery. A long incision is required, usually from the umbilicus to the xiphisternum (bottom of the breast bone), then heavy rib retraction is used, to further facilitate access. This usually results in a prolonged and uncomfortable recovery. With the laparoscopic approach, the muscle-cutting incision is avoided and rib retraction is not required, as the laparoscope can be advanced to provide a magnified, close-up view of the target organs. Instead of 4 or 5 nights in hospital and the need to take painkillers and avoid heavy activities for 4-6 weeks, usually only overnight hospitalisation is needed, with simple analgesics, such as paracetamol, for a few days subsequently. There is little need for restriction of activity.
In the days of open anti-reflux surgery, all general surgeons performed the operation, but few did it frequently. Laparoscopically it is a more technically advanced operation to do, which has meant that relatively few general surgeons are doing it, and then usually only those who have a particular interest in laparoscopic procedures (and, hopefully, particular skills to go with the technology). This is important with anti-reflux procedures, which tend to have an “art” element to them. This relates mainly to how the fundal wrap is fashioned; how it is placed, how tight it is, how secure it is. Clouding the issue further is the fact that different patients have different propulsive powers in their oesophagus, meaning that a wrap that is too tight for one person may be fine for another. It is expected that, if a surgeon is performing these procedures frequently, variations in results should be minimised. Even so, results are not perfect.
Centres of excellence report good to excellent results in 90% at 5 year follow-up; 85% at 10 years. This means that the majority can expect a good long term outcome, with respect to being symptom and medication free, without dietary restriction, but there are always going to be some unsatisfactory outcomes.
Laparoscopic anti-reflux surgery:
Since the early 1990’s it has been possible to use laparoscopic (keyhole) surgical techniques to perform anti-reflux procedures. These are identical to those which are done through open surgery, but the long upper abdominal incision is avoided, removing almost all the pain and misery which is associated with open surgery. This is particularly marked with anti-reflux procedures because heavy rib retraction is required, as well as the painful upper abdominal incision, in order to provide adequate manual access to the relatively inaccessible part of the abdomen where the operation takes place.
The laparoscopic equivalent is done through a series of small (0.5-1cm) incisions which part the muscle rather than cut it. Access is also extremely good as the laparoscope is simply advanced until a close and magnified view is provided. Additional laparoscopic skills are required, compared to when performing laparoscopic cholecystectomy, particularly the ability to suture laparoscopically. Highly specialised equipment is often employed, such as ultrasonic scissors, which use high frequency ultrasound to seal and divide tissues without blood loss.
There are a number of different ways in which the new anti-reflux valve can be constructed. All involve wrapping the top part of the stomach, the fundus, around the bottom end of the oesophagus. When there is more than one way of achieving an end point in surgery, it suggests that there is no one perfect technique and anti-reflux surgery is no exception to this. All have their proponents, but it tends to come down to the individual surgeon and what works best for him and his patients. This may sound very unscientific, but it has been difficult to compare accurately one technique with another, as most surgeons have small, but significant, variations in how they perform what is ostensibly the same operation. Again this emphasises the importance of picking an experienced surgeon, who you hope is not repeating the same mistakes over and over again!
Like other forms of anti-reflux surgery, Nissen fundoplication involves wrapping the fundus (top part of the stomach) around the bottom of the oesophagus. The Nissen employs a full 360 degree wrap, placed snugly enough to discourage reflux from occurring up through the wrap, but not so tight that swallowing is restricted. This is an area where important variations of surgeon technique can make a difference between a successful operation and one which does not have such a good outcome.
Rudolph Nissen serendipitously found that such a wrap prevented reflux about 60 years ago. Since then there have been minor modifications to his technique, but the operation remains the “gold standard” for anti reflux surgery. The procedure involves full mobilisation of the fundus by dividing the short gastric blood vessels between the stomach and spleen so as to ensure that tension on the wrap is minimised. The wrap itself is 1.5-2 cm in length and is often fashioned over an oesophageal bougie (passed down the oesophagus by the anaesthetist during the operation) as a means of “sizing” the wrap.
This is a variation on the above operation where the short gastric blood vessels between stomach and spleen are not divided before forming the wrap. To avoid too much tension on the wrap, a slightly different part of the fundus is grasped and drawn round to form the wrap, which does help, but it is generally felt that this technique, while simpler to perform, has too high an incidence of prolonged dysphagia (swallowing difficulty) post-operatively.
With the Toupet variation of fundoplication, the wrap is brought around behind the oesophagus only 270 degrees, rather than the 360 degrees of a full fundoplication. The wrap itself is around 4cm vertical extent, rather than the 1.5-2cm of the Nissen. The procedure is supposed to cause less dysphagia than the full wrap and be more suitable for patients who have possible swallowing dysfunction, but comparative studies have shown little, if any, difference in outcome between the two variations. There is also concern that the surgical benefits of this partial wrap may not be as sustained as those gained by a full wrap.
With anterior fundoplication, instead of drawing the fundus behind the oesophagus to form the wrap, as in the above two variations, it is drawn across anterior to the oesophagus and sutured in place. This is said to cause the least side effects of all, but not all surgeons find that it provides effective and sustained prevention of reflux.
Operation and recovery
The patient comes in on the day of surgery having not eaten for at least 6 hours before the planned start of surgery. The operation itself is done under a full general anaesthetic, and takes 1-2.5 hours to perform. Patient build has a considerable influence on the technical ease with which the operation is performed. Postoperatively, patients can mobilise to the toilet and are allowed to drink. The next morning a soft breakfast is consumed, the patient showers, has dressings changed and is encouraged to mobilise further. Discharge is usually that afternoon, although sometimes a further night in hospital is required.
Postoperative pain is not usually severe and 2-3 days of paracetamol +/- anti-inflammatories are all that are required. Any abdominal discomfort/pain settles rapidly, but sometimes pain referred from the diaphragm (thin muscle separating the abdominal cavity from the chest cavity) can persist with ongoing analgesic (painkilling) requirements. Patients typically feel somewhat washed out for 1-2 weeks. Return-to-work expectations are, for the self-employed, one week, the employee, two weeks.
Side effects of anti reflux surgery
1. Bruising and swelling in the wrap cause temporary difficulty with swallowing and care needs to be taken with what and how food is consumed. This is largely common sense. A reasonable variety of food types is usually possible and by 3-4 weeks post op swallowing should be relatively free. Ultimately, there should be no restriction whatsoever, although some receive a reminder of the wrap’s presence with certain foods, e.g., the soft bread roll eaten hurriedly for lunch.
2. Stomach capacity is reduced well in excess of the distortion and loss of volume caused by forming the wrap. Patients feel full with an entré sized meal, rather than a main course. This makes for cheap eating out and is a great way to lose on average 5kg, but is only temporary. After about 3 months, stomach capacity returns to normal, or near-normal, but patients frequently comment that they are no longer able to “pig out” as they may have done previously. However, the weight may still go on again…
These both relate to an over-efficient wrap.
1. Most people who have had this operation are no longer able to vomit. This may sound alarming, but when you think about it, vomiting is an extreme form of reflux, and the wrap successfully prevents it by flapping shut when the pressure within the stomach rises. The need to vomit most commonly occurs with food poisoning where retching unsuccessfully against the wrap eventually gives way to diarrhoea. At least one knows which end to direct at the toilet in this situation! Such retching against the wrap is an insult to the wrap, but usually no harm is done to it.
2. On a more day-to-day basis, anti-reflux procedures tend to make people pass more flatus. Most flatus is air that was swallowed in the first place. In the normal situation we are not aware of doing this, nor are we aware of it being released back up the oesophagus. If an over-efficient flap valve is placed at the oesophago-gastric junction, this upward release is prevented. The swallowed air has to go somewhere, so it heads “south”. About 30% do not notice any difference in flatus production, but the majority do, some quite a lot. This is the major trade-off for control of reflux through surgery. It can settle somewhat with time, but tends to be an ongoing feature. Attention to diet and remedies such as activated charcoal can help.
Long term results of anti reflux surgery
Major centres with long-term follow-up of the operation done through an open approach report 10 year good-excellent results of 90%+, 20 year 80-85%+.
Reasons for failure of anti reflux surgery
Failure of the operation to maintain control of reflux can be due to the wrap becoming loose, in which case acid can pass up through it. It can slip down off the lower oesophagus onto the stomach, again allowing recurrence of reflux. Some patients are predisposed to this by having some shortening of the oesophagus, usually as a result of chronic acid damage and scarring. The situation is hard to recognise preoperatively. If the wrap is too tight, persistent dysphagia (difficulty swallowing) can require re-operative modification, though usually with time and endoscopic dilatation, this can be avoided.
Andrew Bowker’s Experience with laparoscopic anti reflux surgery
The first laparoscopic procedures for reflux were done in Belgium in 1990. I became interested in laparoscopic technology the following year, taking up laparoscopic cholecystectomy (removal of the gallbladder for gallstones) and laparoscopic hernia repair. I performed my first laparoscopic anti-reflux procedures in 1992. I now do around 20-30 per year, with a cumulative total of over 590 (as of March 2017). The very first procedure required conversion to the open (large incision) approach, as has one revisional anti reflux operation, but otherwise all operations have been completed laparoscopically.
Success with this operation is never guaranteed. As mentioned above, centres of excellence report long term follow up with good to excellent outcomes of 90% at 10 years and 80-85% at 20 years. My results are in line with these.
First laparoscopic anti reflux procedure – 1992
Initially used Nissen Rossetti variation and has used Toupet partial fundoplication and anterior fundoplications occasionally, but Nissen fundoplication with full mobilisation is the preferred technique
- No. of fundoplications (March 2017) – 590
- No. of revisions – 14
- No. of conversions – 2
- Good-excellent symptomatic result – 85-90 % (long term)