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 … Continue reading Reflux Procedures