Overview of reflux surgery
Reflux surgery (anti-reflux surgery, or fundoplication) is a keyhole operation that rebuilds the valve between the stomach and the oesophagus (food pipe), with the aim of stopping acidic stomach contents from flowing back up. It is the third step in the treatment of reflux disease, after lifestyle changes and medicines. To understand how it helps, it is useful to look first at what reflux is.
Heartburn is a burning pain behind the breastbone, felt between the lower ribs and the neck. It is often a sign of gastro-oesophageal reflux disease (GORD), in which acidic stomach contents come back up into the oesophagus. Other possible symptoms are nausea, difficulty swallowing, a long-lasting cough, especially in the morning, and wheezing.
Where the oesophagus joins the stomach, there is a ring of muscle called the lower oesophageal sphincter. Normally, it closes after you swallow and stops acidic stomach contents from flowing back. If this valve no longer works well enough, the acid irritates and inflames the lower oesophagus. This causes heartburn and, over time, can lead to serious damage.
Some people are born with a weak sphincter. Fatty and spicy food, some medicines, tight clothing, smoking, alcohol, strenuous exercise and changes in body position can also make the sphincter relax, and so encourage reflux.
Who is it for?
Reflux disease is treated in three steps, and surgery comes only after the first two have been tried:
- Lifestyle changes: in some people, symptoms improve when they change their diet, cut down on smoking and alcohol, keep regular sleep habits and take antacids.
- Medicines: if symptoms do not improve with these measures, medicines are used that neutralise stomach acid (antacids) or reduce how much acid is made. They can relieve symptoms and allow irritation and damage in the oesophagus to heal.
- Surgery: an operation may be considered if symptoms continue despite lifestyle changes and medicines, if you need medicines all the time, or if symptoms seriously limit your daily life. The operation is usually done by keyhole (laparoscopic) surgery.
Before an operation is planned, the oesophagus and stomach are usually examined, for example with a gastroscopy, to confirm the diagnosis and look for damage to the lining.
Risks
Keyhole anti-reflux surgery is an established procedure. As with any operation, however, complications can occur:
- reactions to the anaesthetic
- bleeding
- injury to the oesophagus, spleen, stomach or other organs in the abdomen
- wound infection, infection inside the abdomen and blood poisoning (sepsis)
- other, less common complications
There are also some effects that are linked to how the operation works, because the new valve makes the passage into the stomach tighter:
- Some patients have difficulty swallowing for a while after the operation. This settles within one to three months.
- A few develop a narrowing of the oesophagus that has to be widened endoscopically. Rarely, a second operation is needed.
- Some people have trouble belching or a feeling of nausea.
In a very small number of patients, open surgery is needed, for example if the organs cannot be seen clearly or held well with the instruments. Severe obesity and earlier abdominal operations can also make keyhole surgery unsuitable. The surgeon makes this decision before or during the operation, solely for your safety.
Preparation
Preparation for reflux surgery follows a few clear steps:
- Your surgeon will explain the possible risks and ask for your written consent.
- Before the operation, you will have blood tests, a chest X-ray and an ECG (heart tracing).
- Shower the day before or the evening before the operation.
- Do not eat or drink anything from the evening before. Medicines you have agreed to keep taking can be taken with a little water.
- Tell your surgeon if you take blood-thinning medicines, vitamin E or painkillers. These must be stopped one week before the operation.
- Weight-loss medicines should be stopped two weeks before the operation.
- Stop smoking and drinking alcohol, and get support to do so if you need it.
What happens
Before the procedure
A cannula (a thin tube in a vein) is put in for medicines and fluids, and you are given the medicines needed to prepare you. The operation is done under general anaesthesia, so you are asleep throughout.
On the day
The aim of the operation is to rebuild the valve between the stomach and the oesophagus. To do this, the upper part of the stomach is wrapped around the lower end of the oesophagus (fundoplication).
First, the abdomen is filled with carbon dioxide gas. Through small cuts, the surgeon passes in the instruments and a special video camera, and operates while watching the image on a monitor. Compared with open surgery, the keyhole approach means less pain after the operation, a shorter hospital stay and a quicker return to work.
After the operation, you are taken back to your room once you are awake, and you stay in hospital on the day of the operation.
After the procedure
You can usually go home on the afternoon of the following day; if needed, your stay may be longer. You may have mild pain, which can be treated with painkillers. A modified diet is often recommended, moving step by step from liquid to solid food, which also helps while any temporary difficulty swallowing settles.
Aftercare
At home, take things easy at first. You can return to your everyday activities after a short time. Your follow-up is a good moment to talk about your diet and any swallowing difficulty, and as part of it a routine blood test check is done at 6 months.
Please contact your doctor if you have any of the following:
- increasing swelling of the abdomen
- pain that does not ease with medicines
- persistent nausea and vomiting
- feeling very cold or shivering (chills)
- pus coming from the wound
- increasing redness around the wound
- being unable to eat or drink
Keyhole surgery at the lower end of the oesophagus is also part of achalasia treatment, where a fundoplication is added to help prevent reflux.