Laparoscopic Antireflux Surgery

Introduction

Antireflux surgery is performed to correct the reflux of acid up into the gullet from the stomach. The main symptom of reflux is heartburn (a burning pain felt under the breast bone). In the past the only surgical option was the open method, which involved a large cut in either the upper part of the abdomen or the chest. This was a very painful procedure and involved at least 5-7 days in hospital, plus a long recovery period. The same procedure is now performed laparoscopically, using what is popularly known as the keyhole approach. The operation is performed through 5 small puncture holes instead of through a large incision, and involves usually only an overnight stay in hospital.

What is gastro-oesophageal reflux disease?

As the term implies, gastro-oesophageal reflux disease is reflux of the stomach contents into the lower part of the gullet. The majority of the stomach contents are acid; this acid burns the lower part of the gullet causing damage. The burning is felt as heartburn, a burning sensation that radiates through the chest and may radiate up to the throat and neck. The basic cause of this problem is the break down of a valve that normally exists between the stomach and the gullet preventing reflux occurring. Other symptoms that may occur are acid regurgitation where acid is felt coming back into the mouth; vomiting, particularly on stooping and bending; choking attacks, particularly at night; chronic cough and difficulty in swallowing. If this acid regurgitation is allowed to continue, it may cause damage which can lead to narrowing of the gullet and thus lead to difficulty in swallowing.

What contributes to causing gastro-oesophageal reflux?

Some people are born with a naturally low sphincter pressure and reflux from a very early age. In adult life, reflux may be precipitated by fatty and spicy foods, tight clothing, smoking, alcohol and being overweight. In pregnancy, reflux nearly always occurs due to the pressure of the baby pushing the stomach up and aiding reflux. A hiatus hernia may also be present. Under these circumstances, a small part of the stomach has ridden up through the diaphragm into the chest and this situation tends to lead to reflux. However, the presence of a hiatus hernia does not necessarily imply that reflux will occur.

Medical treatment of reflux

Lifestyle changes. The most important lifestyle change to improve the symptoms of reflux is losing weight. If you are overweight, there is often a critical weight. Below this the symptoms of reflux will improve dramatically, above it, reflux will be prominent. Reducing smoking and alcohol consumption will also be helpful. Changing eating habits will also improve symptoms. It is important to have regular meals and to have the last meal several hours before going to bed.

Drug therapy. Drug therapy is usually very successful at improving the symptom of heartburn. Antacids neutralise the stomach acidity and will relieve relatively mild symptoms. If these fail then stronger prescription drugs may be necessary. These are known as proton pump inhibitors. There are several different types of proton pump inhibitors. These drugs dramatically reduce the gastric acid shutting it down to minimal levels. These drugs are usually very effective at relieving heartburn.

Surgey. Surgery is required if medical treatment fails to relieve the symptoms, or, if the medication satisfactorily relieves the symptoms but as soon as the medication is stopped, the symptoms recur. Under these circumstances a large number of patients prefer to go to surgery rather than take medication for the rest of their lives. This particularly applies to the younger aged patients. Surgery now is performed using laparoscopic (key hole) techniques.

How is laparoscopic anti-reflux surgery performed?

In laparoscopic surgery, surgeons use small incisions, ½ inch long to enter the abdomen through cannulae. These are small tube like instruments. Through these tubes, the laparoscope, which is connected to a tiny video camera, is inserted. This gives the surgeon a magnified view of the inside of the abdominal cavity. The entire operation is performed inside, after the abdomen has been expanded by pumping gas into it. In anti-reflux surgery, the top part of the stomach is mobilised using special instruments. This part of the stomach is then passed around the lower part of the gullet and the stomach is sutured onto itself to form a very loose wrap of stomach enclosing the lower part of the gullet. This acts as a valve which prevents the acid contents of the stomach refluxing back into the gullet

What are the advantages of laparoscopic anti-reflux surgery?

  1. Reduced post operative pain. Following laparoscopic anti-reflux surgery you should feel abdominal discomfort for 1-2 days and minimal pain thereafter.
  2. Shorter hospital stay. Your hospital stay should only involve 1-2 nights.
  3. A faster return to work. Those with sedentary jobs should be able to resume work within 1-2 weeks and for heavy manual work, within 3-4 weeks.
  4. Improved cosmetic result. Minimal scarring is present.

What are the risks of laparoscopic anti-reflux surgery?

The complications of laparoscopic anti-reflux surgery are considerably less than with open anti-reflux surgery. However complications may occur as with any operation. Complications during operation may include anaesthetic complications, bleeding, injury to the oesophagus, stomach or very rarely the spleen. Complications after the operation may include wound infection although this is very rare, chest problems such as pneumonia.

What will happen if the operation cannot be completed laparoscopically?

Your surgeon will discuss with you before the operation what will happen if the operation cannot be completely laparoscopically. This will usually mean conversion to an open operation where a much larger cut is made. The usual reasons for this occurring are because it is unsafe to continue with the laparoscopic approach, usually because the vision is not satisfactory, or if complications such as bleeding do occur during the process of the laparoscopic procedure. If you have had a lot of previous abdominal surgery then adhesions may well be present in the abdominal cavity which may make the operation difficult or even impossible.

What are the side effects of this operation?

Longterm side effects are uncommon. The main side effects that do occur are an increased passage of wind (flatus) per rectum. This may be a permanent situation. One of the problems of inserting a valve between the stomach and the gullet is that air cannot be freely belched out. This means that the air passes through the intestines and leads to more air being produced per anum. Another side effect is that you will not be able to bolt your food. After laparoscopic anti-reflux surgery it is important to chew food completely and to eat slowly. Stomach bloating may also occasionally occur.

What to expect before anti-reflux surgery

Before proceeding to anti-reflux surgery, it is likely that your surgeon or physician will want you to undergo a series of tests. The first test is likely to be an endoscopy where a tube is passed down the gullet to look at the oesophagus and assess the degree of damage that is being caused by the acid. Following this two further tests are often performed; one is oesophageal manometry which determines how your gullet works. It demonstrates whether the sphincter between your gullet and oesophagus has broken down and it ensures that your gullet is working normally (has normal peristalsis). The second test that is likely to be performed is 24 hour pH manometry. In this test a fine probe is placed in the lower part of your gullet so that the amount of acid that flows into the gullet can be measured over a 24 hour period. This shows just how much acid refluxes each day.

What to expect prior to surgery

Before undergoing surgery you will have your blood checked to ensure that your blood count and biochemistry are normal. It is customary also to determine your blood group and have serum available should blood be necessary. You may be admitted to hospital the night before the operation or on the day of the operation itself. The operation is done under a general anaesthetic. You will not be aware of the operation being performed.

What to expect post surgery

After the operation, you will recover in a special recovery area near to Theatre until you are fully awake before you return to the ward. Most patients stay in hospital at least one night and often two. If you are feeling sick after the operation, which may occur due to the anaesthetic, you will be given nil by mouth until the nausea and sickness wears off. Usually on the first post operative day you will be drinking clear fluids and start on a light diet on the second post operative day. It is advisable to avoid bread and fizzy drinks for the first 4-6 weeks.

You will often notice during the first few weeks that food tends to stick. It is very important during this early post operative phase to eat slowly and to chew food thoroughly. It often helps to take some liquid with your food. Immediately after your operation you will have 5 little patches on your abdominal wall. These are usually removed at 5 days. Most surgeons use stitches that dissolve and do not need to be removed. You can usually therefore take a bath at about 5 days. For a few days after the operation you may need some gentle pain killers. These should not be necessary after about 5-7 days. Your anti-reflux medication should stop at the time of the operation and should not be necessary thereafter. If, when you go home, you vomit, have severe pain or severe difficulty in swallowing, you should call your doctor immediately.