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Gastro-oesophageal reflux

What is it?

Gastro-oesophageal reflux describes the exposure of the oesophagus to acid produced by the stomach. It is common with approximately 10-20% of the population experiencing weekly symptoms of heartburn or regurgitation. Almost half the population will suffer from reflux during their lifetime.

Common Symptoms

  • Heartburn / indigestion
  • Regurgitation
  • Acid Brash
  • Chest pain
  • Cough
  • Hoarseness of voice

Why does it happen?

Normally, a protective reflux barrier prevents acid reflux from the stomach to the oesophagus. This barrier is comprised of the lower oesophageal sphincter and the diaphragm muscles that surround the oesophagus. These effectively form a valve (sphincter) and depending on an individual’s anatomy the sphincter may not function normally or may become lax with time. An example of this is a hiatus hernia and this may promote reflux of stomach contents into the oesophagus.

When should I seek help?

Gastro-oesophageal reflux is a common and benign condition. However, it can mask more serious underlying conditions if not investigated appropriately. Any patient with new symptoms should be reviewed, especially if associated with any difficulty in swallowing. Patients with persistent or recurrent reflux symptoms should also be considered for endoscopy.

How is it diagnosed?

– Gastroscopy (endoscopy)

Gastroscopy involves the passage of a telescope through the mouth and into the gullet. It is performed with local anaesthetic spray, with the addition of a sedative if required. The procedure assesses the lining of the oesophagus for evidence of acid damage (oesophagitis) and looks for a hiatus hernia. Although only present in the minority of reflux sufferers it can also check for changes which can progress to cancer (Barrett’s Oesophagus). This is detected by biopsies taken at the time of the procedure. It is not painful to have biopsies taken. There may also be inflammation in the stomach and biopsies can be taken to check for Helicobacter Pylori infection.

– Ambulatory pH testing

Gastro-oesophageal reflux is confirmed by measuring the amount of acid present in the oesophagus over a 24-96 hour period. Either a small tube (via the nose) with acid sensors is placed into the oesophagus for 24 hours (catheter pH study) or a small capsule (BRAVO) is placed at the bottom of the oesophagus via endoscopy, which then detaches and is passed spontaneously after 96 hours. During this time the patient carries on performing normal activities and acid exposure in the oesophagus is recorded by sensors. Patients also record symptoms to enable us to understand the relationship between the acid exposure and their symptoms.

– Oesophageal manometry

Oesophageal manometry is a diagnostic test that uses tiny transducers or receivers within a small catheter or tube that is inserted into the oesophagus to measure pressure. This device is used to measure ability of the oesophageal sphincter to relax and to assess the motility of the oesophagus (how well it pushes food and liquid down into the stomach). This is a short procedure, which can be done during a visit for the pH study or as an independent investigation.

How should it be managed?

Lifestyle changes are important and usually the first step of management. Pregnancy, obesity, smoking, stress and dietary factors (e.g. alcohol, caffeine and chocolate) can all promote reflux. Patients often find acid suppression medications (e.g. proton pump inhibitors such as omeprazole) help. Although acid medications are generally considered safe, there are some concerns about long-term use, particularly in higher doses, with the absorption of calcium and iron effected, potentially contributing to conditions such as osteoporosis. Persistent symptoms despite medication should be investigated to exclude a more serious underlying cause. If prolonged medication is not suitable or fails to adequately control the symptoms, then surgery should be considered. Surgery can be very effective as a longer-term reflux treatment and is particularly useful for patients with a hiatus hernia and those suffering with regurgitation.

How effective is surgery?

The LSG specializes in anti-reflux surgery in London, Hampshire and Surrey. Selection of patients for the right procedure is important and surgery should be very successful provided it is performed for the correct indications. Patients should not require regular acid suppression medications after the surgery and can expect immediate resolution of their reflux symptoms. Some symptoms (particularly throat symptoms such as sore throat, cough and voice change) can be more unpredictable and take longer to resolve. The long-term results (beyond 10-15 years) do show that some patients will restart medication again and it is possible for a hiatus hernia to recur. Modern techniques aim the reduce this risk as much as possible.

Are there any risks?

Patients can suffer from gas bloating or increased flatulence (passing wind). This is due to the inability of air to escape past the new sphincter created to prevent reflux. This usually improves over time. Avoidance of fizzy drinks and certain foods may improve these symptoms. Some patients are unable to vomit, but this is not dangerous and complications from this are extremely rare. Temporary difficulty swallowing solid food can occur following anti-reflux surgery due to swelling around the oesophagus and the tighter valve resulting from the operation. This resolves over a short period of time and it is rarely an issue long-term. Some small risks that are present for any kind of surgery (e.g. wound infection) will be discussed during the consent process.
How is the surgery performed?
Anti-reflux surgery is almost always performed laparoscopically. Small cuts are made in the abdominal wall to allow passage of keyhole instruments. The operation generally involves two components. The first part repairs the hiatus hernia and returns the stomach fully into the abdominal cavity where it belongs. The second part involves a procedure to “tighten” the valve at the lower oesophagus – either by performing a fundoplication or Linx procedure. A fundoplication is where the fundus of the stomach is wrapped around the lower oesophagus to recreate the bodies’ natural anti-reflux barrier and reinforce the sphincter. The wrap can be complete (360 degrees) or partial (180 degrees) depending on each individual patients’ characteristics. A linx procedure involves the placement of a magnetic bracelet around the lower oesophagus. This innovative device is designed to open during swallowing (to allow food to pass) but remain closed at other times (preventing reflux). It is explained in more detail separately.

How is the surgery performed?

Anti-reflux surgery is almost always performed laparoscopically. Small cuts are made in the abdominal wall to allow passage of keyhole instruments. The operation generally involves two components. The first part repairs the hiatus hernia and returns the stomach fully into the abdominal cavity where it belongs. The second part involves a procedure to “tighten” the valve at the lower oesophagus – either by performing a fundoplication or Linx procedure. A fundoplication is where the fundus of the stomach is wrapped around the lower oesophagus to recreate the bodies’ natural anti-reflux barrier and reinforce the sphincter. The wrap can be complete (360 degrees) or partial (180 degrees) depending on each individual patients’ characteristics. A linx procedure involves the placement of a magnetic bracelet around the lower oesophagus. This innovative device is designed to open during swallowing (to allow food to pass) but remain closed at other times (preventing reflux). It is explained in more detail separately.

More information on Laparoscopic Surgery

More information on Linx Surgery

How long will it take to recover from the surgery?

Patients are fully mobile after surgery and can commence fluids immediately after. The procedure can be performed as a day-case or a one-night hospital stay. This is mainly to build confidence with oral intake after the surgery. The wound sites will have local anaesthetic injected into them at the time of surgery. This will wear off about 6 hours after the procedure. To stop the sites becoming sore you should take the regular painkillers as instructed. Shoulder tip pain is not uncommon and is due to gas underneath the diaphragm. This should not last longer than 24 hours. You will not be discharged until you are comfortable drinking. On discharge you should be independent and able to climb a flight of stairs.

The post-operative dietary plan varies slightly by procedure.  Following a fundoplication, patients build up steadily over some weeks from liquids to pureed food and then a soft diet before returning to normal eating. This can vary between individuals with swallowing difficulties prior to surgery a predictor of a slower progression after it. Following a Linx procedure, patients are encouraged to return to a soft diet on the day of the procedure as it is beneficial for the device to function (open and close) earlier. 

Link to fundoplication diet sheet

Link to Linx post-op instructions sheet

Where is anti-reflux surgery performed

The LSG performs anti-reflux surgery in London (London Bridge), Hampshire (Clare Park hospital) and Surrey (Nuffield Guildford). Please contact the practice secretary for details.

Which medications will I require after surgery?

You will be discharged from hospital with a supply of simple painkillers with instructions on how to use them. Regular paracetamol is particularly effective and can be combined with an anti-inflammatory (ibuprofen) or a codeine-based drug (dihydrocodeine). Anti-inflammatories are not suitable for all patients and should be taken with food. The codeine-based drugs can cause constipation and should be taken with plenty of fluids. Most patients do not require painkillers after 5 days.

When can I return to work?

Generally, it is recommended to take two weeks off after surgery. Your ability to return to work will depend on your job, your dietary intake and varies between individuals. Patients can often return to work a week after surgery if required. We would not recommend flying immediately after surgery. This should be discussed on a case-by-case basis with the consultant.

When can I drive?

Driving should be avoided in the first week after surgery. Once you can perform an emergency stop in a stationary vehicle and turn to view your blind spot then driving should be safe. It is preferable to contact your insurance company to check for any specific instructions they may have.

Who do I contact if there are concerns?

The group practice telephone is answered in working hours and messages can be left out of hours. Any concerns will be relayed directly to the consultant surgeon on receipt. The hospital ward also provides a 24/7 means of contact. They will contact the consultant about any concerns and are able to give advice if required.

For more information on anti-reflux surgery in London, Hampshire or Surrey please contact us on davies@londonsurgicalgroup.co.uk