Mr. Andrew Davies, Consultant surgeon at Nuffield Guildford, discusses the investigation and management of acid reflux (indigestion) including updates on some new techniques.
Acid Reflux, also known as GORD (Gastro-oesophageal reflux disease), is extremely common with 20-30% of the population experiencing some symptoms on a weekly basis. It is also very expensive with NHS drug expenditure accounting for over £200 million per year. Many different terms are used to describe very similar symptoms including reflux, heartburn and indigestion.
All of us reflux acid from the stomach into the oesophagus (gullet) from time to time but some people reflux larger quantities of acid more frequently and this can result in unpleasant and debilitating symptoms. Risk factors for reflux include certain things in our diet (spicy foods, chocolate, caffeine, alcohol), being overweight, stress and the presence of a hiatus hernia. This is when part of the stomach, which should normally be positioned within the abdominal cavity, pushes up into the chest through a weakness in the diaphragm muscle (the hiatus).
Over the last 5-10 years there have been a number of campaigns aimed at reflux sufferers (predominantly those over 50 years old), encouraging persistent heartburn sufferers to consult with their GP rather than self-medicate with over-the-counter drugs for long periods of time. The driver for these campaigns was a high incidence of oesophageal cancer in the UK, which is associated with a condition called Barrett’s oesophagus, known to be caused by long term reflux. It is important to note that millions of people suffer with reflux, only a small proportion of whom will develop Barrett’s oesopahagus, with a much smaller number of these developing cancer. Nonetheless provided we can strike the right balance between investigation and reassurance, the campaigns will have achieved their goal of raising awareness of these symptoms.
People experiencing reflux symptoms may be reluctant to consult their doctor because of the perception that endoscopy (a camera test that goes down the throat or nose into the stomach) is an unpleasant procedure. In truth, with modern equipment (such as narrow endoscopes) and the options of throat/nasal spray and conscious sedation, this is rarely an issue. In fact, many of the symptoms of reflux can be effectively managed by acid medication and lifestyle changes. The added reassurance of having had an endoscopy can be important to many patients. Many of the risk factors for reflux have been exacerbated by the Covid pandemic and subsequent economic fallout. Our diets are worse, many people have put on weight and we are stressed by lockdowns, work insecurity or financial worries – a perfect storm for reflux.
Surgery may be considered for patients with particularly severe reflux symptoms or those that do not tolerate (or wish) to take long term medication. It can be extremely effective when used correctly, and involves keyhole surgery and (at most) an overnight stay in hospital. It has the advantage over long term medication of dealing with the problem at source i.e. the hiatus hernia can be repaired, returning the patient to “normal” anatomy, unlike drugs which simply reduce the amount of acid within the stomach. There may also be consequences of long-term acid suppression drugs such as reduced absorption of vitamins and minerals in our diet (e.g iron and calcium).
The traditional surgical procedure for reflux involved a repair of the hiatus hernia and a “wrap” procedure, essentially using part of the stomach to wrap around the oesophagus creating a valve to allow food and liquid down and prevent acid from coming back up. This is called a fundoplication. It is an extremely effective and reproducible operation for reflux.
More recently some exciting alternatives have emerged, one of which is the Linx system. This is a small magnetic ring placed around the oesophagus at the end of the standard hiatus hernia repair. It has the advantage of being more responsive than a fundoplication – it relaxes when a patient swallows (allowing food through) and remains closed at other times (preventing reflux). As a result, it may be associated with fewer short-term swallowing issues and gas bloating than a fundoplication. There is now excellent long-term data on its safety and effectiveness and many patients are asking about whether it may be a suitable option for them.
There are certain criteria which are used to guide clinicians in helping patients decide on the best option for them. The most important thing is to speak to somebody who acknowledges the range of available options, each with their own advantages and disadvantages, and who can offer an un-biased perspective. Surgery is not the answer for everybody and of all of the various operations we perform on the stomach, decision-making is arguably most important in anti-reflux procedures. It’s crucial to make the right choices.
Mr. Andrew Davies is a Consultant upper Gastro-intestinal and general surgeon at Guy’s & St Thomas’ NHS trust and Nuffield Guildford. He has a particular interest in laparoscopic anti-reflux surgery as well as being a specialist for endoscopy, abdominal hernias, gallstones and oesophago-gastric cancers. Patients with any of these conditions can be seen at Nuffield Guildford, assessed rapidly and treated. For more information on acid reflux, you may visit the website (www.londonsurgicalgroup.co.uk) under “conditions we treat”. Appointments can be made by contacting Mr. Davies’ office (0203 7635933) or Nuffield Guildford directly.