LAPAROSCOPIC SURGERY FOR GASTROESOPHAGEAL REFLUX

1. What is gastroesophageal reflux disease (GERD)?

GERD is a functional problem that occurs when the door-like sphincter mechanism between the esophagus and the stomach weakens. This results in a backwash or reflux of acid contents of the stomach into the esophagus. When this happens you may get symptoms of heartburn just beneath the breastbone, indigestion after meals and the regurgitation of caustic juices in the mouth.

2. How can GERD be treated?

Most patients with GERD get only occasional symptoms and can be treated by their family doctors. He will usually prescribe medication to reduce the acid in the stomach. Some of these drugs (for example the proton pump inhibitors) are very effective. If symptoms are severe enough to require daily medication, you should probably be seen by a specialist. We recommend a gastroscopy to establish a definitive diagnosis. We can also detect complications of GERD in the lower esophagus, such as inflammation (esophagitis), narrowing (stricture) or Barrett's metaplasia. The latter refers to an abnormal change in the lining of the esophagus which can eventually lead to cancer. We can also look for the presence of a hiatal hernia. This is the slippage of the top of the stomach from the abdominal cavity into the chest. The presence of a hernia can lead to reflux which is difficult to treat medically.

Treatment of GERD needs to be highly individualized. We always recommend losing weight (if the patient is obese), stopping cigarette smoking and avoiding some of the things that are known to aggravate reflux (such as alcohol, caffeine, chocolates and fatty foods). Most patients are put on a course of anti-acid medication and followed up to see how the symptoms improve.

3. When is surgery necessary?

Surgery should be considered if medical treatment is ineffective or if long term medication is required. Taking medication for a long period is probably safe but many patients prefer a permanent cure rather than a lifetime of dependency on drugs. This is especially so if the operation can be done with keyhole surgery. For many patients, their quality of life after surgery also improves. Some studies have also suggested (although not conclusively proven) that the long term risk of developing cancer from constant esophageal damage leading to Barrett's metaplasia is reduced since the reflux no longer occurs.

Before surgery is contemplated, it is necessary to perform a 24 hour pH and motility test to confirm the diagnosis and to establish a baseline before surgery. This test can be a little uncomfortable as a fine tube is passed down from the nostril into the esophagus and left there for a day to measure the frequency and degree of acid reflux on a typical 24 hour period.

4. How is surgery performed?

The operation done is called a fundoplication; this is essentially a repair of the diaphragmatic hiatus, mobilization of the esophageal-gastric junction and a wrap of the stomach around the lower esophagus to create a high-pressure zone that prevents reflux.

We do this operation laparoscopically, using a 1 cm keyhole incision for the telescope and 4 other 5 mm incisions for the operating instruments. Most patients are admitted on the morning of surgery and stay over in hospital for 1 night after the operation. Recovery is usually quick as the operation is minimally invasive. The risk that we may have to convert from a keyhole approach to an open operation is less than 1%.

5. What are the results of Laparoscopic Fundoplication?

There is a 90% chance that you will be completely satisfied with the operation and need no further treatment. Some patients do get occasional minor symptoms after surgery but this can usually be controlled with medication as and when necessary.

Most patients should expect to get some food sticking for the first 4 to 6 weeks after surgery, and will require a sloppy diet eaten slowly. The new valve that is created is usually made tighter than actually required so that it will be just nice over time. For the same reason, some patients find it impossible to belch after surgery. Fizzy drinks should be avoided as it can be uncomfortable when this happens.