Gastroesophageal Reflux Disease (GORD) + Hiatus Hernia
Gastroesophageal reflux disease is a chronic condition caused by a reduction in the effectiveness of the barrier between the oesophagus and the stomach. Often there is an associated hiatus hernia but this is not always the case. As a consequence gastric contents, including acid, reflux into the oesophagus causing a myriad of symptoms and sometimes damage to its mucosal lining.
Signs and Symptoms
- Regurgitation of acid or food
- Upper abdominal discomfort
- Difficulty swallowing (dysphagia)
- Painful swallowing (odynophagia)
- Laryngitis including hoarse voice
- Dental problems
- Pharyngitis and sore tongue
GORD can also cause damage to the mucosal lining of the oesophagus including
- Reflux oesophagitis
- Oesophageal strictures
- Barrett's oesophagus
- Gastroesophageal junctional adenocarcinoma
Medication - a trial on high dose proton pump inhibitors (PPI's) may be suggested.
Conservative Treatment - lifestyle modifications.
Surgical Treatment - despite maximal medication many patients continue to suffer symptoms which significantly affect their lives. For them surgery is often a very good option and can offer the chance of cure. Other patients either do not wish to take medications over the long term because of concerns regarding side effects or find that side effects from them are unacceptable.
Laparoscopic Nissen Fundoplication - this is the standard procedure undertaken to treat patients suffering from chronic oesophageal reflux disease often caused by hiatus hernia. The procedure is undertaken through four or five tiny incisions, each 5-10mm in size. A camera and instruments are inserted through these. The operation usually involves repairing the hole in the diaphragm through which the oesophagus travels which has often become too large allowing the stomach to "herniate" into the chest. A new valve or high pressure zone is created by wrapping the top of the stomach around the oesophagus. This has the effect of preventing acid refluxing into the oesophagus. In approximately 90% of patients the operation is successful in preventing reflux and alleviates most if not all symptoms. Most people are able to stop their antacid medications following anti-reflux surgery.
- Gas-bloat Syndrome - because the surgery tightens the sphincter between the oesphagus and stomach it can sometimes prevent air travelling back up, stopping you from burping. This can cause bloating and an inability to belch. If you suffer from these symptoms it is advised that you avoid foods that cause gas, such as beans and cabbage
- Perforation of the oesophagus or stomach
- Visceral Injury
- As with all keyhole surgery there is a risk that the procedure may need to be converted to an open one
Recovery following Nissen's Fundoplication
After your surgery you may experience difficulty swallowing straight away. You should start with fluids only and then gradually build your diet up, progressing to soup and soft foods. You will gradually be able to introduce foods of a thicker consistency. Ensure that you chew your food well, eat slowly and drink fluid with your meals to keep food moist. Avoid fizzy drinks, crusty bread, tough meat and raw vegetables as they may be difficult to swallow. Everybody is different and there are no hard and fast rules of what you should or shouldn’t eat, but the best advice is to take your time and build up slowly. The small wounds in your abdomen are closed using dissolvable sutures and small dressings will cover these. Dressings can be removed after 4-5 days. Try to keep the wounds clean and open to the air as much as possible. Due to lack of activity after your operation your chances of developing a chest infection or blood clots increases. This may be prevented by performing deep breathing activities and gentle movement. Remember that it may take up to three months for things to settle completely. You should refrain from driving for at least 48 hours after surgery, but in some cases it may take up to two weeks. Only drive once you feel able to perform an emergency stop without difficulty. (Please check with your insurance company about any special restrictions). You should avoid any heavy lifting for two to three weeks.
- Over 90% of patients experience satisfactory outcome following the Nissen procedure, but there are some associated shortcomings. These include: difficulty swallowing, abdominal bloating, an inability to belch or vomit. Probable loss of effectiveness over time. Recovery period lasting several days.The LINX Reflux Management System is a new technology which aims to address these shortcomings. It is composed of a flexible band of interlinked titanium beads with magnetic cores. This sits around the bottom of the oesophagus and replaces the failed oesophageal valve mechanism. It therefore prevents reflux of acid from the stomach into the oesophagus.The advantages are that it is undertaken as a day case and patient recovery is faster. The evidence to date would suggest that the LINX procedure is effective and causes less side effects than traditional Nissen fundoplication.