Gastroesophageal reflux (GORD)
What is gastroesophageal reflux?
Gastroesophageal reflux (GORD) is a common condition resulting from acid and stomach contents travelling up into the oesophagus. It is a common misconception that it is due to a hiatus hernia. Although many patients with troublesome reflux have a hiatus hernia, reflux can and does occur in the absence of a hiatus hernia as the basic underlying abnormality is a failure of the lower oesophageal sphincter, or valve between the oesophagus and the stomach.
What are the symptoms of GORD?
The classical symptoms are heartburn after meals and when laid in bed or bending down, as well us regurgitation of stomach contents up into the oesophagus. However, some patients present with atypical symptoms such as chest pain which can resemble angina and hoarseness and sore throat (laryngopharyngeal symptoms).
How is GORD diagnosed?
If the symptoms are typical and there are no ‘red flag’ symptoms (e.g difficulty with swallowing), most patients will have been started on antacids and acid suppression treatment by their GP, with improvement in symptoms. GORD is diagnosed by gastroscopy which may show tell-tale features of oesophageal inflammation, but a normal gastroscopy does not exclude GORD. Where there is doubt, oesophageal function studies can be helpful. These are invasive tests to measure acid reflux into the oesophagus and take the form of 24-hour pH studies or the Bravo study. For the 24-hour pH study a pH sensor is suspended at the bottom of the oesophagus using a fine tube that passes through the nose and is connected to a digital recorder. For the Bravo study a wireless pH pill is temporarily tethered to the lower oesophagus by endoscopy and sends data to a digital recorder over a period of 2 to 4 days before the pill spontaneously unlatches from the oesophagus and passes through the bowels in the motion. It is more comfortable for the patient and a four day recording is more likely to give a better picture of reflux.
pH studies not only measure the amount of acid reflux to determine whether it is more than expected in people without GORD, but can be helpful in determining whether the reflux is the cause of the symptoms. During the recording period the patient is asked to press buttons on the recorder for pain, heartburn, sore throat, etc. One can therefore determine whether there is good symptom association with reflux episodes.
pH studies are often carried out in conjunction with oesophageal manometry since, in some patients, abnormalities of oesophageal motility can mimic symptoms of reflux, Manometry is also helpful in confirming that the propulsive action of the oesophagus (peristalsis) is normal, particularly if antireflux surgery is contemplated.
What are the indications for antireflux surgery?
Most commonly, antireflux surgery is considered when medical treatment is only partially effective or for what is termed ‘volume reflux’. Volume reflux is the regurgitation of stomach contents into the oesophagus since acid suppressing drugs only relieve heartburn but cannot stop reflux. Other reasons include intolerance to or side effects of acid suppressing drugs and as an alternative to lifetime treatment with drugs in a young patient.
Antireflux surgery has to be chosen with care in patients with laryngopharyngeal symptoms, since the results from published studies are not as good as for surgery in patients with classical GORD symptoms.
What is antireflux surgery?
The most common operation for GORD is a fundoplication, which involves wrapping part of the top of the stomach (fundus) loosely round the lower oesophagus. The Nissen fundoplication is a complete wrap and it is now quite common to offer a partial (270 degree) wrap, which is also effective. There are a number of other procedures including the LInx device which is a magnetic bracelet implanted round the lower end of the oesophagus. This procedure, along with endoscopic intervention such as Stretta, are relatively new procedures which have not been evaluated as thoroughly as surgical fundoplication.
How long does treatment take?
A fundoplication is a keyhole surgical procedure and usually takes around two hours.
What is the recovery time for hiatal hernias?
After keyhole surgery, patients will typically be discharged within a day or two.
It is common to keep to a liquid diet for two to four weeks after surgery and then recommence a normal diet. Most patients will be able to go back to work within a week or 10 days.
What are the results of fundoplication for GORD?
A fundoplication is a highly successful procedure to control reflux although over 10 years about 10% of patients will develop recurrent symptoms, although in most cases these are mild and easily controlled with medication. About 10% of patients develop difficulty with swallowing solids such as meat and potatoes and a similar percentage develop abdominal bloating. The incidence of these side-effects is less with a partial fundoplication, which is just as effective in controlling reflux.
What are the complications of antireflux surgery?
A laparoscopic fundoplication is a very well worked out operation in technical terms and has a very low complication rate in experienced hands. There is a less than 1% risk of inadvertent injury to the oesophagus, the vagus nerve and internal organs, of bleeding, infection or a recurrent hiatus hernia. Very rarely, the fundoplication can migrate into the chest due to disruption of the repair of the oesophageal hiatus and this may require urgent reoperation.
What are the causes of failure of antireflux surgery?
In my experience, one of the commonest reasons for ‘failure’ of the operation is that the symptoms for which the operation was performed were not due to reflux. This is why it is very important to ensure that the symptoms are due to reflux before embarking on surgery.
Other causes of failure include a tight fundoplication or hiatal repair resulting in permanent and severe difficulty in swallowing, a disrupted or slipped fundoplication resulting in recurrence of reflux and a migration of the fundoplication into the chest which can present with a variety of symptoms including difficulty swallowing, recurrent reflux and chest pain.