Up to 20 per cent of the western population is affected by gastroesophageal reflux disease (GORD). In 1998 there were 14.8 million consultations made for acid-related disorders in general practice in the United Kingdom.
Studies have shown that seven per cent of the American population suffer from daily heartburn and indigestion which are two of the most common symptoms of acid reflux disease.
The majority of people with reflux problems have mild symptoms which can be managed by some changes in eating habits and simple ‘over the counter’ medications like Gaviscon or Rennie. Recurrent or persistent symptoms which are not relieved by simple medications can affect patients significantly. It gives them pain, inconvenience, effects productivity and reduces their quality of life.
It is, however, possible to treat reflux disease and surgery can give patients significant relief from this debilitating disease. Top Doctors speaks to extensively trained consultant general and upper GI (gastrointestinal) surgeon Professor Khurshid Akhtar about GORD and his expertise in treating the condition.
The mechanisms of the oesophagus and how it is related to GORD
Normally there are mechanisms which prevent a reverse flow from the stomach to the oesophagus by allowing solids and liquids to pass down from the oesophagus into the stomach.
These mechanisms are:
- The lower oesophageal sphincter pressure
- Length of intra-abdominal oesophagus
- The angle of His (also known as the esophagogastric angle) and folds of the gastroesophageal junction
These prevent any reflux across the gastroesophageal junction by acting in combination. One, or a combination, of these mechanisms are disturbed in the case of gastroesophageal reflux. The development of a hiatus hernia is the most common reason for this failure.
Heartburn is a complaint by the majority of patients with reflux disease. However, a variety of symptoms, some of which are not always apparent, can indicate gastroesophageal reflux.
Symptoms of GORD
Reflux can cause a variety of symptoms. It is also possible to have severe reflux disease with no or minimum symptoms.
- Heartburn and acid taste in back of the throat
This is one of the most common symptoms of reflux disease. Patients usually complain of a burning sensation in the upper abdomen and behind the breast bone. Burning sensation may be associated with a feeling of tightness in the lower chest. These symptoms are worse after meals and at night time.
This is another common symptom where patients feel that stomach acid and food are coming up behind the breast bone and sometimes all the way to the back of throat and mouth.
- Dysphagia (Difficulty in swallowing)
Some patients may complain of pain and difficulty in swallowing food. This is usually due to inflammation (oesophagitis) involving the lower part of the oesophagus due to acid reflux. However, difficulty in swallowing is also a symptom of serious conditions like cancer of the oesophagus. If anyone is experiencing difficulty in swallowing it is strongly advised that they should get a doctor’s advice at the earliest.
- Water brash (excessive salivation giving a feeling of excessive liquid in the mouth)
- Minor food regurgitation and vomiting
- Dyspepsia (abdominal fullness and belching)
- Upper abdominal and lower chest discomfort
Atypical symptoms/uncommon symptoms:
Reflux disease sometimes could be associated with symptoms which are normally not considered as reflux. These are mostly in addition to usual reflux symptoms like heartburn but it is possible that some patients may only have these atypical symptoms listed below.
- Sore throat
- Aspiration into the lung
- Teeth discolouration
These symptoms are also called extra oesophageal symptoms. They occur because of migration of reflux all the way up to the back of the throat.
Medical treatment is not always very effective in controlling extra oesophageal symptoms.
These neutralise stomach acids and can be alkaline liquids or tablets. Commonly used ones are Rennie and Gaviscon, which can be bought over the counter or prescribed. On their own they are only effective for minor reflux disease. They are usually used in combination with others in severe reflux disease cases.
Acid suppression medicines
- H2 blockers (Histamine receptor blockers)
These medications suppress the acid secretion in the stomach by blocking the histamine receptor. Cimtidine (Tagamet) and Ranitidine (Zantac) are commonly used H2 blockers.
- Proton-pump inhibitors (PPIs)
These are very powerful acid suppressing medications. Commonly used ones are Omeprazole (Lozec) and Lansoprazole. For many patients, the majority of symptoms can be brought under control by these medications and they may need to take them for long periods.
Lifestyle modifications and medication use do not help all patients, however. Significant proportions of patients continue to experience symptoms even when they are on continuous medication because they suffer from severe disease.
Many patients are put on higher and higher doses of medicine but still have symptoms of heartburn, dyspepsia and food and fluid regurgitation to the back of the mouth. These are very distressing symptoms and significantly affect the quality of life of patients.
Patients whose symptoms are not controlled on medication and those who are unable to take medicine for any reason or don’t want to be on lifelong medication can be treated by anti-reflux surgery.
When patients are referred to us for surgery, they will have an in-depth meeting and discussion with Professor Khurshid Akhtar. The team to help discuss the process and outcome so that they can make an informed decision about their treatment choice.
Most of the patients will need to have further investigations before surgery which will be discussed during the consultation.
When is surgery considered as an option for the treatment of GORD?
People with severe, chronic oesophageal reflux might need surgery to correct the problem if their symptoms are not relieved by other medical treatments. If left untreated, chronic gastro-oesophageal reflux can cause complications such as:
- Oesophageal ulcers
- Bleeding or scarring of the oesophagus
- Lowered quality of life
Patients who may be considered for surgery are as follows:
- Patients who do not respond to medical treatment
- Patients requiring increasing doses of PPIs
- Young patients with long-term need for aggressive medical therapy
- Patients who do not wish to undergo long-term medical therapy because of the inconvenience or fear of side effects
- Patients who have severe erosive disease and are likely to require long-term high dose treatment
- Patients with large hiatus hernias
- Patients who develop severe complications of GORD, despite medical therapy, like oesophageal stricture, ulceration, Barrett’s oesophagus
- Patients with progressively worsening extra-oesophageal symptoms, despite regular use of PPI
It is important that a patient with severe gastro-oesophageal reflux disease, whose symptoms are not controlled by non-surgical treatment should be offered a choice of surgery. In an expert hand the operation for gastroesophageal reflux disease is safe and has a very good result. The operation is done using the keyhole technique which results in a quick recovery. Patients usually stay in the hospital for one or two days and get back to normal activity within two to three weeks.
Details of the operation
The operation is done under general anaesthesia.
With the keyhole technique, the patient will have four or five small cuts of 0.5cm to 1cm in size in the upper part of abdomen.
The operation usually involves two distinctive parts.
- Repair of the hiatus hernia
Most patients have a hiatus hernia which needs repairing. The two images below are showing a diagrammatic representation of a hiatus hernia and what the repair of a hiatus hernia looks like. In a hiatus hernia, a part of the stomach has moved up through the diaphragmatic hiatus into the chest. The repair process involves bringing this back in to the abdomen and then repairing the hiatus to narrow the opening to prevent the herniation.
- Creation of a valve like mechanism to prevent reflux (Fundoplication)
The second part of the operation is the creation of a valve-like structure to prevent reflux of stomach content in to the oesophagus. In laparoscopic Nissen fundoplication, which is the gold standard operation for GORD, the fundus of the stomach is wrapped around the lower oesophagus, creating a 360-degree valve.
This is a very effective operation to control reflux and has excellent long-term results. I have been doing this procedure for more than twenty years and it is my preferred procedure to use.
In patients who have marked oesophageal dysmotility or hypomotility (poor contraction) I will sometimes do a partial (Toupet) fundoplication. The wrap is covers two-thirds (270-degree wrap) of the oesophagus.
One of the main side effects of a fundoplication operation is difficulty in swallowing. In the beginning every patient experiences some degree of swallowing difficulty.
A dietician will advise you regarding your diet in your period of recovery. It normally consists of a soft and liquid diet in the first few weeks which, in most cases, will gradually return to normal at around six weeks.
Most of the patients will have little trouble with this and our dieticians advise patients on how to maintain nutrition over the several weeks before normal solid food can be taken again.
Frequently asked questions about GORD
Who can have this operation?
Any patient that is suffering severe symptoms which are affecting their quality of life and has not been able to be control them, in spite of having full medical treatment. Also, patients who are unable to take medication because of side effects.
Is the operation done by keyhole surgery?
Yes. The keyhole technique is used on the majority of patients. In my own practice 99 per cent of patients have keyhole surgery. The operation is done through five little cuts in the upper abdomen. These incisions are 0.5cm to 1.2 cm in size. These heal very quickly and by 2 to 3 weeks they are healed enough to allow the patient to get back to most of their day-to-day activities. The advantage of keyhole surgery is:
- Less pain
- Small scars
- Quicker recovery
- Early return to normal activities
How long will I be in hospital?
After their operation, the majority of patients will stay in the hospital for one or two nights. The patient will have seen the dietician at the time of discharge. They will advise the patient about their dietary intake during post-operative recovery.
Will there be a lot of pain after the operation?
Like any operation there will be some pain, however we aim to reduce this as much as possible. I inject local anaesthetics into each of the wounds at the end of operation. You will also be given pain medication as required. In the majority of patients, these measures control pain very well and most of the patients are able to be up and about and go home on the first or second day after the operation. I do advise patients to take regular pain killers for a few days to allow good pain control and free mobility. Most patients will be able to stop pain medication after four or five days.
When can I drive again?
It’s usually advised not to drive within the first week. You should be able to drive if pain and discomfort is not a problem in the second week of the post-op. You should avoid long distance and prolonged driving during the first few weeks.
When can I return to work?
In most cases you should be able to return to work in four weeks after the procedure unless the work requires heavy lifting and strenuous activity. A slow return to work is advised and heavy lifting should be avoided in those situations for six to eight weeks.
Would I need to continue to take medication for reflux?
No. The operation is to provide a cure to your reflux problem and you will be advised to stop taking medication soon after your operation.
If you need medical attention for your GORD symptoms, Professor Akhtar can provide expert assistance. Visit his Top Doctors profile to arrange an appointment with him.