Surgery for reflux disease has been was first described in the 1950’s. With the development of keyhole surgery in the early 1990’s this became an attractive and very popular option for patients suffering with chronic symptoms as an alternative to prolonged medical therapy.
The operation involves using the upper part of the stomach (fundus) to create a “wrap” around the lower oesophagus. This then creates a new valve system, which abolishes reflux. All (total), or just part (partial) of the fundus can be used, depending on the condition of the oesophagus and severity of the disease. Operations are often named with this description or the surgeon who first described or popularised it.
The most common procedure is a total wrap referred to as a Laparoscopic Nissen Fundoplication which appears associated with the best long-term outcomes. Partial (Toupet, Watson) fundoplication may be preferred performed if the oesophagus is weak and might struggle to open the wrap during swallowing causing difficulty in swallowing (dysphagia). Partial wraps may also produce fewer side effects after surgery such as bloating and flatulence.
Since these operations are performed by keyhole surgery, the recovery is rapid, making laparoscopic fundoplication an attractive alternative to suffering with chronic symptoms and becoming dependant on drugs. The operation is also regarded as being highly cost-effective, as it saves the NHS and individuals spending money on expensive medicines and prescriptions for many years
The procedure is usually carried out by laparoscopic (keyhole) surgery. Five small incisions are made in the abdomen (two about 1cm, three about 0.5cm).
The area around the lower oesophagus and upper stomach is freed up (mobilised). This involves dividing some of the ligaments and blood vessels. The upper part of the stomach is then fashioned into a wrap to go around the lower oesophagus. The wrap can go all the way around the oesophagus (360-degrees, total or Nissen) or partially (270-degrees, partial or Toupet). Other less common variations also exist and are used in certain situations. The wrap is stitched in place.
The area through which the oesophagus passes through the diaphragm (hiatus) is also then stitched, which repairs any hiatus hernia that might be present. The procedure usually takes between 90 -120 minutes to complete.
Patients are kept overnight after surgery, and the following morning a contrast swallow is performed to confirm that the repair is satisfactory. Drinking and then eating can start.
Relief of symptoms is immediate. Patients do however have to have a mousse diet for several weeks after the operation so that the oesophagus can get used to the new barrier, building up strength to open it against during swallowing. Anti-acid medication can be stopped immediately or at the earliest convenience.
Belching and vomiting may difficult after surgery, and minor side-effect such as bloating and flatulence, but these usually improve with time, and are very minor compared to the original reflux.
Thank you so much for giving me back the enjoyment of eating and drinking everything again. For so long my acid reflux has dominated my life, making it rather miserable at times but since my operation I am one hundred per cent better and can’t believe the difference it has made, it’s just wonderful.
Dysphagia, bloating and flatulence most common problems that are reported after surgery. This is because the fundoplication is predominantly a one-way barrier, allowing swallowed solids, liquids and air to enter the stomach, but not easily leave – this of course is what prevents reflux.
Swallowing does improve with time, as the oesophagus gradually gets used to the new resistance barrier. For this reason, patients are advised to go on a soft (mousse) diet for about 4-6 weeks following which a normal diet can be resumed. Occasionally, if dysphagia does not improve, then gentle dilatation of the wrap with a balloon during endoscopy may be necessary
Bloating and flatulence are variable symptoms, and many patients with co-existing functional bowel disorder have these any way. This is because gas which is either swallowed or created in the stomach used to escape spontaneously through the oesophagus (burping), but now is forced to pass through the gut in the normal manner, which it is not used to. Usually these symptoms improve with time and represent little more than a minor irritation, and certainly better than the severe symptoms of reflux or side-effects of medication.
Wrap loosening or herniation are rare but can occur. Symptoms of reflux may then return, and if these are severe, then re-operation may need to be considered.
As with any surgical operation, there are also uncommon risks of bleeding, infection and damage to internal organs, and the risks of a general anaesthetic.
Fundoplication for reflux is a well-established operation, and long-term outcomes (ten-years or more) with regards to symptom control, drug-dependency and health related quality of life are very good, particularly when the procedure is carried out by specialist high-volume surgeons. It is a viable option for patients who are finding symptoms problematic despite life-style modifications and drug therapy, as well as those who simply do not want to have to take medication permanently.
As with many operations however, there will be an element of wear and tear over decades, and some patients to get mild recurrent symptoms over time. This may also be because the oesophagus and stomach become naturally less effective with age and this can cause symptoms which are similar, but not the same a reflux. At least with a fundoplication, the more severe reflux symptoms, and progressive damage to the oesophagus are avoided.
Fundoplication offers a definitive and well-established treatment for reflux. It deals with the underlying problem of a weak barrier, and in repairing it removes the symptoms of reflux as well as on-going damage to the oesophagus.
Consequently, drug therapy, its side effects and dependency over decades is avoided.
Health-related quality of life and general wellbeing are much improved.