Gastro-oesophageal reflux

Anti-reflux surgery, or Laparoscopic Fundoplication surgery is a procedure to treat gastro oesophageal reflux disease (GERD).

Acid reflux, also called gastro-oesophageal reflux disease (GERD), is a condition where the stomach contents (food or liquid) rise up from the stomach into the oesophagus, a tube that carries food from the mouth to the stomach.

Normally the stomach contents do not enter the oesophagus due to constricted LES. But in patients with acid reflux stomach content travels back into the oesophagus because of a weak or relaxed lower oesophageal sphincter (LES). Lower oesophageal sphincter is a ring of muscle fibres that surrounds the lower-most end of the oesophagus where it joins the stomach. LES acts like a valve between the oesophagus and stomach preventing food from moving backward into the oesophagus.

Heartburn is usually the main symptom; a burning-type pain in the lower part of the mid-chest, behind the breast bone. Other symptoms such as a bitter or sour taste in the mouth, trouble in swallowing, nausea, dry cough or wheezing, regurgitation of food (bringing food back up into the mouth), hoarseness or change in voice, and chest pain may be experienced.

The exact cause of what weakens or relaxes the LES in GERD is not known, however certain factors including obesity, smoking, pregnancy, and possibly alcohol may contribute to GERD. Common foods that can worsen reflux symptoms include spicy foods, onions, chocolates, caffeine containing drinks, mint flavourings, tomato based foods and citrus fruits. Certain medications can also worsen the reflux.

Diagnostic Tests

There are several tests that can be performed to diagnose acid reflux and they include:

Endoscopy

This test allows the doctor to examine the inside of the patient’s oesophagus, stomach, and portions of the intestine, with an instrument called an endoscope, a thin flexible lighted tube.

Barium X-rays

These are diagnostic x-rays in which barium is used to diagnose abnormalities of the digestive tract. You are asked to drink a liquid that contains barium. The barium coats the walls of the oesophagus and stomach and makes the abnormalities visible more clearly. Then X-rays are taken to see if there are strictures, ulcers, hiatal hernias, erosions or other abnormalities.

Twenty-four-hour pH monitoring

In this procedure, a tube will be inserted through the nose into the oesophagus and positioned above the LES. The tip of the tube contains a sensor, which can measure the pH of the acid content refluxed into oesophagus. A recorder, strap-like device that can be worn on wrist, will be connected to record the pH of the acid content. The tube will be left in place for 24 hours. Patients can also go back home and perform their regular activities and can record the pH of the acid content when they experience the symptoms. On the next day, the recorder will be connected to a computer and the data will be analysed.

PH Capsule

It is a new method of measuring acid exposure in the oesophagus. A small wireless capsule, which is introduced into the oesophagus by a tube through the nose or mouth. The tube is removed after the capsule is attached to the lining of the oesophagus. The pH sensor transmits signals to a computer, which collects the data about the acid exposure over the usual 24 hours. The capsule falls off of the oesophagus with time and is passed in the stool.

Impedance study

This test is similar to pH test but requires two probes; one is placed in the stomach and the other just above the stomach. The dual sensor helps to detect both acidic and alkaline reflux.

Medications

Antacids are over-the-counter medicines that provide temporarily relief to heartburn or indigestion by neutralizing acid in the stomach. Other medications such as proton pump inhibitors and H2 antagonists may be prescribed to reduce the production of acid in the stomach.

Anti-reflux Surgery

Anti-reflux Surgery may be an option for patients whose symptoms do not go away with the medications. The Laparoscopic Toupet Fundoplication is a surgical procedure in which the upper part of the stomach is partially wrapped around the end of your oesophagus and oesophageal sphincter, where it is sutured into place. This surgery strengthens the sphincter and helps prevent stomach acid and food from flowing back into oesophagus.

Surgical Procedure

Toupet Fundoplication is performed as day surgery either in the hospital or outpatient surgery centres usually with the patient under general anaesthesia.

The surgeon uses a needle to inject a harmless gas into the abdominal cavity near the belly button to expand the viewing area of the abdomen giving the surgeon a clear view and room to work. The surgeon makes a small incision in the upper abdomen and inserts a tube called a trocar through which the laparoscope is introduced into the abdomen. Additional small incisions may be made for a variety of surgical instruments to be used during the procedure.

With the images from the laparoscope as a guide, your surgeon wraps the upper part of the stomach, the fundus, part way around the back of the lower oesophagus to create a valve, suturing it in place.

The hole in the diaphragm through which the oesophagus passes is then tightened with sutures. The laparoscope and other instruments are removed and the gas released.

The tiny incisions are closed and covered with small bandages.

Laparoscopy is much less traumatic to the muscles and soft tissues than the traditional method of surgically opening the abdomen with long incisions (open techniques).

Specific complications for Toupet Fundoplication include:

• Postoperative fever and infection.
• Surgical injury to blood vessels.
• Surgical injury to stomach or oesophagus.
• Swallowing difficulties (less likely than with the Nissen fundoplication).
• Gas embolism – If gas is used to distend the abdominal cavity for better viewing there is a risk of gas embolism or gas bubbles in the bloodstream.
• Adhesions – Extensive scar tissue formation can form in the surgical area.