How to find out if you need anti-reflux surgery:
John came to my clinic recently to discuss his heartburn. Medically this is known as gastro-oesophageal reflux disease. It’s when acid from the stomach ‘refluxes’ up the oesophagus and causes symptoms. John was finding his symptoms of burning in the lower chest were made worse after:
- Eating a large meal,
- Drinking lots of tea or coffee
- At night when lying down in bed
Some patients occasionally taste acid at the back of their throats especially when bending over. Like many patients, John had been to his GP to discuss the issue and been put on ‘proton pump inhibitors or PPI’s. These are medications like omeprazole or lansoprazole which block the ‘acid or proton pump’ in the stomach so the stomach reduces its acid production. John had been on this medication for many years and wanted to discuss a more permanent solution to his problem with surgery. He was also worried about the long-term side effects of PPI’s which have recently hit the press.
Non-surgical treatments for heartburn:
We discussed other ways to improve his reflux symptoms without an operation and these included:
- To avoid eating large meals late at night just before bed
- Reduce intake of substances like caffeine, chocolate and alcohol (all the nice things in life!) as these relax the lower oesophageal sphincter (the muscle which closes to prevent reflux occurring up the oesophagus or gullet)
- Avoiding known acidic foods such as tomatoes or citrus fruits. Some patients find it helpful to keep a symptom diary to identify their trigger foods
- Weight loss can help reflux by reducing the pressure around the waist
- Proton pump inhibitor medication is often most effectively taken 30mins before eating to ensure its maximally effective
- Propping the head of the bed up by 15 to 30 degrees can help patients who get a lot of reflux in bed at night
We then discussed what tests John might require before anti-reflux surgery to assess whether surgery would in fact help…
Important pre-surgery investigations:
Upper Gastrointestinal Endoscopy
An Upper Gastrointestinal Endoscopy is where a camera is placed down the gullet. A procedure that can be done under either local anaesthetic spray or with intra-venous sedation. It examines the whole gullet, stomach and the first part of the small bowel (the duodenum). An upper GI endoscopy can look for signs of the causes of reflux (such as a hiatus hernia) or signs of reflux damage (this is called oesophagitis and is where acid burns the lower oesophagus). It can also check for Barrett’s oesophagus which is important to know about.
I perform around 400 endoscopies per year and am fully JAG accredited endoscopist. If John had any signs of severe and persistent heartburn for several weeks or difficulty swallowing he would need the endoscopy performed urgently to make sure there was not a sinister underlying cause for his symptoms.
A barium swallow
A barium swallow is required in some patients. This is performed in the X-ray department where flavoured barium dye is swallowed and several X-rays are taken. These look at the oesophagus and stomach. It is particularly good at assessing the size and anatomy of any hiatus hernias which might be present. I work with specialist Upper Gastrointestinal Radiologists who can help read these types of X-rays.
24 pH studies and manometry tests
24 pH studies and manometry tests are specialist investigations normally performed off PPI medication. It involves attending the hospital and a small catheter being placed down the nose and 10 swallows of water are performed to assess how well the gullet or oesophagus contracts and physiologists gets pressure measurements of the swallow strength and the sphincters muscles. Another small catheter which senses the amount of acid coming from the stomach into the oesophagus is left in for 24 hours. Patients are sent home wearing the catheter and record their symptoms in a diary with times. This can then be linked to see if the symptoms link or correlate with acid coming up.
It is usually a fairly crucial test to decide whether surgery is justified. Some patients, despite having very bad symptoms, do not have any measured acid coming up the oesophagus and therefore surgery can be avoided. The interpretation of these tests is quite tricky. I work with several specialist GI physiologists at the Queen Elizabeth or Heartlands Hospitals who can offer this test to private or self funding patients.
Deciding whether to have surgery, or not
Weighing up the pros and cons of surgery is tricky and John had some difficultly deciding whether to go ahead with surgery. It is an important decision and one that should not be rushed. John was struggling on a daily basis and the medication was only partly effective. He’d also had tried all the non-surgical strategies so he decided to proceed with the tests.
The endoscopy was performed and showed some oesophagitis (inflammation of the oesophagus due to reflux) and the barium swallow showed a hiatus hernia. The 24 pH studies and manometry confirmed high levels of acid reflux which correlating with John’s symptoms of acid coming up the gullet. It also showed his swallowing mechanism was normal.
We had a further discussion about keyhole surgery which usually involves only an overnight stay in hospital. This is especially likely with John as he was young, of good health and with normal physical fitness. I also provided John with a diet sheet as patients having anti-reflux surgery require a special diet for 6-8 weeks after the operation. We also discussed some of the potential unwanted side-effects of surgery and made a surgical plan to minimise these.
Mr Griffiths was trained in anti-reflux surgery in the Royal Adelaide Hospital in Australia. He regularly performs a wide range of anti-reflux operations and hiatus hernia repairs at the Queen Elizabeth Hospital, Birmingham and the BMI Edgbaston Hospitals. If you would like a private consultation with him please contact his private secretary by email on firstname.lastname@example.org
*I’ve changed my patient’s name to protect their identity – the story is based on a real conversations.