Acid Reflux and Hiatus Hernia Surgery

Luckily, acid reflux and heartburn are usually temporary problems. However, when they become part of your daily or weekly routine it’s time to seek specialist advice…

At times of overindulgence, such as Christmas parties, almost everyone can suffer from acid reflux. Commonly referred to as heartburn and caused by acid coming back up the gullet from the stomach. For most patients, it’s a sensation which lasts only a few minutes, but for others in can be a persistent problem with every meal.

Gastro-oesophageal reflux disease (GORD) can affect men and women of any age and can get progressively worse. Specialist Upper Gastrointestinal Surgeon Mr Ewen Griffiths regularly performs endoscopy and operations for reflux disease or hiatus hernias.

Here he answers some questions about the problem and potential solutions…

Q1 At what stage would you advise someone with Gastro-Oesophageal Reflux Disease to see their GP?

If someone is regularly suffering from heartburn or regurgitation. First stage treatment will usually be anti-acid medication of some kind. Patients with difficulty swallowing, weight loss and vomiting blood should urgently see there GP for an urgent referral, as this could indicate something more serious. Persistent symptoms for several weeks should also be taken very seriously and an urgent referral requested.

Q2 What causes acid reflux?

Acid reflux is commonly caused by weakening of the lower oesophageal sphincter (muscle or valve which normally closes to stop acid refluxing up into the gullet).

This can be weakened either due to intake of alcohol, chocolate, caffeine or tobacco. It is therefore important that patients minimise their intake of these substances.

A hiatus hernia (which is when the diaphragm is weakened and part of the stomach moves up into the chest, thus weakening this valve) is a common cause of reflux. Pressure on the abdomen either due to pregnancy or being overweight can also cause acid to reflux up into the oesophagus. One way of treating acid reflux is to try to lose some weight.

Q3 What is an upper GI endoscopy?

Upper GI endoscopy, also called OGD (oesophago-gastro-duodenoscopy), ‘gastroscopy’ or simply an ‘endoscopy’, is a test which allows the doctor to look directly at the lining of the oesophagus (the gullet), the stomach and around the first bend of the small intestine – the duodenum.

In order to do the test, an endoscope is passed through your mouth into the stomach. The endoscope is a thin flexible tube (no larger than a finger) with a bright light and video camera at the end.

The endoscopist gets a clear view of the lining of the stomach and can check whether or not any disease is present. Sometimes the endoscopist takes a biopsy – a sample of tissue for analysis under the microscope in the laboratory, the tissue is removed painlessly through the endoscope using tiny forceps.

Q4 What further tests or investigations might be suitable to see if I’m eligible for surgery?

Most patients need more tests to see if they are suitable for surgery. These may include:

Oesophageal manometry (special pressure test) can check the function of the oesophagus and lower oesophageal sphincter. This checks that the contractions of the oesophagus are normal. If they are abnormally weak, surgery can either be adapted to allow for this (partial wrap or fundoplication can be performed)
24 hour pH monitoring can check for acid in your oesophagus. The physiologist inserts a device into your oesophagus via the nose and leaves it in place for 24 hours to measure the amount of acid in your oesophagus. Symptoms are also measured and the acid readings can be correlated to symptoms
A barium swallow (oesophagram) can check the size of a hiatus hernia and anatomy. This is particularly useful for larger hiatus hernia to provide a road map for surgery.

Q5 What does anti-reflux or hiatus hernia surgery entail?

Under a full general anaesthetic, 3 to 5 small cuts are made in your belly. A thin tube with a tiny camera on the end is inserted through one of these cuts.
Surgical tools are inserted through the other cuts to actually carry out the operation. The camera or laparoscope is connected to a video monitor in the operating room. The procedure is carried out while viewing the inside of your belly on the monitor.
Occasionally it may be necessary to switch to an open procedure in case of problems or difficulties. This is actually fairly rare
The first part of the procedure is to repair the hiatal hernia (this is where the stomach has moved up in to the chest), if one is present. This involves tightening the opening in your diaphragm with permanent stitches. This keeps your stomach from bulging upward through the opening in the muscle wall.
Next a wrap or fundoplication is performed. This is when the upper part of your stomach is wrapped around the end of your oesophagus with stitches. The stitches create pressure at the end of your oesophagus. This helps prevent stomach acid and food from flowing up from the stomach into the oesophagus. There are different ways to perform this. For example, a Nissen fundoplication is a full 360 degree wrap. There are other ‘partial wraps’ where the stomach is wrapped around either 270 degree or 180 degrees
Surgery most often takes between 1.5 to 3 hours, depending on how big the hiatus hernia is.

Q6 What is the post-operative recovery like after fundoplication surgery?

The average patient who is treated with keyhole surgery should be discharged the next day.
Light activity while at home after surgery is encouraged. However, patients should avoid heavy lifting or strenuous activity for around 4-6 weeks after surgery
Post-operative pain is generally mild although some patients may require prescription pain medication for a short period of time.
Anti-reflux medication is usually stopped after surgery.
Temporarily modification of the diet is required after surgery as often bruising and swelling can cause difficultly in swallowing. Particularly in the early weeks after surgery. Mr Griffiths has a special diet sheet written by a dietitian which gives full details of the textures of food to take for 6-8 weeks after surgery
It is really important to avoid retching or vomiting after surgery as this can disrupt the stitches from the operation