Laparoscopic Fundoplication - Surgery for Acid Reflux

This is keyhole surgery to repair hiatus hernia and recreate a one way valve at the lower end of the oesophagus (gullet) to treat heartburn or Gastro-Oesophageal Reflux Disease (GORD).

When to consider surgery for GORD?
How does surgery work for GORD?
Tell me more about Laparoscopic fundoplication.
What are the side-effects of surgery?
What are the complications of surgery?
Preparation for Surgery
What should I expect after surgery?

When to consider surgery for GORD?

A combination of lifestyle changes and medical treatment is effective for most patients.  However, surgery should be considered if:

1. Failure of maximum medical treatment to control symptoms;
2. A patient decides not to take medications on a long term basis
3. Patients who develop a complication of GORD.
4. Patients who cannot take medications due to serious side effect.
5. Patients with "volume reflux", this is the continual regurgitation of food and fluid into the back of the throat. Medical treatment is effective in making the refluxing fluid not acidic but it does not stop fluid from going the wrong way into the oesophagus.
6. Patients with recurrent respiratory complications e.g. chest infections, night cough and asthma.

How does surgery work for GORD?

Surgery works by creating a new valve at the lower end of the oesophagus thus preventing the reflux from happening.  This is done by pulling the stomach back into the abdomen, repairing the hiatus hernia and creating a new valve by wrapping the top end of the stomach around the lower end of the oesophagus.

Surgery is done laparoscopically i.e. keyhole in almost all patients as it offers:

1. Less pain
2. Quicker recovery
3. Shorter stay in hospital (usually two days)
4. Faster return to work and normal activities

In some patients open surgery may be necessary particularly if they had previous upper abdominal surgery. This is still safe and effective, however, patients stay longer in hospital and take longer to recover.

Tell me more about Laparoscopic fundoplication.

This is a keyhole surgery done under a general anaesthetic. Two 10 mm  and three 5 mm cuts are made in the abdomen. The abdomen is filled with CO2 gas to create a working space and telescope-like instrument with a video camera attached at the end is inserted.  The liver is held out of the way. 

The stomach is pulled back from the chest into the abdomen.

 

 

 

 

The opening in the diaphragm through which the stomach has slipped through is tightened up with sutures and sometime reinforced with mesh.

 

 

 

 

 

 

The top part of the stomach is wrapped around the lower end of the oesophagus.

 

 

 

 

 

 

 

The wrapped stomach is sutured to each other infront of the oesophagus. 

 

 

 

 

 

 

When the pressure in the stomach goes up the wrap squeezes the bottom part of the oesophagus shut thus preventing fluid from going back into the oesophagus. There are several ways to do the wrap; complete (Nissen) or partial (e.g Toupet). The optimum surgery is tailored to each patient. Surgery is effective in the vast majority of patients so 95% of patients stop all GORD medications.

 

What are the side-effects of surgery?

Creating a new valve with the wrap can cause some side-effects. These are normal expected effects rather than complications. They tend to be temporary but in some patients they are permanent.

·         Swallowing: After surgery, there is will be a temporary difficulty with swallowing due to temporary tissue swelling. This settles in the majority of patients by 6 weeks.  However, in some patients there can be a permanent restriction that may require adjustment of the diet or endoscopic dilatation.

·         Inability to belch: The new valve at the top of the stomach may prevent belching. This tend to improve with time but you need to avoid fizzy drinks.

·         Inability to vomit. The new one way valve may prevent you from vomiting. This is not a problem usually but you need to be aware of this and inform doctors should you develop gastroenteritis or any condition that lead to vomiting. Continued dry retching and strong vomiting can damage the valve.

·         Gas Bloat: The inability to belch the swallowed air can lead to a bloating sensation.

·         Excess Flatus: as a consequence of inability to belch you may experience excess passage of wind from the back side. This improves with time and can be managed by avoiding food that makes wind.

What are the complications of surgery?

Specific Complications:

1. Injury to the spleen (1%): The spleen lies next to the stomach with short vessels connecting it to the stomach.  These vessels are divided most of the time and rarely the spleen can get injured leading to bleeding. If this can not be controlled then the spleen will need to be removed by open surgery. Removing the spleen increases the risks of certain infection life-long and you may have to take regular vaccines and antibiotics.
2. Injury to oesophagus or stomach: This is very rarely but a serious complication. It requires repair of the perforation which may be have to be done by open surgery
3. Injury to the bowel:  The bowel can get injured while putting different instruments in and out. It is very rare but can be serious if not seen and fixed at the time.
4. Slipped wrap: The wrap can slip up into the chest or down onto the stomach. This tend to occur after  severe vomiting or heavy lifting soon after  surgery. The slip can cause difficulty with swallowing and may require repeat surgery.
5. Incisional or Port-site hernia: This is a weakness at the site of one of the incisions causing fat or intestine to pop out through the hole in the abdominal wall. This may cause bowel obstruction and requires surgery.
6. Adhesions formation:  Scar tissue form after any operation. This may lead to bowel blockage as the bowel twist around or get caught in the adhesions. This is very rare after keyhole surgery and may require operation to cut the adhesions.
7. Need for conversion from keyhole to open surgery (2%): for a variety of reasons it is not always possible to complete the operation keyhole and open surgery may be needed.
8. Continued or recurrent symptoms after surgery: Cure can be expected in more than 90% of patients however some patients can continue to have the same symptoms. This may be due to another gut problem e.g. irritable bowel syndrome. Occasionally the reflux recur due to deterioration of the repair over the years.

General Complications:

these can happen with any operation

1. Cardiovascular problems: heart attacks and strokes. Both are very rare.
2. Respiratory problems: pneumonia and aspiration.
3. Wound infection or urinary infection
4. Clots in the legs that may travel to the lungs. This is a rare but serious complication.
5. Wound pain and abnormal (keloid) scarring.
6. Death from general anaesthetic. This is very rare (1 in 40,000).
7. Chipped teeth and sore throat form the insertion of the breathing tube.
8. Drug reactions

 

Preparation for Surgery:

1. Shower at home the morning of the operation
2. Do not shave the surgery site! If needed, this will be done in the operating room. Shaving at home increase the chance of wound infection.
3. You need to fast for 6 hours prior to surgery. The time to fast depend on the time of your operation and the hospital will notify about that time. Generally, for morning operations, you should fast from midnight the night before and for afternoon operations, you should have a breakfast at 6 AM then fast.  You can still take your heart and blood pressure medications with a small sip of water.
4. If you are diabetic let me and the anaesthetist know to advice you about changes to your medications.
5. Do not smoke for 4 weeks before surgery. Smoking increases the complications.
6. Do not drink alcohol for 24 hours prior to surgery.
7. Let me and the anaesthetist know If you are on drugs that thin the blood. Some of these drugs need to be stopped or changed a week before surgery to reduce the risk of bleeding.
8. Stop herbal medications for two weeks prior  surgery. Medications like Garlic, fish oil, St John's Wort, Ginseng, Ginko can increase the risk of bleeding.

What should I expect after surgery?

After surgery you will spend time in recovery before going to the ward.

Pain relief: usually liquid or intravenous Panadol is all that is needed after keyhole surgery. Occasionally you may need narcotics e.g. morphine for first 24 hours. Pain in the shoulder is very come and is caused by irritation from the CO2 gas. This quickly settles as the gas get absorbed within 24 hours.

Nausea and Vomiting: It is essential that you do not vomit or have dry retching as this may damage the fresh repair. You will have regular antiemetic drugs to prevent this, however, if you still feel sick then inform your nurse.

You usual tablet medications: You will not be able to swallow tablets normally soon after surgery. If your medication comes in liquid form then use that for the first week. If you medication comes only in tablet form then the tablets may need to be crushed and taken with liquid or custard. Some medications e.g. potassium tablets, aspirin and NSAIDs can burn the oesophagus if they get stuck, therefore these should not be taken orally till swallowing is normal.

Diet: This is the hardest part of your recovery. The expected temporary swelling after surgery causes narrowing of lower end of the oesophagus making swallowing more difficult.

Fluid phase: Immediately after surgery you can have sips of water then clear fluids. The day after surgery you will progress to free fluids which include soups and milky drinks. You will go home when you are able to take enough fluids and when nausea and pain are no longer an issue. You should continue on the fluid diet for a week after going home. Patients with large hiatus hernias will have a swallowing radiologic test the day after surgery to ensure all is good prior to increasing their fluid intake. Remember, you should not have fizzy drinks.

Puree diet phase: After the first week you may start pureed food for the next 3 weeks.  This include cereals and porridge softened with milk, thick soup, minced meat, pureed fruits, mashed potato and gravy, yoghurt, mouse and crème caramel. Do not have bread, rice, pasta or steak.

Solid food phase : 4 weeks after operation and when you are able to tolerate the puree diet well you can gradually start solid food. Be guided by what you can swallow.

Activity: You should not drive for at least a week after surgery and only when you can respond in an emergency. Walking and light activities are encouraged from day one. Breathing exercises are important to prevent chest infection Heavy lifting (more than 10 kg) should be avoided for 6 weeks. Swimming can be resumed two weeks after surgery. Sexual activity can be resumes after one week.

When to return to work? Desk jobs can be resumed within one week. If your job requires lots of bending down or heavy lifting then you should go on light duties for 6 weeks.

Follow-up: I see most patients within 1-2 weeks after surgery.  You should come and see me at any time if you  have any one of the following:

1. Fever >38 degrees or chills
2. Increasing pain or redness around the incision
3. Increasing pain, nausea or vomiting
4. Feeling dizzy or light headed
5. You are not able to tolerate liquids
6. Persistent cough or shortness of breath
7. Persistent pain in the shoulders
8. If you are concerned about anything