Acid-Reflux Surgery

Heartburn (or acid-reflux as it is known) can be very uncomfortable but, occasional symptoms are normal. If you overeat or drink excess alcohol on a night out, then the burning symptoms might be expected. However, symptoms on a daily basis that start to affect your day-to-day activities are certainly not normal and need attention. Symptoms vary between patients and can include burning in the middle of the chest, foul acidic taste in the mouth or night-time cough as the acid comes up the gullet and spills over into the lungs. Often associated with heart burn is what we call “volume regurgitation” – this is where the stomach contents can come up into the mouth when bending forward or lying down. Both of these symptoms need attention. The problem is that long term acid in the gullet can cause damage which, left unchecked, can cause a change in the lining of the gullet to what we call “Barrett’s oesophagus”(so called after Norman Barrett who discovered the problem in 1950). Patients with this issue have a thirty times increased risk of life-threatening cancer of the gullet. The cause of the acid reflux or volume regurgitation is usually a “hiatus hernia” where part of the stomach has pushed up through the diaphragm through a natural hole into the chest.

After recognition of the problem, attendance at your GP is crucial. The first thing to try is lifestyle modifications which may include measures such as stopping smoking, avoiding trigger foods or alcohol. If these don’t make a significant difference then medication is the next step. Different varieties exist but the most common is called Omeprazole which switches off the stomach acid. Starting at low dose is advisable and sufficient for most people, but doses may need to be increased as symptoms dictate.

If you do not wish to take long term medication or if the medication fails to control the symptoms then you may need to be referred for a surgical opinion. You will need investigations which may include a camera investigation (a “gastroscopy”), an x-ray investigation while you drink (a “barium swallow”) and a 24 hour acid check via a small probe placed down the nose into the gullet. If all of these investigations confirm acid reflux, hiatus hernia or Barrett’s oesophagus then surgery may be recommended.

Surgical options

Fundoplication

A fundoplication is done through key-hole surgery and involves correcting the acid control mechanisms. This is usually in two parts – firstly bringing the stomach back down into the normal position and secondly repairing the hole in the diaphragm (the hiatus hernia) and anchoring the stomach in the new position. There are various ways to anchor the stomach – complete wrap (Nissen fundoplication), partial wrap (Toupet fundoplication) and anterior wrap (anterior fundoplication). This decision is determined at the time of surgery and in response to your particular symptoms. The surgery is considered to be safe and very effective but usually requires several weeks of puréed diet following surgery as there is often significant swelling. After this time, diet will return to normal.

LINX device

The LINX^® System is a medical device which is placed around the Lower Oesophageal Sphincter (LOS) using a simple technique called laparoscopy (keyhole surgery). The device consists of a small flexible band of interlinked titanium beads with magnetic cores and is placed around the LOS in the closed position. The beads will separate temporarily as the force of a swallow allows food and drink to pass into the stomach. The magnetic attraction between the beads then brings the device back to the closed position to prevent reflux occurring. The magnets are calibrated to allow higher gastric pressures to open the device, but will not open for the lower gastric pressure of reflux. This means that the device will also open if there is a need to release increased pressure in the stomach (for example when belching or vomiting).

The LINX® System is made with neodymium permanent rare earth magnets. The magnets are cased in titanium and each bead is joined by individual titanium wires. The Roman arch design means that the device does not compress the tissue around the oesophagus and a specially designed clasp securely locks one end of the device to the other so it will not come undone. The device is positioned so it will not move from its location inside the body.

Symptoms

acid heartburn
a small hiatus hernia (or no hiatus hernia)

Treatment/Procedure

Preoperative investigations include gastroscopy, barium swallow (xray) and acid monitoring studies

The procedure can be carried out through keyhole surgery and takes approximately 90 minutes.

Revisional/ Redo Surgery

Revisional/Redo Surgery is revising previous fundoplication surgery and can be challenging. It is often considered a last resort after medication no longer works.