Acid reflux – otherwise known as gastro-oesophageal reflux (GORD) is a condition where the natural defences within the body’s upper digestive system is impaired. These defences are in place to prevent the acidic contents of the stomach entering the oesophagus causing a burning sensation that in laymen’s terms we call heartburn.
One of the primary causes of this condition is a hiatal hernia – a condition where the stomach protrudes through the diaphragm into the chest cavity. The other is damage of the anti-reflux defense mechanisms including lower oesophageal sphincter (LOS).
Approximately one in five people in the developed western word suffer from GORD and require acid reflux treatment. Prolonged reflux can lead to damage to the lining of the oesophagus causing various complications such as oesophagitis, ulcers and Barrett’s oesophagus.
Diagnosis is usually confirmed by tests like gastroscopy, barium swallow x-ray and oesophageal pH and manometry test.
Surgical therapy should be considered, when a diagnosis of reflux, acid or non-acid (or bile reflux), is objectively confirmed and when the patients:
- Have failed medical management (inadequate symptom control, severe regurgitation not controlled with acid suppression)
- Some patients opt for a surgery, despite successful medical management to avoid taking medication or if they develop side effects to the medication
- Due to complications of GORD, including erosive esophagitis, stricture, and/or Barrett’s oesophagus (condition where the inner lining of the oesophagus changes to that of the stomach lining, due to acid irritation)
- Have extra-oesophageal manifestations, such as asthma, hoarseness, cough, chest pain, and/or aspiration
How is the Hiatal Hernia Repair surgical procedure Performed?
The surgical procedure used is called Hiatal Hernia Repair with Fundoplication. This done via keyhole (laparoscopic) surgery.
- In this procedure, the lower end of the oesophagus and the upper part of the stomach is freed completely
- The hernia is reduced, thus bringing the gastro-oesophageal junction below the diaphragm
- Then, the opening on the diaphragm is narrowed, allowing a free passage of oesophagus without any external compression on the wall of the oesophagus. This narrowing is performed with sutures, and is called a diaphragmatic crural repair or cruroplasty
- To prevent recurrence of the hiatal hernia and reflux of gastric acid, the gastric fundus (upper part of the stomach) is wrapped around the lower part of the oesophagus
- The wrap could either be a complete 360 degree wrap, or a partial 270 degree or 180 degree wrap
- Complete 360 degree wrap is called Nissen Fundoplication
- Partial posterior 270 degree wrap is called Toupet Fundoplication
- Anterior 180 degree wrap
- The procedure can be performed via open or laparoscopic approach, through the abdomen or through the chest
- Large diaphragm defects and presence of weak tissue may require placement of synthetic or biological mesh.
How Well Does It Work?
- Long term studies show that ninety-one to ninety-three percent of patients reported a good overall outcome at late follow-up, with good reflux control maintained long-term in the majority of patients 80 % report no heartburn, 13 % mild occasional symptoms, and 7 % report significant reflux symptoms at late follow-up. Proton pump inhibitor (eg Nexium) use was seen in 27 % of patients at 10 years follow-up,”
- But compared to people who do not have surgery, people who do have surgery are less likely to need medicine every day and have less severe symptoms when they stop taking medicine. Also, people who have surgery for GORD seem to be happy with the results, even if their symptoms do come back and they have to take medicine again.