Gastroesophageal reflux disease (GORD) is a common condition affecting up to 20% of the western population1. The majority of patients with reflux disease complain of heart burn. However, gastroesophageal reflux can result in a variety of symptoms.
Patients with this disease could present with:
- vague symptoms of epigastric and retrosternal discomfort
- mild heartburn to severe heartburn with a taste of acid in the back of the throat
- minor food regurgitation or vomiting
- extra oesophageal symptoms of chronic cough, asthma, sore throat, teeth discolouration and destruction
Normally there are mechanisms which allow solids and liquids to pass down from the oesophagus into the stomach and prevent a reverse flow from the stomach to the oesophagus. There are multiple factors which in combination prevents any reflux across the gastroesophageal junction. These mechanisms are the lower oesophageal sphincter pressure, length of intra-abdominal oesophagus, angle of His and folds of the gastroesophageal junction. In the case of gastroesophageal reflux one or a combination of these mechanisms are disturbed. The most common reason for the failure is the development of a hiatus hernia.
The majority of patients have minor reflux symptoms which are usually controlled by dietary modification and/or simple medications. However, significant proportions of patients suffer from severe disease and continue to experience symptoms even when they are on continuous treatment with increasing doses of proton pump inhibitor (PPI). Surgical treatment offers a possibility of a cure for these patients.
The surgical treatment for gastroesophageal reflux disease is very effective in controlling reflux symptoms2. The operation consists of repairing of the hiatus hernia and then construction of a valve like mechanism by means of a partial 275 degree or a complete 360 degree Fundoplication3. These operations nowadays are carried out by keyhole technique in more than 95% of cases4.
The indications for patients’ referral for surgical consideration are as follows:
- Patients who do not respond to medical treatment
- Patients requiring increasing doses of PPI
- Young patients with a long-term need for aggressive medical therapy
- Patients who do not wish to undergo long-term medical therapy because of the inconvenience or fear of side effects
- Patients who have severe erosive disease and are likely to require long-term high doses of treatment
- Patients with a large hiatus hernia
- Patients who develop severe complications of GORD, despite medical therapy, like oesophageal stricture, ulceration or Barrett’s oesophagus
- Patients with progressively worsening extra-oesophageal symptoms, despite regular use of PPI
It is important that patients with severe gastroesophageal reflux disease should be offered a choice of surgery and are not left to continue to suffer.
I have been performing anti-reflux surgery for many years with good results and high patient satisfaction. In 2010 we presented the result of 100 cases of laparoscopic Nissen Fundoplication at the 18th International Congress of the EAES, Geneva. The results were excellent with all patients having keyhole surgery and only 3 patients continuing to complain of dysphagia at one year after the operation.
- J Dent, H B El-Serag et al. Epidemiology of gastro-esophageal reflux disease: a systemic review. Gut. 2005 May;54(5): 710-717
- C S Davis, A Baldia et al. The Evolution and Long-Term results of Laparoscopic Antireflux Surgery for the Treatment of Gastroesophageal Reflux Disease. JSLS. 2010 Jul-sep; 14(3): 332-341.
- W K Kauer, J H peters, T R Demeester et al. A tailored approach to anti-reflux surgery. J Thorac Cardiovasc Surg.1995;110(1):141-147
- M Terry, C D Smith et al. Outcomes of laparoscopic fundoplication for the gastroesophgeal reflux disease and paraesophgeal hernia. Surg Endosc. 2001 Jul; 15(7):691-699.
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