Gastro-oesophageal reflux disease can be treated both surgically and non-surgically (conservatively). This section discusses surgical treatment.

When is it indicated?

  • Surgery is carried out if medication to reduce stomach acid and lifestyle changes have an insufficient impact on the reflux (failure of medical therapy).
  • Surgery may also be considered if patients do not want to take antacids for the rest of their lives, if medication is not well tolerated or if medication is not taken reliably.
  • Surgical treatment is applied if reflux complications occur, such as poorly-healing or relapsing inflammation of the oesophagus (oesophagitis), benign constriction of the oesophagus (benign stricture), Barrett’s metaplasia (without serious dysplasia or carcinoma) or asthma.

Process

Preparation

  • If the patient is in full health, no specific preparations are necessary. However, smokers are advised to stop smoking because of the increased risk of lung infection, thrombosis (clot in blood vessel) and wound infections.
  • In case of known lung conditions, such as asthma or emphysema (COPD), the lungs must be in optimal condition before surgery is carried out.
  • The patient must fast from midnight on the day of the procedure.
  • Certain medications may still be taken in the morning on the day of the surgery: this will be decided by the attending physician. Make sure to report any use of blood thinners: certain types must be stopped a few days before the procedure.
Nissen procedure

Procedure

The surgery is always performed under general anaesthetic and usually in the form of keyhole surgery (laparoscopy). For this, the abdomen is inflated using carbon dioxide to create space to work, and instruments are placed through five small holes in the abdominal wall to perform the operation. An advantage of this method compared to the ‘classic’ procedure is that the hospitalisation and recovery periods are often shorter because the wound is much smaller.

In exceptional cases (for instance in case of too much scar tissue due to past procedures in the upper abdomen), the same operation is done through a classic incision which is associated with a larger scar and slightly longer periods of hospitalisation and recovery.

The most frequently used surgical technique is the Nissen procedure (or Nissen fundoplication). This involves the retraction of the part of the stomach located in the chest cavity, into the abdominal cavity. If necessary, the too wide opening in the diaphragm is narrowed. The upper portion of the stomach is detached from the spleen and then wrapped like a cuff around the oesophagus and secured at the front of the stomach.

Variations of the Nissen fundoplication exist where the cuff is not fully wrapped around the stomach but only partially so, as for the Dor or Toupet fundoplication. In exceptional cases, a partial cuff is created through the left side of the chest, which is called a Belsey fundoplication.

After the procedure

Contrast swallow

A contrast swallow is performed on the first day after the operation. This requires patients to drink a contrast fluid to confirm smooth passage through the junction between the oesophagus and the stomach, which is where the cuff is wrapped around. This can also rule out any leaks (due to detachment of the stomach).

If the contrast swallow results are reassuring, the patient may start on fluids and liquid, mixed foods. While you are in hospital, a dietitian is consulted to explain your dietary advice for when you are home, and he or she will provide you with a diet plan.

If fluids and liquid food are consumed without any problem, the IV drip can be removed on the second day after the operation and the patient may potentially be discharged.

Discharge

The hospitalisation duration depends on a number of factors. Age, overall condition and the patient’s situation at home (e.g. living alone) all play a role. Patients who have undergone surgery using a classic incision will often remain in hospital a bit longer.

Possible complications

As with any operation, several general complications can occur such as bleeding, wound infection, thrombosis or lung infection, etcetera. The following complications may occur too:

Shoulder pain

Shoulder-tip pain is a commonly occurring complaint after a laparoscopy and will disappear by itself in a few days. This is caused by the gas that is used in the procedure and leads to irritation of the diaphragm, which is registered by the nervous system at the tip of the shoulders.

Bleeding

During the operation, bleeding of the spleen (or liver) is the most important, but fortunately uncommon, complication.

Collapsed lung

Detaching the stomach which has moved up in the chest may also lead to a collapsed lung (pneumothorax). This is due to perforation of the lung, which causes air to leak into the chest leading to a partial collapse of the lung. This sometimes requires a drain (plastic tube) to be placed in the chest cavity to remove the air and fluid between the lung membranes and allow for the lung to unfold again.

Diarrhoea and gastrointestinal passage problems

During the procedure, nerves that run along the oesophagus and stomach may also be damaged, resulting in (usually temporary) diarrhoea and gastrointestinal stool passage problems.

Stomach perforation

In rare cases, stomach perforation may occur due to detaching the stomach from the spleen or from the chest cavity. This may lead to stomach acids leaking into the abdominal cavity, usually requiring a new operation to repair the perforation.

Results

For 80 to 90% of the patients, good to excellent improvement of reflux is achieved for a minimum of ten years after the procedure. In less than 20% of patients, symptoms persist afterward.

Approximately 10 to 15% of patients undergoing a Nissen fundoplication experience more difficulty, usually temporary, with food passing through the oesophagus (dysphagia). This may cause the patient to lose up to 10% of their body weight after the procedure. These dysphagia symptoms will improve after four to six weeks. If symptoms persist or in case of too much weight loss, contact the surgeon.

Belching may be more difficult in the beginning too. The patient may therefore complain about flatulence or bloating.

To achieve the best possible result, it is essential that the correct indication (patient who has demonstrable symptoms or oesophageal damage due to gastro-oesophageal reflux) is selected. Individual differences exist too, and precise outcomes cannot be predicted.

Guidelines for at home

Wound pain

Wound pain after a surgical procedure is normal to a degree. This pain may persist for a week or even for a number of weeks when coughing or lifting things. Feel free to use pain relief during this period. The intensity of the pain should decrease progressively. If the pain increases, the wounds must be checked partway through. Contact the GP or surgeon for this.

Shoulder pain

Shoulder pain may occur after any keyhole surgery as a result of the position the patient is in during the procedure, but also because the abdominal cavity is inflated with carbon dioxide. The stretching of the midriff may result in irritation of the nerve to the shoulder. This shoulder pain is no cause for concern and usually disappears after a few days.

Diet

  • During a Nissen procedure or anti-reflux surgery, the stomach is placed behind and around the oesophagus and secured with a few
    sutures. To protect the sutures, dietary adjustments are necessary in the first few weeks.
    After the contrast swallow, the patient is started on fluids and liquid, mixed foods. The first 14 days after the operation
    , only liquid or mixed food may be consumed (step 1).
  • Then the gradual change to soft foods can be made (step 2). Since burping is difficult during the first weeks after the procedure, fizzy drinks must be absolutely avoided.

Details about the composition of the diet can be found in the following leaflet.

Medication

After the procedure, anti-reflux medication is generally no longer necessary.

Sutures

Sutures may be removed by the GP on the tenth day after the procedure. Until then, make sure to protect the wounds from contact with water. Bandages may be changed when they are soiled or loosened.

Exercise

Exercise is indicated as soon as the level of pain allows. Early mobilisation reduces the chance of clots forming in the blood vessels. Exercise must be kept below the pain threshold, and patients should wait three weeks before starting sports to prevent a small incisional hernia in the incision area. General fatigue during a number of weeks after the procedure is normal.

Centres and specialist areas

General Surgery
Digestive Centre

Latest publication date: 05/02/2021
Supervising author: Dr Pletinckx Pieter, Dr Vanderstraeten Erik