Surgical Procedures

What causes reflux?

In a healthy person, the muscle closing off the lower esophageal section "opens" during swallowing, allowing food to slide down into the esophagus, but then it closes and prevents backflow. Reflux occurs when this muscle does not function properly, i.e., it does not prevent the stomach contents from refluxing back into the esophagus.

A diaphragmatic hernia (hiatal hernia) can also contribute to the development of reflux, as in this case, the upper part of the stomach partially or entirely "slips" up into the chest cavity, where the stomach contents flow back due to negative pressure.

What are the symptoms of reflux?

When the acidic (or bile) stomach contents enter the esophagus, they cause a sensation of heartburn due to irritation. If the stomach contents reach higher, it can lead to throat irritation, unpleasant taste sensations, dry mouth, coughing, or even asthma.

The symptoms caused by reflux can be categorized into "typical" and "atypical" groups.

Typical symptoms include heartburn and regurgitation (food coming back up into the oral cavity). Atypical symptoms include asthma, persistent cough, hoarseness, nausea, vomiting, and excessive saliva production at night. Certain foods, medications, and conditions can significantly exacerbate reflux symptoms, including smoking, pregnancy, obesity, alcohol, caffeine and coffee consumption, fatty foods, and carbonated drinks.

What complications can reflux cause?

The acid and/or bile irritate the lower section of the esophagus, which can eventually cause damage to the cells of the mucous membrane. The first step is the development of esophageal inflammation (oesophagitis), which, if persistent, can lead to bleeding, ulceration, or narrowing of the esophagus (stricture). Persistent inflammation can also cause long-term mucous membrane damage (Barrett's esophagus), which increases the risk of tumor development.

Reflux treatment options

If you experience recurring heartburn or the above symptoms, we recommend seeking the attention of a gastroenterologist.

The first step is lifestyle optimization, followed by medication, and finally, surgical intervention may be considered.

What is meant by lifestyle optimization?

• Avoid foods, alcohol, carbonated drinks, caffeine and coffee that cause reflux!
• Quit smoking!
• Have dinner earlier than usual!
• Elevate the head of your bed at night!

Medication options:

Over-the-counter options: we recommend taking antacids (such as Gaviscon) that can reduce or eliminate stomach acidity, thus relieving heartburn.

Prescription options: H2 blockers (Ranitidine, Famotidine) can usually reduce symptoms for a short time. Proton pump inhibitors (Omeprazole, Controloc, Losec) significantly reduce stomach acid production, and their use for 4-6 weeks greatly reduces symptoms, but stopping these medications often leads to a recurrence of symptoms.

Surgical treatment: Nissen procedure (Fundoplication)

In this minimally invasive surgical procedure for treating reflux, a cuff is formed around the lower part of the esophagus from the upper part of the stomach, which will function as a valve: it allows food to pass from the esophagus, but prevents the stomach contents from refluxing back into the esophagus.

The intervention takes 60-90 minutes and can be performed laparoscopically through five small incisions. After the procedure, it is recommended to spend one night in the hospital, and after another 10-14 days of convalescence at home, patients become able to work again (if heavy physical work is done, an additional 4 weeks of waiting is necessary).

Who is surgery recommended for?

• those for whom drug treatment did not bring the expected result
• those who, with medication, can control their reflux symptoms well, but do not want to take medication for a lifetime
• those who have already developed complications as a result of reflux, such as Barrett's esophagus, ulcers, bleeding, esophageal stricture
• in case of atypical symptoms (hoarseness, coughing, asthma)
• those who cannot continue taking medications due to side effects of drug treatment

Steps of surgical preparation

• Thorough gastroenterological symptom review
• Stomach endoscopy, eradication of Helicobacter
• Esophageal functional examinations:

During the esophageal functional examination, a thin tube is led down to the stomach, with which we collect data for 24 hours. During the examination, we seek to find out whether the patient's complaints show a connection with the acidic reflux reaching the esophagus, that is, whether the elimination of this is expected to eliminate the symptoms.

Beyond the above, 24-hour pH measurement, it may be necessary to examine the muscle function of the esophagus as well. This is esophageal manometry, during which we study the coordinated movement, contraction of muscle fibers. In case of improper muscle function, the Nissen surgery is not recommended.

Benefits of surgery

After the surgery, about 90% of patients are extremely satisfied with the result and report the cessation of heartburn. Asthma, coughing caused by reflux improve in about 85% of cases. In the case of Barrett's esophagus, it is not expected that the condition will regress as a result of the Nissen surgery, but since the corrosive effect of acid-bile does not take effect, the condition generally does not deteriorate further.

Possible complications of surgery

Transient difficulty swallowing is common in almost all patients after surgery, so a liquid-pulp diet is recommended for this period, for 1-2 weeks. After this, however, patients can return to normal diet, and the antacid medications taken before surgery can be discontinued. The chance that dilation would become necessary due to difficulty swallowing is very small.

It is important to be aware that the air swallowed with food cannot always leave through the mouth (belching is not always possible), so abdominal tension may occur, and these gases usually leave through the other end of the digestive tract.

Long-term complications may include slippage of the cuff, which leads to the loss of the beneficial effect of the surgery.