Anti-Reflux Surgery

Anti-reflux surgery is the surgical treatment of gastro-oesophageal reflux disease (stomach acid flowing back into the gullet). The most commonly used method is Nissen fundoplication: the upper part of the stomach (fundus) is wrapped around the lower end of the gullet, strengthening the valve mechanism between the stomach and the gullet.

This reduces the backflow of stomach contents into the gullet. During the operation, a hiatus hernia (hiatal hernia), if present, is also repaired. Today this operation is mostly performed by the laparoscopic (keyhole) method, through a few small incisions made in the abdomen.

Most people with reflux find relief with lifestyle changes and medication; not every reflux patient needs an operation. Surgical treatment is generally considered in the following situations:

• Patients whose symptoms continue despite regular medication
• Patients who find relief with medication but do not wish to take medicines long term, or who experience side effects from them
• Patients with a large hiatus hernia (hiatal hernia)
• Patients who develop changes in the gullet due to reflux, such as inflammation (oesophagitis), narrowing (stricture) or Barrett’s oesophagus
• Suitable patients with reflux-related symptoms such as chronic cough or hoarseness

Before a decision on surgery, tests such as endoscopy, measurement of pressure in the gullet (manometry) and acid measurement (pH test) are usually carried out. These tests both confirm the diagnosis and help in choosing the most suitable surgical technique. It is important to assess together with your doctor whether surgery is suitable for you.

The operation is performed under general anaesthesia and usually takes 1.5-3 hours. In the laparoscopic method, a camera and surgical instruments are inserted through small incisions made in the abdomen.

First, a hiatus hernia, if present, is repaired and the part of the gullet inside the abdomen is freed. The upper part of the stomach is then wrapped around the lower end of the gullet. In the Nissen method this wrap is complete (360 degrees); in some patients partial wrap techniques may be preferred. Which technique is used is decided according to the patient’s test results.

Rarely, it may be necessary to switch to open surgery during the operation for safety reasons. Your doctor will discuss this possibility with you before the operation.

As with any surgical procedure, this operation carries some risks. Most of them are rare and a large proportion can be treated:

• Bleeding, wound infection and problems related to anaesthesia
• Difficulty swallowing (dysphagia): common in the first weeks due to swelling at the operation site and usually resolves on its own; rarely it may be permanent and require a further procedure
• Wind and bloating: because belching becomes more difficult, gas may build up in the abdomen and a feeling of bloating may occur; this usually lessens over time
• Return of reflux symptoms as a result of the wrap loosening or shifting over time
• Injury to the gullet, stomach or surrounding organs (rare)

These risks may vary according to a person’s general health. At the pre-operative consultation, do not hesitate to ask your doctor about the risks specific to your situation.

The hospital stay is usually 1-2 days. After operations performed by the laparoscopic method, pain is mostly mild and patients are up and about within a short time.

Eating is progressed gradually: fluids are recommended in the first days, followed by soft and puréed foods for several weeks. During this period, keeping mouthfuls small, eating slowly and avoiding fizzy drinks reduce difficulty swallowing and bloating. The transition to a normal diet is usually completed within 4-6 weeks.

People with desk jobs can mostly return to work within 1-2 weeks; for those doing heavy physical work this period may be longer. Avoiding heavy lifting in the first weeks is recommended. If symptoms such as fever, increasing abdominal pain, inability to swallow or persistent vomiting occur, you should contact your doctor without delay. Attending follow-up appointments regularly is important for monitoring your recovery.