Keyhole Operations

Oesophageal Reflux Surgery ( Keyhole Operations )

Gastro-oesophageal

Anti-reflux surgery is surgery to correct a problem with the muscles at the bottom of the oesophagus (the tube from your mouth to the stomach).

Problems with these muscles allow gastro-oesophageal reflux disease (GERD) to happen.

This surgery can also repair a hiatal hernia.

Introduction

GORD is a condition that causes food or stomach acid to come back up from your stomach into your oesophagus. This is called reflux. It can cause heartburn and other uncomfortable symptoms. Reflux occurs if the muscles where the oesophagus meets the stomach do not close tightly enough.

A hiatal hernia occurs when the natural opening in your diaphragm is too large. Your diaphragm is the muscle and tissue layer between your chest and belly. Your stomach may bulge through this large hole into your chest. This bulging is called a hiatal hernia. It may make GORD symptoms worse.

A procedure called fundoplication is the most common type of anti-reflux surgery. During this procedure, your surgeon will:

  • First repair the hiatal hernia with stitches. The surgeon will tighten the opening in your diaphragm to keep your stomach from bulging through.
  • Your surgeon will then use stitches to wrap the upper part of your stomach around the end of your oesophagus. This creates pressure at the end of your oesophagus and helps prevent stomach acid and food from flowing back up.

Surgery is done while you are under general anesthesia (asleep and pain-free). Surgery usually takes 2 to 3 hours.

Ways your doctor may do this surgery are:

  • Open repair: Your surgeon will make an incision (cut) in your belly area (abdomen). Sometimes the surgeon will place a tube from your stomach through the abdominal wall to keep your stomach in place. This tube will be removed when you no longer need it.
  • Laparoscopic repair: Your surgeon will make 3 to 5 small incisions in your belly. Your surgeon will insert a laparoscope (a thin, hollow tube with a tiny camera on the end) through one of these incisions and other tools through the other incisions. The laparoscope is connected to a video monitor in the operating room that allows your surgeon to see inside your belly and do the repair. The surgeon may need to switch to an open procedure if there is bleeding, a lot of scar tissue from earlier surgeries, or the patient is very overweight.

Endoluminal fundoplication is a new procedure that uses a special camera called an endoscope. The tube is passed down through your mouth and into your oesophagus. Your doctor will place small clips on the inside where the oesophagus meets the stomach. These clips help prevent food or stomach acid from coming back. An endoscope is similar to a laparoscope. This procedure is done to help prevent reflux.

Costs

With Private Health Insurance

There is no waiting list. If you wish, your operation can usually be performed within a week or two or planned at a time of your choosing. For most patients with full private health insurance there will be some extra costs not covered by Medicare or your health fund. The cover provided by your health fund will vary according to which fund and which table you are on and in some cases you may have to pay an "excess". It is your responsibility to check with your health fund prior to surgery. Full financial details will be provided to you prior to surgery. Occasionally other tests, procedures or specialist consultations may be necessary and some other costs incurred.

Providing you have private health insurance you can expect to be out of pocket around between $1900.00 - $2300.00 depending on which health fund you are registered with.

Without Private Health Insurance

Public hospital waiting lists are very long and the surgery is usually carried out by trainee surgeons under the supervision of one of the specialist surgeons appointed by the hospital. There is no choice of surgeon in the Public Hospital and your LapSurgery Australia surgeon may or may not be involved in your operation.

Hospitals used by LapSurgery Australia for this surgery are:

  • The Valley Private, Mulgrave
  • Knox Private, Wantirna
  • St John of God, Berwick
  • The Bays, Mornington

If you do not have private health insurance you can expect to be out of pocket between $7000.00 - $7500.00 depending on the hospital your surgery is performed at. Following your consultation with our surgeon our staff will be able to give you an informed financial consent prior to going ahead with surgery.

Please contact our office if you have any other questions in regard to costings for this surgery:
(03) 9760 2777

FAQ

What is Gastro-oesophageal Reflux Disease (GORD)?

Although "heartburn" is often used to describe a variety of digestive problems, in medical terms, it is actually a symptom of gastroesophageal reflux disease. In this condition, stomach fluids most commonly acid, bile or other digestive juices reflux or "back up" from the stomach into the oesophagus.

Heartburn is described as a harsh, burning sensation in the area in between your ribs or just below your neck. The feeling may radiate through the chest and into the throat and neck. Many adults experience this uncomfortable, burning sensation at least once a month. Other symptoms may also include the sour taste of acid in the mouth known as waterbrash, vomiting, difficulty swallowing and chronic coughing or wheezing.

Other symptoms associated with reflux include the backing up of fluid in the bending over position or when lying down in the horizontal position at night causing a choking sensation.

Other associated symptoms such as worsening of asthma, chronic hoarseness of voice can sometimes be secondary to reflux.

Is reflux (GORD) precancerous?

The risk of developing cancer of the gullet secondary to reflux is small. However a precancerous condition known as Barretts Oesophagus can be a precursor of cancer and this condition is often associated with reflux. Surgery to treat reflux may reduce the chance of progression to cancer in selected cases.

Are there Long term effects of  reflux GORD?
Long term effects can occur these include a tight narrowing of the gullet causing blockage, in some cases a change in the lining of the gullet known as Barretts can occur in a small percentage of cases Barretts can progress to cancer of the Gullet.

What causes GERD?

When you eat, food travels from your mouth to your stomach through a tube called the oesophagus. At the lower end of the oesophagus is a small ring of muscle called the lower oesophageal sphincter (LOS). The LOS acts like a one-way valve, allowing food to pass through into the stomach. Normally, the LOS closes immediately after swallowing to prevent back-up of stomach juices, into the oesophagus. GORD occurs when the LOS does not function properly allowing acid to flow back and burn the lower oesophagus. This irritates and inflames the oesophagus, causing heartburn and eventually may damage the oesophagus.

What Contributes to GORD?

Some people are born with a naturally weak sphincter (LOS). For others, however, fatty and spicy foods, certain types of medication, tight clothing, smoking, drinking alcohol, vigorous exercise or changes in body position (bending over or lying down) may cause the LOS to relax, causing reflux. A hiatus hernia (a common term for GORD) may be present in many patients who suffer from GORD, but may not cause symptoms of heartburn. The hiatus hernia can also be repaired at the time of surgery.

What special tests can be carried out to confirm the diagnosis of GORD?

Your specialist may recommend a Gastroscopy where a camera is passed down the swallowing tube to confirm the diagnosis and check for a Hiatus hernia. On occasion other tests such as a Special Barium X ray may be required.

An extremely good method of confirming the diagnosis and also checking for suitability for treatment with surgery is Manometry.  The gullets function of squeezing food is checked with the use of a special catheter passed through the nose. This is a mandatory requirement prior to surgery. The specialised equipment to perform the test is available at LapSurgery Australia and trained staff can perform the test where indicated as a same day procedure.

Another test that is extremely good at confirming the diagnosis is a pH test. This is a test done to study the nature of fluid backing up into the gullet and correlating it to the symptoms it also requires a fine catheter to be placed in the swallowing tube which monitors the fluid that is backing up and the test is carried out over a 24 hour period. The specialised equipment to perform the test is available at LapSurgery Australia and trained staff can perform the test where indicated as a same day procedure.

How is GORD treated?

GORD is generally treated in three progressive steps:

  1. Lifestyle Changes

    In many cases, changing diet and taking over-the-counter antacids can reduce how often and how harsh your symptoms are. Losing weight, reducing or eliminating smoking and alcohol consumption, and altering eating and sleeping patterns can also help.

  2. Drug Therapy

    If symptoms persist after these life style changes, drug therapy may be required. Antacids neutralize stomach acids and over-the-counter medications reduce the amount of stomach acid produced. Both may be effective in relieving symptoms. Prescription drugs such as Nexium, Somac, and Pariet (PPI drugs) may be more effective in healing irritation of the oesophagus and relieving symptoms. This therapy needs to be discussed with your surgeon.

    There is some contrervesy about lifelong therapy using these medications. In some cases the drugs are not effective in controlling reflux this is particularly so when there is large amounts of fluid backing up due to a weak valve at the junction of the gullet and stomach. It may be appropriate to consider surgery in selected cases where drug therapy is in effective in controlling symptoms

  3. Surgery

    Patients who do not respond well to lifestyle changes or medications or those who continually require medications to control their symptoms, will have to live with their condition or may undergo a surgical procedure. Surgery is very effective in treating GORD.

What are the advantages of the Laparoscopic (key hole) method?

The advantage of the laparoscopic approach is that it usually provides:

  • reduced postoperative pain
  • shorter hospital stay
  • a faster return to work
  • improved cosmetic result

Are you a candidate for the laparoscopic method?

Although laparoscopic anti-reflux surgery has many benefits, it may not be appropriate for some patients. Obtain a thorough medical evaluation by a surgeon qualified in laparoscopic anti-reflux surgery in consultation with your primary care physician or Gastroenterologist to find out if the technique is appropriate for you. In all cases special tests such as Gastrsocopy, Manometry and pH studies will need to be carried out prior to considering surgery.

What to expect before laparoscopic anti-reflux surgery:

  • After your surgeon reviews with you the potential risks and benefits of the operation, you will need to provide written consent for surgery.
  • Preoperative preparation includes blood work, medical evaluation, chest x-ray and an EKG depending on your age and medical condition.
  • After midnight the night before the operation, you should not eat or drink anything except medications that your surgeon has told you are permissible to take with a sip of water the morning of surgery.
  • Drugs such as aspirin, blood thinners, anti-inflammatory medications (arthritis medications) and Vitamin E will need to be stopped temporarily for several days to a week prior to surgery.
  • Diet medication or St. John's Wort should not be used for the two weeks prior to surgery.
  • Quit smoking and arrange for any help you may need at home.

What to expect the day of surgery:

  • You usually arrive at the hospital the morning of the operation.
  • A qualified medical staff member will place a small needle/catheter in your vein to dispense medication during surgery.
  • Often pre-operative medications are necessary.
  • You will be under general anesthesia - asleep - during the operation which may last several hours.
  • Following the operation you will be sent to the recovery room until you are fully awake.
  • Most patients stay in the hospital the night of surgery and may require additional days in the hospital.

How is laparoscopic anti-reflux surgery performed?

  • Laparoscopic anti-reflux surgery (commonly referred to as Laparoscopic Nissen Fundoplication) involves reinforcing the "valve" between the oesophagus and the stomach by wrapping the upper portion of the stomach around the lowest portion of the oesophagus - much the way a bun wraps around a hot dog.
  • In a laparoscopic procedure, surgeons use small incisions (1/4 to 1/2 inch) to enter the abdomen through cannulas (narrow tube-like instruments). The laparoscope, which is connected to a tiny video camera, is inserted through the small incision, giving the surgeon a magnified view of the patient's internal organs on a television screen.
  • The entire operation is performed "inside" after the abdomen is expanded by inflating gas into it.

What happens if the operation cannot be performed or completed by the laparoscopic method?

In a small number of patients the laparoscopic method is not feasible because of the inability to visualize or handle the organs effectively. Factors that may increase the possibility of converting to the "open" procedure may include obesity, a history of prior abdominal surgery causing dense scar tissue, or bleeding problems during the operation. The decision to perform the open procedure is a judgment decision made by your surgeon either before or during the actual operation. When the surgeon feels that it is safest to convert the laparoscopic procedure to an open one, this is not a complication. The decision to convert to an open procedure is strictly based on patient safety.

What should I expect after Surgery?

  • Patients are encouraged to engage in light activity while at home after surgery.
  • Post operative pain is generally mild although some patients may require prescription pain medication.
  • Anti-reflux medication is usually not required after surgery.
  • Some surgeons modify patients diet after surgery beginning with liquids followed by gradual advance to solid foods. As a matter of routine Surgeons at LapSurgery Australia will involve a specialist dietician who will instruct you on specific dietary modification following surgery.
  • You will probably be able to get back to your normal activities after a period of approximately 7-10 days. These activities include showering, driving, walking up stairs, lifting, working and engaging in sexual intercourse.
  • A scheduled follow-up appointment within one week after your operation.

Are there side effects to this operation?

Studies have shown that the vast majority of patients who undergo the procedure are either symptom-free or have significant improvement in their GERD symptoms.

Long-term side effects to this procedure are generally uncommon.

  • Some patients develop temporary difficulty swallowing immediately after the operation. This usually resolves within one to three months after surgery.
  • Occasionally, patients may require a procedure to stretch the oesophagus (endoscopic dilation) or rarely re-operation.
  • The ability to belch and or vomit may be limited following this procedure. Some patients report stomach bloating.
  • Rarely, some patients report no improvement in their symptoms.

What complications can occur?

Although the operation is considered safe, complications may occur as they may occur with any operation.
Complications may include but are not limited to:

  • adverse reaction to general anesthesia
  • bleeding, blood clots and embolism to the legs (preventative measures are used routinely to try and minimise this)
  • injury to the oesophagus, spleen, stomach or internal organs
  • infection of the wound, abdomen, or blood.
  • other less common complications may also occur.

Your surgeon will discuss these with you and also help you decide if the risks of laparoscopic anti-reflux surgery are less than non-operative management.

When to call your doctor

Be sure to call your physician or surgeon if you develop any of the following:

  • Persistent fever over 101°F (39°C)
  • Bleeding
  • Increasing abdominal swelling
  • Pain that is not relieved by your medications
  • Persistent nausea or vomiting
  • Chills
  • Persistent cough or shortness of breath
  • Purulent drainage (pus) from any incision
  • Redness surrounding any of your incisions that is worsening or getting bigger
  • You are unable to eat or drink liquids

Surgical Risks

Risks for any anesthesia are:

  • Reactions to medicines
  • Breathing problems, including pneumonia
  • Heart problems

Risks for any surgery are:

  • Bleeding
  • Infection

Risks for this surgery are:

  • Gas bloat, which makes it hard to burp or throw up. It also causes bloating after meals. These symptoms slowly get better for most people.
  • Pain and difficulty when you swallow, for some people. This is called dysphagia. For most people, this goes away in the first 3 months after surgery.
  • Damage to the stomach, esophagus, liver, or small intestine. This is very rare.
  • Respiratory complications, such as a collapsed lung. This is also rare.
  • Recurrence of the hiatal hernia

Before the Procedure

Your doctor may ask you to have these tests:

  • Blood tests (complete blood count, electrolytes, or liver tests)
  • Upper endoscopy. Almost all people who have this procedure have already had this test. If you have not, you will need to.
  • Other tests, such as manometry (to measure gases) or pH monitoring (to see how much stomach acid is in your esophagus).

Always tell your doctor or nurse if:

  • You could be pregnant
  • You are taking any drugs, supplements, or herbs you bought without a prescription

During the week before your surgery:

  • You may be asked to stop taking aspirin, ibuprofen (Advil, Motrin), vitamin E, clopidogrel (Plavix), warfarin (Coumadin), and any other drugs or supplements that affect blood clotting several days to a week before surgery.
  • Ask your doctor which drugs you should still take on the day of your surgery.

On the day of your surgery:

  • Do not eat or drink anything after midnight the night before your surgery.
  • Take your drugs your doctor told you to take with a small sip of water.
  • Shower the night before or the morning of your surgery.
  • Your doctor or nurse will tell you when to arrive at the hospital.

Surgical Benefits

Anti-reflux surgery repair is a safe operation. Heartburn and other symptoms should improve after surgery. But you may still need to take drugs for your heartburn after surgery.

Some people will need another operation in the future to treat new reflux symptoms or swallowing problems. This may happen if the stomach was wrapped around the oesophagus too tightly, the wrap loosens, or a new hiatal hernia develops.

Post Operative Instructions

Patients who have laparoscopic surgery usually spend 1 to 3 days in hospital. Those who have open surgery may spend 2 to 6 days in the hospital after the procedure.

Most patients go back to work 2 to 3 weeks after laparoscopic surgery and 4 to 6 weeks after open surgery.

For instructions relating to this operation, please visit the Patient Care Instructions page.

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