Gastro-oesophageal reflux disease [GORD] is an increasingly common condition, where acid from the stomach leaks up into the oesophagus.  In the long term this can cause injury to the oesophagus, and over time, this injury can lead to development of oesophageal changes such as Barrett’s oesophagus and eventually cancer.  It is often managed in the first instance with lifestyle modification such as weight loss and smaller evening meals, as well as anti-acid medication such as a proton pump inhibitor [PPI]. Over the past decade there has been increasing evidence that long-term use of PPIs are associated with adverse effects such as :

• Calcium and magnesium malabsorption and deficiency ; 
• Vitamin B12 deficiency ; 
• Clostridium difficile colitis [bowel infections] and 
• Community acquired pneumonia [chest infections].

Reflux disease can exist independently or together with a weakness in the diaphragm opening that the oesophagus passes through, which is referred to as a hiatus hernia.  A hiatal hernia is a common condition in people over the age of 50.  In this condition, part of the stomach passes through the diaphragm opening, and depending on the size of this opening it can lead to strangulation of the stomach, which is a surgical emergency.

Reflux, which is often described as a burning pain behind the sternal bone, is usually worse after a large meal or on lying flat.  With bad reflux patients often describe needing to sleep on two or more pillows and may have vomit on the pillow case on waking.  

Hiatal hernias are often found incidentally, without any associated symptoms.  In some cases however, patients can present with one or all of :

• chest pain
• heart burn
• belching and difficulty swallowing.

If left untreated, a hiatus hernia may develop an associated ulcer, which can bleed and cause iron deficiency anaemia.  Hiatus hernias can also contribute to aspiration, which is where food and fluid in the stomach is regurgitated into the lungs and can lead to infection.

In large hernias the stomach can twist on itself and become ‘strangulated’, meaning there is a cut off of blood supply to the stomach.

The following tests are generally done in the work up for anyone considering anti-reflux surgery : 

Barium swallow & meal: Involves swallowing a barium preparation, which is then followed through a series of xrays.  This helps to exclude other issues with swallowing such as achalasia, which is a contraindication for anti-reflux surgery.  If there are concerns of achalasia, you may be asked to travel to Adelaide for further swallow testing [manometry and pH studies].

Endoscopy: To examine the inside of your oesophagus and stomach with an instrument called an endoscope. This allows us to directly visualise the hiatus hernia and any potential complications.

CT Scan: This scan can detect how much stomach and other organs are in the hiatus hernia.

Reflux can be managed effectively using a minimally invasive laparoscopic approach to repair the restore the lower oesophageal sphincter.  This is called a laparoscopic fundoplication.  This involves reducing any hiatus hernia, repairing the diaphragm opening, and wrapping the upper part of the stomach around the oesophagus to restore function.  In general PPI medication can stop from the day of surgery.

For 90% of patients undergoing this procedure, the wrap will feel ‘just right’.  For the other 10% of patients it may feel either ‘too tight’ or they may still have some reflux despite the wrap.  Most of the time wraps that feel ‘too tight’ will relax with time, however occasionally they require either an endoscopy and dilatation or second revisional surgery.  For the patients who have residual reflux, most of the time this is insignificant compared to pre-surgery and can be managed with occasional use of PPI medication.  For a small percentage of patients revisional surgery might be required. 

In cases of hiatus hernia repair there is a small risk of early or late recurrence of the hernia.  This is mostly associated with larger hiatus hernias.

For most patients this operation is a minimally invasive procedure using 5mm ports only, so return to normal activities can resume almost immediately following surgery.  Patients will stay overnight on clear fluids and upgrade to a puree diet day 1.  Most patients will be discharged home after one night in hospital.

Be careful to follow post operative diet instructions.  You will be advised by your surgeon to have puree food only for 2 weeks following your fundoplication surgery. 

After your 2 week follow up with the surgeon, your diet will be upgraded.  You should still aim to chew your food very well and have extra water with meals to aid in lubrication of the oesophagus and to help food pass into the stomach.  

Bread and meat tend to be the most challenging foods to eat after this surgery and should be introduced back into the diet after 2 weeks with care.