We've tried to include answers to some of the more frequently asked questions we are regularly asked. We would be delighted to add more at your request
- Is it safe to take PPIs long-term?
PPIs are one of the most commonly prescribed group of drugs worldwide. They are sold under a variety of names including Nexiem, Omeprazole, Esomeprazole and Lansoprazole. Generally they are considered safe; however, there have been a steady stream of scientific studies published in recent years associating them with a variety of health issues. These include reduced absorption of calcium, magnesium and other minerals, bone fractures, c. difficile gastroenteritis, and, more recently, chest infections, heart attacks and chronic kidney failure. Ultimately, PPIs are extremely powerful antacids and significantly change the usual physiology in the stomach. It is therefore not surprising that there may be consequences to their use. More studies will need to be done to clarify the risks but meanwhile more and more patients are choosing not to take PPIs continually. This is an accepted indication to consider a surgical route to cure reflux.
- Do antacid medications cure reflux?
Antacid medications can help reduce symptoms but they cannot cure reflux. The fundamental cause of reflux is the failure of the Lower Oesophageal Sphincter (LOS) which when working correctly prevents stomach contents from refluxing into the oesophagus, throat, mouth and lungs. Gastric contents include acid and this can cause some of the symptoms experienced by people with reflux. Medication reduces acid secretion from the stomach but cannot stop the reflux of fluid which can also be non-acidic. Consequently, in up to 30% of patients, even powerful antacids will not be completely effective and some people will continue to suffer symptoms caused by non-acidic gastric juice. Some patients will find that although their burning and indigestion are improved by PPIs they continue to suffer from other symptoms such as cough, sore throat or regurgitation. Finally, as the LOS becomes increasingly weak over time, some patients who benefitted initially will find antacid medications become increasingly ineffective.
- What is a Hiatus Hernia?
A hiatus occurs when part of the stomach moves from the abdomen to the chest. Normally, the oesophagus passes from the throat to the stomach through the chest, behind the heart and in front of the spine. The abdomen and chest cavities are separated by a large flat muscle used for breathing called the diaphragm. The oesophagus passes through a hole in the diaphragm called the hiatus. When a hiatus hernia develops the ligaments between the oesophagus and the diaphragm become weak and the hiatus enlarges. This allows the stomach to move up and down between the abdomen and the chest. Usually, when this occurs the valve mechanism at the bottom of the oesophagus is disrupted and reflux is the result.
Hiatus hernias are classified according to the associated anatomy. The most common is Type I, in which the top of the stomach “slides” up into the chest. In Type II part of the stomach ‘rolls’ up into the chest alongside the bottom of the oesophagus, which stays in its normal position.
Type III is a combination of these and in some patients the whole stomach can move into the chest. Finally, in type IV the hiatus can become so large that as well as the stomach other abdominal organs can also be involved. In addition to reflux symptoms, these larger hiatus hernias can cause the stomach to become intermittently blocked or even to twist around itself (volvulus). This can cause belching, vomiting, pain, and occasionally require emergency surgery.
- Is a hiatus hernia repaired when anti-reflux surgery is performed?
When surgery for reflux is performed, the operation almost always includes repair of an associated hiatus hernia. Usually this involves repairing the hiatus so that its normal size is restored by sewing the muscles back together. Sometimes this includes the use of a patch of ‘mesh’ to strengthen this repair and also securing the stomach below the diaphragm to reduce the chances of the hernia recurring.
- What is laparoscopic surgery?
Standard surgery involves making large incisions in order to gain access to the organs inside body cavities. Laparoscopic surgery, otherwise known as ‘keyhole’ surgery, employs tiny holes in the abdomen (usually 5-10mm in size) through which special instruments are inserted. The surgeon can see inside the body by inserting a specially-designed camera and watching the image on a TV screen. This allows high definition closeup views of the organs inside the abdomen, pelvis and chest.
- What are the advantages of laparoscopic surgery?
Because it employs tiny holes laparoscopic surgery tends to cause significantly less pain and discomfort than standard operations. It also causes less of a physiological insult on the body as a whole - for instance, less fluid or temperature loss. As a result patients tend to recover much faster from their operation and return to normal activities sooner.
- How long will my recovery after surgery take?
Following both Nissen’s fundoplication and LINX® surgery most patients are able to leave hospital on the same day if they wish to. On average most patients have returned to normal activities within a few days. Patients tend to recover faster following LINX® as it is less invasive.
- What are the indications for surgery in patients with reflux?
Gastro-oesophageal reflux disease is very common and 20-30% of adults experience regular symptoms. Most can manage their symptoms with changes to the lifestyle or regular antacid medications. However, this is not always sufficient and some patients will consider surgery. This is particularly the case as new options because available, including the LINX® procedure.
The indications might change over time as more is learnt from scientific research but currently the following are accepted reasons to consider surgery:
- Patients with heartburn and regurgitation symptoms that are incompletely controlled by antacid medications (including proton pump inhibitors)
- Patients with respiratory or laryngo-pharyngeal symptoms such as cough, sore throat, husky voice, or post-nasal drip
- Patients whose reflux is controlled but seek a definitive, one-time treatment perhaps because they do not want to take medication long term
- Patients who experience side effects from medication
- Large hiatus hernias causing discomfort, pain or vomiting suggesting intermittent obstruction of the stomach
- The presence of oesophageal complications from reflux (including Barrett’s oesophagus and persistent oesophagitis which is not controlled by medication)
- The presence of non-oesophageal complications from reflux such as osteoporosis in postmenopausal women and respiratory conditions such as bronchiectasis
- Why LINX® or Nissen’s?
The choice of which operation is the most appropriate for a patient is a complex one. The decision should be individually tailored to each patient and should be made between them and the surgeon performing the operation as well as with the multi-disciplinary team managing the case. The factors influencing the decision include the type of symptoms, size of hiatus hernia (if present), the findings from an endoscopy, and the results of other tests including special physiology tests and, of course, patient preference.
- What is different about a partial fundoplication?
Over the years several different types of operations have been devised to reduce reflux. They almost always involve sewing part of the stomach called the fundus around the bottom of the oesophagus to create a high pressure zone; hence “fundoplication”. Of these different operations the most commonly performed worldwide is called the Nissen’s Fundoplication. This operation involves entirely encircling the oesophagus with the fundus. It is therefore known as a “total” fundoplication. The other procedures are different in that as they only partially encircle the oesophagus. For instance, in the procedure known as the ‘Toupet’ the fundus is brought 270 degrees behind the oesophagus and in the procedure known as the ‘Dor’ the fundus is brought 180 degrees in front of the oesophagus.
Many studies have been performed to compare the outcomes of these operations. There appears to be little evidence that there is any benefit in attempting to tailor one procedure or another to individual patients. On balance, the Nissen seems to offer the best control of reflux symptoms but at the price of slightly increased risk of side effects.
The most important factor in the outcome of any of anti-reflux operation is that it is performed to a high technical standard in a reproducible and systematic fashion. One of the advantages of the LINX procedure, in addition to its inherent physiological benefits, may be that there is less scope to deviate from the standard described operation.
- Why do RefluxUK use a Multi-Disciplinary team?
It is now accepted standard practice that the treatment of complex medical conditions is best managed by a team of specialists with their own expertise rather than individual surgeons or doctors. As more has been learnt about gastro-oesophageal disease it has become clear that it can indeed be a very complex problem. It can cause a wide variety of symptoms which often go unrecognised as being reflux-related. Its assessment and treatment, including surgery, requires not only experienced experts but also access to the most modern diagnostic tests. Therefore, the comprehensive assessment and treatment of patients with reflux is best managed by a team of dedicated specialists.
- Do PPIs protect against oesophageal cancer?
In short, it is not known for sure.
What is known is that in the western world the incidence of oesophageal cancer has increased significantly over the last 30 years. In some countries the increase has been by as much as 600%. This increase has coincided with the introduction and widespread use of PPIs. We also know that most oesophageal cancers in the west are associated with Barrett’s oesophagus, which is considered a pre-malignant condition. Studies have shown that while PPIs are extremely effective at eliminating, or at least reducing, heartburn symptoms, the severity and duration of these symptoms are associated with increasing risk of developing cancer. Similarly, research also suggests that PPIs do not prevent the development of Barretts’s and, in fact, some experts think that PPIs might actually promote the development of Barrett’s and oesophageal cancer. This is because reduction in acid allows other substances in stomach juice, including bile, to damage the oesophagus.
There is clearly a need for more research but it should not be assumed that taking PPIs for reflux will protect against developing oesophageal cancer. There is also a clear need to clarify the impact of anti-reflux surgery on the development Barrett’s and cancer.
- Will anti-reflux surgery prevent cancer?
Further study is needed to clarify the impact of anti-reflux surgery on the development Barrett’s and cancer.
We know that reflux is associated with the development of Barrett’s oesophagus and in turn this is the biggest factor in the development of oesophageal cancer. Common sense suggests that eliminating or reducing reflux would reduce the likelihood of developing the disease.
Population studies suggest that while cancer can still develop following anti-reflux surgery, its development seems to stabilise over time, whereas patients taking PPIs are exposed to an increasing likelihood of developing the disease. Similarly, following surgery those patients experiencing recurrent reflux seem to be most at risk. This may be because of the known failure over time of the standard fundoplication operations; all of the research to date that has looked at the issue of cancer was published before the introduction of LINX. Finally, there is evidence that regression of Barrett's, loss of dysplasia and normalisation or stabilisation of various biomarkers associated with Barrett's and carcinoma all can occur after anti-reflux surgery. The available research therefore does suggest that anti-reflux surgery impacts upon the natural history of reflux disease.
Nonetheless, the evidence remains relatively weak and more research is needed in particular to evaluate if successful fundoplication or alternative potentially more durable procedures, like LINX, can reduce the likelihood of developing cancer to the level found in the normal population. But, as things stand today prevention of cancer should not be considered as an evidence-based reason to undergo anti-reflux surgery.
- What will happen after your referral?
Firstly, we will arrange an appointment to be seen by one of our specialists. We will ask you to complete and return in advance a questionnaire which has been specially designed to allow us to make an initial assessment of your problem.
In the clinic you will be asked about your symptoms, your previous medical history and any other information relevant to the condition. You may undergo a physical examination and you will then have a discussion regarding options for diagnostic tests and treatment options. Depending on your choice and necessary tests you will be seen to discuss the results and a decision made with you regarding treatment.
- Is reflux the same as heartburn?
The terms reflux, acid reflux, heartburn, indigestion and Gastro-oesophageal reflux disease (GORD, or GERD) are often used interchangeably. While reflux is a very common medical condition that can cause heartburn symptoms, these symptoms can also be caused by other conditions. These include serious diseases including cancer and ulcers, medications including NSAIDs, helicobacter pylori, gallstones and non-ulcer dyspepsia. Additionally, reflux can cause many other symptoms which may be intestinal, respiratory, laryngo-pharyngeal (LPR) or oral and these symptoms vary from patient to patient. The right diagnosis will be made from considering the history, examination and test results.
- Will reflux go in time if it is left untreated?
Gastro-oesophageal reflux disease (GORD) occurs when stomach contents flow up into the oesophagus. It is caused by failure of the valve at the bottom of the oesophagus which normally stops reflux occurring. It is not caused by too much acid production. It often produces frequent or severe symptoms which can affect quality of life and if left untreated, can result in serious damage to the oesophagus, pharynx, or respiratory tract. It is a chronic condition and will not resolve on its own.
- Does reflux feel like a lump in the throat?
Patients with reflux disease can experience many symptoms, some of which may not be easily recognised as reflux-related. These include throat or so-called LPR (Laryngo-Pharyngeal Reflux) symptoms as well as chest symptoms. LPR may cause a sensation of a lump or food sticking in the throat. You may feel that you always have to clear your throat or a persistent sore throat. It can also cause hoarseness or a weak voice. Chest symptoms can include asthma and chronic cough as well as more serious problems caused by gastric juice entering the lungs and damaging them over a longer period of time.
- Does reflux feel like a heart attack?
A common complaint of GORD is chest pain. This can take the form of discomfort and pain behind the sternum (breast bone) or occasionally can be severe enough to mimic heart related pain called angina. Some patients will experience such severe pain from reflux that they attend A&E. If there is any doubt then you should consult your doctor to exclude heart related problems.