Surgical treatments

The majority of patients with reflux will not require surgery. However there are many people who will continue to experience symptoms despite all other treatment including medication. In fact, this group of patients is often under-estimated and unrecognised. Studies have shown that despite high dose Proton Pump Inhibitor (PPI) treatment approximately 30% of patients continue to suffer symptoms.  It has been estimated that this group amounts to about 2% of the adult population. 

In other words, in the UK alone there are approximately one million people who regularly experience significant reflux symptoms  which compromises their quality of life and cannot be controlled through non-surgical treatment.

Is surgery successful?

Many people believe that anti-reflux surgery is a last resort and that it is often unsuccessful. This is simply untrue. Studies have shown that fundoplication procedures reduce reflux symptoms and improve quality of life better than medications including PPIs. More recently further evidence has shown that the LINX®device produces excellent symptom control that is maintained years after surgery. In particular it appears to be better at maintaining its effect over time following surgery and side effects that some patients experience after fundoplication seem to be much less of a problem. It is these which put some patients off surgery but remember only 10-20% of patients will experience them and for most these will have a far smaller impact on their quality of life compared to their reflux. Important considerations for outcome include proper diagnostic tests and interpretation, patient selection and the quality of surgery by a high volume surgeon including an assessment of his/her results.

Failure of other treatments

Despite lifestyle changes and medications, persistent symptoms remain.

Desire to avoid long term medication

Further study is needed into the impact of long-term use of anti-reflux medications, but, increasingly, concerns about the possible side effects are motivating patients to seek alternative options.

Complications from GORD

Possible complications arising from GORD may include oesophageal narrowing (strictures) and inflammation (oesophagitis) as well as respiratory, oral problems and Ear, Nose and Throat (ENT).

Which surgical option is right for me?

At your consultation you will have the opportunity to discuss all the options and access all the information needed to help you make the right decision for you. There are two types of surgery which the team may recommend.

Surgical options

Laparoscopic fundoplication

The most common type of fundoplication operation performed is known as the Nissen fundoplication. named after Dr Rudolph Nissen, the first surgeon who performed it in 1955. The Nissen fundoplication was initially performed as an open procedure. It was first performed as a laparoscopic or “keyhole” surgery in 1991.

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  • How is it performed?

    Four or five tiny holes are made. The surgeon operates using an image on a screen from a telescope. Part of the top of the stomach, the fundus, is wrapped around the bottom of the oesophagus and sewn to itself to create a high pressure zone that mimics the function of the normal valve. If there is a hiatus hernia present this is repaired at the same time.

    The Nissen fundoplication is a ‘full’ fundoplication in that the fundus is wrapped 360 degrees around the bottom of the oesophagus. Partial fundoplication procedures are also sometimes performed. In approximately 90% of people the operation is successful. (banner text)

  • Does it work?

    In short, for the overwhelming majority, yes it does.

    There have been many scientific studies performed over the last 25 years to look at how well fundoplication surgery works. There were three large prospective randomised trials published in 2006, 2007 and 2008 that all showed very similar results: surgery is better at controlling reflux symptoms than medication in the majority of people. Approximately 90-95% of patients will find that their reflux symptoms are better controlled than they were before surgery.

  • What are the problems?

    A minority of patients will experience side effects. These side effects are unpredictable but if the surgery was performed well, these tend to be to do with the new fundoplication causing hold up of swallowing or preventing belching and vomiting. Side effects can include:

    Difficulty swallowing solid food This usually resolves over time but occasionally can require an oesophageal stretch.

    Gas-bloat If a patient is unable to belch then swallowed air and gas can cause bloating, abdominal discomfort and excessive flatus.

    Inability to vomit

    Diarrhoea

  • Does the effect last?

    Studies have shown that over time the effect of the operation diminishes and that some patients’ symptoms return. Five years after the operation 20-30% of patients will have experienced a return of some of their symptoms and many of these will be taking PPIs once more. However, overall quality of life still appears to be better in patients who have had surgery than in those who have not.

  • What about recovery following surgery?

    Some patients can return home on the day of surgery and virtually everyone else the following day. Most people find they are able to resume the majority of their normal activities 2-3 weeks after surgery.

  • What are the possible complications?

    All surgery carries the risk of complications. However, these are rare, and serious complications occur in less than 1% of patients. Possible complications include: - Perforation of the oesophagus or stomach. - Hernia - Bleeding - Visceral injury - As with all keyhole surgery there is a possibility that the procedure may need to be converted to an open one

LINX® Reflux Surgery

The LINX® System is designed to reproduce the physiological valve at the bottom of the oesophagus. It is a small, flexible band of interlinked titanium beads with magnetic cores that helps create a barrier to the reflux of acid and bile. The LINX® System is placed around the oesophagus just above the stomach during a laparoscopic or “keyhole” surgery, which is generally completed in less than an hour.

When the LINX® System is in place, swallowing forces temporarily break the magnetic bond to allow food and drink to pass normally through the Lower Oesophageal Sphincter (LOS). The magnets then close the LOS immediately after swallowing to restore the body’s natural barrier to the reflux of acid and bile.

This procedure is relatively new. However, there have now been well over 4000 operations worldwide and the results are very encouraging. It has been shown to work very effectively to stop reflux symptoms, it is safe and has fewer associated side effects than the fundoplication operations.

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  • Does it work?

    There have now been several research studies published which have looked at the safety and efficacy of LINX® up to five years following surgery. These have consistently shown. - Significant and maintained reductions in reflux symptoms - Normalisation of acid exposure in the oesophagus - Significant improvements in quality of life - Most patients remain off medications - Significantly fewer side effects than those caused by Nissen’s fundolplication operations - Low complication rate

  • What are the side effects?

    Side effects following the LINX® System procedure are minimal and generally resolve over time.

    Mild dysphagia (discomfort when swallowing) occurs in less than half of patients after the procedure and is generally resolved within 90 days without treatment.

    Unlike other surgical treatments, the LINX® System does not have the side effect of restricting belching and vomiting.

  • Does the effect last?

    Studies have shown that over time the effect of the operation seems to be maintained much better than after Nissen’s fundoplication.

  • What about recovery following surgery?

    Surgery to insert the LINX® system is less invasive than fundoplication. The majority of patients return home on the same day as surgery.

    The LINX® System starts to work as soon as it is in place. Patients should be able to resume a normal diet within a few hours of surgery and can usually return to normal activities in less than a week.

  • What are the possible complications?

    While all surgery carries the risk of complications the LINX® System procedure does not involve any changes to the anatomy of the stomach and is fully and easily reversible. The first LINX® Reflux Management System procedure took place in 2007. In the time that the procedure has been performed there have been no reports of injury or damage to the oesophagus or surrounding tissue and there have been no reports of the device migrating from the site of implantation.