Especially in recent years we have come to hear of reflux frequently. This condition is most commonly triggered by nutritional causes and more so, by stress. Reflux represents a potential damage to the oesophagus, loss of voice and even cancer. However, as medicine advances, a permanent treatment is possible with surgery. Surgery, using an advanced laparoscopic method, is not only straightforward but it also allows the person to eat foods that would have previously triggered reflux.
Stressing the importance of laparoscopic reflux surgery being conducted by experienced specialists, Anadolu Medical Centre General Surgery Specialist Prof. Dr. Metin Çakmakçı answers some frequently asked questions about this condition.
What kind of an illness is reflux?
Under normal circumstances, highly acidic stomach fluids in healthy people will not come in contact with the oesophagus unless the person vomits. The mucosal layer lining the inside of the oesophagus is sensitive to acidity and is adversely affected by acidic environments. This illness, known as stomach reflux, occurs as a result of gastric fluids seeping into the oesophagus. High volumes of acidic fluids, normally only present in the stomach, for long durations within the oesophagus will cause damage in the mucosal layer. The individual feels this damage in the form of a burning sensation.
How does reflux develop?
Reflux is most commonly due to the stomach becoming herniated in the thoracic cavity, which under normal conditions should remain completely in the abdominal cavity. The oesophagus located in the thoracic cavity enters the abdomen by means of a special opening known as the hiatus where it meets the stomach. In other words, in healthy people the oesophagus is in the thoracic cavity whereas the stomach is in the abdominal cavity. Surrounding the area where the two structures meet, the hiatus is where the oesophagus passes through and acts as a kind of clamp mechanism between the oesophagus and stomach. This clamp mechanism is what actually prevents reflux. An increase in normal hiatus width and deterioration of anatomic relations in the region will cause herniation of the stomach inside the thoracic cavity resulting in stomach hernia accompanied by reflux. Another mechanism preventing reflux is the physiological valve system located at the point where the oesophagus meets the stomach. Damage to this valve system will also constitute a cause for reflux, making it easier for gastric fluids to contact the oesophagus.
What damage does acid cause to the oesophagus?
The structure of the mucosal layer lining the oesophagus is sensitive to both bile and acidic substances. Acid contact caused by reflux results in damage to this layer causing the process termed “esophagitis” which can be simply explained as the development of an ulcer. The severity of the ulcer worsens as the frequency and duration of contact increases. Chronic oesophageal damage can result in a diseases termed “Barrett”, which has the potential of transforming into cancer.
The further reflux gets up the oesophagus the more the extent of damage to the mucosal lining. In some patients reflux has found to have reached considerable distance, even up to vocal cords. There are some rare cases where gastric fluid has accessed the lungs, causing considerable damage to lung tissue. In such circumstances damage is not only limited to the oesophagus, but also causes deterioration of voice, recurrent lung infections and asthma like conditions.
How is reflux treated?
The most common solutions in treating reflux are medication and surgical. Results obtained from endoscopic methods, which have become more popular in recent years, have not achieved the level of success seen with medical and surgical treatment.
Surgery is the primary option for reflux patients that also have a stomach hernia. Drug treatment should be the first option for reflux patients without stomach hernias. Surgery is the only option for patients unable to overcome the condition with drug treatment or who present recurrence of the condition after completing treatment.
Surgery must also be considered for young patients living an active lifestyle who are unwilling to use drugs for long durations. Since those drugs should be used for life, another group suitable for surgical treatment, are people who develop side effects to medication treatment.
Is surgery a viable treatment option?
Surgical treatment is the most effective option in treating stomach reflux. In other words, long-term results are far superior to drug treatment and endoscopic method. This kind of surgery has been possible for some time with minimal invasive (laparoscopic) methods. This method not only significantly reduces the discomfort experienced by the patient, it also reduces hospitalisation periods and shortens recovery time. During surgery the laparoscopically herniated stomach is drawn back into the abdominal cavity. Simultaneously, the expanded and anatomically damaged hiatus is repaired. Using various methods the stomach is wrapped around the region where the oesophagus and stomach unite. Hence, the damaged anatomy is repaired and a new structure is created to replace the malfunctioning protective mechanisms. This puts an end to the patient experiencing reflux.
Can all reflux patients undergo surgery?
Theoretically of course all patients can choose the surgical treatment method however there is a more important issue; that is making the right to decision on which patient to operate on. The patient’s story and physical examination is decisive in this process. Determining the severity of reflux with endoscopy as well as clarifying if the patient has accompanying stomach hernia is also fundamental. Executing a 24-hour acid level measurement for some patients can help in choosing the right treatment for the individual. In some cases the method of treatment is determined by a joint decision made by doctor and patient.
What could the outcome be in operating patients with progressed level of reflux?
Not treating patients with advanced level reflux can cause irreversible damage to the inner lining of the oesophagus. A number of problems may arise in untreated patients including damage to vocal cords, lung infections and asthma-like illnesses. On the other hand, deterioration at the bottom end of the oesophagus can result in a deformation termed “Barrett Oesophagus” which, though very rare, can result in cancer.
Is reflux surgery a complicated operation?
This is a very technical surgery and we believe that it could not and should not be executed by any surgeon. The surgeon must not only be experienced in laparoscopy but also be extremely familiar with the anatomic structures of this area. However, surgeries executed by experienced specialists mean that things are very straightforward for the patient. Under normal circumstances the patient will be discharged from hospital in maximum two days.
How long after the surgery will it take for patients to resume their regular diet?
The patient can start consuming a soft food and fluid based diet the day following the surgery. Some patients do experience difficulty in swallowing after surgery however this feeling wears off quickly. Returning to the patient’s normal diet will usually take 5 to 7 days. After the operation, the patient can consume any food, even those that would have previously triggered reflux.
