GASTROESOPHAGEAL REFLUX SURGERY AFTERCARE
Category: General Surgery
Abstract : It has been estimated that heartburn occurs in more than 60% of adults. About 20% of the population take antacids or over-the-counter H2 blockers at least once per week to relieve heartburn. In addition, about 80% of pregnant women have significant heartburn. Hiatal hernia is believed to develop in more than half of all persons over the age of 50 years. Hiatal hernia is present in about 70% of pat
It has been estimated that heartburn occurs in more than 60% of adults. About 20% of the population take antacids or over-the-counter H2 blockers at least once per week to relieve heartburn. In addition, about 80% of pregnant women have significant heartburn. Hiatal hernia is believed to develop in more than half of all persons over the age of 50 years.
Hiatal hernia is present in about 70% of patients with gastroesophageal reflux disease, but the majority of patients with hiatal hernia do not have symptoms of gastroesophageal reflux disease. In addition, about 7-10% of the population has daily episodes of heartburn. It is these individuals who are likely to be classified as having gastroesophageal reflux disease.
Description
The most common type of gastroesophageal reflux surgery to correct gastroesophageal reflux disease is Nissen fundoplication. Nissen fundoplication is a specific technique that is used to help prevent the reflux of stomach contents back into the esophagus. When Nissen fundoplication is successful, symptoms and further damage to tissue in the esophagus are significantly reduced. Prior to Nissen fundoplication, open surgery was required to gain access to the lower esophageal region. This approach required a large external incision in the abdomen of the patient.
Fundoplication involves wrapping the upper region of the stomach around the lower esophageal sphincter to increase pressure on the LES. This procedure can be understood by visualizing a bun being wrapped around a hot dog. The wrapped portion is then sewn into place so that the lower part of the esophagus passes through a small hole in the stomach muscle. When the surgeon performs the fundoplication wrap, a large rubber dilator is usually placed inside the esophagus to reduce the likelihood of an overly tight wrap. The goal of this approach is to strengthen the sphincter; to repair a hiatal hernia, if present; and to prevent or significantly reduce acid reflux.
Fundoplication was greatly improved with the development of the laparoscope. The laparoscope is a long thin flexible instrument with a camera and tiny surgical tools on the end. Laparoscopic fundoplication (sometimes called “telescopic” or “keyhole” surgery) is performed under general anesthesia and usually includes the following steps:
• Several small incisions are created in the abdomen.
• The laparoscope is passed into the abdomen through one of the incisions. The other incisions are used to admit instruments to manipulate structures within the abdomen.
• The abdomen is inflated with carbon dioxide. The contents of the abdomen can now be viewed on a video monitor that receives its picture from the laparoscopic camera.
• The stomach is freed from its attachment to the spleen.
• An esophageal dilator is passed through the mouth into the esophagus. This dilator keeps the stomach from being wrapped too tightly around the esophagus.
• The portion of the esophagus in the abdomen is freed of its attachments.
• The top portion of the stomach (the fundus) is passed behind the esophagus, wrapped around it 360°, and sutured in place.
• If a hiatal hernia is present, the hiatus (the hole in the diaphragm through which the esophagus passes) is made smaller with one to three sutures so that it fits around the esophagus snugly. The sutures keep the fundoplication from protruding into the chest cavity.
• The laparoscope and instruments are removed and the incisions are closed.
Diagnosis/Preparation
The diagnosis of gastroesophageal reflux disease can be straightforward in cases where the patient has the classic symptoms of regurgitation, heartburn, and/or swallowing difficulties. Gastroesophageal reflux disease can be more difficult to diagnose when these classic symptoms are not present. Some of the less common symptoms associated with reflux disease include asthma, nausea, cough, hoarseness, and chest pain. Such symptoms as severe chest pain and weight loss may be an indication of disease more serious than gastroesophageal reflux disease.
The most accurate test for diagnosing gastroesophageal reflux disease is ambulatory pH monitoring. This is a test of the pH (a measurement of acids and bases) above the lower esophageal sphincter over a 24- hour period. Endoscopies can be used to diagnose such complications of gastroesophageal reflux disease, as esophagitis, Barrett’s esophagus, and esophageal cancer, but only about 50% of patients with gastroesophageal reflux disease have changes that are evident using this diagnostic tool. Some physicians prescribe omeprazole, a proton- pump inhibiting drug, to persons suspected of having gastroesophageal reflux disease to see if the person improves over a period of several weeks.
Aftercare
Patients should be able to participate in light physical activity at home in the days following discharge from the hospital. In the days and weeks following surgery, anti-reflux medication should not be necessary. Pain following this surgery is usually mild, but some patients may need pain medication. Some patients are instructed to limit food intake to a liquid diet in the days following surgery. Over a period of days, they are advised to gradually add solid foods to their diet. Patients should ask the surgeon about the post-operative diet. Such normal activities, as lifting, work, driving, showering, and sexual intercourse can usually be resumed within a short period of time. If pain is more than mild and pain medication is not effective, then the surgeon should be consulted in a follow- up appointment.
The patient should call the doctor if any of the following symptoms develop:
• drainage from the incision region
• swallowing difficulties
• persistent cough
• shortness of breath
• chills
• persistent fever
• bleeding
• significant abdominal pain or swelling
• persistent nausea or vomiting
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