Chronic acid reflux and hiatal hernia are conditions where stomach acid escapes into the oesophagus, leading to discomfort, but can often be resolved through minimally invasive surgical techniques.
This is a condition where stomach acid travels backwards from the stomach into your gullet (oesophagus). It is a normal occurrence in everyone, but we all have mechanisms to reduce the effect of it. If these are faulty, it can cause reflux disease, and there are two main types.
The muscle valve between the stomach and gullet (oesophagus), which normally allows food to pass into the stomach, can become weak or relax inappropriately and let too much acid up into the gullet. The normal gullet would squeeze this back into the stomach, but this can become impaired and the acid has its symptomatic effect.
This is a condition where part of the stomach, not just the position of the gastro-oesophageal junction (GO-junction), migrates through the opening in the diaphragm (hiatus) into the chest. There are several types:
Many of the risk factors for primary GORD also lead to a hiatus hernia over longer periods of time. Older age is a significant factor, as muscles weaken, and most large hiatus hernias occur in patients over 60. A few hiatal and diaphragm hernias are congenital and occur after birth, but Mr Hopkins does not treat childhood conditions.
Other problems that may be related must be investigated urgently and separately:
Mr Hopkins will review your symptoms in detail in clinic and the diagnosis is normally made on the basis of your symptoms. If there are any doubts about your symptoms, they are persistent or unusual, where medications do not work, and always where surgery is being considered, you will be referred for further tests - these include:
This is the procedure where a telescope is passed via the mouth to examine the gullet (oesophagus), stomach, and duodenum.
It is recommended to fully assess your hiatal anatomy and to fully investigate GORD-related symptoms such as:
You must not eat or drink for at least 4 hours before the procedure, although you may drink a small cup of water up to 2 hours before the test. You should take your regular prescription medications, unless you are otherwise advised by Mr Hopkins to stop any specifically for the test.
The test is normally carried out while you are conscious, using throat spray (local anaesthetic to numb the back of your throat—like at the dentist) or sometimes with a sedative injection to make you slightly drowsy. Most patients tolerate it with throat spray alone, allowing a quicker recovery and return to normal after the test. If you do have a sedative, you cannot drive, work or operate machinery for 24 hours and you would need someone to take you home and stay with you overnight. Sedation is not a full general anaesthtic, which is rarely required unless you are having a more complicated therapeutic endoscopy.
After the throat spray, you will be positioned comfortably on your left side and a small mouthguard placed to protect your teeth. Any sedation requested will be given, and once you are ready, the small telescope will be passed through your mouth and through your throat and into the gullet. It does not interfere with breathing, and any saliva that collects in your mouth is removed by the nurse using a sucker.
During the procedure, small amounts of gas are used to inflate the areas, and sometimes a tissue sample (biopsy) may be taken for laboratory examination.
The test normally takes between 3–5 minutes. After throat spray, you cannot eat or drink for one hour, as the local anaesthetic temporarily affects your swallowing. If you have sedation, a friend or relative should collect you and ideally stay with you overnight. Mr Hopkins will discuss the results with you immediately after the test, will provide a written report for you, and a copy will also be sent to your own GP.
Everyone experiences a short-term sore throat, but complications are very uncommon following diagnostic endoscopy (less than 1 in 1000). Rarely, these include bleeding, perforation or a reaction to the drugs given.
A thin tube is passed into your gullet via the nose, and a series of pressure measurements are made while you swallow small sips of a drink. This is very safe, and your breathing is not affected by the tube, although patients can feel some discomfort in the throat during the 10-minute test. This test measures how well the muscles in your gullet are working, and Mr Hopkins will interpret the results from the physiology team in a follow-up clinic with you.
Again, a thin tube is placed via the nose into your gullet, where it can stay for 24–72 hours, while you eat, drink, and carry on normally. Your breathing will not be affected during the procedure, and it may be a little uncomfortable rather than painful on insertion, but this will settle quickly. The tube will be taped to the outside of your nose, passed around your ear and attached to a small recording box which is worn on a shoulder strap or belt around your waist, which will also record your symptoms when you press a button. You will be able to eat, sleep, and carry on normal daily routines. The tube is removed painlessly once the test is completed and the recording box analysed. Mr Hopkins will interpret the results from the physiology team in a follow-up clinic with you. The test measures levels of acid exposure time within the oesophagus, and sees if it correlates to your symptoms.
As an alternative to manometry, or if this did not give all the correct information, you can have a swallowing X-ray instead. Here, you drink a liquid containing an X-ray dye that enables live swallowing pictures to be taken. Again, Mr Hopkins will interpret the results from the swallowing X-ray in a follow-up clinic with you.
Medical and lifestyle treatments can be very effective for some of the symptoms. Surgery is an option when:
The aim of surgery is to restore or strengthen the normal anatomy at the hiatus, correcting any hiatal hernia and to reinforce the (faulty) valve at the junction between the gullet and stomach. This second part is the ‘fundoplication’ or ‘wrap’, stitching the top section of the stomach (fundus) over the front of the lower end of the gullet, to the hiatus muscles. The procedure normally takes less than 1.5 to 2 hours and takes effect immediately.
Once we agree to go ahead with surgery, you will need to attend a pre-op assessment clinic, at which a number of routine checks and sometimes blood tests will be performed. You should do everything you can to maintain your health and fitness before an operation—we call this pre-habilitation. Smoking is strongly discouraged as it not only affects your breathing and the risk of anaesthetic problems, but can increase wound healing and infection problems. Improving your heart and lung fitness, with regular exercise, taking all your usual medications, and avoiding the risks of infections immediately before your operation is also advised. Regular vitamin and mineral supplements, especially if your diet can be variable, help make sure your body is ready for healing after surgery. Some patients may be asked to complete a special liver-reducing diet in the two weeks before surgery.
Some patients can be discharged on the same day as the operation (daycase), many stay overnight. You would be ready to be discharged if your pain is controlled with tablet painkillers, you can walk and you have eaten and passed urine. Anti-reflux medication can be reduced or stopped following surgery—depending on how much you take before surgery and Mr Hopkins will give you clear individual instructions.
All stitches are dissolvable. The glue or waterproof dressings used are suitable for the shower after 2 days, and can be removed or cleared after 7 days, but you should not soak in a bath for 7 days.
You will be advised to drink fluids only for the first 24 hours after surgery, before commencing a special diet for the following few weeks. Mr Hopkins will give you a diet sheet with clear advice on the stages of progression after surgery. Solid foods will be gradually reintroduced as surgery settles down.
Standard recovery takes 1–2 weeks after keyhole surgery, for driving and office work. Recovery after keyhole surgery for return to full activities including sport, exercise, gardening or DIY, and heavy lifting is up to 4 weeks. You should discuss your work or sporting activities with Mr Hopkins in clinic.
Pain: Paracetamol and ibuprofen, with occasional codeine or tramadol, should give adequate pain relief at home. I advise taking some regularly (i.e. 4–6 hourly) for the first 48 hours following surgery, then continued as required.
There may be some bruising at the operation site. This is entirely normal and will gradually go down. (If bleeding or swelling increases rapidly, within hours of surgery, you should seek medical attention.)
Mobility: This is very important. Try to remain normally active. If you feel tired, you should sit down and put your feet up for short periods, but you should not go to bed during the day. This is to improve circulation in your legs, and reduce the risk of blood clots occurring.
If you experience any of these, it is important to seek medical attention as soon as possible, via the emergency department if needed, and it is important to tell everyone that you have had keyhole surgery.
Anti-reflux and hiatal surgery is a safely performed keyhole operation, but, like any type of surgery, there are risks:
Surgery is more likely to be considered in those patients who can have more severe symptoms or where there is a risk of complications relating to the larger hiatus hernia. Surgery is still performed with advanced keyhole (laparoscopic) surgery by five tiny incisions, but the part of the operation to restore the normal anatomy at the diaphragm (hiatus) and reduce the stomach back into the abdomen, can take more time and be more difficult to perform. In some cases, the muscles of the hiatus are reinforced with a special mesh if Mr Hopkins thinks they are too weak during the operation. Again, the top section of the stomach (fundus) is usually wrapped around the lower end of the gullet to minimise reflux and fix the stomach within the abdomen, but sometimes this is felt not to be an advantage to the hiatal repair. The procedure normally takes 2 hours, but occasionally up to 4.
After surgery, the post-operative course is usually the same as for a normal anti-reflux operation, but Mr Hopkins will give you individual advice about your surgery, the recovery, and the post-operative diet. Occasionally, a few days’ stay is advised by the anaesthetist, or for complex hiatal surgery you may be required to stay in hospital until Mr Hopkins is happy your recovery is progressing. The risks of surgery are the same as above, but there is a higher rate of recurrence of the hiatal hernia or symptoms such as heartburn or regurgitation in the future.
