Primary Anti-Reflux Surgery (Fundoplication)

Definition- Elective, life style, anti-reflux surgery with or without a synchronous hiatus hernia repair (type I/type II/type III hiatus hernia <1/3 of stomach in chest or ≤ 5 cm migration of GOJ from hiatus), that are associated with small and medium size hiatal defects.

Primary indications for surgery

- patients in whom the primary symptom is volume reflux/regurgitation

- a confirmed diagnosis of acid reflux and adequate symptom control with medical therapy but do not wish to continue with long term therapy

- patient with breakthrough symptoms despite maximum medical therapy

- a confirmed diagnosis of acid reflux and symptoms that respond to medical therapy but who are intolerant of medication side effects

- atypical symptoms such as aspiration, cough or hoarse voice and confirmed evidence of GORD (these patients as a group have less successful outcomes than patients with typical symptoms)

 

As minimum pass complex/equivocal patients through a hiatal MDT* prior to surgery, best practice to discuss all patients prior to surgery

Enter data into a registry to audit outcomes

BMI >30 is not a contraindication to surgery, however the initial treatment should be weight loss advice, as anti-reflux surgery in this group is safe, but possibly more difficult (longer operating times/length of stay) and less effective in the long term

Those patients eligible for bariatric surgery (BMI >35 + comorbidity or BMI >40) should have consideration for Roux en-Y Gastric-bypass to treat reflux

All patient who are eligible for LINX should be made aware this option of treatment exists and referral to a unit that provides LINX if required if patient wishes. Also patients should be made aware of endoluminal therapies also

Laparoscopic conversion to open < 2%

Less than 24 hr stay for Laparoscopic Fundoplication > 90%

Re-Operation rate within 30 days < 5 %

Readmission rates after fundoplication within 30 days < 5%

>50% of patients should not require regular (once daily) anti-acid medication at 5 years after surgery (excludes initial surgery for atypical symptoms)

>75% improvement of GERD-QoL at 5 years after surgery

Morbidity <5%

Mortality < 0.1%

Minimum pre-operative investigation set to prove objectivity of reflux pathology and exclude functional oesophageal pathology prior to anti-reflux surgery

Primary Symptom                           Secondary Symptom       Investigation

Volume reflux/regurgitation           *Heartburn                       OGD and ambulatory pH and manometry                       bbbbbbbbbbbbbbbbbbbbbbbbb                                         analysis/contrast swallow if unable to aaaaaaaaaaaaaaaaaaaaaaaa  aa a                                           tolerate manometry

Heartburn without dysphagia         +/-Volume reflux             OGD and ambulatory pH and manometry aaaaaaaaaaaaaaaaaaaa              a                                            analysis/contrast swallow if unable to aaaaaaaaaaaaaaaaaaaaaaaa  aa a                                           tolerate manometry

Heartburn with dysphagia               +/-Volume reflux             OGD and ambulatory pH analysis and high vvvvvvvvvvvvvvvvvvvvvvvvvvvvv                                                 resolution manometry analysis

Dysphagia                                          Heartburn                       OGD and ambulatory pH analysis and high                              dddddddddddddddddddddddddddddddddddddd   resolution manometry

**Atypical symptoms                        +/- Heartburn                  OGD and pH analysis and manometry and                          ssssssssssssssssssssssssssssssssssssssssssssssssss              ENT or respiratory opinion

*Heartburn- substernal burning sensation that may extend toward neck or base of throat                                           ** Atypical symptoms- chronic cough/asthma exacerbation/sore throat/ tooth decay/hoarse voice

 

Other investigations to consider in patients with additional upper gastrointestinal symptoms such as bloating, nausea, vomiting, pain and early satiety: impedance studies/gastric emptying study

Hiatal MDT Desirable Representation: ≥2 Surgeons/ Gastroenterologist/Radiologist/GI Physiologist and Specialist Nurse

Hybrid Anti-Reflux/Hiatus Hernia Surgery

Definition- Elective, life style primary intention anti-reflux surgery* +/- associated secondary symptoms ** in the presence of a synchronous large hiatus hernia (>1/3 of stomach in chest or GOJ >5 cm from hiatus, includes intra-thoracic stomach). These hernias are associated with medium and large hiatal defects. This classification of anti-reflux surgery is separate to primary anti-reflux procedures in the presence of smaller type I, II and III hiatus hernias, and does not fall into the same classification as primary hiatus hernia surgery.

* Primary Symptom

Reflux

- patients in whom the primary symptom is volume reflux/regurgitation

- a confirmed diagnosis of acid reflux and adequate symptom control with medical therapy but do not wish to continue with long term therapy

- patient with breakthrough symptoms despite maximum medical therapy

- a confirmed diagnosis of acid reflux and symptoms that respond to medical therapy but who are intolerant of medication side effects

- atypical symptoms such as aspiration, cough or hoarse voice and confirmed evidence of GORD (these patients as a group have less successful outcomes than patients with typical symptoms)

 

** Secondary Symptom

Post-prandial chest pain/Shortness of breath/Nausea/Dysphagia/

weight loss/Iron deficiency anaemia

 

Minimum pre-operative investigation set to prove objectivity of reflux pathology and exclude functional oesophageal pathology prior to anti-reflux surgery

Primary Symptom                           Secondary Symptom       Investigation

Volume reflux/regurgitation           *Heartburn                       OGD and ambulatory pH and manometry                       bbbbbbbbbbbbbbbbbbbbbbbbb                                         analysis/contrast swallow if unable to aaaaaaaaaaaaaaaaaaaaaaaa  aa a                                           tolerate manometry

Heartburn without dysphagia         +/-Volume reflux             OGD and ambulatory pH and manometry aaaaaaaaaaaaaaaaaaaa              a                                            analysis/contrast swallow if unable to aaaaaaaaaaaaaaaaaaaaaaaa  aa a                                           tolerate manometry

Heartburn with dysphagia               +/-Volume reflux             OGD and ambulatory pH analysis and high vvvvvvvvvvvvvvvvvvvvvvvvvvvvv                                                 resolution manometry analysis

Dysphagia                                          Heartburn                       OGD and ambulatory pH analysis and high                              dddddddddddddddddddddddddddddddddddddd   resolution manometry

**Atypical symptoms                        +/- Heartburn                  OGD and pH analysis and manometry and                          ssssssssssssssssssssssssssssssssssssssssssssssssss              ENT or respiratory opinion

*Heartburn- substernal burning sensation that may extend toward neck or base of throat                                           ** Atypical symptoms- chronic cough/asthma exacerbation/sore throat/ tooth decay/hoarse voice

 

Other investigations to consider in patients with additional upper gastrointestinal symptoms such as bloating, nausea, vomiting, pain and early satiety: impedance studies/gastric emptying study

As minimum, pass complex/equivocal patients through a hiatal MDT* prior to surgery, best practice to discuss all patients prior to surgery

Enter data into a registry to audit outcomes

Laparoscopic conversion to open < 5%

Readmission rates after fundoplication within 30 days <10%

Morbidity <10%

Mortality < 0.1%

Hiatal MDT Desirable Representation: ≥2 Surgeons/ Gastroenterologist/Radiologist/GI Physiologist and Specialist Nurse