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.

​

​

​

​

​

​

​

​

 

 

 

 

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)

 

​

General Recommendations:

​

• As a minimum, all complex/equivocal patients should be discussed at 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 and referral to a unit that provides LINX should be provided if patient wishes. Patients should also be made aware of endoluminal therapies

​​

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

​

​

Audit outcomes:

​

• Laparoscopic to open conversion < 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)

​

• >50% improvement of GERD-QoL at 5 years after surgery

​

• Morbidity <5%

​

• Mortality < 0.1%

​​

​

​Pre-operative investigations​:

​

Minimum pre-operative investigations should prove objective evidence of acid reflux 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                                                                                                                                           analysis/contrast swallow if unable to                                                                                                                                                  tolerate manometry

​

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

​

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

​

Dysphagia                                              Heartburn                             OGD and ambulatory pH analysis and high                                                                                                                                        resolution manometry

​

**Atypical symptoms                              +/- Heartburn                       OGD and pH analysis and manometry and                                                                                                                                         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

​

​

​

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 (with indications for surgery as listed above)

** Secondary Symptoms: post-prandial chest pain, shortness of breath, nausea, dysphagia, weight loss/iron deficiency anaemia

 

​

General recommendations:

​

• As a minimum, all complex/equivocal patients should be discussed at a hiatal MDT* prior to surgery, best practice to discuss all patients prior to surgery

​

• Enter data into a registry to audit outcomes

​

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

​

​

Audit Outcomes:

​

• Laparoscopic conversion to open < 5%

​

• Readmission rates after fundoplication within 30 days <10%

​

• Morbidity <10%

​

• Mortality < 0.1%

​

​

Pre-operative investigations:

​

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                                                                                                                                           analysis/contrast swallow if unable to                                                                                                                                                  tolerate manometry

​

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

​

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

​

Dysphagia                                              Heartburn                             OGD and ambulatory pH analysis and high                                                                                                                                        resolution manometry

​

**Atypical symptoms                              +/- Heartburn                       OGD and pH analysis and manometry and                                                                                                                                         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​​​​​​