Gastro-Oesophageal Reflux Disease (GORD) and Hiatus Hernia

Antireflux surgery attempts to correct a deficiency in the strength of the valve that prevents acid reflux up into the lower oesophagus (gullet). This involves performing either a partial or complete wrap of part of the stomach around the lower oesophagus. Any hiatus hernia (defect in the diaphragm muscle) present is routinely repaired. Very large hiatus hernias can lengthen the operation. This operation can be achieved by key-hole surgery in the majority of cases using 5 small incisions (ranging from 5-12 mm in length). The operation time is very variable, ranging from 60 min for a straight-forward case to 120 min for very large hiatus hernias.

Side-effects of this operation include some increased downwards flatulence and inability to belch (gas bloat). Some patients notice that their swallowing is different especially in the first 4-6 weeks. This usually improves. A minority of patients may develop troublesome difficulty in swallowing or may get recurrent reflux symptoms. Further surgery can sometimes be advised if symptoms are severe.

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Oesophageal Achalasia

Achalasia is a rare condition that causes problems with swallowing and regurgitation. The valve at the lower end of the gullet usually relaxes to allow swallowed liquids and solids into the stomach. Oesophageal achalasia is characterised by a failure of relaxation of this valve so that swallowing is difficult. The gullet loses its propulsive ability as another feature of this condition (aperistaltic oesophagus). The diagnosis of achalasia is confirmed by features identified at endoscopy, during barium swallow studies and by measuring pressures in the oesophagus.

Achalasia may be treated by stretching the valve (endoscopic myotomy) or endoscopic injection of Botox into the valve. This can be performed without a general anaesthetic and only requires a day in hospital. However, this procedure may have to be repeated as the benefit gained from it is generally short-lived.

This condition is probably best treated by a cardiomyotomy (carefully dividing the muscle valve) and can be performed by key-hole surgery. The benefit of this is usually more prolonged. However, it can fail to improve swallowing in some patients and require a further procedure. An antireflux operation should be done at the same time to prevent reflux of acid caused by releasing this valve. There is a small risk of making a hole in the stomach or the gullet during this operation. This is usually repaired during surgery if it happens.

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The most sensitive way of investigating any problems with swallowing (dysphagia) and concerning symptoms from the oesophagus or stomach is a flexible upper endoscopy. This involves asking you to swallow a small long flexible tube with a camera built into the end which allows us to examine the lining of the gut. Is is performed with either a spray to numb the throat or an injection of a drug that makes you sleepy and forgetful (sedation). The procedure takes 5-10 minutes and is done as a day case which means you can go home shortly afterwards (provided you have someone with you if sedation is used).

A combination of difficulty swallowing or vomiting and weight loss should be investigated URGENTLY as these symptoms could be related to a cancer diagnosis. This can be done through your GP or a private appointment.

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