This is information about the treatment of Gastro-oesophageal reflux disease (GORD) and hiatus hernia.
General Changes You Can Make
- Lifestyle changes can make a difference in relieving your symptoms. Raising the head of the bed (about six inches) and avoiding heavy lifting reduces heartburn by allowing gravity to minimize reflux of the stomach’s contents into the oesophagus. You can slide blocks or books under the legs at the head of the bed or sleep on a specially designed wedge. Tilting the bed is better than trying to sleep on several pillows, which can increase pressure or even make GORD worse.
- Reducing weight and stopping smoking are recommended because both weaken the LOS, (lower oesophageal sphincter) and increase stomach acid production and irritation.
- Avoid wearing tight garments.
- Avoid lifting heavy objects or bending forward if possible.
- Avoidance of certain foods & drinks that can weaken or reduce LOS pressure such as citrus and tomato products, caffeine, chocolate, carbonated drinks, fatty foods, spicy foods, onions, mint, nicotine, alcohol especially spirits and red wine.
- Eating smaller, more frequent meals rather than three large ones a day and avoid eating close to bedtime (usually 2-3 hours).
Medications include those which neutralise the acid or reduce its effect, reduce acid production, increase gastrointestinal motility and those which protect the mucosa. Over-the-counter medications such as antacids (Rennie) may offer some comfort. They are usually taken after meals or at bedtime. Antacids, if taken regularly, can neutralize acid in the oesophagus and stomach and provide at least temporary or partial relief. If an antacid has not provided relief in several weeks, it probably won’t. Alginates (Gaviscon) are compounds that form a “raft” that floats on the surface of the stomach contents to reduce reflux. Long-term use of antacids can result in side effects, including diarrhoea, constipation, changes in the way your calcium metabolizes, and a build-up of magnesium in the body. Those with kidney disease or high blood pressure should consult their GP first. Similarly, if antacids are needed for more than 3 weeks, then your doctor should be consulted. If the symptoms continue, then acid reducing drugs are used. These include H-2 blockers (such as cimetidine, ranitidine). Another type of drug, the proton pump (or acid pump) inhibitor (PPI) such as Omeprazole and Lansoprazole. H-2 blockers may cause confusion in elderly patients, can increase the effects of alcohol. Antacids and cimetidine should be taken one hour apart because antacids reduce the drugs effectiveness. Other medical approaches include increasing the strength of the LES and quicken emptying of stomach contents with motility drugs that act on the upper gastrointestinal tract. These drugs include Motilium and Metoclopramide. Still, these drugs can have serious side effects. These drugs are usually prescribed for short-term use. Their side effects include stomach or abdominal pain, diarrhoea and nausea. Aspirin and anti-inflammatory drugs like ibuprofen? reduce the protective lining of your stomach, which can lead to more irritation.
There are several types of surgical procedures now available for treating hiatus hernias and Gastroesophageal reflux disease. The traditional surgical procedure, known as Nissen fundoplication, involving a single long incision, a hospital stay of 4-6 days. Because the abdominal muscles must be cut to perform the surgery, you probably will experience more pain and discomfort in the hospital and later at home. The recovery period is 6 to 8 weeks. As a result, surgery has typically been limited to those patients with extreme or life-threatening conditions. Now a laparoscopic technique makes it possible to perform the same operation in a minimally invasive manner. Most patients go home in 1 or 2 days with only 5 tiny marks and, in most cases, can return to work and other normal activities within a week or two.
With either method, the hernia is repaired based on the “traditional” procedure developed by Dr. Nissen in 1948. The upper portion of the stomach is wrapped around the intersecting area where the oesophagus opens into the stomach like ?a Sausage in a bun?. This strengthens the area and prevents acid and food from refluxing up into the gullet. Studies have shown that more than 93% of patients who undergo the procedure say their symptoms are cured or improved after 10 years.
Involves having a laparoscope (slender tube, with a special system of lenses, a light source and a tiny video camera which transmits an image of the organs being inspected) in addition to special surgical instruments which are inserted through small abdominal incisions. These usually heal fairly quickly with less discomfort than with the traditional open Fundoplication.
Should I be concerned that the laparoscopic technique is new?
Laparoscopy has been used in gynaecological surgery for nearly 3 decades, and today, more than 97% of all gallbladder surgery is performed laparoscopically. More recently general and thoracic surgeons have applied the laparoscopic technique to a broad range of surgical procedures including appendectomy, hysterectomy, and lung and bowel surgery.
What are the side effects and what can go wrong?
The procedure is generally safe and there has been a low or zero mortality in most? ? experienced surgeons’ hands.
Side effects include:
- Short term difficulty swallowing especially white bread or lumpy foods. This is due to bruising of the lower oesophagus. It can last up to 3 months. It usually settles in due course.
- Bloating and increased flatulence. This is due to the inability to burp up swallowed air. It slowly improves with time.
- Diarrhoea can rarely occur in patients with large hernias caught in the chest as damage to the vagus nerves can occur in reducing the hernia out of the hiatus.
- General anaesthetic complications such as heart irregularities, chest infection, deep venous thrombosis and pulmonary embolism… etc.
- Bleeding from the spleen or gastric vessels.
- Tearing of the oesophagus resulting in leakage.
- Slippage of the wrap or breakdown of the hiatus resulting in pain or difficulty swallowing.
- Recurrence of the reflux or the associated hiatus hernia.
The incidence of serious problems is very small and patients in the vast majority of cases are very happy with the outcome of their surgery. If anything goes wrong at surgery the patient may require an open procedure to repair the damage.
Am I a candidate for laparoscopic Nissen fundoplication?
Although the majority of patients are eligible for a laparoscopic procedure, it may not be appropriate for some patients, including those who have had previous abdominal surgery on the stomach or the diaphragm or who have some pre-existing medical conditions. A thorough medical evaluation by your surgeon at the consultation, can determine if laparoscopic antireflux fundoplication is an appropriate procedure for you.
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