Weight loss, cessation of smoking, the use of alcohol, a change of eating and sleeping habits can often relieve symptoms. Avoid tight clothing and elevate the top end of the bed. Reduce one's stress levels.
In many case the use of commercial antacids can control the symptoms. In the event that the symptoms of GORD persist despite the adoption of the above measures, treatment by a doctor is indicated. Treatment can vary from antacids and drugs which improve peristalsis to strong acid inhibiting medicines. Prescribed medications are more effective in the reduction of acid production than commercial products, and thus control symptoms better. These medicaments will probably have to be tn for a long period if not for life if the symptoms are to be controlled, since medications alone cannot restore the valve to its normal function. The treatment will in all likelihood produce relief of symptoms during the taking of the medicine. With return of symptoms directly medication is terminated. Or the symptoms are not entirely cured but only reduced, when the dosage must be increased to achieve relief.
Unfortunately the medication is very expensive.
Surgery offers effective relief of the symptoms of GORD. Cost implications regarding medicines, the complications of GORD and the prospect of lifelong medication, are often causes of consideration to be given to surgery. Medicines cannot make a valve function properly and the disease often flares up after cessation of therapy.The operation was previously performed either via an abdominal or trans-thoracic approach. A long vertical incision in the upper abdomen or a transverse incision through the left lower thorax was employed with considerable post operative pain and discomfort and a long period of convalescence with residual surgical scars.The operation is currently being performed by means of laparoscopic surgery. This method involves a short period of hospitalisation for approximately 48 hours, a good cosmetic result, minimal pain, rapid recovery, and a quick return to normal work and other activities.
The laparoscope is a long tubular telescope lens containing a light source for illumination of the operational field. A special long tubular lens, 10 millimeter in width is used to perform the operation. The lens is coupled to a special video camera. This lens and camera system is known as aa video laparoscope. Hene the term laparoscopic surgery.The operation is performed under general anaestthesia.
The laparascope is coupled to a special video camera which processes the information. The moderns laparoscopic image is digitally enhanced..The camera also possesses additional specialised functions.
This type of surgery is also known in the layman's literature as laser surgery, keyhole or buttonhole surgery. The abdominal cavity is distended with carbon dioxide via an insufflator, which is placed in the abdominal cavity via a special needle. The gas filled abdomen isneeded to create space in which to perform the procedure.
The insufflator is an apparatus which regulates the pressure and flow of carbon dioxide to the abdominal cavity. Several safety mechanisms are incorporated in the apparatus. The apparatus also heats the carbon dioxide gas as it passes through the instrument.
Then a 10 mm incision is made just above the umbilicus. A special tube containing avalve to prevent any escape of carbon dioxide is placed through the incision into the abdominal cavity. This tube is known as a trochar and cannula. The trochar is removed and the cannula left in situ. The laparo-scope is then passed through the cannula in order to view the scene. The image is displayed on a video screen which the surgeon views . The image is enlarged 10 to 20 times on the screen in front of the surgeon. Two such screens are utilised - one for the surgeon and theatre sister and another for one of the two assistant doctors who assist with opera-tion. One of the two assistant doctors control the camera. A further four small 5 mm incisions are made to introduce other trochars withtheir respec-tive cannulae. Operational instruments are then passed through these additional cannulae. The positions of the various trochars which allow access to the abdominal cavity
The operation consists of the following steps:
The valve area where the oesophagus and stomach are in continuity is opened. The stomach is loosened and replaced in the abdominal cavity. The short blood vessels between the spleen and the stomach are divided to increase mobility of the upper fundal end of the stomach. The defect in the diaphragm, the hiatus, is sewn up and reformed. ( The hiatus hernia repair). A valve is made between the oesophagus and the stomach, by utilising a portion of the somewhat redundant stomach in the form of a collar around the distal oesophagus. ( The valve repair).
The oesophagus and stomach are freed and the stomach is replaced in the abdomen. The hiatus through the diaphragm is narrowed to its correct width by pla-cing stitches through the surroun-ding muscle. The short blood vessels between the stomach and the spleen are divided to free the stomach and make it more mobile. The stomach is placed posterior to the oesophagus and stitched into position. The valve is completed by forming a 360 degree collar around the distal oesophagus with the tissues of the stomach. This valve creation procedure is known as a Nissen Fundoplasty. Dr Rudlof Nissen described the technique for the procedure which now carries his eponym. The Toupet anti-reflux procedure differs from the Nissen in that a collar of only 270 degrees is made. This type of valve creation proce-dure was described by the French-man, Toupet. The Nissen valve is visualised through a gastroscope in a back-ward view from within the stomach. The previous wide opening has now been replaced by a valve which will control the reflux.
On completion of the operation and the anaesthetic, the patient is transferred to the recovery room within the theatre complex. Directly the patient is awake he is transferred to the ward. The patient is usually in the theatre complex for about an hour.Analgesics are given after the operation when the patient is in a stable condition. Most patients experience pain in the shoulders and thorax and do not usually complain of abdominal pain. This pain is referred pain as a result of the surgical trauma to the diaphragm. It is seldom necessary to give more than one or two analgesic injections.
Booking of the operation and hospital is performed at the Consulting rooms after the physical examination had been completed. The necessary admission forms which contain all the account and medical aid information will be provided. The forms are filled in by the patient at home and on admission are taken to the hospital. The medical aid provider has usually to be informed of the planned admission and operation. The fund requires certain tariff codes for the operation. These codes can be obtained from the consulting rooms.
You must bring with you: I.D. Document, Medical Aid Society membership card, Empowerment number from the Medical Aid society, Chronic medication, Pyjamas, Toiletries, and Reading matter.
Admission to the hospital occurs at 06.00 on the morning of the procedure.
The patient is not allowed to eat, drink or smoke from 22.00 on the previous night. It is important that the patient be in a fasting condition on arrival at the hospital at 06.00 . Early arrival at the admission office is advisable in order to be prepared for the theatre in the ward, particularly in the case of those patients who are scheduled to be operated upon at the beginning of the list.
Private pateints must arrange pre payment with the hospital authorities. Quotations can be applied for. Please leave valuables and jewelry at home.
The operation is known as:
Laparoscopic Hiatus hernia repair with Nissen Fundoplasty.
The patient signs consent for the administration of a general
anaesthetic to be given and the operation to be performed.
The anaesthetic practice is Dr Gerry Brink and partners.
The anaesthetic will be rendered by one of the specialist anaesthetists from the practice.
A pre-operative information document will be given to the patient.
A form for the anaesthetist must be completed at home prior to admission which must contain all the previous medical history of the patient and former treat-ments. All the medical history as well as all the medications being used must be given to the anaesthetist. All medicines must be listed even commercial preparations such as headache pills, powders, sleeping pills, slimming aids, and obviously any heart, blood pressure and other prescribed medicines.
In the event that there may be any questions or querries about the anaesthetist regarding fees or associate anaesthetic problems, the anaesthetists should be contacted at the telephone numbers which are available in the information form. Please read the information form diligently and make yourself aware of its content.
The total period of hospitalisation is usually two days. If the operation is performed on a Tuesday, the admission takes place on Tuesday morning at about 06.00.Discharge is on Thursday morning and the patient can go home by about 09.00. In the event that unforeseen incidents occur, the period of hospitalisation may have to be prolonged.
A physio-therapist will visit the patient during their stay in hospital to provide pre and post operative lung physio-therapy treatment. In this manner lung complications and post anaesthetic problems are reduced or eliminated. Early mobilisation and activity are encouraged by the physio-therapist and nursing staff in the hospital. The patient will also receive instructions on how to stand up from the lying position to the erect to avoid stress or pressure on the abdomen.
No abdominal or any other hair should be shaved off. The umbilicus is cleaned in the hospital. After admission to the ward, prior to the operation, the patient takes a bath for which anti-septic soap is provided. An intra-venous drip will be put up by the nursing staff for intra-venous fluid administration.
At the time of discharge from the hospital the patient must ensure that the following items are received from the Ward Sister:
Any home medication which was handed during admission.
Analgesics and the balance of all prescribed medicines which were being taken during the period of hospitalisation.
Any special medication which the surgeon may have prescribed.
Two weeks are normally required before return to full employment. However, if the work is more sedentary in nature or of an administrative nature, normal work may be resumed before two weeks have elapsed, provided there is no physical stress involved. A sick certificate will be issued during the early wound healing period visit to the consulting rooms after the operation.
After discharge of the patient wound care is performed every Friday morning between 08.00 and 10.00 hours at the consulting rooms. No appointments are needed. The registered nurses are on duty and waiting to assist the patients.
The patient must attend the first wound care clinic on the Friday after the operation on Tuesday. The nursing staff will change the dressings and replace the plasters. Arrangements will be made for the removal of stitches or metal clips. The stitches or metal clips are normally removed 12 to 14 days after the operation. Any abnormality redness, swelling or drainage from the wound must be immediately reported.
The patient should feel better day by day.
The following symptoms or signs must immediately be reported to the consulting rooms of the surgeon.
Fever, bleeding, increasing abdominal pain, or chest pain, discomfort or swelling, cold shivers, continuous cough, shortness of breath, inability to swallow or drainage from the wound.
A follow up consultation and evaluation follows 6 - 8 weeks after the operation. This appointment is be made by appointment during the first wound care visit at the consulting rooms or at discharge from the hospital. During the follow up consultation the oesophagus and valve are checked with oesophageal manometry and gastroscopy. The oesophageal ulcers can sometimes be healed in cases of Barrett's oesophagus.
Return to normal work can take place in the interval between discharge and the follow up consultation.
A private dietician will visit the patient in hospital and a further recovery diet will be planned for the patient's specific needs. It is important to follow the dietary instructions and in tis manner to hasten the recovery from the operation. No alcohol may be taken in the recovery period. For the first fewe days after the operation the patient is only allowed to drink liquids. Fizzy gas containing liquids are advised to encourage the patient to learn to break winds in the form of burps. Solid foods must be chewed very finely and it is very important to learn to eat slowly. Normally patients lose 5 to 10% of their body mass after the operation. It is usually regained
The patient is encouraged to return to his/her normal acitivities e.g bath, shower, driving a motor vehicle, climbing steps, picking up light objects, work and sexual intercourse. During the first three weeks after the operation no heavy objects should be lifted or picked up. During the three too six week post operative period light exercise is encouraged such as walking, cycling, and limited stretch exercises. Physical stress and contact sports must be avoided entirely in the first six post operative weeks.
Driving a motor car can be undertaken a few days after the operation directly physical movement is painless and easy.
After the 6 week post-operative visit, all normal activities can be resumed, even contact sports, gymnasium exercises etc.
Numerous studies have already demonstrated that the vast majority of patients who have undergone laparoscopic surgery for GIRS, are symptom free with amarked improvement in their quality of life.
This type of surgery is much safer than the former traditional surgery - indeed ten times safer according to published studies. However, complications do occasionally occur such as may occur with any other type of surgery.
Specialist anaesthetists are used for all the operations.
In the event that the patient has experienced previous problems associated with anaesthesia, it is imperative that the anaesthetist be informed thereof. Anaesthetics are only given after mature consideration and are performed with the utmost degree of safety for the patient.
Some patients experience nausea from the administration of post-operative analgesics. Allergic reactions to specific analgesics can also occur, but are not common. Routine injections to prevent such nausea are routine given to prevent or inhibit this problem.
Bleeding and damage to other organs in the vicinity of the oesophagus and stomach
As is the case with all forms of surgery, these complications are always a factor. With laparoscopic surgery the operative field image is enlarged 20 times on the video screen. Special preventative measures are taken during laparoscopic surgery to limit or eliminate these complications. Blood loss during laparoscopic surgery is very little and it is uncommon for a patient to require a blood transfusion after or during normal laparoscopic surgery. This type of surgery is thus particularly useful in the event that the patient's religious beliefs offer opposition to blood transfusions. Slight bleeding does occasionally occur in the small surgical incisions which occasionally require drainage.
With surgery, infection of the wound or the abdominal cavity is an ever present danger. Specific wound care is always performed to avoid any risk of infection. Wound infection in laparoscopic surgery cases is unusual and rare.
Deep venous thrombosis or blood clots in the calf veins are an ever present risk in all forms of surgery. Pre-operative preventative measures are taken by giving sub-cutaneous injections of heparin. This injection is given on a daily basis while in the hospital. Physio-therapy to maintain good lung function is given and early ambulation or activity is encouraged to prevent possible deep vein thrombosis. Patients at risk are provided with special anti-thrombotic stockings to reduce the chance of developing deep calf vein thrombosis.
Conversion of a laparoscopic procedure to a traditional open surgical operation
In a very small percentage of cases it has been found that it is not possible or safe to perform laparoscopic surgery. If the surgeon decides that to complete the procedure or to revert to traditional open surgery, it should notbe considered as a complication, but as a sound surgical decision since there is never a good reason to subject a patient to a hazardous operation. Factors which may contribute to such a decision include previous abdominal operations resultant scar formation or adhesions, previous infections of the abdominal cavity which have produced adhesions, previous diaphragmatic hernia operations, and other complications such as bleeding , or where in other cases the completion of the operation laparoscopically is not safe because of technical problems encountered. The decision to revert to traditional surgery is based on the procedure which is safest for the patient.
Side-effects of the operation
Long term side effects after the operation are unusual.
Some patients complain of difficulty in swallowing in the immediate post operative period. The normal swallowing mechanism returns to normal within a one to three month period after the operation. It is seldom necessary to resort to post operative dilatation of the oesophagus after the operation.
In the event that a stricture of the oesophagus was present prior to the operation, it may on occasion be necessary to perform dilatation of the oesophagus after healing of the oesophagus. It is very rare to have to resort to further operation.
Most patients find that they can break winds after the operation but there is a small percentage of patients who find difficulty in doing so. This may lead to abdominal discomfort and distension and increased passage of flatus. In rare cases there isaninability to vomit after the operation.
It is unusual that the symptoms of Gastro intestianl reflux do not improve after the operation.
Further questions
In the event that there are any other questions concerning gastro-intestinal reflux disease, please do not hesitate to make enquiries from the personnel at the consulting rooms, nursing staff or the surgeon himself. All questions will be answered to the best of their ability.