Gastro-Oesophageal Reflux (GORD)

The major problem is the pain caused by the stomach acid being pushed or refluxed from the stomach into the oesophagus.  This acid burns the tissues and causes discomfort or “heartburn”.

Dietary Treatment

Treatment

Treatment aims to reduce this reflux;
• by decreasing the volume of food in the stomach.
• by avoiding alcohol and foods which relax the muscles at the  lower end of the oesophagus and so allows reflux to occur.
• by avoiding or limiting smoking because nicotine also relaxes these muscles.
• by improving posture which can physically aggravate reflux.
• by reducing excessive body weight.
• by having adequate fibre in the diet which will prevent constipation and the accompanying straining which may add to the problems of pressure on the stomach.

 

Weight

Excess body weight aggravates the condition.  If you are overweight it is important to lose weight which will decrease painful symptoms.

Clothes

Tight slacks, skirts or underwear can increase pressure on the stomach

Posture

Improved posture helps to relieve symptoms.
• Sit up straight whilst eating
• Avoid lying down, bending and straining soon after eating
• Sleep with the head of end of the bed raised 6 inches by placing blocks under the bed head, or a rubber wedge under the mattress.  Extra pillows are not as effective.
• Eat smaller meals to prevent overfilling stomach.
• If symptoms are severe the volume in the stomach can be further reduced by drinking at least half an hour before or after meals instead of with meals.
• As the amount of food is reduced, it may be necessary to eat more often, with larger amounts between meals.
• The last meal of the day needs to be light and eaten almost 3 hours before retiring.
• Foods which relax the oesophageal muscles need to be avoided or limited:

1. Alcohol.
2. Fatty foods, e.g., fatty meat, food cooked in oil, chips, pasties, donuts, too much butter or oil, cream, oily salad dressings.
3. Food containing caffeine. e.g., tea, coffee, coke, cocoa, chocolate Try:  decaffeinated coffee, drinks made from roasted cereal, e.g., Caro, “Natures-Cuppa”

• Spicy food such as curry, chili, garlic, black pepper sometimes cause problems.  They need only be avoided or limited if they cause “heartburn” consistently.
• Aim to eat a good nourishing diet with adequate cereal, low fat milk, lean meat, fish and chicken and plenty of fruit and vegetables.
• Increase the amount of fibre in the diet by using wholemeal bread, wholegrain cereal and unpeeled fruit and vegetables

 

Surgical Treatment 

Gastro oesophageal reflux disease is a common condition affecting about 1 in every 5 adults. It seems to be more common as we get older. The commonest symptoms of reflux are a burning sensation behind the breast bone (heartburn) and regurgitation of fluids. Regurgitation sometimes causes spillover problems such as cough, hoarse voice, and even asthma. There are other symtoms which are common in the community, such as an acid taste in the mouth, burning in the back of the throat and even chest pain, which may sometimes be associated with gastro oesophageal reflux, but often are due to other causes. In many people, the symptoms of reflux can be controlled with simple changes in eating and drinking habits (that is, you avoid the things that cause the problem). If the problem is troublesome, medication is usually taken in the form of either H2 receptor blocking agents such as Ranitidine (Rani II, Zantac) or proton pump inhibitors (Losec, Zoton, Somac, Pariet, Nexium) and these medications often control the symptoms, particularly if the main symptom is heartburn. Such tablets do not cure the problem, however, and prevention of reflux can only be achieved by surgery.

Techniques

If the operation is being carried out for the first time, it is nearly always achieved today via the keyhole method (laparoscopic surgery). Even if it is a second operation, we are sometimes able to carry it out laparoscopically. Most patients have a hiatus hernia associated with their reflux, and repair of this hernia is undertaken at the same time as antireflux surgery. (see diagram) There are several types of antireflux operations which can be carried out, depending on certain circumstances, but they all have one principle in common, that is, the construction of a one-way valve from the oesophagus to the stomach. It is because the operations prevent reflux from the stomach into the oesophagus, that we call the procedures“antireflux surgery”. You can have a complete fundoplication, where the upper part of the stomach is completely wrapped around the lower oesophagus, and a partial fundoplication where the stomach encircles anything from 90-180o of the oesophagus. Depending on the patient’s body type, the operation usually takes between 60 and 90 minutes to carry out.

The Post-Operative Period in Hospital

There is a fine line dividing acute discomfort and soreness from pain, but most patients do not really have much in the way of pain after laparoscopic surgery, rather just some abdominal and chest discomfort. Simple pain killing tablets should relieve any discomfort in the small incision sites during the first 2 to 3 days. You will have a dry dressing over your incisions. You can shower with this dressing on, and remove it after 2 days thereafter leaving the wounds uncovered.

Many patients do experience some degree of pain in their shoulders after the procedure. This is a referred pain from the diaphragm where stitches have been placed as part of the operation. Such discomfort and soreness tends to disappear over the space of 24 to 48 hours, although in a few patients this can last longer. Because the surgery has been performed laparoscopically, you will find that you are able to get out of bed on the same day of surgery, if necessary. Certainly you will be mobile on the first post-operative day. Most patients go home on the second day after surgery.

The Post-Operative Period at Home

Because of the lack of any wound pain, by the time you go home you may well think that you are able to act as though you have not had an operation. Nevertheless, you will find that you get tired easily, and you may even wish to have a sleep in the afternoon, for a few days. We also ask the patients to avoid heavy lifting for at least 4 weeks (no trying to move the fridge!). This is so that you don’t put unnecessary stress on the sutures used for the operation. Most people can otherwise resume normal activities comfortably about 10 to 12 days after their operation.
You should refrain from driving a car until you have free range of movement and can push the brake pedal comfortably (between 1 and 4 weeks). We advise you also to check this matter with your motor vehicle insurance company. Sporting activity can be recommenced after 4 weeks. Most patients find with their meals that they become full very quickly, and so eat much less, at least for a few months. This means that most patients lose weight as a result of the operation, and many patients see this as a bonus! Most people regain their original stomach capacity at a later stage.

Occasionally, if your attention is diverted for some reason, you may swallow a large lump of food, which becomes stuck in the lower oesophagus. Whilst this can cause acute discomfort, it does not place you in any danger, and in particular, you will not choke because of the food being stuck there. Depending on how long it takes before the food either moves through or you bring it back, it can lead to acute irritation of the oesophagus, which then produces large amounts of white mucus, which you will probably bring up. None of this puts either you or your operation in jeopardy.

Because the operation is a one-way valve, any air or gas which is swallowed cannot be easily belched back. (You will be able to produce small belches from air in your oesophagus above the valve). For this reason you should avoid gassy drinks for at least 4 weeks after your operation, and you should avoid drinking large volumes of such drinks at any time. Any air in your stomach has to move through your gastrointestinal tract, so that many people are aware of increased flatulence after the operation, and pass more wind. This problem tends to get better with time, but some degree of increased passage of wind often remains.

It is important that for the rest of your life you avoid vomiting. Vomiting can occasionally tear out your internal stitches and the operation may have to be performed all over again. Therefore, it is advised that you do not drink alcohol to excess, and that if you feel ill, nauseated, or sick, you should go to your local doctor or the nearest emergency department to get an injection to stop yourself vomiting if required.

If you notice any redness, swelling or discharge from your wound after leaving hospital, you should make an urgent appointment to see your surgeon or your local doctor. Providing all goes according to plan, an appointment will be made for you to see your surgeon regarding your progress about 4 to 6 weeks after discharge.

Complications

Antireflux operations have a very low rate of complications. Of course any operation entails some risk, but to put this in perspective, when we drive our cars this also entails a risk, and the risk of antireflux surgery is probably about the same as the risk involved in driving a car from Adelaide to Melbourne. By risk, we are talking about dying as a result of the operation, and the risk from these procedures is certainly lower than having your appendix out.

Complications specific to antireflux surgery, but which occur extremely rarely (less than 1 in every 400 operations) are:
1. Damage to the oesophagus, stomach or bowel, leading to leakage from the area, and sometimes necessitating a further laparoscopic procedure, or even more rarely, an open operation, to address the problem.
2. Bleeding, again possibly requiring a further laparoscopy or open operation. Such bleeding is sometimes associated with the spleen, and necessitates removal of that organ. This used to be much commoner in the period of open surgery, but occurs very infrequently since laparoscopic surgery was introduced.

 

Difficulty Swallowing After Surgery

Almost all patients have some difficulty in swallowing after surgery due to the fact that the oesophagus tends to be rather inactive for a week or two, and as well there is usually some swelling in the area of the fundoplication. Some surgeons recommend you take soft and moist food only for a few days, until you see what degree of difficulty you have. Some surgeons recommend that no solid food at all is taken for two weeks, but this can be individualised, according to the type of fundoplication performed. Other surgeons prefer all patients to remain on a vitamised diet for the first 6 weeks after the operation. Before your operation, your surgeon will explain your recommended dietary plan, and a dietician may also go over this with you again in hospital. Some patients have very little difficulty at all, and others have quite severe difficulty for a few days, and problems with solids for weeks to months.

You will find your ability to swallow getting progressively better over days to weeks, and the vast majority of patients eventually swallow normally after antireflux surgery. A small number of patients find that very lumpy food tends to stick in the lower oesophagus when swallowing, which then causes discomfort. This of course is not really a problem for patients if they avoid eating large lumps of food and making sure that food is chewed thoroughly before it is swallowed.

Sometimes, difficulty in swallowing in the first couple of days after operation, taken with barium meal findings, suggests to us that a stitch needs readjusting. At this early time after an operation, it is extremely simple for the patient to have another anaesthetic, have the same small wounds used for access, and for the surgeon to readjust the stitches. If, on the other hand, we leave it for even a week, it can sometimes be really quite difficult, and beyond a week sometimes extremely difficult, and we need then to wait for several months before we can do anything. In these situations, we usually obtain a barium swallow x-ray on the first or second day after operation, and if we are not satisfied, we have a low threshold for going back and adjusting a stitch. This does not happen very often, perhaps one in 50 cases. Even if you are unfortunate enough to be the one in fifty, it usually only delays discharge from hospital by a couple of days, and it makes very little difference to the convalescent period.

 

Eating after Fundoplication (Anti-Reflux Surgery)

Fundoplication surgery helps relieve the chronic heartburn caused by severe reflux. This reflux usually occurs due to a weak “valve” muscle between the stomach and the esophagus, which allows stomach acids to move back up into the esophagus.

To strengthen the "valve" between the stomach and the oesophagus, the surgery involves wrapping the upper portion of the stomach, or fundus, around the bottom of your oesophagus (like a collar). This causes some swelling and will make the oesophagus less pliable where it enters the stomach. Initially you will not be able to eat normally. As the swelling settles the oesophagus becomes more supple and you will be able to manage a normal diet.

 

Before Surgery

We recommend you take Nutricia PreOp. It is a clear, lemon flavoured carbohydrate drink; designed to prevent you feeling hungry and thirsty just before your surgery. Take 2 of the 200 ml drinks the evening before surgery. And take another 2 of the 200 ml drinks two hours before admission on the day of surgery. In Hospital

Initially following your surgery you will be graded from a fluid diet to a smooth pureed diet (see separate information on the Smooth Pureed Diet). You will be given guidelines in hospital for how long to follow each dietary stage. You’re eating patterns and volume will change due to the nature of the surgery. It is likely that you’ll be eating and drinking less than what you would normally. Therefore unintentional weight loss may occur. To prevent this from occurring you will be given nourishing foods and fluids whilst in hospital.

 

After Discharge

You must remain on a smooth pureed diet for a minimum of 4 weeks. At the 4 week mark, you will have a follow-up appointment, where you may be progressed to soft diet dependant on your recovery. Check with your surgeon and dietitian if you have any concerns.

 

Vitamins and mineral supplements

A multivitamin supplement is advised after surgery. We recommend you take 2 BN multivitamins every day for the first 6 months after surgery (available from our office). After 6 months Blackmores Conceive Well Gold may be a suitable option (dont worry its a pregnancy vitamin!). These are available at most chemist shops.

 

Weight loss

It is important to monitor your weight. If you are losing weight you will need to include small frequent meals and eat at regular meal times, and may need to reschedule your review appointment sooner. See separate information on A Nourishing Diet or speak to your dietitian.

 

Constipation

If constipation is a problem check that your fluid intake is adequate – aim for at least 1500ml (1½L) daily. A soluble fiber supplements such as Benefibre® or Metamucil Fibresure® may be useful. These are colourless and tasteless and can be easily mixed into most fluids. You could also try drinking prune or pear juice. Increase your activity with some light walking if possible. If you still do not experience any improvement, check with your doctor.

 

Long-term tips

• Eat and drink slowly – avoid gulping food and fluid.
• To minimise burping and belching, avoid fizzy drinks, chewing gum and drinking through a straw.
• Chew all foods well and avoid foods that are not easily broken up such as tough meat or chicken, sausage skins, raw vegetables or tough skins or stringy parts on fruit and vegetables. Fresh, doughy bread may also be difficult and may be better tolerated when it is toasted.

This can be discussed in greater detail at your review appointment, 4 weeks after your surgery.