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The typical complaints of a reflux disease, such as heartburn and regurgitation, can sometimes be relieved by a change in diet. There are also effective medications. For some people, an operation can be useful.
Not everyone manages to take medication daily for years to relieve the reflux symptoms. It may also be that the drug treatment in reflux does not bring the desired success or the symptoms are very strong. Then some people consider whether they should be operated on against reflux.
The aim of an anti-reflux operation (fundoplication) is to prevent acid from flowing back from the stomach into the esophagus. In this operation, the upper part of the stomach is placed around the lower end of the esophagus and sutured to the diaphragm, stomach or esophagus. This strengthens the occlusion at the bottom of the esophagus (the esophageal sphincter) and is designed to prevent heartburn and reflux.
Today, reflux is usually performed laparoscopically. In doing so, the doctor inserts the surgical instruments into the abdominal cavity through small skin incisions.
A fundoplication can occur in two ways, depending on whether part of the stomach is completely or partially placed around the esophagus. If the stomach completely surrounds the esophagus, this is called a fundoplication according to Nissen and Rosetti. In the fundoplication according to Toupet, the stomach only partially encloses the esophagus. This surgical technique is preferred, for example, when the movement of the esophagus is disturbed (so-called motility disorder).
Heartburn (pyrosis) is a disturbing symptom of reflux of aggressive stomach acid into the esophagus. If acid inhibitors no longer help and a change in the stomach's position can be detected, surgery can help to reduce the symptoms. The following text presents the currently available keyhole surgeries and explains the risks.
In a reflux disease, aggressive gastric acid flows back into the esophagus and irritates the mucous membrane there. In 90% of cases, it is responsible for a shift of the stomach. He is then no longer completely in the abdominal cavity, but slips through a hole in the diaphragm into the chest (hiatal hernia). During an operation (antireflux operation), the stomach can be pulled back into the abdomen and the passage of the stomach through the diaphragm be narrowed. This is done either by a direct suture or a net is sewn into the diaphragm. This quite new operation method is called 3-shift procedure. In order to prevent the stomach from re-sliding upwards and to establish a more favorable angle between the stomach and the esophagus, the upper part of the stomach is sutured to the diaphragm (fundopexy).
To reduce gastric acidity in the esophagus, the gastric entrance is additionally narrowed. For this purpose, the upper part of the stomach is formed into a cuff and placed around the rest of the stomach. It creates so under the actual stomach entrance another intended bottleneck. Depending on whether the stomach is folded in half and is sutured to the opposite diaphragm or a complete cuff is formed from the upper stomach, this surgery is called Semifundoplicatio (after Toupet) or Fundoplicatio (after Nissen-Rosetti).
All these operations can all be performed with a keyhole technique in most cases. This means that only very small cuts in the abdomen have to be placed and operated with the help of a camera and specially made instruments in the abdomen. Experience reports have confirmed that this method can lead to a faster recovery time and above all to less pain after the operations.
Risks and side effects
As with any surgery, there are basically risks of bleeding or injury to nerves and surrounding organs and a risk of infection. However, keyhole technology has made these risks very rare. If the gastric cuff is stitched too tightly, some patients experience difficulties with swallowing, which usually recede after three to twelve months. Partial gas from the stomach can no longer escape through the narrow esophagus, a regurgitation is impossible. Ingested air and gases in the stomach must then find their way through the intestine, which can manifest itself in a feeling of fullness and flatulence. If the stomach slips out of the sewn cuff, a second operation must be done in rare cases.
Reflux: Is surgery useful?
Many people suffer from it: Burning pain behind the sternum, pressure in the stomach area and acid regurgitation after eating. Often the symptoms get worse in a lying position, when drinking alcohol or after consuming acidic foods. Popularly these complaints are called heartburn. They are - if they occur more frequently - expression of another disease: gastroesophageal reflux disease (GERD). Those who suffer from heartburn are not alone in this, because about 20% of the population in the western industrial nations suffer from it.
When does an operation make sense?
There are several surgical options for gastroesophageal reflux, but all have in common that some important criteria must be met.
First of all, surgery should only be considered if there is a long-term need for treatment and effective acid blocking drugs can not relieve the symptoms. This means that the heartburn over long periods of time must occur again or constantly. If this is the case, some research must be done to objectively measure the extent of reflux. This includes a so-called pH-metry, ie a measurement of the pH value in the lower esophagus. This measurement shows how severe the acid load in the esophagus actually is and how often it occurs. In addition, it can be measured by means of a manometry, how strong is the relaxation of the circular muscle actually and whether additionally there is a paralysis of the esophagus. Only in combination of these results of the examination with the patient's psychological stress should the possibility of surgery be discussed. It is also important that all drug treatment options should be exhausted. In rare cases patients suffer from intolerance to proton pump inhibitors. If you can not tolerate omeprazole and pantoprazole, but you still have constant gastroesophageal reflux, surgery may be a good long-term alternative.
That could be interested
Oatmeal consumption reduces the likelihood of heartburn. In heartburn, stomach acid rises into the esophagus and causes chest and neck pain. This happens over a longer period of time it is called reflux disease. The mucous membranes of the esophagus can take permanent damage. The high content of fiber in oatmeal binds the stomach acid and thus reduces the amount of acid present. The likelihood of gastric acid secretion into the esophagus is reduced and the symptom of heartburn is temporarily improved.
How and why do oatmeal help with heartburn?
Oatmeal is made from seeds of oats. To understand the effects of oatmeal in the stomach, the properties of the oat seed must be considered.
Germination is primarily by water absorption. The large amount of fiber acts as a kind of sponge. When the oat seeds come into contact with water, it "sucks up" the liquid. The stored water causes the fibers to swell and the shell of the seed bursts. The plant begins to germinate. This mechanism of fluid retention is used in the treatment of reflux disease. The oatmeal reaches the stomach with food and absorbs the gastric juice there.
The sour porridge then passes into the intestine, where the acid is neutralized by the juice of the pancreas. The reflux disease is mainly caused by a disturbed closure of the stomach entrance. This can be favored by overweight. Oatmeal can also help in reducing weight (weight reduction) in regular use in addition to the acid-reducing effect. The swelling effect of oatmeal produces a faster and longer-lasting satiety.
In summary, fiber in oatmeal reduces the incidence of heartburn. When taken regularly, they are proven to reduce the development of reflux disease and its associated sequelae, such as oesophageal mucosal changes (such as Barrett's esophagus) and esophageal cancer.
Reflux disease (gastroesophageal reflux disease) is a pathologically increased reflux of the acidic gastric contents into the esophagus. About every fifth person in Germany is concerned. Patients with reflux disease suffer from heartburn and pain behind the sternum, which often worsens when lying down. With the help of a 24-hour pH-metry, the reflux disease can be reliably diagnosed. Medication or a diet change relieve the symptoms.
Reflux disease: description
The occasional reflux of gastric juice into the esophagus is quite normal during the day. In gastroesophageal reflux disease, the amount of acidic gastric juice, which rises back into the esophagus (esophagus), but increased morbid. Gastric acid is good if left in the stomach. There, the low pH of between 1 and 4 helps in the digestive process and the killing of harmful substances. The stomach is also specially protected from the acid. Not so the esophagus - her mucous membrane is not resistant enough and is attacked by the acid.
On the way from the mouth to the stomach, the esophagus passes through a small opening in the diaphragm. This is usually the cause of the reflux disease: The lower sphincter muscles, which actually ensure that after swallowing the food porridge, the esophagus closes again, are dysfunctional. Reflux disease causes the lower oesophageal sphincter (lower oesophageal sphincter) to no longer seal completely when lying down or bending over, and the hydrochloric acid from the gastric juice comes into contact with the esophageal mucosa. If this happens for a longer period of time, the mucous membrane of the esophagus is damaged. This can lead to a painful inflammation with mucosal changes (reflux oesophagitis).
Reflux disease: who is concerned?
In the western population, ten to twenty percent of people suffer from the reflux disease. It is therefore a very common disease that affects women more often than men. The incidence of reflux disease increases with age, but in rare cases, babies and toddlers are concerned.
Reflux disease: forms
Distinction NERD and ERD
Reflux without mucosal changes is called non-erosive gastroesophageal reflux disease (NERD). NERD accounts for approximately 60 percent of all patients with gastroesophageal reflux disease. On the other hand, if mucosal changes can be detected in a tissue sample from the esophageal reflection, this is referred to as erosive reflux disease (ERD).
Distinction primary and secondary reflux disease
In addition, two different forms of reflux disease are distinguished: primary and secondary reflux disease. Both have either a loss of function of the lower oesophageal sphincter (esophageal sphincter) and / or a restriction of mobility of the esophagus. This means that the body's own cleaning mechanism of the esophagus is impaired. Normally, it eliminates gastric acid through its proper movements (peristalsis). If mobility is limited, however, the duration of contact of the acid to the oesophageal mucosa is prolonged and slight damage occurs.
Primary reflux disease
Primary gastroesophageal reflux disease is by far the most common form of reflux disease. Primary means that no clear cause was found for it. But it is clear that the lower sphincter of the esophagus relaxes outside of the regular swallowing act and no longer seals the esophagus sufficiently against the stomach. There are several factors that favor the development of primary reflux disease. These include obesity, certain dietary habits (see Causes and Risk Factors), a weakening of the diaphragm or inadequate protective mechanisms of the esophagus (reduced mobility or reduced production of saliva).
Secondary reflux disease
Secondary gastroesophageal reflux occurs as a result of a known physical change - it is less common than primary reflux disease. For example, in 50 percent of women in the last trimester of pregnancy pregnancy causes a reflux disease due to the pressure increase in the abdomen. Furthermore, digestive tract disease leading to anatomical changes in the esophagus or stomach may trigger secondary reflux disease.
Reflux disease: causes and risk factors
Reflux disease is usually due to relaxation of the lower oesophageal sphincter (lower oesophageal sphincter). The sphincter does not adequately seal the esophagus outside of the swallowing cycle with respect to the stomach. Especially when lying down and bending over, acidic gastric contents enter the esophagus and irritate the mucous membrane. In other cases there is a reduced motility of the esophagus, whereby the esophagus can not cleanse sufficiently and the stomach acid has longer contact with the mucous membrane. The corrosive gastric acid damages the mucous membrane, which in many cases causes burning pain (heartburn).
Reflux - surgery
If the reflux disease is in a very advanced stage and can not be treated by medication, surgery may be necessary. In the so-called surgical technique "Nissen Fundoplication", a cuff is formed from the upper area of the stomach, placed around the lower end of the esophagus and sewn up. The cuff serves as a stabilizer of the esophageal sphincter. The operation can be fraught with complications and should therefore only be performed if, for example, no improvement can be achieved despite proton pump inhibitors or antacids. Even if gastric juice has already returned to the trachea (aspiration), surgery should be discussed otherwise it may lead to pneumonia. In addition to Nissen fundoplication, other surgical procedures such as hiatoplasty and fundopexy are also available.
Reflux disease: disease course and prognosis
The listed therapies reduce the discomfort in most patients. Left untreated, however, persistent acidity can lead to various complications.
Gastroesophageal reflux disease with esophagitis
Esophagitis is an inflammation of the esophagus caused by increased acid contact in the gastroscopy with changes in the mucosa. Typically, the inflamed mucosa is red and swollen. If there are no mucosal changes in a gastroscopy and the tissue samples taken, it is a non-erosive gastroesophageal reflux (NERD).
The mucous membrane of the esophagus is not made for contact with stomach acid. As a result of high levels of acidity and recurrent inflammation, the mucosa in some patients changes and adapts to constant contact with the stomach acid. The tissue is rebuilt and then contains more resilient cells (columnar epithelium) with mucus-producing cells (goblet cells) which are more resistant to gastric acidity. This cell transformation (metaplasia) of the esophagus is referred to as Barrett's esophagus or Barrett's syndrome. The cell changes, however, increase the risk of a malignant tumor (adenocarcinoma) of the esophagus. About every tenth patient with Barrett's esophagus develops esophageal cancer. Therefore, in case of known Barrett's esophagus, a consistent reflux treatment should be carried out with regular controls.
Reflux disease - further complications
There is a risk that the stomach acid gets into the trachea. The corrosive properties can irritate the larynx, causing inflammation (laryngitis). Patients often suffer from hoarseness. The "inhalation" of gastric acid can also cause a chronic irritable cough. Acid-induced damage to the lungs also causes pneumonia (aspiration pneumonia). The mucosal damage of the esophagus can also lead to chronic bleeding, which can lead to anemia (anemia). Reflux disease should therefore always be treated in order to avoid the consequential damage.