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When is surgery considered? Surgery is considered if: your symptoms do not improve with medications, if they repeatedly return after the medication is stopped, if lifelong medication is needed, if you are unwilling or unable to take medication for prolonged periods or if there is severe damage to the esophagus due to reflux. A large hiatus hernia, esophageal ulcer, narrowing or change in the lining of the esophagus, such as Barrett's esophagus may be further indications for surgical therapy. The procedures most commonly performed are thelaparoscopic Nissen fundoplication and the laparoscopic Toupet fundoplication. How Does Antireflux Surgery Work? For more than thirty years surgeons had performed an operation known as a fundoplication to prevent reflux. Before 1991 it was necessary to make a long incision between the breastbone and the "belly button". This resulted in significant discomfort and a hospital stay of about five to ten days, with an average time for return to normal daily activities of about six to eight weeks. Since 1991, surgeons have used a laparoscope to do the fundoplication. This is a long, thin telescope the size of a finger which is placed into the abdomen. Five or six small incisions, each no longer than the width of a quarter are used to gain access to the abdomen. Dissecting instruments, thread and other materials can be inserted and removed through these small holes, allowing the surgeon to perform the operation. If there is a hiatus hernia, which is a slippage of part of the stomach through the diaphragm into the chest, this is repaired by pulling the stomach into the "belly". Then the hole in the diaphragm is sewn closed so that it only allows the esophagus to pass through. A small portion of the upper stomach is loosened from the surrounding tissues and wrapped around the lower esophagus. As a result the valve between the esophagus and the stomach is tightened. The operation is performed in one to three hours. Other variations of this procedure may be performed. The most common of which is the partial wrap or Toupet in which the stomach is wrapped around two thirds of the lower esophagus. This procedure is used for people who have weakened muscles of the esophagus. Patients usually have little pain and discomfort after laparoscopic surgery when compared to open surgery, therefore they recover more quickly. Some patients may go home on the day of surgery but most leave the hospital in one or two days. Return to social and work activities may occur in one to three weeks, which is much sooner than with the open surgical technique.
*Rattner DW, Brooks DC. Arch Surg.1995;13:289-294. What are the Complications of Surgery? Surgical complications are rare but do occur in 2 to 4 % of patients who undergo laparoscopic surgery. With any surgery performed under general anesthesia, there is a less than one in a thousand chance of severe complications from the anesthesia medications. There is a less than 1 in 500 possibility of severe bleeding that may require transfusion. All surgeries carry the risk of wound infection, postoperative pneumonia or blood clots forming in the deep veins in the legs. These risks are reduced by the use of antibiotics, anticoagulant medication and the laparoscopic technique, which allows the patient to be active soon after surgery. There are complications specific to the surgery. Damage to organs such as the stomach, esophagus, spleen or liver may occur. This may or may not be identified by the surgical team during surgery and could result in serious infection but these problems can usually be repaired at the time of laparoscopic surgery. Tracking of air into the chest cavity or the space around the lungs may occur. In our experience of over 70 cases complications were rarely encountered and were appropriately handled. Occasionally it is not possible to complete the operation with the laparoscopic technique because of difficulty with visualization or because of a complication. The need to convert to an open operation with an upper abdominal incision is necessary in less than one in two hundred cases. The risk of death after this operation is less than 1 in 600. In Dr. Floch's experience there have been no mortality or conversions. Other complications may arise after surgery. If the wrap is too tight there may be persistent difficulty in swallowing. This can occur in 20% of patients immediately after surgery but drops to about 5% after one to two months. Four percent of patients will need dilation of the esophagus. The wrap may slip into the chest or become undone resulting in difficulty swallowing or recurring symptoms. If this occurs, reoperation may be required. |
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