Anti-Reflux Surgery (Fundoplication)

At the lower end of the oesophagus, a ring of muscle and the angle at which the oesophagus enters the stomach act together as a valve, helped by the diaphragm muscle that surrounds them. In reflux disease this barrier is weakened, often because part of the stomach has slipped up through the opening in the diaphragm, a hiatal hernia. Anti-reflux surgery restores the barrier. The surgeon brings the stomach back into the abdomen, narrows the widened opening in the diaphragm with stitches, sometimes reinforced with mesh, and then wraps the upper part of the stomach, the fundus, around the lower oesophagus. In a Nissen fundoplication the wrap goes fully around, 360 degrees; in a Toupet fundoplication it covers about 270 degrees at the back, which may cause fewer swallowing and bloating problems. A different option for selected patients, the magnetic sphincter device known as LINX, places a ring of magnetic beads around the lower oesophagus.

Surgery is recommended for gastro-oesophageal reflux disease confirmed by testing when symptoms remain troublesome despite adequate medicine, when regurgitation of food or fluid persists even though heartburn is controlled, or when someone prefers not to take acid-suppressing tablets for life. It is also considered for complications such as severe oesophagitis, or for reflux that causes chronic cough, hoarseness or asthma-like symptoms when testing links them clearly to reflux. Large hiatal hernias, especially paraoesophageal hernias in which the stomach has moved up alongside the oesophagus and can twist, are a reason for repair even with mild reflux. Barrett's oesophagus alone is usually managed with medicines and surveillance, and surgery does not remove the need for surveillance. Heartburn that does not respond to any acid suppression needs careful investigation first, because it often has another cause. For people with significant obesity and reflux, a gastric bypass may be the more suitable operation.

Anti-reflux surgery is usually done laparoscopically under general anaesthesia, through about five small cuts in the upper abdomen, and robotic assistance is used in some hospitals. The surgeon frees the lower oesophagus and any hiatal hernia from the chest, bringing the stomach and a sufficient length of oesophagus back into the abdomen. The muscular edges of the opening in the diaphragm are then stitched together behind the oesophagus to narrow it, with mesh added for some large hernias. Next, the fundus of the stomach is passed behind the oesophagus and stitched to form either a complete Nissen wrap or a partial Toupet wrap, sized around a soft tube in the oesophagus so that it is not too tight. At the end, the team checks for bleeding and confirms the position of the wrap. The operation usually takes about 1.5 to 3 hours, longer for large or recurrent hernias, and conversion to open surgery is uncommon.

The right candidate has reflux proven by tests, responds at least partly to acid-suppressing medicine or has troublesome regurgitation, and has an oesophagus that moves food normally. Before surgery, an upper GI endoscopy looks for oesophagitis, Barrett's oesophagus and the size of the hernia. A 24-hour or longer pH or impedance study measures how much reflux actually occurs, and high-resolution manometry checks how strongly the oesophagus squeezes food down, which helps decide between a Nissen and a Toupet wrap and excludes conditions such as achalasia. A barium swallow or CT scan may map a large hernia. Weight reduction is advised where needed, and smoking should be stopped. International patients often complete part of this testing at home and send the reports, so the surgical team can confirm suitability and plan the visit, sometimes with the remaining tests arranged on arrival.

Most people stay one or two nights. You start with fluids, then move to a soft or pureed diet for about four to six weeks, eating small, frequent meals and chewing well, because swelling around the wrap makes swallowing harder early on. Mild difficulty swallowing is common in the first weeks and usually settles over about six to twelve weeks. Shoulder pain from the gas used in surgery, bloating and difficulty belching are common at first, and avoiding fizzy drinks, bread and dry meat early on helps. Most people return to desk work within one to two weeks and avoid heavy lifting for about six weeks to protect the hernia repair. For travel, plan about seven to ten days abroad so the team can confirm you are eating safely before you fly. Acid-suppressing medicines are usually stopped after surgery on your surgeon's advice.

Fundoplication is an established operation that gives good long-term control of reflux in most well-selected patients, but it has trade-offs. Difficulty swallowing is common early and occasionally persists, sometimes requiring endoscopic stretching or a revision. Gas-bloat, a feeling of fullness with difficulty belching, and more wind are known side effects, and many people find it hard to vomit after a full wrap. A Toupet wrap may reduce these effects, with similar reflux control in many studies. Less common risks include injury to the oesophagus or stomach, air leaking into the chest, bleeding and injury to the spleen. Over the years the wrap can loosen or the hernia can recur, especially after repair of large hernias, and some patients need medicines again or a second operation. Good results depend on a correct diagnosis, which is why testing before surgery is not optional.