- Refractory reflux despite maximal medical management (PPI plus H2 receptor antagonist)
- Complications of reflux e.g. oesophageal ulceration or structuring
- “Volume” reflux i.e refluxing or vomiting on physical activity that involves stooping, unable to lie flat due to reflux with associated sleep disturbance
- Patients who respond to acid suppression therapy but this is not tolerated e.g electrolyte disturbance
- Patients requiring daily reflux medication despite lifestyle modification with a strong desire to discuss surgery rather than continue acid suppression therapy long-term. This may be particularly relevant to young fit patients on high doses of PPI
Anti-reflux surgery
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Audience
- Highland HSCP
- Primary and Secondary Care.
Please see upper GI reflux guideline for the initial medical management of patients presenting with reflux.
Lifestyle modifications and drug therapy remain the mainstay of treatments for reflux.
Some patients with symptoms that are not well controlled with medical management may benefit from anti-reflux surgery (usually, laparoscopic fundoplication). This is however only indicated in a minority of patients with reflux.
If reflux symptoms have not responded at all to anti-acid therapy, please consider an alternative diagnosis in the first instance. Failure of acid suppression to make any difference to symptom control is a predictor of poor outcome to anti-reflux surgery.
In carefully selected patients the outcome of surgery can be life changing but carries with it the risks of slippage of the “wrap” with resultant ongoing/recurrent symptoms, dysphagia (which is very common in the first few weeks but usually settles spontaneously), gas bloat (the sensation of “trapped wind” after eating due to the inability to “burp” after surgery) and persistent diarrhoea (exact mechanism unclear).
No requirement for investigation prior to referral. The patient may be vetted to undergo an OGD (+/- oesophageal manometry and pH studies) prior to clinic review.
NB OGD may be normal and this does not preclude referral. Oesophageal manometry and pH studies will be requested in secondary care prior to consideration of surgery
Recurrence of reflux after previous anti-reflux surgery can occur in 5 to 10% of patients over a period of 5 to 10 years and this is usually managed medically. Revision surgery is rarely indicated.
If you feel the patient requires surgical review due to reflux or late complications of surgery (the most common of which are outlined above), please refer back to upper GI surgery on a routine basis (unless the patient has red flags which would warrant an USC referral).
| Abbreviation | Meaning |
| PPI | proton pump inhibitor |
| OGD | Endoscopy to view the Oesophagus, Gastro and Duodenum |
| USC | Urgent Suspected Cancer referral |