Mr. X comes in. He is a man in his forties, a little’ overweight, well dressed. He looks around constantly with two bright eyes. He is holding a clipboard overloaded with paper. He is accompanied by a woman a bit younger, who looks worried. After the usual introductions he begins telling me his story. His voice is a bit hoarse and tends to become low-pitched as he speaks. For nearly 10 years he has frequent episodes of heartburn in his epigastrium (the “mouth of the stomach”) and behind his breastbone, and sometimes feeling of acid in his throat. In recent years he had episodes of discomfort in is neck, as if a bit of food was stuck in the foodpipe.
Six years ago he underwent laparoscopic cholecystectomy for gallstones. Two years ago he had a screening colonoscopy, which showed the presence of sporadic diverticula in the sigmoid. For several years he had sudden drops of voice, sore throat and dry cough, mostly in the morning. Six months ago he had a small polyp removed from his right vocal cord. He was also under an ENT Consultant for recurrent otitis media. Over the past two years he has attended five times the emergency department for chest pain, arising always at night, but all heart investigations were always negative.
He has had numerous electrocardiograms and echocardiograms, a pair of Holter-ECGs, a treadmill test, a myocardial scintigraphy and even a coronary angiography, all negative. During the last admission, a Cardiologist raised the possibility that Mr X may suffer with a gastroesophageal reflux disease with the classic angina-like chest pain.
Gastro-Oesophageal Reflux Disease (GORD) is a widespread disease; it is considered the most common digestive disorder in Western countries. It is due to permanent or transient incompetence of the oesophagogastric valve system, called “lower oesophageal sphincter” (LOS).
This system is a set of anatomical structures which perform a valve function. Incontinence of LOS causes reflux of gastric content into the oesophagus, causing a chronic inflammation which, in a reasonably long time, can result in the transformation of the oesophageal internal lining (gastric metaplasia, Barrett’s oesophagus), and then predispose to the development of cancer. Gastroesophageal reflux – which is usually more intense at night due to the supine position – causes pain; it is a stabbing pain behind the breastbone that can be mistaken for a heart pain.
Often, it gives heartburn and often acid regurgitation. The chronic reflux affects the oesophageal motility and causes an odd “globus feeling”, namely that “nagging feeling of a mouthful stuck in the throat.” GORD can also causes extra-oesophageal problems: cough, hoarseness, asthma, recurrent otitis, polyps of the vocal cords, dental erosions … up to pneumonia, cancer of the larynx and interstitial pulmonary fibrosis. Very often, GORD is associated with gallstones and colon diverticulosis – the so-called “Saint’s triad”.
On examination, Mr X is in good general condition. Abdomen is soft and moderately tender at palpation in the epigastrium. Medical history and clinical presentation are consistent with GORD. The diagnostic process includes oesophagogastroduodenoscopy (OGD), oesophageal pH monitoring, oesophageal manometry and barium swallow. OGD confirms the suspicion of reflux disease, with a big hiatus hernia and reflux esophagitis with a 4 cm Barrett’s oesophagus.
There is also duodenogastric reflux. Biopsies confirm the presence of Barrett’s oesophagus with no dysplasia and reflux oesophagitis. Barium swallow confirms the presence of the hiatus hernia and supine reflux. The 48-hour oesophageal pH monitoring – so-called Bravo test – confirms pathologic acid reflux. Manometry highlights an hypotonic LOS with nonspecific motility disorders of the oesophagus.
Failure of LOS is often associated with hiatus hernia. It is due to part – or sometimes the whole – of the stomach sliding into the chest through an enlarged hiatus. In turn, hiatus hernia can cause chest discomfort and pain, breathing difficulties and palpitations, especially in the postprandial period. Gastro-oesophageal reflux is usually associated with duodenogastric reflux of bile.
Sometimes, bile can flow back up into the oesophagus causing an alkaline oesophagitis, which is even worse than the “normal” acid reflux, as it is more likely to cause Barrett’s and predispose to cancer. All this can be clearly seen at endoscopy. In fact, the first test to be performed is OGD. It is to be admitted this is quite an “annoying” procedure, but it can be easily tolerated by anyone without the need for anaesthesia, also for its short duration. However, in very selected cases it can be performed under general anaesthesia. Oesophageal manometry is an investigation which studies the motility of the oesophagus and the LOS and can demonstrate LOS failure and alterations of oesophageal peristalsis.
This is not a common procedure and it is utilized very occasionally. It is usually well tolerated and takes just a few minutes. Oesophageal pH monitoring takes 24 or 48 hours. The classic investigation entails the use of a small wire into the oesophagus through the nose. This is connected to a transducer which analyses the variation of the acidity of the internal oesophageal environment. More recently, a new investigation is in use, called Bravo.
A probe is inserted and fixed to the internal oesophageal wall with an endoscopy. The probe is wirelessly connected to a recorder which should be kept within 2 meters from the patient’s body for 48 hours. It records all the variations of oesophageal pH during two “normal” days. In order to get reliable results, the patient is suggested to live a completely normal life during the investigation, as there is no wire coming out from the patient’s nose and the probe gives no discomfort or any other sign of its presence.
After 48 hours the recorder must be handed back to the hospital while the probe detaches by itself and is eliminated through the usual physiologic way. PH-monitoring is used to measure the extent and duration of reflux, and their correlation with the patient’s activities and symptoms. Manometry and pH-metry give a precise evaluation of the functionality of the LES and can detect the presence of acid reflux or oesophageal dysmotility.
Ultimately, these two diagnostic methods, together with endoscopy and radiography, allow us to choose the therapeutic strategy that is the most suitable for that single patient. In the last years a new investigation has been introduced in the clinical settings. It is the so-called Multichannel Intraluminal Impedence Monitoring, which is able to detect also non-acid reflux.
Based on the diagnostic findings and clinical history of the patient, I discuss with him the various treatment options. The presence of severe acid reflux with oesophagitis and Barrett’s oesophagus, along with a sizeable hiatal hernia, suggests considering antireflux surgery. However, it is worth trying with medical treatment instead of rushing to surgery, so I prescribe him the classical triad of proton pump inhibitor (PPI), prokinetic and membrane-protector, associated to the classic lifestyle recommendations. I will see him again in my clinic in 3 months time.
In the presence of GORD, there are three treatment options, each with its indications, contraindications and side effects. Medical therapy is based on PPI, prokinetic and membrane-protector. It is effective in many cases, but does not eliminate the cause of reflux and has not a great efficacy on non-acid reflux.
However, the main aim of drug therapy is to inhibit the production of gastric acid, protect the esophageal and gastric mucosa and try to improve the gastric motility in order to get it draining into the duodenum and not back into the oesophagus. Drug treatment should always be associated with some lifestyle changes: reduce the intake of foods that somehow stimulate acid production or are themselves acid (tomato, citrus, liquorice, mint, chocolate …), no smoke and alcohol, not lying down for at least two hours after the evening meal, tilt the bed so that the chest is raised with respect to the abdomen …
Drugs and lifestyle changes are lifelong treatments. Unfortunately, medical treatment is still not effective – or not completely effective – in about 30% of cases. Probably, these are cases where GORD is due to non-acid reflux, that is duodeno-gastro-oesophageal bile reflux. These are the cases where higher is the risk of Barrett’s and adenocarcinoma of the oesophagus.
Another group of patients are those where treatment is effective but they don’t want to continue taking lifelong medications, with their side effects and long term complications, or they developed intolerance to those drugs. When medical treatment is not effective or not tolerated, surgery can be considered. This choice cannot be taken easily, and general conditions of the patients, age, associated medical conditions and – mostly – their preference should be taken into consideration.
At followup visit, 2 months later, Mr X reports that medical therapy has improved his symptoms but they did not disappear completely and mostly they came back immediately when he stopped his medications. He is very keen to solve his problem once and forever, avoiding the nuisance of taking daily oral medications which he often forgets. I therefore offer him a more definitive treatment with antireflux surgery. Due to the presence of oesophageal dyskinesia I opt for a 270-degree fundoplication.
If we want to achieve a definitive treatment of GORD, that is, resolve the incontinence of the LOS, it is essential to recreate an high pressure zone whose length is more than 2 cm that can work as an antireflux valve between oesophagus and stomach. Such a result can be obtained by several methods.
The more diffuse of these methods entails fashioning a wrap around the distal oesophagus using the gastric fundus. The wrap can be complete (360-degrees) or incomplete (180 or 270-degrees). This operation is usually performed by keyhole surgery, that is, with 4-5 small holes on the surface of the abdomen.
Under general anaesthesia, the abdomen is inflated with carbon dioxide to create an operative space. The surgeon inserts four or five cannulas through which long surgical instruments and a camera are brought into the abdomen to create the wrap. The choice between complete or incomplete plication depends on the preferences and experience of the surgeon and on the preoperative evaluation of the oesophageal function.
Both types allow a very good control on gastro-oesophageal reflux but complete plication can have an increased risk of complications, namely dysphagia, that is, difficult swallowing due to an excessively tight wrap. Our preference goes to an incomplete plication. The patient is allowed to drink immediately after the operation, and to eat semisolid food within 8 hours. He/she can be discharged home when comfortable, usually 24 hours after the operation. At home, he/she should have a soft diet for about 3 weeks, and then gradually he/she can gradually come back to his/her normal diet.
Oral medications can still be necessary for some months after surgery. We should not forget that every surgical operation carries some risks and complications are part of surgery. Other than generic complications, such as allergy to any of the components of general anaesthesia or surgical wounds infections, there are specific risks of this procedure, namely dysphagia, lung injury, oesophago-gastric injury and bleeding.
The real rate of these complications is very low, less than 10%. Usually, it is quite easy to deal with these adverse events during the operation itself, either by laparoscopy or by open surgery after conversion. A certain degree of postoperative dysphagia may be normal and resolves spontaneously in about a month. In very rare cases, however, it may be necessary to dilate the plastic by endoscopy or even re-operate to “dismantle” the plastic.
In a quite low percentage of cases (less than 5%) it may not be possible to complete the surgery laparoscopically and is necessary to convert to laparotomy. Antireflux surgery is effective in about 90% of patients, which might have an absolute (about 70% of cases) or relative benefit (20%, with the need to take medical treatment from time to time). Indications for surgery are, as mentioned, lack of response to medical treatment, presence of hiatus hernia and/or anatomical LOS failure, patient not compliant with the medical treatment or not willing to take lifelong medications.
Mr X operation is uneventful and takes less than 60 minutes to be completed. As expected, patient goes home the very next day, with the prescription to continue taking PPI for 6 other months. After three months Mr X is eating and drinking normally, he has no dysphagia and he does not complain of any of his usual symptoms he had when we met for the first time. An OGD performed 6 months after surgery confirms the hiatus hernia has completely disappeared and oesophagitis has healed properly.
There is still a short segment Barrett’s (less than 2 cm in its maximum length). At next follow up, one year later, OGD shows that there is no Barrett’s and Mr X is completely asymptomatic. His voice is back to normal and his wife admits he restarted singing in the shower.