Gastric Sleeve Surgery

What investigations are required prior to considering anti-reflux surgery in Tauranga?

All patients require a Gastroscopy.  This is where a flexible endoscopic camera is passed via the mouth, down the oesophagus, and into the stomach. This procedure is safe and takes about 15 mins. It is typically performed with some sedation (not a full general anaesthetic) and local anaesthetic throat spray that numbs the back of the throat and helps prevent gagging.

Gastroscopy is vital to:

• demonstrate whether there is visible inflammation of the oesophagus (because of acid)
• discover whether a hiatus hernia is present or not
• ensure there are no other more sinister causes for the symptoms (cancer or pre-cancerous conditions) (This is especially important in those over the age of 50)

However, a normal gastroscopy does not necessarily mean that a patient does not have GORD. It may just be that there are no visible signs of it.  In fact, having no visible signs of GORD is common, with approximately 50% of those with GORD having no signs of inflammation on gastroscopy. BUT, if this is this case, before surgery can be offered, objective confirmation of the diagnosis must be achieved via another investigation – namely, pH monitoring.  This is a specialised test that is not performed in Tauranga at present (so requires a trip over to Hamilton!).  It is conducted by a Specialist Gastroenterologist and gives a very accurate and objective measure of whether reflux is occurring and if so, to what severity.

Occasionally, a special x-ray called a barium swallow is also required.

What operation is performed to treat reflux?

The operation that is typically performed to treat reflux is called a Fundoplication. A fundoplication involves wrapping the top ‘floppy’ portion of the stomach around the base of the oesophagus.  This creates a mechanical valve that helps stop acid reflux up into the oesophagus.  

If there is a hiatus hernia present as well (and there almost always is) this is repaired by bringing the stomach down out of the chest and tightening the “hole” in the diaphragm through which it was protruding.  This repair is performed with sutures (not mesh).  

The operation is a key-hole (or laparoscopic) procedure, takes approximately 2 – 2.5 hours, and requires 2 nights in hospital.

What results can I expect after anti-reflux surgery?

Studies that have involved large numbers of patients undergoing anti-reflux surgery, have consistently demonstrated that quality of life after surgery significantly improves.  Eighty to 90% of patients 10 years after the surgery continue to report markedly reduced symptoms of reflux.  Several long-term follow-up studies suggest excellent results even at 25 years post-surgery.  

However, proportion of people do need to go back on acid suppression medication some years after surgery. This typically controls symptoms.

Potential complications and side-effects of surgery

No surgery is risk free. Fundoplication is a major operation that carries both the risk of serious complications that are very rare, but also the potential for some side-effects that, though not usually severe, are more common.

General risks of any abdominal surgery

• Bleeding: There is a 1 – 4% risk of bleeding during or immediately after surgery, to the extent that a blood transfusion is required.
• Infection: All surgery carries risk of infection, ranging from minor infection of wounds to serious infections within the abdomen. With laparoscopic anti-reflux surgery these risks are very low – although deep abdominal infections are serious if they occur.
• Injury: The insertion of laparoscopic ports and instruments can result in injury to bowel or other organs (eg spleen).

Risks specific to fundoplication and hiatus hernia repair

• Food/fluid unable to be swallowed – regurgitation/retching: This can occur if the wrap is too tight, such that it prevents the passage of food. If it occurs early (within 24h) a return to theatre to loosen the wrap may be required.
• Pneumothorax: Sometimes a breach can be made into the chest cavity (where the lungs sit) during this operation. This does not usually cause any problems.  Rarely, however, it can cause a the lung on the affected side to collapse.  This would then require the placement of a chest drain.
• Perforation of the oesophagus or stomach: Rare (1%).  If recognised during the procedure, these injuries can be repaired at the time.
• Conversion to open (non-laparoscopic) surgery: Very occasionally (<1%) technical difficulties or complications encountered during the procedure may require conversion from a key-hole (laparoscopic) operation to an open operation requiring a large abdominal incision.  Were this to occur this would significantly prolong both in-hospital and subsequent recovery.
• Failure of the wrap/disruption of the repair: Rarely, severe retching immediately after the surgery, can cause the repair or wrap to come apart.  This would require return to theatre – ideally within 12 – 24 hours.

Potential Side-Effects

• Bloating/Unable to belch/Increased flatulence: A fundoplication wrap makes it difficult to belch (burp).  This means that gas is easily trapped in the stomach with the result of causing increased abdominal bloating.  This can sometimes be very uncomfortable. This is worsened by anything that increases gas in the stomach – such as fizzy drinks. A variety of surgical techniques are used to try and prevent (or minimize) this side-effect.
• Dysphagia (food not going down): This can sometimes become more of a problem as time goes by.  This might because of scarring. Sometimes it is because the hernia repair has failed and the stomach has gone back into the chest. Depending on the severity there are a variety of endoscopic or surgical options that can be used to address this.

Death

Anti-reflux surgery is very safe. Published mortality (death) rates are typically less than 0.1% (< 1/1000).

Recovery – after surgery

In hospital

Day of surgery:

- You will wake up in the recovery unit.

- When recovery staff deem appropriate, you will be transferred to the ward

- Key medical interventions on the ward (Day 0)

• DVT (clot) prevention: This is achieved through compression (TED) stockings, Flowtron calf compression pumps, and Clexane injections
• Pain relief
• Regular anti-nausea medication

- Key patient objectives on the ward (day 0)

• Encourage early mobilisation (up-to-chair)
• Deep breathing exercises
• Sips of water as desired

Day 1 post op

- The first day after surgery is primarily about increasing mobility and gradually increasing the volume and consistency of fluid you can tolerate.  

- You will be reviewed by Dr Mafi and by a physiotherapist during the day

- Key medical Interventions (Day 1)

• Physiotherapy and guided mobilisation
• Increase diet to Free fluids (includes soups)/sloppy diet
• IV medication switched to oral medication (including pain relief)
• Remove urinary catheter if present
• Stop IV fluids
• Continue all anti-blood clot measures

- Key patient objectives on the ward (Day 1)

• Aim to slowly drink at least 1L of water over the day
• Increase mobility (short walks)
• Continue deep breathing exercises

Day 2 post op

- Diet is usually increased to puree/soft diet.

- Increase frequency and distance of walks (Physiotherapist input)

- Most patients will be ready for discharge on Day 2

At home

- Patients will be discharged with a prescription for some medications:

• Simple pain relief
• Anti nausea medication
• +/- laxative

- Continue to take all your usual medications that you were on before your surgery

- TED stockings should be worn for a total of 10 days after your surgery

- Refrain from alcohol and fizzy drinks

Dietary Instructions for when you get home

Your post-operative diet should be a soft or pureed diet for at least 2 weeks.  You can gradually return to a normal diet thereafter.

Return to work

- Most people will be ready to return to work by 2 weeks

- If you have a desk job, you may feel up to returning after 7 – 10 days

- No heavy lifting (> 5kg) for 4 weeks

Follow-up

You will be seen by Dr Mafi at:

- 1 week (to check wounds and dressings)

- 4- 6 weeks

- 4 months