Gastroesophageal reflux (GORD) is common reported by 5 %-10% of our population as a daily occurrence,15-20% as a weekly event and experienced by 25-40% monthly. It occurs when gastric content flows up into the oesophagus across the lower oesophageal sphincter initiating a burning sensation that is felt rising behind the breastbone and at times is associated with an acidic taste in the mouth. Symptoms of GORD are best investigated by upper gastrointestinal endoscopy.
These more classic symptoms referred to as heartburn may be associated with mucosal inflammation, scarring and the development of Barretts intestinal metaplasia over time. Symptoms may also be reported by patients who are found to have very minor or no inflammation at endoscopy and this is referred to as non-erosive reflux disease (NERD). Indeed 60-70% of patients with reflux symptoms have NERD whilst only 30-40% have erosive changes found at endoscopy. It is Interesting that the relationship between symptoms and endoscopic findings is often poor.
The description of typical reflux dyspepsia outlined above contrasts with silent reflux where regurgitation may be occurring, as demonstrated by oesophageal pH monitoring, but without classic heartburn symptoms. As many as 20-30% of patients with actual reflux may be in this category. Some of these patients are said to have laryngopharyngeal reflux and may report a number of extra-oesophageal symptoms including chronic cough, nocturnal exacerbation of asthma, repeated micro aspiration, hoarseness, globus sensation, halitosis, dental enamel erosion and non-cardiac chest pain.
Whilst medical management is generally very effective and includes acid suppression using pharmacologic treatments combined with lifestyle modification focussed on weight loss toward a healthy BMI as well as reduction in exposure to caffeine containing drinks and alcohol. Other advice includes the recommendation to eat 3 hours before retiring and to avoid smoking. Despite these relatively simple conservative strategies there are still some patients who fail to respond, have breakthrough symptoms or would like to consider surgical options. Eventually about 1-3% of patients with chronic reflux or complicated reflux will progress to corrective surgery by fundoplication. This technique has high success rates in selected patients quoted as 85-90% at five years although 5-10% may require revision and 15-30% resume acid suppression treatment at some point post operatively.
To review the surgical approach to GORD management in more detail we are joined by upper gastrointestinal surgeon Dr Hamish Shilton.
Hamish performs upper gastrointestinal surgery through predominantly laparoscopic and robotic techniques including management of oesophageal neoplasia by minimally invasive esophagectomy but also hiatal hernia repair, cholecystectomy and bariatric surgery. He completed subspecialty training in both Auckland and Norwich in the UK - both high volume bariatric and oesophageal cancer units. He works at Cabrini Hospital Malvern and has an appointment at Monash Health in Melbourne.
Please welcome Hamish to the podcast.
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