Thank you for choosing Augusta University Medical Center and the Minimally Invasive and Digestive Diseases Surgery Section at the Medical College of Georgia for your healthcare needs. This information is to help answer come common questions you may have about your operation and provide instructions to follow during your recovery period.
Reflux, or GERD (Gastro-esophageal Reflux Disease), is the upward flow of stomach acid into the esophagus. Common symptoms include central burning chest pain after eating (indigestion), bloating, belching, and regurgitation of bitter tasting fluid. Atypical symptoms include coughing, asthma, or other breathing difficulties. Most of the time, GERD can be treated effectively with medications. Some patients continue to have symptoms that are not controlled with medications, cannot tolerate the medications used to treat reflux or have changes in the esophagus indicating a continued acid reflux problem. These patients may benefit from surgery to decrease acid reflux into the esophagus and reduce associated complications like narrowing of the esophagus and development of cancer of the esophagus.
The most common surgery done to treat reflux is called a Nissen Fundoplication, or simply Nissen. Other similar operations may be done and depends on extend of reflux, length of the esophagus and ability of esophagus to move food bolus into the stomach (dysmotility). Recovery time, pain, diet and overall results are similar with each type of operation.
Most reflux surgery is done as an elective procedure and requires you to stay in the hospital 1-2 days. You will usually have an x-ray swallowing study done the morning after surgery and, if the study is OK, be advanced to a liquid diet before being sent home. You will have specific diet restrictions after reflux surgery and will be seen by a nutritionist before your discharge.
Preoperative Information
Prior to reflux surgery, you will be asked not to eat or drink anything after midnight prior to your surgery. You will be given specific instructions from your surgeon or anesthesiologist about which medications you should or should not take prior to your surgery. You should not take any blood thinning medications at least 5 days prior to your operation. This should be discussed with your surgeon at your preop visit.
Your work up before having reflux surgery will include an upper endoscopy to look directly at the esophagus and stomach and take any biopsies, if necessary, to look for precancerous and cancerous changes. You may also have a pH study to evaluate the severity of your reflux. This study involves a tube placed in your nose to the lower esophagus to monitor how often and severe your acid reflux is. A swallowing study (x-ray study) is also needed to show if the esophagus is narrowed at its lower end and the condition of the esophagus above the area of narrowing. You will also have a Manometry to evaluate the ability of the esophageal muscle to push a food bolus toward the stomach as well as the ability of the lower esophageal sphincter to relax when you swallow.
You will also have a detailed discussion with your surgeon about the risks and benefits of reflux surgery, including the possibility that your symptoms will not get better or that you may need to continue taking medications to help control your symptoms. If the upper endoscopy and pH study show a significant reflux problem and you have adequately tried medical therapy, and you continue to have poorly controlled symptoms, there is a good chance you will benefit from reflux surgery
If you are significantly overweight (BMI >35), the benefit of reflux surgery is much lower and symptoms are often improved with medical weight loss or weight loss surgery more so than reflux surgery. Your surgeon will discuss these options with you.
Postoperative Information
Most reflux surgery can be performed laparoscopically. In this case, you will stay in the hospital overnight and likely be discharged 1-2 days after surgery.
In the event that you require an open reflux operation, you may have to stay in the hospital a little longer for pain control, though not in all cases.
Activity
You can resume most usual activities gradually beginning shortly after surgery. You
should begin walking the night of surgery or the following morning and continue to
increase as you are able. Increased activity reduces the risk of blood clots, and
improves breathing to prevent pneumonia
While in the hospital, you will be asked to walk several times a day, beginning no later than the morning after surgery in most cases. You will usually need assistance to get out of bed, especially the first time, since you will likely have IV tubing and sometimes drains or catheters that need to be disconnected in order for you to get around. A Physical Therapist often helps you get out of bed and regain your strength after major surgery. Walkers, canes or crutches will be made available as needed. In some cases a short stay in a rehabilitation center or short-term nursing home may be needed. This is uncommon and usually only needed for people who had to have emergency operations or had some other complications and a long hospital stay.
After discharge from the hospital, avoid lifting more than 10 pounds for 4 weeks and excessive bending or twisting for 1-2 weeks following surgery. This is to allow healing of the incisions, specifically the fascia (the strongest layer of the abdomen wall) and decrease the risk of a hernia developing. For laparoscopic reflux surgery there may be less risk for developing a hernia and it may be safe to return to unrestricted activity sooner.
Avoid driving until you no longer need narcotic pain medication. Driving while taking them can impair your ability to drive safely.
You should be able to return to work in 1-3 weeks. If your job involves heavy lifting and light duty is not an option, you may need up to 4 weeks off work to recover
Wound Care, Drain Care, Ostomy Care
If your reflux operation was done laparoscopically, small gauze and clear tape dressings
or a small white dressing is typically placed over each incision. These dressings
can be removed 48 hrs (2 days) after the operation. If you are in the hospital more
than one day, these may be removed before you leave the hospital. Below this dressing
are small brown or white pieces of tape (called Steri-Strips); these will fall off
on their own within 1-2 weeks or be removed at your follow-up visit with your surgeon.
If your surgeon gives you specific instructions other than this, please follow those
instructions.
If your reflux operation was done open, you will probably have a long white dressing or gauze and tape dressing over your incision. This dressing can be removed 48 hrs (2 days) after the operation and will probably be removed before you leave the hospital. Your incision will probably be closed with small metal staples. These will be removed at your postop visit, usually 10-14 days after your operation. If you are in the hospital more than a week, these may be removed before you go home.
Occasionally, a feeding tube (gastrostomy) is placed into the stomach at the time of a reflux operation. If this is necessary, you will be given specific instructions on how to care for the tube, including how to clean it, flush it and administer medications or feeding. You will also see a nutritionist who will assist you in learning about the tube and any feeding you may need.
You may shower after 48hrs (after the gauze and clear tape dressing is removed). It is okay to get soap and water on the incisions. Pat the area dry. You will be able to shower in the hospital after 48hrs as well. Your nursing staff can assist you if needed. It is not recommend that you submerge underwater (in a bathtub, pool, or hot-tub) for at least two weeks post-op.
If you notice drainage from your incisions, particularly if it is thick and foul-smelling or associated with a fever, you should contact your surgeon.
If you notice redness around your incisions, especially if it is getting worse or associated with drainage or a fever, you should contact your surgeon.
Medications - Pain Management
You may be given as-needed IV pain medicine immediately following surgery or placed
on a device that provides pain medication to you whenever you press a demand button
(called a PCA, or Patient Controlled Analgesia). Once you are able to start taking
an oral diet, the IV medication will be weaned off and you will be started on oral
pain medications. It is very important to us that your pain be well controlled. Your
pain should be controlled well enough for you to begin getting out of bed the morning
after surgery and for you to perform deep breathing exercises. If you have pain that
is not well enough controlled to allow you to walk or breathe deeply, talk to your
surgery team. You may need to have your pain medications changed or increased.
If your reflux operation is performed laparoscopically, pain is typically just around the site of incisions. However, you may have more general abdominal pain or even shoulder pain due to the air used to inflate your abdomen during the surgery. Pain from air inflation will go away in 24 to 48 hours. If an open operation is needed, there may be more pain during the first few days after surgery.
You will be discharged with pain medication, typically a mild to moderate strength narcotic. Take as needed and as prescribed. You may also take over-the-counter medications such as advil for pain. Most narcotic medications prescribed are combined with Tylenol (acetaminophen) and you should not take additional Tylenol if you are taking a narcotic medication that already contains Tylenol.
Nausea
It is very important to control any nausea you might experience after your surgery,
particularly if the stomach is wrapped partially or completely around the esophagus
as part of the surgery to reduce any anticipated postoperative reflux. You will have
access to IV anti-nausea medication throughout your hospital stay. Oral anti-nausea
medication or rectal suppositories that can control nausea will be prescribed as needed
upon hospital discharge. Please let your surgeon know if you develop nausea after
discharge so that he or she can address this further.
Other Medications
You will likely be prescribed a stool softener when you go home. Pain medications
can cause constipation and a stool softener may help. You may also be given nausea
medication if you have experience nausea or vomiting from taking your pain medication.
Home Medications
Unless otherwise instructed, you should be able to resume your usual home medications
the night of or the morning following your surgery.
Diet & Bowel Care
Following reflux surgery, you will be given specific diet instructions and be seen
by a nutritionist.
More details about post-Nissen diet
Many patients will notice their stomach feels very full quickly and have bloating after having hiatal hernia surgery if the stomach wrap is also performed. This happens because you are not able to belch normally after reflux surgery. Eating smaller meals, separating intake of solids and liquids, and avoid foods or drinks that you know make you gassy (such as carbonated beverages, alcohol, some vegetables) will help with these symptoms. You may also need to take nausea medication prescribed by your doctor. This usually gets better within a few weeks after surgery when the swelling of the stomach wrap goes down.
It is common to have some constipation after surgery, especially when taking narcotic pain medications. You will probably be prescribed a stool softener when you are discharged. If you are having trouble moving your bowels after surgery (if your stool is hard or you have to strain excessively) you may need a laxative. Over the counter medications can treat this well. Senna, Miralax, or dulcolax are some of the most common and are available at most drug stores or grocery stores. Take as directed.
If you are having trouble having a bowel movement AND have abdominal bloating, nausea or vomiting, and not passing gas, you should call your doctor.
Follow Up
You will be given a date and time to see your surgeon following surgery, usually 3
weeks if done laparoscopically and10-14 days if done open. You will likely be given
your follow-up date when you see your surgeon for preop. If you are discharged late
in the day or over the weekend, you will be given a number to call the following business
day for an appointment. If you are having trouble making an appointment, you should
call your doctors' office directly for assistance.
Call Your Doctor If:
Contact Information
Daytime hours: Call 706-721-4686 or 7597
After hours and weekends: Call 706-721-8400