The Silent Burn: Understanding GORD Beyond Heartburn
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Gastroesophageal reflux disease, or GORD, is more than just heartburn. It's a chronic and often progressive condition that affects up to 20% of adults in Western countries, including Australia. While common, the diagnosis and treatment can sometimes be challenging. Symptoms can often overlap with upper GI disorders, and not all patients respond predictably to standard therapies. Additionally, some may present with non-erosive reflux or atypical symptoms such as chronic cough or laryngitis, making both detection and management more complex.

Today I'm joined by Dr. Harsh Kanher, a highly experienced upper GI and hepatopancreatobiliary surgeon. Dr. Kanher brings a wealth of international and Australian experience, having trained in India and in New York's Memorial Sloan Kettering Cancer Centre and across major Australian hospitals. He is currently the head of upper GI surgery at the Royal Allied Hospital. In this episode, we'll explore what exactly gastroesophageal reflux disease is. So whether you're a student, junior doctor or experienced clinician, join us.

Tune in for a comprehensive and practical discussion on gastroesophageal reflux disease. Welcome to Aussie Med Ed. G'day and welcome to Aussie Med Ed, the Aussie-style medical podcast. Our pragmatic and relaxed medical podcast designed for medical students and general practitioners, where we explore relevant and practical medical topics with expert specialists.

Hosted by myself, Gavin Nyman, an orthopedic surgeon, this podcast provides insightful discussions to enhance your clinical knowledge without unnecessary jargon. I'd like to start the podcast by acknowledging the Kaurna people as the traditional custodians of the land on which this podcast is produced. I'd like to pay my respects to the elders both past, present and emerging.

and recognising their ongoing connection to land, waters and culture. I'd like to say that this podcast is for educational purposes only and does not constitute medical advice. Always refer to clinical guidelines and consult a qualified healthcare professional before making medical decisions. It's my pleasure now to introduce Associate Professor Harsh Kaniyar, the head of the Upper GI Unit at the Royal Aid Hospital. He's going to talk to us about gastroesophageal reflux disease and issues associated with it. Welcome Harsh, thank you very much for coming on Aussie Med Ed.

Thanks, Gavin. Thanks for having me. Pleasure. It's great to have you here to hear about this really important condition. I believe it affects about 20% of those in Australia. And perhaps you can tell us exactly what is gastroesophageal reflux disease and how it differs from occasional reflux.

Yeah, so 20% is a ruled estimate that affects the Australian population. When we say someone's got reflux disease, we really talk about the stomach regurgitating or refluxing back into the esophagus. Mainly affects the lower esophagus, but sometimes can go quite high into the esophagus as well.

from a symptomatology point of view. We all know that we all occasionally get the heartburn when we've had hot spicy food or done something that we shouldn't do from an eating or drinking point of view. But that's an occasional bit of reflux that we can all live with. However, people who get reflux every day continually, it's a really significantly debilitating problem and affects their quality of life quite significantly. So...

Those are the ones that really need treatment, and the 20% of Australians, the one you find Australians do suffer from reflux from what we know, but the percentage might be even higher because we don't really come across everyone who has reflux that doesn't present to GP, so they've got this problem.

Okay, and what are the main symptoms you'll get of it? Is it purely heartburn or are there other symptoms in my experience? Heartburn and indigestion are the two most commonly presenting symptoms. When we say heartburn, it's really a burning sensation behind the centre of the chest, retro-sternal as we call it, behind the sternum, and a significant burning sensation there.

A lot of people call that indigestion type symptoms. So when you ask patients what exactly they mean by indigestion and grill it down, they will say they get burning sensation in the chest. Yeah, that's the most important symptom.

However, some people do get non-acid reflux. There's fluid and fluid that regurgitates from the stomach up into the esophagus, and that's seen many times in people who have hiatus hernias and in recovery condition. That's another common symptom that's experienced by people with reflux.

The atypical symptoms, ones that are not categorically related to reflux but may have association, are respiratory symptoms, chronic cough, people having dry, hacking cough, related to reflux but not quite because of reflux many times. Some people can complain about sinusitis, ENT symptoms. But those are the main typical symptoms of reflux.

At times, because of acid, people may get myelophageal or esophageal spasm. So a significant amount of chest pain might be the other symptoms. What we do see is sometimes in large hiatus hernias that people have reflux. But a couple of unrecognized symptoms of those large hiatus hernias are shortness of breath,

and iron deficiency in the air. So those two are also quite commonly seen in people who have large, high dysthernias. And there's various reasons for that which we might touch on in the physiology of this. Obviously, retro-sternal chest pain always makes people concerned about something like a cardiac event. What other conditions can look like it and how can you differentiate between a cardiac event and esophagitis or reflux? Most commonly...

Rather than pain, it is a burning sensation in the retrosternal area. And people at times do confuse it with cardiac pain, and certainly cardiac pain is one of the differentials of reflux. Typically with reflux, the pain doesn't get referred to the left shoulder or down the left arm or anything that's caught. It is many times daily in people who have more reflux. It's

A bit different to having cardiac pain. Having said that, we do need to differentiate it from cardiac pain and do all the investigations to make sure it's not of cardiac origin. And reflux sometimes can be a diagnostic elimination. So what other conditions could look like reflux then in that scenario? Gastritis. Gastritis usually is an acute condition, but they do present with similar symptoms. At times, people who have gallstones can have

Similar symptomology, although not exactly the same. Typically biliary colic, which is pain from the gallstones, you do get a significant amount of pain in the epigastric region, and then that radiates to the back or the outside. But that epigastric pain can sometimes mimic reflux-type symptoms. So those are mainly the symptoms.

Okay, so gastritis is something that most of us would experience after maybe having a big night out, a bit of alcohol? Yeah, pretty much, pretty much. And gastritis, on the contrary, we see a lot of patients diagnosed with gastritis who are presented to an emergency department. Gastritis doesn't actually cause a lot of pain, but it does cause a fair bit of nausea, vomiting, reflux-type symptoms, heartburn, burning sensation in their gastrointestinal

So, yeah, it does mimic your ride. It's visually associated with a big night out or something of that sort. What are the main risk factors for developing reflux then, Harsh? Are there particular things we need to watch out for? Look, the clear factors that we know of are smoking,

caffeine intake, weight. So obesity definitely is related to significant reflux disease. There is an association of kids, so children who have reflux, and that's an underdiagnosed condition as well at times. People who have reflux as infants or children will carry on to have significant reflux later in adult life as well, unless that was treated during childhood. So

Weight gain, increased caffeine intake, cigarette smoking are definitely the risk factors. Hiatus hernias. So hiatus hernia is a bit of a different entity in the sense that hiatus hernias may present without reflux and have other symptoms. But hiatus hernias can again be related to multiple pregnancies in women. Weight gain, collagen disorders as well can predict for hiatus hernias.

So yeah, I think those are the known risk factors. Male gender, slightly more preponderance of reflux, probably because of lifestyle more than anything. And beyond that, I think we really don't know. Some people just have some predilection to develop reflux, and that's because there are so many protective factors in the body that can go wrong. Those other things are difficult to pinpoint.

I understand when you have reflux, you should avoid anti-inflammatory medications. Is that because the anti-inflammatory medications can make the reflux worse or it causes reflux in the first place?

Not so much that they cause reflux, but they do increase acid production and reduce the protection of the mucosa from the acid that's produced. They don't per se cause reflux, but it's this indirect action on the prostaglandin inhibition that causes increased acids and the effects of acid from the stomach.

So more related again to gastritis many times, that reflux as such. So the non-steroidals are ulcerogenic in terms of peptic ulceration. I'd like to let you know that Aussie Med Ed is sponsored by VART, Medical Legal Indemnity Insurance. They tell me they offer holistic support to help the doctor practice safely and believe they have extensive cover that's continually evolving to meet your needs in the ever-changing regulatory environment.

They have a specialist medical indemnity team located here in Australia and have access to medical legal experts 24-7 in emergencies. And is that why you should also avoid blood thinners such as Warfarin and other medications in that scenario because of the risk of bleeding associated with it? Or was there any other reason for it as well? Look, we are not all that concerned in people who have mild reflux esophagitis with being on anticoagulants.

And just going back to what I said earlier, with large hiatus hernias, there is a risk of iron deficiency anemia. And sometimes these people develop what's called as Cameron's erosions or Cameron's ulcers. These are basically ulcers which are formed in the stomach.

where the stomach is indented by the diaphragmatic crura. And they're more vascular insufficiency kind of lesions than acid-related, but these can bleed, and they can bleed quite a bit. And that's where we are a bit concerned about people being on anticoagulants, aspirin. Aspirin by itself is a little bit of a problem in people who have reflux because it has that non-steroidal property.

to an extent. That's why we are a bit cautious with using aspirin. Sometimes we actually change over from aspirin to clopidogrel or something non-gastritis produced type medication. What about the high dysphonia then? How does that actually cause a reflux? Does it just affect the sphincter at the bottom end of the esophagus or is there other reasons for it? So I'll just go to what

prevents reflux from occurring in the first place in normal adults. There are protective mechanisms. So essentially, the epithelium of the esophagus is not really equipped to deal with any acid coming up from the stomach. So the esophagus has a squamous epithelium. Stomach has a columnar-type epithelium with goblet cells that secrete mucin that protects against the acid.

which is not there in the esophagus. So there need to be some protection or protective measures for this acid to not come up into the esophagus. And the first and foremost is the lower esophageal sphincter.

So the lower esophageal sphincter is basically a thickened smooth muscle at the bottom end of the esophagus, which naturally opens up when the food is peristalsing through, but snaps shut, so to speak, if anything from the stomach wants to come back up into the esophagus. This lower esophageal sphincter is normally entirely intra-abdominal. So this is in the abdominal portion of the esophagus.

The other protective mechanisms are what's called a phrenoesophageal ligament, which binds the esophagus, stomach, and the diaphragm together and keeps it in one place and avoids movement of the esophagus. Being in the abdominal portion, so the lower four or five centimeters of the esophagus are in the abdomen, and that means it's in a positive pressure area. So things from the stomach are not allowed to reflux up so much.

When there is a hiatus hernia, essentially we're talking about a situation where part of the stomach has migrated up into the posterior mediastinum. There's two types of hiatus hernia, sliding and rolling. Typically, with either of these, you do get reflux symptoms. But with the sliding type hiatus hernias, the gastroesophageal junction actually migrates up into the mediastinum.

And as it goes into the mediastinum, it's then exposed to a negative pressure zone because every time we breathe in and out, there is negative pressure in the chest. And that renders the lower esophageal sphincter quite ineffective and it can't snap shut. And that's what predominantly causes the acid reflux or allows the acid to come up into the esophagus. When there is a rolling type hydroscania,

The gastroesophageal junction might still be below the diaphragm, but the fundus of the stomach rolls up by the side of that into the chest. And again,

the diaphragmatic hiatus is widened and that stomach sitting next to the gastroesophageal junction again makes the lower esophageal sphincter go ineffective and it again doesn't work. And again, in those type of hiatus hernias, the other structural mechanisms are also disrupted. So the phrenogastric ligaments all get disrupted when there are large hiatus hernias and

and they don't hold things in place. So that predisposes people to have a lot of reflux. Okay, that's amazing to hear this. Just thinking as you're talking about it then, if we look at 20% of the Australian population as having reflux disease, what percentage would have high-dose hernias? So what are people who don't have any risk factors, including high-dose hernia, what percentage of those people have reflux as well? Hard to say. Gavin, we are in an obesity epidemic, unfortunately, and

20% of Australians have reflux, but over 40% of Australians are overweight, DMI criteria-wise. So there is a strong association there. You don't have to have a heart ashenia to have reflux. Reflux can just be because of degenerative changes in the smooth muscle, the lower esophageal sphincter.

And unfortunately, as we age, the muscle tone and the muscle strength does decrease, and that can predispose to reflux. So you're right that all 20% don't have these known proven risk factors, but they do get reflux. We do see a lot of people actually have

small hiatus hernia. So what we're talking about is one to two centimeters of hiatus hernia, but they've absolutely never experienced reflux in their lifetime. Those people we don't really need to do much about apart from a baseline endoscopy to rule out that there is no sort of silent reflux going on. So

So what I mean by that is that the acid's causing some damage to the lower esophagus, but people are just not getting symptoms from it. So those are the ones that can be a little bit tricky, but a baseline endoscopy is really a good thing for them if an incidental small hiatus hernia is diagnosed. But many times these small hiatus hernias are actually diagnosed on an endoscopy, which has been done for some other reasons.

What you're really saying, though, in the vast majority of people, if we could get rid of smoking and get their weight under control, then this wouldn't be such an issue. It wouldn't be such an issue. And there's certainly a direct correlation with weight and reflux.

And we know that there is a significant correlation between weight and developing gastroesophageal junctional cancers, as well as other cancers. So definitely, I think primary prevention with weight reduction is significantly important.

And smoking. Yeah, of course. We talked about the symptoms and purely just based on the symptoms, you can get an idea of the diagnosis. But how do you actually confirm that diagnosis? What other investigations would you do? Yeah, great questions. We always say clinical, radiological and sometimes biochemical.

There's not much biochemical in terms of diagnosing reflux, but what we typically say is clinical symptoms, endoscopy findings, and radiology are the three sort of cornerstones. So clinical features typical of heartburn, indigestion, in some people, shortness of breath, iron deficiency, anemia, we would always consider doing an endoscopy.

On endoscopy, the things to look for would be finding of a hydrosania reflux esophagitis, and that's classified from grade A to grade D based on Los Angeles classification. So we typically would write in the report LA grade A to B to C or D being the most severe condition.

esophagitis or findings of Barrett's esophagus on the endoscopy. Again, looking for hiatus hernias, boat sliding, rolling. A lot of people who are on proton pump inhibitors because of clinical symptoms, we might see gastric polyps and things like that in those patients on endoscopy.

And then, of course, radiologically, you can do a barium swallow or enlarge hiatus hernias. We many times do a CT scan of the chest to look for the anatomical disposition of the hiatus hernias, as well as to rule out any respiratory causes or respiratory symptoms, if there are any respiratory symptoms. So those are quite helpful. Based on the endoscopy and clinical findings, we sometimes, not in all instances, but the majority of the times now,

progress on to esophageal physiology testing. So that involves testing the actual pH in the esophagus as well as the motility of the esophagus. Typically call them the pH and manometry studies. And that involves putting a thin catheter through the nose that sits across the gastroesophageal junction and actually measures the pH over 24 hours in the esophagus.

And that gives us a very good idea as to how long the esophagus is being exposed to acid.

If there is no acid reflux, but there is only fluid and food regurgitation, impedance pH measurement is actually quite a good test. So they can both be done at the same time. So with the impedance pH measurements, what is done is there's an electric probe that goes along with a pH measurement. And every time there's fluid that comes up into the esophagus, the electric current is impeded because of the fluid.

So we get to know how many fluid regurgitation episodes are present in people with reflux. So basically, if someone comes to me with symptoms of reflux, we start with an endoscopy, do a pH and manometry study, and sometimes we get a barium swallow or a CT scan.

Okay. What about the patient who has the atypical type symptoms? You've made the diagnosis, you do exactly the same investigations as well in that scenario. Are there any things you might do to try and exclude any other causes as well? Absolutely. Great question. Because I think many times the decision to do surgery on large hiatus hernias for shortness of breath or iron deficiency is basically dependent on diagnosis of elimination.

And we do need to exclude other causes for shortness of breath, essentially cardiac and respiratory for shortness of breath.

And iron deficiency anemias, again, we get a lot of people that actually get sent to us by hematologists who are investigating iron deficiency anemia and can't find a cause for iron deficiency anemia. But they get a CT scan, and on the CT scan, there's a large hydrosania. And sure enough, we do an endoscopy, we might find small erosions. So in those instances, both shortness of breath and iron deficiency anemia,

What I can say is these are very under-recognized symptoms of hiatus hernias. They might not be the absolutely only cause for these symptoms, but they definitely contribute to these symptoms. And if there is no other significant cause found, then it's definitely worthwhile looking at operating and fixing the hiatus hernias.

And just before you progress, you mentioned Barrett's esophagus. Perhaps you can just outline what that is, as well as also you mentioned also the use of proton pump inhibitors causing gastric polyps and why that was the case as well. Sure. Look, Barrett's esophagus is basically the body performing a protective mechanism to protect the lower end of the esophagus from the acid. And that's

A fascinating change. So essentially, the squamous epithelium of the lower esophagus start changing over into a columnar type epithelium with intestinal type of mucosa to essentially try and protect against the acid that's constantly refluxing into the esophagus. So it is effectively a metaplastic change, which means

Obviously changing from one type of epithelium over to another type of epithelium. Now unfortunately, despite the body being such a fascinating machine, so to speak, this change is not perfect and that mucosa is quite unstable.

And if Barrett's is then continuously again exposed to acid, then that goes through architectural disruptions and changes and goes on to forming low-grade dysplasia, progresses to high-grade dysplasia, and ultimately can progress to adenocarcinoma esophagus.

Touching on your second question in terms of proton pump inhibitors causing gastric polyps, that's a well-known thing. And that's predominantly, I think, because they suppress the acid production. And that provides a negative feedback to the glands in the stomach to hypertrophy and start producing more and more gastrin. And that's what leads to multiple gastric polyps. These polyps, many times, fundic gland polyps,

can be benign. Hyperplastic polyps can be benign. Gastric polyps, we're not too concerned about unless they are related to certain specific conditions. PPIs causing gastric polyps usually will not cause any major problems. Having said that, there is new evidence with H2 receptor blockers as well as some PPIs being linked to developing gastric cancers with high dosage over a long period of time.

In fact, I think ranitidine has now been removed from the US FDA's list of medications because of that risk.

We've gone to the treatment of gastroesophageal reflux disease. What are the first lines of treatment? Obviously, you've implied stopping smoking and weight loss is important, and obviously other lifestyle factors. What about exercise? Is that part of it, or does that just help you lose weight? Look, I think it helps to lose weight. It helps to keep yourself in a good sort of physical as well as psychological condition, I think.

But yeah, as you alluded to, it's a stepwise process in terms of treatment or reflux. First and foremost, you need to look at what the cause of the reflux is. If it's a large hiatus hernia and the patient is fit and well,

then surgery might be the best thing to offer. Having said that, most people have small hiatus hernias. They might have some other risk factors in terms of comorbidities. So the first line treatment there is usually going to be lifestyle modifications. Try and lose weight, eat healthy.

decrease the use of caffeine, reduce the alcohol intake, especially fizzy drinks, beers, which is a bit difficult for us Aussies, unfortunately, and smoking. So stop smoking. Those are the main sort of pillars. We initially start with low-dose proton pump inhibitors, something like pentoprazole, esomoprazole in low doses, 20 to 40 milligrams once a day.

It's important regarding the timing of taking these medications. Typically, they were prescribed to be taken at night before sleep, but we do know that they're best taken half an hour before a meal, many times half an hour before breakfast in the morning so that you get through the day without getting problems with acid heartburn and reflux. So that's first-line treatment.

We then have to see how they're progressing with this treatment. Some people really do very well with these treatments and don't require anything. Others, unfortunately, require sometimes escalating doses of the proton pump inhibitors. And then we really have to look at them in terms of saying, do you want to be on this high-dose proton pump inhibitors throughout the rest of your life?

Or should we look at doing surgery to treat the reflux? And certainly in fitted middle-aged young people, we would consider doing an operation. But we do say that people with reflux probably should do their surgery rather than straight away go to surgery. With hiatus hernias, however, if they have a large hiatus hernia, I think surgery is a better option than looking at

just lifestyle modifications. Before we move on to the surgery, one of the other things I read up about was the issues with dysphagia with reflux as well at the upper end of the esophagus. Is that an issue as well or is that just pretty rare?

It's not unusual. We do see a few patients who do get septic strictures from constant acid reflux. And at times it becomes quite a difficult situation where we have to basically rule out any malignancy or malignant strictures before we call them benign strictures. So again,

In the lower end of the esophagus, any stricture that's there, you set out thinking that this is going to be a malignant stricture unless you can prove otherwise.

And many times, certainly, we've come across a situation where people get dysphagia from these strictures. The other interesting phenomenon with reflux disease is something called as a Schatzky ring. Some people develop a fibrous ring at the lower end of the esophagus, which at times is an attempt, again, of the body to narrow things down to avoid the constant acid reflux.

But that Schatzky ring, if it's severe, can cause dysphagia and difficulty in swallowing as well. So there are instances where you can get dysphagia with reflux. You then have to be careful and make sure that it's benign stricturing or benign issues and hasn't transformed into something malignant.

Now, if you were going to consider surgery for reflux, are there any particular workups you need to do as well in preparation for such, or the manometry and the previous endoscopies is all you require? Most of the times, that's pretty much what we need, endoscopy, pH and manometry, and a very detailed discussion with the patients who are undergoing surgery, primarily because

When we do these operations, they're actually quality of life operations rather than treating a significant medical issue. Reflux essentially is constant heartburn. Yes, that's a symptom, but it is something that affects people's quality of life more than cause any major urgent problems. Having said that, if it goes untreated, it can lead to serious problems. So in a way, we are treating people to improve their quality of life.

and also to preempt problems like cancers developing or baricesophagus developing down the track. So we do need to have a detailed discussion with patients in terms of their expectations from the surgery. But in terms of investigations, endoscopy, pH manometry, CT scans or burying swallow, and then investigations to just make sure there's no other cause of the shortness of breath, iron deficiency, anemia. Fitness, obviously, that's something that we'll

need to be worked up with any surgery as you well know those are really the things that we look for and if someone comes to you to ask about surgery and they say they're okay with a protein pump inhibitor but they're concerned about the side effects of it i know there are some side effects listed such as osteoporosis and we've already talked about the other ones are those side effects a good enough reason for doing surgery or the side effects quite rare

These are conjectural side effects, to be honest. But there are population-based studies from the US which do suggest that high dose of PPIs over a long period of time are associated with reduction in life expectancy.

Now, this again needs to be taken with a bit of pinch of salt, I think, because there is an association which is not causation, and the association can be because of multiple different reasons. So there

There may be people who are taking high-dose PPIs for a long period of time because they've got other medical conditions that actually reduce their life expectancy rather than the PPIs themselves. So it's actually something that we shouldn't read into too much. And I certainly don't offer surgery for people because they think there are significant side effects.

So osteoporosis in women, yes, postmenopausal women, yes, there is a bit of a concern if they are going to need high-dose PPIs over a long period of time. So many times they have their bone studies and densitometry and things done, and they come with that and say, look, I'd rather have surgery than be on PPIs, then that's fair enough, quote, unquote.

Many times we leave it to the patients after discussion in terms of which bath they want to choose. The big advantage of surgery these days is it's all done minimal access with laparoscopy and the surgical risks have reduced significantly.

quite significantly. And in the good old days, open surgery, we used to be having a significant risk with esophageal injuries and tears, injury to the spleen and pneumonias, DVT, PE. Whilst those are still a bit of a risk, but the frequency with which these complications occur is extreme in the prescriptive surgeries that we do these days.

Perhaps go on and tell us a little bit about surgery then. Is there only one type of operation or are there a few different types? There's a few different types and a few different options. The gold standard, I think, for a long time was denison fundoplication, which is very infrequently used these days, especially in Australia.

So the basic principle of any anterior reflux surgery is twofold. First is to restore the anatomy as it should be, and then try and restore the physiology as it should be. And to restore the anatomy, essentially, we've got to reduce any hiatus hernias. So if there are any hiatus hernias, those hiatus hernias need to be reduced.

So essentially, you need to get about four or five centimeters of esophagus into the abdomen. The gastroesophageal junction needs to come back into the abdomen. We need to restore what's called the angle of his. So that's the angle between the esophagus and the stomach on the greater curve side. That needs to be acute and not choose. If it's not choose, then things will slide easily back and forth. So atomically, those things from a gastroesophageal

junctional point of view need to be restored. Once you've got the stomach and the esophagus into the abdomen, you basically need to tighten the diaphragmatic hiatus. It allows the esophagus just to really fit through that hiatus and not leave a big room for the stomach or any other structures to migrate up.

So that's done by putting sutures into the hiatus, and there's various different ways. Basically, surgeon's choice in terms of how they repair it. But the principle is that the right and the left crura need to be approximated and just allow the esophagus with a little bit more extra space so when the food goes through, you don't get dysphagia. If it's too tight, it can cause dysphagia post-operatively.

So once you've restored that anatomy, esophagus, gastroesophageal junction, angle of his hiatal closure, then you look at trying to restore the physiology. And that's basically done by doing a fundoplication or a...

wherein the top part of the fundus of the stomach is essentially wrapped around the lower end of the oesophagus and sutured. So in a 360 fundoplication or a Nissan fundoplication, the stomach is wrapped basically all around the lower end of the oesophagus. The stomach is sutured to each other with a stitch going through the oesophagus so it doesn't taut or twist.

There are now moves away from a 360-degree fundoplication because whilst it controls reflux very well, it can have some irritating side effects. And the most irritating side effect is sometimes gastric bloat sensation because you can't belch or burp. People can't drink fizzy drinks, can get acute gastric distension because you're not able to belch or burp.

That means that the air has to pass some other way and it increases flatulence. You basically can fart a lot, causing social embarrassment and side effects. So it's gone out of fashion in terms of doing a full 360 degree run, especially in Australia.

We do use what's called a partial fundoplication nowadays. We can do an anterior 180 degree fundoplication or a posterior 270 degree or 200 to 40 to 70 adjusted accordingly. Our default position many times is to do a posterior fundoplication. That again depends on the motility studies of the esophagus. If there is normal motility in the esophagus,

you can get away by doing a higher degree of wrap. If the motility has been affected because of acid reflux and it's weak, and the esophagus is basically not peristalsing as well, you don't want to create a really high pressure zone at the bottom end of the esophagus. Otherwise, the food will not pass through and they get significant difficulty in swallowing type symptoms. So basically, three types of fundoplication, anterior 180, posterior partial,

or a 360. Those are the three types of front applications.

Quick question on that one. When you do wrap them around, obviously when I do a stabilisation of a shoulder, we have to abrade the soft tissue to help it adhere to the bone when we tie it down. Do you need to do the same sort of thing when you wrap a part of the stomach around onto itself? Do you need to abrade the outside or external aspect to try and get it to stick? Look, what we do at times is put sutures through the stomach and into the diaphragmatic crura to hold it in place. When we do a fundoplication, we

do take sutures going through the esophagus. So stomach through the esophagus, through the stomach in a 360, or esophagus to the stomach in a posterior fundoplication. Anterior fundoplication, you would do stomach, wall of the esophagus, and onto the crura. And that basically holds everything in place. You don't need to bolster it with other soft tissue or anything. That's what's required most of the time.

I was probably just thinking as I was asking that question, actually, one of the issues with abdominal surgery is the risk of adhesion. So probably the stomach and the abdominal cavity is actually greater risk of scarring than you get in the shoulder, for instance. There is, but with laparoscopic surgery, we know that the risk of adhesions is significantly reduced. With open operations, there's a pretty high risk of laparoscopic surgery reduced quite a bit.

And that stabilizing stitch is sometimes required, not just to keep the stomach in place, but to prevent the torting of the esophagus around when the stomach wants to rotate. So yeah, that sometimes is done. You asked about types of surgery. So there have been other, what I would only say, experimental approaches to reflux.

In the olden days, they used to use what's called an angel cheek prosthesis, which was a prosthesis which was tied around the esophagus like a precursor of a lab band. And that was supposed to prevent reflux. That's never used now, and we've seen complications from that. The Lynx device is a magnetic device.

beads which are interconnected and basically are placed with a laparoscopic approach around the gastroesophageal junction. And the principle behind that is when the food bolus is passing through, it expands the links between the magnets and allows the food to go through. But once the food has passed, the magnets come and stick to each other and form a ring which prevents reflux.

I've never done this. Can't really tell you about outcomes and results from that, to be honest. Front duplication remains the gold standard. And currently, how long do a patient stay in after having a higher dyspnea or a repair? Yeah, look, open ones usually took about a week to even 10 days at times in hospital. And not just related to open surgery, but we're comparing different time eras as well. So this was standard of care surgery.

over 20, 30 years ago, a lot of things have changed in medicine. Typically with a laparoscopic hiatus hernia repair, if they're large hiatus hernias, usually two nights in hospital, small hiatus hernias, anti-reflux procedures only can be discharged the next day, overnight stay.

We are actually trying to move towards doing these day surgery procedures with small hydrosanias and anti-replex procedures with adequate support at home. So certainly things have come a long way from that big open laparotomy or even a thoracotomy to fix the hydrosanias and then stay in hospital for 10 days to two weeks with all the attendant risks.

What are the risks of the laparoscopic surgery then? You've talked about being maybe a bit tight, causing some dysphagia or issues with burping afterwards and passing wind that way. Is there any risk of the surgery in itself? I mean, the risks are less than 1% to 2%. So when we talk to the patients as well, we go through the risks that are intraoperative,

immediate post-operative medium to short long-term. Immediate risks during the surgery, the most important risk, although

quite infrequent is an esophageal perforation or esophageal tear. Sometimes the hiatus hernia is very complex, especially if you're doing a redo hiatus hernia or re-redo hiatus hernia. Lots of scarring around, sutures, things that does increase the risk of esophageal perforations and tear. Risk of injury to the spleen, so splenic tears causing significant bleeding.

bowel injury, any laparoscopic procedure with trochlea placement, anything there can be an increase of bowel injury.

So from a surgical point of view, those are the important intraoperative complications. At times with hiatus hernia repairs, there can be a tear of the pleura, or typically as we say, the pleura is breached on one side or the other side. That can cause pneumothorax or capnothorax. Intraoperative bleeding can occur. So those are the immediate sort of intraoperative risks involved with doing the surgery.

Short-term in post-operative period, risk of dysphagia, increased flatulence. We do partial fundoplications, but even with those, there can sometimes be a little bit of that occurring. Most of the immediate or short-term post-operative complications are more related to medical issues, so chest infection, DVTP, those kinds of things. At times, esophageal injury can manifest

post-operatively. So typically in all large hiatus hernias, as well as recurrent hiatus hernias, post-operative day one, we do a CT scan with oral contrast to just ensure that there's no leak from the esophagus. The repair is robust day one before we start the diet.

In the medium to long term, the problems, especially with hiatus hernia, are recurrence of hiatus hernia, recurrence of the symptoms or reflux. Gastroparesis or delayed gastric emptying is one of the problems. And that can occur in people who've had very large hiatus hernia, intrathoracic stomachs.

called entire stomach sitting in the chest for a long period of time, the risk of recurrence is between 27 to 40% during your lifetime after surgery. So it's quite a high percentage. Most of those recurrences are quite small recurrences. They're not symptomatic, mostly radiologically diagnosed, and many times they don't need any treatment.

So obviously patients are counseled about all these risks. In reality, how common are these risks and how successful is the procedure in itself in general for the average person? So if I went for surgery, what would you say the success rate would be for someone with a medium-sized hiatus hernia and with symptoms of reflux? So overall, the risks associated with hiatus hernia repair are extremely low in days with laparoscopic surgery.

All of these risks of esophageal injury or splenic injury, I'd say less than 1%. The other risks are still within 2% to 5% realm, which are extremely low complexity of surgery. In terms of the success rate, and given your example of medium-sized hydrosania with improving reflux, we would say that you'd get 100% benefit from hydrosania repairs and from replications.

The durability of the symptom relief depends on how good you are in terms of maintaining your lifestyle and sticking to what's required. Unfortunately, not all of us are highly disciplined in terms of doing what needs to be done. But typically, a hiatus hernia repair for a medium to large hiatus hernia repair

would last you at least 10 years, if not many times, lifetime cure. You might need to occasionally take a proton pump inhibitor. So you go from someone who has got reflux continually to someone who's got an occasional bout of reflux, which can be easily managed by short term medication.

And in the end, really, apart from the symptoms, which obviously is the main reason for people having this surgery, but the other hidden reason is the risk of developing esophageal carcinoma secondary to the stratification associated with Barrett's disease and things. What's the chance of actually reducing the risk of Barrett's and reducing the risk of esophageal carcinoma from these sort of surgeries? That's a difficult one and a very good question, Gavin, because essentially we really don't know what the baseline incidence of Barrett's esophagus is because

People with Barrett's might not have any symptoms and may never get an endoscopy. So we don't really know. But there have been studies done in people with Barrett's who've had fundoplications or people who've not had fundoplications have been treated with PPIs. And both seem to be effective in reducing the progression of Barrett's esophagus. Do they actually reverse the process?

The evidence there is quite murky, and I don't think either of them reverse the process of esophagus, but they do reduce the progression of merits from no dysplasia to low-grade dysplasia or hyperdysplasia. So that progression is significantly controlled. In terms of your other query in terms of development of cancers,

Barrett's is a precursor of esophageal adenocarcinomas. But what we do know is it goes through steps of Barrett's to low-grade dysplasia, to high-grade dysplasia, to in situ cancer, to cancer. So even if we do an anti-reflux procedure in someone who's got Barrett's esophagus,

They still need to be on a surveillance program with regular endoscopies to monitor that esophagus. That can't be skipped. So we've got to be still ultra careful that they do get their routine endoscopies. In people who have no dysplasia, we can do endoscopies every couple of years. But nowadays...

If someone has even low-grade dysplasia, we act on that, do an ablation of the Barrett's esophagus endoscopically. So those things we've got to continue. And does everyone who develops adenocarcinoma of the esophagus, would they have had Barrett's at some stage? I presume you may not know that because you may not have done an endoscope on them, but is it thought that they've all had it at some stage?

That's exactly right. You can't get adenocarcinomas in squamous epithelium. So you've got to have some sort of glandular epithelium to produce adenocarcinomas. So if we're talking in terms of lower esophageal cancer where there is squamous epithelium normally and there's adenocarcinoma, which is typically called as a C-word type 1 cancer,

then there is logically got to be some Barrett's in the background to start with. But as you say, you can sometimes get cancers because we never know that they've had Barrett's before. And that area...

typically is difficult because we've got a junction between the squamous epithelium and columnar epithelium normally. So the gastroesophageal junction is where the squamous and columnar epithelia meet. So if you have a true junctional cancer,

that might arise in the proximal stomach gastroesophageal region. It could still be an adenocarcinoma, which just creeps up into the esophagus. So the C-word type 1 cancers, which develop in the lower esophagus, I would say logically would have to have a Barrett's. But C-word type 2, which is a junctional cancer, or a C-word type 3, which is a proximal stomach cancer,

they don't require to have Barrett's before they arise from columnar epithelium. And so in that scenario, it would have actually been another causative factor like a genetic mutation? No, not particularly. I think even in those cancers, so typically we call them as junctional cancers, very similar risk factors.

And then finally with the question about the use of PPIs working almost as well for someone with moderate hydrosonia as opposed to having a hydrosonia surgery. There are two different mechanisms. One's just reducing the acid in the reflux fluid and the other one is actually reducing the reflux and obviously the acid which goes with the reflux is not getting the reflux. But they work just as well in that scenario. So

That implies that actually reflux itself with normal fluid won't cause any issues at all. It does, and we do operate on people who don't have acid reflux symptoms but do have regurgitation and fluid reflux and vomiting symptoms. Although the PPIs are effective in controlling acid reflux,

They don't control volume reflux, as we say, to that extent. They do control a bit of volume reflux because they suppress acid production. So the volume is naturally reduced, but you don't get complete relief from the volume reflux. So

Basically, when we say they're equally effective, they are equally effective in controlling the heartburn and indigestion symptoms. They're not the same with the fluid regurgitation, volume regurgitation, shortness of breath, iron deficiency. So you've got to have that conversation with patients as well to explain the subtle differences there. Right.

Where do you think things are heading for the future? What do you see on the horizon in your area? Look, at the moment, I think we are very much going on a track where hiatus hernia repairs or anti-reflux surgery is the mainstay of treatment from a surgical point of view for reflux. I think future developments are certainly going to come from an endoscopic maneuver of some sort to try and control reflux.

At this point in time, I'm not aware of a lot of things that have been done in that regard. There has been trials previously. I'm pretty sure we will keep getting more advancements from a pharmaceutical management or medical management of reflux going forwards. And certainly primary prevention, that's got to be the cornerstone in terms of non-hydrocephalic reflux.

Brilliant. It's been fantastic hearing all about this, Harsh. It's been brilliant information and a huge area that affects many Australians. So thank you very much for your time today. Thank you very much. Thank you, Gavin. It's been a pleasure. Thanks for having me. It's been brilliant. Cheers. I'd like to remind you that all the information presented today is just one opinion and that there are numerous ways of treating all medical conditions. It's just general advice and may vary depending upon the region in which you are practising or being treated.

The information may not be appropriate for your situation or health condition and you should always seek the advice from your health professionals in the area in which you live. Also, if you have any concerns about the information raised today, please speak to your GP or seek assistance from health organisations such as Lifeline in Australia. Thanks again for listening to the podcast and please subscribe to the podcast for the next episode. Until then, please stay safe.