Mr Abuchi Okaro

Good evening, welcome. This is a webinar hosted by myself, Mr Abuchi Okaro, and Ahmed Hamouda who are Consultant Upper GI Laparoscopic and Bariatric surgeons. So, we'd like to welcome you to this webinar that is really going to try in the next sort of 45 minutes or so to really go through a very common problem - heartburn and acid reflux - and see really where we are with our understanding and, of course, options but also most importantly - you know - where or how we can help in terms of help with symptoms and, of course, treatment. So, a little bit about who we are.

Mr Ahmed Hamouda is an Upper GI and Bariatric surgeon, as I said. These are some of his qualifications. I think most importantly, I think to say, between him and I, we have been in consultant roles now for over 15 years - so combined 30 years of really expert consulting, independent practice and I think that's really very important - particularly in the field such as upper GI or certainly reflux disease, because there is a lot that hinges a lot on expertise. And of course, that more specific type of practice that really can only be built up. So, Mr Hamouda and I also very much mirror in terms of specialty with him. And we are hopefully going to be able to provide you with some insight, some education, information and possibly some assistance if possible. So, let's go right through. What are we going to cover today?

Now gastroesophageal reflux or heartburn or GERD – they are all synonymous - is a really common problem, really very common indeed. Now it is important today we're going to discuss in the context of an isolated reflux problem or heartburn problem, but it must be mentioned that sometimes it can be part of a problem that involves a whole of the gastrointestinal tract, such as irritable bowel or functional bowel conditions other than irritable bowel. But we're specifically going to look at it as an isolated problem in terms of symptoms. And so, we're going to talk about that. We're going to give some definition - a bit of history, I think is it worth it - then treatment options and I think certainly from our point – surgery - we will finish with that and then of course questions and answers will follow that. So that's really what we're going to try and cover this evening.

So gastroesophageal reflux disease, as I said, is a chronic condition. It really affects the stomach and the oesophagus, and it's understood really to be as a result of acid and/or bile coming up into the oesophagus, which is the gullet, and then staying around for at least over five or six sort of ten minutes to cause the irritation. And I say five to ten minutes because, actually, reflux is something that happens generally in most normal situations but it's sort of the frequency or indeed the duration that actually makes reflux sometimes a problem. So, patients obviously experience it either when there's a bit of a problem with the valve, which is the barrier, or a hiatus hernia. And symptoms are classically heartburn - so you feel that burning sensation at the back of your breastbone, your chest. Some people feel it coming up towards their neck and some people in their ears and also some people in the back, between their shoulder blades. So, it does come in a variety of different symptom patterns. But the important thing is obviously to note that you will notice that staying upright can ease it and lying flat or after meals can make it worse.

Now there are some times that reflux or GERD can give you some rather atypical symptoms like chest pain, and a lot of patients do end up going to see their cardiologist, worried that maybe, possibly something is wrong with the heart or the lungs. And it's not particularly unusual for it to be considered possibly a heart attack type symptom because it can actually even get to the left arm. But that isn't indeed the more common symptoms. Some patients get is a lot of belching, a lot of nausea can also be a symptom and, in the cases that have not just acid but what we call volume reflux or quantity reflux, you do find regurgitation - so when you belch or burp you sometimes find suddenly your mouth is full of maybe fodd or saliva or stuff you've eaten before - and that can be quite uncomfortable. And particularly at night, if you're lying flat, usually coughing can happen in the middle of the night and you end up with this - what we call - aspiration pneumonia.

So, these broad range of how the reflux (or GERD) can present. Now, unfortunately in (maybe) untreated cases or when it's persistent, then you can get complications like inflammation-like esophagitis which is really where the tissues are now getting angry. That usually makes the pain more persistent, particularly gnawing and sometimes actually really feeling like a burn, and patients do end up having a lot of Gaviscon or milk so that's really where things can get into difficulty and, of course, unfortunately scarring can occur and on the rare occasion - or less common - is where you get Barrett's (Oesophagus) which is quite serious. It is worth mentioning that, of course, you really have to have had reflux very bad for quite some time to get Barrett’s, which is where the oesophagus becomes more or less a stomach and cells unfortunately can get a little bit unstable and sometimes lead to cancer - which we're not going to talk a lot about today because it isn't a very common complication, but it is worth mentioning. What clearly are the risk factors? Of course, anybody that's obviously suffering from suspected or confirmed reflux or GERD will always think “What can I do to make things better? What are the things I'm doing that are making it worse?” and this is really very, very important.

Makes sense if you are overweight and there's a lot of pressure in your abdomen then, of course, the pressure can actually create that pushing up of the reflux or the acid or the bile. Smoking is clearly a risk factor. Having a hiatus hernia, which we will touch on a bit later in this presentation. The importance, the real importance of the hiatus hernia, which is really a hernia as we know it but more around the diaphragm and its linkage with reflux and that really requires special attention, so we will talk about that a little bit later. Of course, certain medications understandably can cause it and, of course, the important thing always with reflux - most times - is actually: is it reflux or is it something else? And I think diagnosis is still, I think, sometimes a concern. Some patients are always worried ‘Is it reflux?’ and if it is they getting any damage? And I think when we look at the diagnosis then normally the story can tell a lot. But occasionally we have to do cameras and sometimes we have to do dye tests and sometimes we have to look at acid levels in the oesophagus. We may touch on a little bit later the relevance of that because proving reflux with any shadow of doubt is absolutely critical if you're ever beginning to move in the trajectory of surgery, because there is no way that anything operative or surgical can be done if we are not certain that we're dealing with reflux. And, you know, because it's a common problem, of course, we don't want it to be mimicked or masquerading as another problem. So that's really very important to have a diagnosis confirmed and that's why sometimes we have to actually measure the acid in the oesophagus.

So yes, all right, hernia. Now some of you may or may not have had a diagnosis of a hiatus hernia but essentially, it's where the diaphragm (the hole that is present in the diaphragm, naturally as part of the way the body has been created or designed) is wider. It's wider than it should be. Unfortunately, that means that the stomach’s upper portion can move up and down into the chest and that is unfortunately where reflux can be precipitated or can be caused by that simple change in pressure or change in position of the stomach. And the oesophagus which is a hiatus hernia and that is probably linked with GERD or reflux probably in about more than 40 to 50 percent of cases and so it is important. Now how do you make the diagnosis? With an endoscopy in most instances but occasionally it can be picked up on a chest x-ray or a body scan - that's a CT scan or MRI scan - so it could be more of an incident we’re finding. But most times in clinic with an endoscopy it's quite simple to pick it up using an endoscopy, which is a camera into the mouth looking down into the stomach and the gullet.

This is just an example here on this image that just shows what the hiatus hernia looks like. The diaphragm: you can see I don't know yet because this is really the hole in the diaphragm which is quite wide. This is the heart in the top here and the liver over here and you can see the stomach has actually gone quite high up and this is a problem, and this would potentially be what we would call a predisposing factor to reflux disease.

So really going back to more or less the complications of reflux and GERD (and I've mentioned them earlier) but I think we'll just go back to them again. When there's inflammation, which is soreness or redness or irritation, then that can cause damage to the oesophagus and that usually is picked up with an endoscopy. As you look down, you'll see the redness, you'll see maybe some - what we call erosions or some scarring - and that is very much diagnostic of reflux or GERD; very diagnostic, frankly. You see that, you know that there is something that is irritating the lower part of the oesophagus. Now unfortunately, if this is not treated or if it persists for a very long time - as we all know, when the body heals you tend to get scar tissue and that scar tissue can lead to narrowing or strictures which we call peptic or benign strictures. Now they do cause blockage on occasion, and you might - or patients may - experience difficulty swallowing certain things like solid foods, like bread or meat. Now the good news is that they are not the commonest causes of narrowing or stricturing of the oesophagus, it must be said - but they can occur. As I highlighted earlier, Barrett's is a condition where there is a very abnormal change in the lining of the oesophagus, usually as a result of long-standing reflux - untreated particularly - and that is a serious condition, partly because it can - on occasion - lead to cancer of the gullet or oesophagus. So, we take that very seriously indeed. But as I mentioned earlier it is not a common or frequent complication of reflux that we see in usual instances - so it's certainly not something we like to scare patients about because it is certainly a rarity when it comes to overall reflux that we see in the population. As I mentioned earlier, cancer can obviously be a problem and it's normally linked directly with reflux when it comes to GERD or reflux disease. On occasion reflux can cause hoarseness of the voice, partly because as it causes the acid to lift up into the oesophagus. It goes higher into the neck and can trickle down into the voice box and you do occasionally find certain, you know, individuals who maybe are singers can get problems of low tone or loss of voice function - and that can be a bit of a problem when it comes to career. So yes, problems with the voice box can occur in reflux and hoarseness is a recognised type of symptom of reflux disease. As I did highlight and mention earlier, on occasion that you can get it in the lung and then get pneumonias but that again isn't very particularly common but can occur.

As I highlighted, it is a common problem; reflux affects pretty much most of us - all of us - at some point and a lot of us have seasonal reflux or, you know, maybe a curry or a few beers and you get a bit of reflux overnight. So, it is quite common. I think it's where it is persistent that I think a lot of patients find it uncomfortable; certainly, when it interferes with quality of life, where you pretty much can't eat anything apart from bland types of foods then clearly that is something that needs attention. The problem was picked up, actually, way back by a gastroenterologist in 1925 and it was at the time linked with a hiatus hernia which – again - we mentioned earlier. And that is extremely important to make that connection. Now the relevance of this is that reflux has really been around for a while in terms of diagnosis. It is part of the human condition, you could say. But I agree it shouldn't interfere with consistent quality of life and - of course - we always like to have the chance to treat patients if they feel their quality of life (particularly when it comes to choice of foods and drinks and just general well-being) and being affected by this problem. Which kind of swiftly brings us on to treatment. So how do we treat reflux? Now I mentioned a lot about how food and lifestyle can kind of affect it really and that makes sense that actually changes to diet, particularly what we eat, when we eat, how much we eat of course is critical in the management of reflux disease - absolutely a cornerstone.

So, we really emphasise the importance of looking very, very carefully at your diet and lifestyle because you can make some significant roads in treatment just by simply adjusting the diet and things like lifestyles, such as bringing the head of the bed up. Some people sometimes have to put things like blocks to get it right up. Going to bed with a stomach that is empty which means last meal maybe five, six (o’clock) and then sleeping at around nine, ten maybe. Pillows help, certainly losing weight – it’s absolutely important to try and lose some weight to reduce the pressure and measures like that certainly can help. Of course, stopping smoking, if you have to indulge in tobacco. So that really can make a big difference. Now for the patients that doesn't work for then, of course, there are things to add on to that which would always be things like maybe antacids which would be the Gaviscon and so on, using omeprazole or one of the other proton pump inhibitor drugs which need a prescription mostly but are very effective indeed. And it is worth mentioning here now that they can be used in the long term; long term being over a period of five or ten years and a lot of the scare, or a lot of the press reports of problems with proton pump inhibitors or acid suppression long term is really - as far as I'm aware - data from use over 20 years (and you get thinning of the bones and so on) so we're looking at short term use, three to five or so years. At the moment, I don't think it's a reason not to try at least to use these to control symptoms. You can sometimes use things that help to push the stomach contents out, which we call prokinetics but again not a significant number of patients do need to go and use these extra drugs.

Now of course, what are the foods that do come up as sort of culprits as it were? Now the important thing to say is that processed foods, generally, are a problem and they would be fried, of course, fast foods, pizzas, all the kind of foods that we can easily get our hands on. But it is worth being very careful, of course, if you are prone to reflux to really pay attention to that. Now, unfortunately some other foods are really tomato-based, of course, citrus we know, chocolate - hard one, you know we all like a little bit of chocolate - but of course certainly if you know that you're finding that this precipitate it then it is important to consider reducing them or indeed eliminating them from the diet. Now of course it's important to mention they are good foods apparently that can particularly help, and these are fibre foods which I've listed a few here. Alkaline foods also can be useful and certainly home remedies, so these are things that definitely there's evidence to show that they can be really helpful and - without a doubt – I think a combination of different things is usually found to be more beneficial in kind of getting things under control to allow at least the ability to sleep at night, particularly an ability to obviously make better choice of meals and improve quality of life.

So, I'm going to - if it's okay with everybody - go on to surgery. So, let's say you tried all the medical things, and you know the life quality, the kind of concern is that the patient’s really concerned that they don't feel that, or they don't want to have medical therapy permanently, then really, we have to give consideration to surgery. And that's really where we come in with the care or the management basically, because of course as surgeons, we would really only be looking at managing (in a slightly larger sort of sense) patients who are either keen or good candidates for surgery. And the operation that we tend to go for - which is the gold standard, I would say - is what they call the laparoscopic fundoplication, you know, and then with your surgeon, for example, the discussion is whether it's a complete wrap which means 360 degrees or a partial wrap (which won’t get too technical about as far as the purpose of discussion today is) but the point is: surgery in the right patient obviously with the right preparation can make quite a difference to experience and quality of life and, of course, reduce reflux. So, a little bit about the history. The operation itself was first performed in 1955, so it's been around for quite some time. It's got some different names, of course, but I think the most important thing to say is that it really became very popular in the 70s and also in the 80s and 90s when keyhole surgery came about, and I think that's really why the Nissen (if you're looking at operations) in history that stood the test of time. This is an operation that has stood the test of time, which is good because it's a procedure that is actually technically quite easy to do but does require a level of skill and precision in order to make sure that it's done in a way that will give a good chance of success.

Now of course it's an operation and then indeed there are complications. There are certainly side effects which cannot be ignored, you know, when it comes to - you know - a procedure, of course. But the most important thing to say is that the patients that are best suited to have surgery are usually patients who probably have long-standing reflux, possibly medical therapy hasn't worked for if the hiatus hernia is quite large. We do find that you can get better treatment with surgery and certainly patients who get what we call ‘volume reflux’ - so when they either stoop down or lie down they get not just acid, but they get, you know, fluid and volume coming up because that valve has just gone - usually can benefit from an operation.

So technically, what does the operation involved? Now it's in two parts, really, f you think about it from a technical point of view. If you recall I did mention earlier that the diaphragm had a bit of a wide opening, or it was sort of elongated, we will always narrow that so that's the set first part of the operation. The second part is just to do what we call the fundoplication, which is the wrap, so we are wrapping the upper stomach around the oesophagus and then anchoring it and I have a few images that might help to explain what it involves. And that is really what the operation involves - two technical components. As I mentioned earlier, it's being done keyhole.

The good news is that patients could either go home if we most times the following morning the following day but occasionally the same day. The pain levels are very low indeed which I think really makes it quite acceptable. There's no need for anything strong like morphine after the surgery, patients are able to get a drink quite quick and get up and about and pretty much back into the office, back into work within about sort of 10 days-ish as it were. So - and I think that's why it's quite – well, sort of accepted really or welcomed I think when it comes to a procedure that can revolutionise care and make patients really experience lower and reduced amounts of symptoms. So here we are. So, these are the sort of the illustrations really and, as I mentioned earlier really the diaphragm is the sling. We put a few stitches in the diaphragm. We then use some stitches to create this wrap, which is really where we free up the upper stomach and we wrap it below and around the oesophagus to create a snug - it's not tight - it's a very snug, well-positioned sort of spiral suture and anchoring around the oesophagus that allows the stomach to essentially stop allowing contents to go up into the gullet. And that's still the fundamental way it works.

So basically, what happens is the oesophagus closes as the stomach obviously raises its pressure, in which case bile or acid or whatever can't go back up. And that's really how it works. So those are the two components of the Nissen fundo and of course the other component is it does create a slightly higher-pressure area in the lower oesophagus. So of course, the question is how effective it is, and the most important thing is that it's got a very low risk of complication and that is important. It's performed on patients who are generally otherwise well, so we don't want to get patients getting into difficulty or having a lot of uncertainty around whether they're going to have a complication after the surgery. And that's why, again, surgeons who operate on that part of the body (because of all the kind of critical structures) have to have a very firm and very sort of balanced eye and hand to do the work. And that's why the results remain very good when it comes to technical problems. In terms of impact on reducing reflux, a lot of the studies are saying that patients really get about 80% benefits thereabouts. Maybe 70-80% and occasionally up to 90% when it comes to quality-of-life, reduced symptoms - and it is sustainable. Some studies quote ten percent recurrence at about five to ten years and occasionally there's some that have to go for second surgery. So as far as I think the track record of the operation in terms of the longevity of it, I think it stands up very well against any of the more recent or more newer procedures which we may touch on today. So Nissen is still the gold standard operation for this treatment of reflux.

There are certainly some complications, absolutely there are some side effects or complications. I would probably call them more side effects. And that really is a fact that is part and parcel of what we've done is the side effect that you can get bloated you don't belch as much; you don't always find it easy to release the gas which causes the bloating.

There is evidence, of course. It happens obviously a little bit earlier of course in the beginning and after about two, three four months there is some improvement generally, but gas bloat usually can be self-limiting. I certainly find that now what we do advise is that patients must be very careful to avoid any gassy drinks, fizzy drinks possibly, try not to swallow a lot of air and there's certain things to try and cut down. On the very rare occasion it becomes really irritating or debilitating then of course we can use things like charcoal, peppermint teas and so on to try and make things more comfortable.

Difficulty swallowing, understandably, is something you always expect after this surgery, and I think one of the reasons is the swelling after any procedure. Now it's very important to mention that certainly, after any fundoplication procedure we would always recommend liquid to soft diet for about three to four weeks just to minimise the difficulty that you would expect as food passes down where the diaphragm has been stitched. And that's very important to say, so we do recommend soft diets. Now the good news is that most of the patients that have that difficulty over the course of 8-12 weeks, it kind of settles. The thing we don't want patients to ever really go through after this type of operation is vomiting so we really do everything we can to minimise the chance of that with drugs but also what patients are allowed to drink and eat.

But overall, bad difficulty swallowing does not occur commonly. I think particularly in surgeons or in practices that are able to get a really good gauge of how tight and how snug to make things, I should say. There's some rarer complications or side effects that can occur, the vagus nerve with damage for example, then you may get some dumping, again, diarrhoea. And these are rare, it must be said. I think the ones that certainly we would always make very important mention of would be the gas bloat, increased passage of wind from the bottom as a consequence of not being able to belch and the difficulty with swallowing and the need to obviously chew your food up very much - a lot of mastication to really break the food down and make sure it's moist. Certainly, in the first three months it’s key not to rush foods so that you don't get any food sticking; that's very important after this surgery.

So, we're coming probably towards the last few slides here now. Now I've got to mention the procedure that some of you may have heard of - the LINX. The LINX procedure - and there will be an illustration or diagram of it - is a very new procedure in terms of coming and sitting quite next to the fundoplication in, you know, it's very cutting edge. They use a bead, or a series of magnetic beads and they're positioned at the lower end of the oesophagus pretty much to mimic a bowel, pretty much, and so it's quite effective in that respect. Now the only slight issues unfortunately is that with the LINX procedure there's quite a lot of restrictions on who can have it to a degree if you've got a big hiatus hernia it can't be used, if you've got Barrett’s or if you've got any bad esophagitis then it's something that shouldn't really be used and - of course - if you are going to possibly have an MRI because it's not MRI compatible.

But apart from that, LINX has gained a little bit of popularity mostly because of the fact patients can belch, you know, after - or at least belch more than if they had a fundoplication but there still are difficulties, swelling problems, vomiting, there's nausea so there are still some recognised side effects, so it isn't exactly without any side effects like any operation. And here's a diagram of it. Essentially so it's a magnetic ring. It's basically calibrated at the time of the surgery using a special calibration device and then the beads or the rings are placed in accordance to the size or the aperture of that space for that particular patient and then deployed and anchored. And I think the key here is that it has a way of letting food in or letting material pass it by relaxing and then opening up later on if you need a belch and releasing. So that's really how it works.

We don't offer that, I must say, at the Benenden. It is not a procedure that we offer at Benenden but probably one or two centres around Kent, but we don't offer it. I think I'm coming towards the end, really. So just to sort of close with a few important extra components to mention. One, there are other devices that can be used to treat reflux such as one called the Stretta, which is using electrodes to create a bit of swelling at the lower end of the oesophagus. Not that common, I must say, not that popular overall. Some of the other procedures that were brought out have actually gone off in popularity so really, I think we really stand with the core treatment being lifestyle modification, diet modification and of course drugs like omeprazole are really effective. And then for the patients that come through that and don't actually get a good response, you certainly can then start look at things like procedures like fundoplication.

So, to summarise, thank you all obviously for making time to attend. I hope you found this useful. Reflux is common indeed. Using non-operative management strategies is really effective and is a cornerstone but, on occasion, of course surgery can be used, and it can be extremely effective for the right patient with very good outcomes and low chance of morbidity or mortality.

And yes, I'll be handing over to my colleague Ahmed Hamouda for the question session and I’d like to thank you once again for joining us. Thank you.

Mr Ahmed Hamouda

Thank you, thank you very much Mr Okaro. I think Mirella is going to take us through some questions that she has.

Mirella Falcone

I have, thank you Mr Hamouda and Mr Okaro. So, we have some questions for you. So, the first one is I don't have any symptoms of reflux except that I have what feels like constant phlegm in my throat. I have tried all sorts of treatments, but nothing has worked. I'm on 40mg a day of omeprazole (sorry if I haven't pronounced that correctly), I don't smoke, not overweight, I've had this for about four years with no reasons apart from my doctor thinks it is reflux.

Mr Ahmed Hamouda

Thank you very much for the question and I would like to say that, obviously Mr Okaro and the comprehensive review that he's done of this subject has been very, very useful, very informative. And sort of linking back to what he said, the symptoms can be very, very typical. So, where you get chest pain and classic heartburn there's burning behind the chest plate, and it comes back up into your throat with a bit of regurgitation or volume reflux. That can be quite a typical presentation, but there are certain circumstances where there are symptoms that are very atypical such as phlegm for example or spluttering or cough or erosion of teeth.

And some people have gone to see different specialists - an ENT specialist for example first - or they've gone to see the dentist and, after exhausting all the different pathways to a diagnosis, someone will say well actually, have you thought of reflux, could this be reflux, could it be that there's an excessive amount of acid coming up into your gut? And that's why it's quite difficult to make a diagnosis in certain selected cases.

That's why again going back to what Mr Okaro said, when you come and see us, we've got the comprehensive service that allows us to go in with a camera. have a look inside your gullet and see whether there's any evidence of acid burn to the low end of your gullet – esophagitis - which he described as being quite typical in diagnosing an acid reflux problem. So that would be the first thing that we look at. And then the second thing that's really important to support our endoscopy findings would be a diagnostic test to see how much acid is actually coming up into the gullet. And if there is an excessive amount of acid coming up with gullet on a pH test then obviously that is more diagnostic.

But I would have to say that sometimes at the end of our tests we turn around and say we really can't find evidence that acid is the problem here and it could be that your gullet is hypersensitive. There's a very small amount of acid that's coming up into it, but your gullet is just very sensitive to it and therefore you get the symptoms. Or let's revisit again some of the other specialties. It could be a chest physician that needs to look after you, maybe the phlegm is caused by - you know - an ongoing bronchiectasis or a condition of the lungs that could be contributing to this matter. So that's why it's really useful to come to a comprehensive service like ours where we can offer all the diagnostics. We can give you a diagnosis and then we can start treatment. We can advise you whether or not an operation such as a fundoplication will help resolve your symptoms. Thank you.

Mirella Falcone

Thank you very much. The next question is from Donna. I have been on PPIs for 30 years and have hypermobile EDS. What would help me please?

Mr Ahmed Hamouda

So again, I think going back to what I said previously, and what Mr Okaro has been alluding to, is that: has a diagnosis been made? Have we gone in with an endoscopy, have we looked at the lower end of your gullet, have we made a diagnosis of a hiatus hernia, esophagitis or possibly even Barrett’s and is there some evidence that would support us doing a pH test to test how much acid is coming up into your gullet? Hypermobile EDS, yes I mean there is joint weakness, there could be an element that that's contributory to reflux. However, it won't be the clinching diagnosis here. What we need to do is have a look and that is an endoscopy, a pH test, come and see the specialists.

Mr Okaro, is there anything that you would add to that at all?

Mr Abuchi Okaro

Not at all, I think it's absolutely important, as you say, to firm up a diagnosis and I think endoscopy is a very straightforward, simple tool - but it can shed a lot of light, particularly with regard to the lower end of your oesophagus and what may well be going on in the low end of the oesophagus.

So, yes, absolutely I think you're absolutely right. I agree that we really need to see and then advice. 

Mirella Falcone

Lovely, thank you. Thank you very much. Next question is from Claire. I have GERD and a hiatus hernia and diverticulum. This has occurred since my gastric sleeve in 2018. Would Nissen, the surgery, help me?

Mr Ahmed Hamouda

So, a bit more complex, obviously, and interesting the situation that we're presented with. Having had a gastric sleeve means that you have lost the fundus of the stomach, the floppy bit of the stomach that Mr Okaro was describing. That is essential for us to do the operation because that's the bit of stomach that wraps around the lower end of the gullet in this operation and recreates the valve-like effect that prevents acid from coming up.

So, I would have to say that you would need to come and see us for a specialist opinion and it's very likely that to treat reflux and even a hiatus hernia, depending on what the size of it in this situation, we may need to look at - you know - things like doing a mini bypass or a bypass procedure because without the fundus of the stomach. We really don't have anything to wrap around the lower end of the gullet, thank you.

Mirella Falcone

Thank you very much. Next question is from Rosemary. Can LYNX be used with a pacemaker?

Mr Ahmed Hamouda

I will ask Mr Okaro perhaps to answer that question.

Mr Abuchi Okaro

I don't know! I suspect yes but I don't actually know that for certainty really. I mean, you know, thinking about it - there shouldn't be any reason why not. I mean the only thing with pacemakers, of course, is obviously electrical activity coming from sort of the iPhone. These and other devices.

So, I think, off the top of my head I would say I can't see why not, but I think - of course - we don't offer the service so I would definitely make a recommendation to maybe inquire with one of the other centres in London if they're about to offer it. Maybe ask them directly. Sorry we can't give any certain answer.

Mirella Falcone

Okay, thank you. Just a couple more anonymous questions I have in front of me. So, I'm a woman in my 40s who suffers frequently from symptoms such as heartburn, regurgitation and breathing problems. The latter may be caused by my asthma. How would you diagnose if what I'm struggling with is GERD?

Mr Ahmed Hamouda

Again, this really is going back to the presentation, going back to the information that we talked about GORD is one of those things that can be very easy to diagnose. If it's classical heartburn, it is related to something that you eat that's quite obvious a spicy meal, a curry, having some wine at an evening where after that you develop classical chest burn or burning behind the chest plate and it's very easy to diagnose. And there will be instances where it is more difficult because the symptoms are not typical, and I'd have to say that there is a substantial amount of people that actually have atypical symptoms.

So going back to getting the appropriate support within a comprehensive service - where you have consultants that have been dealing with this for years and years but also all the diagnostics based at the same place and a multi-disciplinary approach - so not just myself and Mr Okaro within the team but also gastroenterology colleagues, physicians who deal with this on a daily basis. And what would happen is you would come and see us and we would start off by doing an endoscopy, looking at the lower end of your gullet, making a diagnosis and then moving on swiftly to a pH test where we test how much acid comes up and I would have to say that without those tests it's very difficult to tell just purely based on symptoms and therefore I would encourage you to make an appointment, come and see us if you really wanted to look into this further. Thank you very much.

Mirella Falcone

I researched lifestyle changes which I thought would help improve my acid reflux. I lost a bit of weight, didn't eat late at night, I'm a non-smoker and I've been trying to sleep on my left side. But none of this has made a big difference. Would you recommend medication for me or surgery?

Mr Ahmed Hamouda

It's very interesting. Again the question, of course, relates to whether or not you have acid reflux and GERD or GORD and of course one of the things that happens on a daily basis is that people presenting to their GPs tend to - with the symptoms that you described - get a trial of PPIs;  omeprazole, otherwise known as acid suppression medication, for a period of anywhere between six weeks to two three months to see whether it helps their symptoms. And that's usually the normal way that people will get a medication or a diagnosis.

Now if the medication is given without having an endoscopy to look at the lower end of your gullet we are really treating you blind or empirically and I would suggest that it would be much better if we were able to do a diagnostic test first and so, if you do suffer with symptoms similar to what you've described, it would be much better to come and see us have a diagnostic test done like an OGD. And then we would be able to advise yes or no regarding the medication.

Regarding obviously the lifestyle changes that you've made which are spot-on but whether or not we can then progress things and help with an intervention like a fundoplication.

Mirella Falcone

Thank you very much, next question is I'm commonly trying to eat a high fibre diet to help with my symptoms of GERD after having fundoplication surgery. Would I still need to manage the foods that I eat and follow the lifestyle changes?

Mr Ahmed Hamouda

Mr Okaro, would you like to take the question or would you like me to?

Mr Abuchi Okaro

No, please go ahead.

Mr Ahmed Hamouda

So obviously after you've had an operation, things change a bit. There is a tighter, higher-pressure zone at the lower end of the gullet and that - in essence - means that we give you what is almost like a gastric band in that area, because we're trying to prevent any acid that's in the stomach from moving up into the gut, so things will need to change. And what will happen is you'll need to eat literally often. You potentially will need to have very small mouthfuls, chew food very well.

There will be instances where there might be ‘stuck’ episodes where you have a piece of meat, for example, and you feel it sticking behind your chest plate and either wait for it to go through or you might need some fizzy water to try and push it through that high pressure zone. And when it comes to consistency of food and fibre in in your food. I don't particularly think that there's any stipulation to change your diet in any way or change the quality of what you're eating, but it's very important to chew food very well, have small mouthfuls and allow things to go through that high pressure zone like Mr Okaro described in his in his diagrams. But I don't think that there is any special diet that you have to follow and, of course, if there are any particular food matters that in the past have made you suffer with the reflux, then perhaps avoiding them would obviously be a good idea after the operation.

Mirella Falcone

Thank you very much. Is fundoplication surgery a day case procedure? If so, would I be allowed to drive myself home from the hospital?

Mr Ahmed Hamouda

So, two components to that question. First is it a day case surgery procedure and will you be able to drive home after an operation? It's easy to answer the second part, which is a consistent no; you can never drive yourself home after an operation because you've had a general anaesthetic, you're tender and sore from the wounds. It's very possible you might have an episode of vomiting or feel a bit dizzy so that is a definite no. In terms of doing it as day case, fundoplications have been advocated as day surgery cases over the past maybe 10-15 years and we tend to aim for approximately 30 to 40 percent of our patients going home on the same day.

Having said that, there is an argument to be made for staying in overnight for this procedure because we want to get on top of any sickness that may occur, any nausea that may occur. We have the access to intravenous fluids but also painkillers to allow the body to rest and heal and therefore I think it is an individual judgment to be made and consultation with your upper GI consultant and the expectations are that yes you may be able to go home on the day if you fit unhealthy and you don't suffer with any of the other things that I said: nausea, vomiting, pain etc. But there is also provision for you to spend the night if need be.

Mirella Falcone

Thank you very much. Just a couple more questions. What is the difference in the recovery time from the different treatment options for GORD? I'm a working mum in her late 30s who can't really afford to take too much time off.

Mr Ahmed Hamouda

Well, I believe Mr Okaro covered this really well in his presentation. He said that, you know, within 10 days after a keyhole operation to treat reflux with a fundoplication, people should be back to normal. So, we are talking about potentially driving within a week or so being able to get back to work within a week to 10 days. I mean to be honest with you, with most people working from home these days potentially you could be sitting at your laptop and two days after the operation doing your work, you know, and getting through loads and loads of stuff.

So, the keyhole element of this procedure has changed the world. I remember and I don't know whether Mr Okaro agrees with me, but these operations used to be done through a massive incision through the chest and the abdomen about 40 years ago. I mean it was an operation that needed to be survived first of all and the element of changing it into a keyhole operation that can be done as day surgery at the moment with very quick recovery means that it's changed the world for people who suffer with reflux.

Mirella Falcone

Thank you very much. Last question, I had a gastric sleeve fitted a couple of years ago at Benenden Hospital. Since then, I've reached my goal weight, but I now suffer with a lot of acid reflux. Would I be a suitable patient for fundoplication surgery?

Mr Ahmed Hamouda

Yes, again going back to what we said previously in answer to the other question, unfortunately a gastric sleeve means by definition we've taken away the fundus of the stomach. We've taken away that floppy, voluminous bit of stomach that can be wrapped around the lower end of the gullet and reflux is one of the known problems that happens with restrictive weight loss operations such as a band or a sleeve. So, reflux is common after a sleeve; it can and should be treated with medication to start off with.

If it becomes problematic, then well (I shouldn't say unfortunately) but the only way to perhaps maybe progress it is to change that sleeve into a mini bypass procedure, where the lower end of the stomach, the sleeve is emptied into the bowel quite quickly and - without creating a pressure zone within the sleeve or a Roux-en-Y gastric bypass procedure - and again things these are things that we do at Benenden, we can offer you the help and the support. And if it's becoming a bit of an issue, your reflux, then please come and see us because we can definitely do something about it.

Mirella Falcone

Thank you very much. Thank you, Mr Okaro, Mr Hamouda and thank you everybody who asked questions at this evening's webinar. If you would like to book your consultation, please contact us on the number on screen before 8 o'clock this evening. Alternatively, between 9am and 5pm Monday to Friday.

You will receive a short survey and we would be grateful if you could spare a few minutes to let me have your feedback on today's webinar. Our next webinar is on the 16th of May with Consultant Orthopaedic surgeons Mr Richard Goddard and Mr Raman Thakur who will be discussing hip and knee replacement surgery.

So, on behalf of Mr Hamouda, Mr Okaro, myself and the team at Benenden Hospital I'd like to say thank you very much for joining us today and we look forward to you joining us again on another webinar very soon. Have a good evening everyone, thank you, thank you very much.