Anti reflux surgery

1. Anti-reflux
surgry
When .. &
How ..
Ahmed Nassr
Assistant lecturer in
surgery department
Faculty of medicine
,Minia Univesity

2. GERD
Definition
Clinical
reflux of gastric
contents into the
esophagus results in
symptoms and/or
complications
Pathophysiological
presence of
characteristic mucosal
injury seen at endoscopy
and/or abnormal
esophageal acid exposure
demonstrated on a reflux
monitoring study

3. How common ?
• One of the most common diagnoses
made by primary care givers and
gastroenterologists.
• 18.1%-27.8% in North America, 8.8%-
25.9% in Europe.
• 2.5%-7.8% in East Asia, 8.7%-33.1%
in the Middle East.
• 11.6% in Australia, 23.0% in South
America.
• GERD is prevalent worldwide, and
disease burden may be increasing.
El-Serag, Hashem & Sweet, Stephen & Winchester, Chris
& Dent, John. (2014). Update on the epidemiology of
gastro-oesophageal reflux disease: A systematic
review. Gut. 63. 871-880. 10.1136/gutjnl-2012-304269

4. Historical overview

5. • Dr Rudolph Nissen is a great
surgeon who operated
on Einstein's abdominal aortic
aneurysm. he also introduced
Nissen fundoplication for GERD
in the year 1956.

6. Historical overview
• In the mid-1930s, Nissen encountered a
patient with a distal esophageal ulcer
penetrating into the pericardium. He resected
the distal esophagus and cardia and
anastomosed the esophagus to the proximal
gastric body. To protect the anastomosis,
Nissen wrapped the anastomosed area with
the body of the stomach
• He later learned that the patient remained
well and free from reflux 15 years after the
original procedure
2019_Book_The SAGES Manual Of Foregut Surgery

7. Historical overview
• Other investigators suggested
partial fundoplication to avoid
problematic dysphagia, specifically
Dor (anterior partial fundoplication)
in 1962, and Toupet (posterior
fundoplication) in 1963
• The first description of
laparoscopic fundoplication was
by Bernard Dallemagne in 1991
2019_Book_The SAGES Manual Of Foregut Surgery

8. So ,
• Is Anti reflux surgery is the
magical treatment for
reflux symptoms ?

9. Key facts
Patients undergoing surgery
demonstrated better short-
term and long-term symptom
control as well as evidence
of improved pH
normalization relative to
medically treated patients.
A poorly done
fundoplication upon a
poorly selected patient can
be worse than the disease
itself.
The wrong fundoplication,
done on the wrong patient ,
is a recipe for disaster.
A well-done fundoplication
, performed in a patient
with severe reflux disease
will not be considered to
be an absolute blessing by
that patient.
Varying proportions of
patients underwent surgery
, experience postoperative
dysphagia ‘mostly
transient’ , gas bloat
syndrome , recurrence or
persistence of symptoms and
pursuing on PPI treatment.
SURGICAL TREATMENT OF GERD: SYSTEMATIC REVIEW AND META-ANALYSIS,
reviewed and approved by the Board of Governors of the Society of
American Gastrointestinal and Endoscopic Surgeons (SAGES) in Nov
2020.

10. Keys for
successful ARS
Confirmed
diagnosis of GERD
Proper patient
selection
Comprehensive pre-
op work up
Tailor the surgical
approach to the
individual patient.

11. Pre-op Work up
confirm the
diagnosis of
GERD
1
Rule out other
etiologies for
the symptoms
2
Define the
anatomy
3

12. confirm the diagnosis of GERD
• Accurate clinical history : Heartburn .. Regurgitation
Current Surgical Therapy 13th Ed

13. confirm the diagnosis of GERD
Accurate clinical history
Current Surgical Therapy 13th Ed
Response to empirical PPI treatment
PPI is a good predictor of the presence of abnormal reflux.

14. confirm the diagnosis of
GERD
• Upper gastrointestinal endoscopy
Los Angeles classification

15. Esophageal Diagnostic Advisory Panel recommends:
• LA grade A and mild B esophagitis require pH testing to document
the presence of GERD.
• LA grade C or D esophagitis do not require pH testing

16. Barrett Esophagus
• Prague classification
• Esophageal Diagnostic Advisory Panel :
• short-segment BE (<3 cm) requiring pH testing.
• long-segment BE (≥3 cm) do not require pH

19. confirm the diagnosis of GERD
Ambulatory pH
monitoring
DeMeester score
(>14.7 )

20. Indications
pH monitoring
required for all patients being
considered for antireflux surgery
nonerosive GERD,
LA grade A or mild B esophagitis,
short-segment BE (<3 cm).
patients with GERD not responding
to PPI therapy

21. RULE OUT OTHER
ETIOLOGIES OF
SYMPTOMS
• Esophageal manometry
• Gastric scintigraphy

22. Define the
Anatomy
Upper
gastrointestinal
series
Computed
tomography scan

24. ACG Clinical Guideline for the Diagnosis
Gastroesophageal Reflux Disease
• There is no gold standard for the diagnosis of GERD.
Thus, the diagnosis is based on a combination of
symptom presentation, endoscopic evaluation of
esophageal mucosa, reflux monitoring, and response to
therapeutic intervention

25. ACG Clinical Guideline for the Diagnosis and
Management of Gastroesophageal Reflux
DiseaseAm J Gastroenterol 2022;117:27–56

26. Indications of ARS
• Symptoms ,especially regurgitations failed to be controlled by medical
management
• Symptoms and large hiatal hernia
• Patient preference , poor compliance , young patients who refuse lifelong
PPI
• Gastroesophageal reflux disease complications (stricture, esophagitis,
Barret)
• Contraindications to proton pump inhibitor
• Lung transplant patient
• Atypical symptoms with documented reflux
2019_Book_The SAGES Manual Of Foregut Surgery
Current Surgical Therapy 13th Ed

27. Indications of ARS
• Based on SAGES guidelines, objective evidence of esophageal reflux must be
demonstrated prior to surgery
• Risk factors that predict a poor response to medical therapy:
• –– Nocturnal reflux on 24-h esophageal PH study
• –– Structurally deficient lower esophageal sphincter
• –– Mixed reflux of gastric or duodenal juice
• –– Mucosal injury at presentation
2019_Book_The SAGES Manual Of Foregut Surgery
Current Surgical Therapy 13th Ed

28. Surgical options
ACG Clinical Guideline for the Diagnosis and Management of
Gastroesophageal Reflux DiseaseAm J Gastroenterol 2022;117:27–

29. ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux
DiseaseAm J Gastroenterol 2022;117:27–56

30. Surgical options
Fundoplication
Magnetic sphincter
augmentation (MSA
with the LINX
Reflux Management
System)
Roux-en-Y gastric
bypass
Endoscopic
antireflux
therapies :
- radiofrequency
antireflux
treatment
(Stretta)
- TIF (endogastric
solutions)

31. • Selection of a partial
versus complete
fundoplication is based
upon an assessment of
the esophageal
contractility and the clinical
presence of dysphagia
2019_Book_The SAGES Manual Of Foregut Surgery

32. Contraindications
• Inability to tolerate surgery
• Esophageal cancer or high-grade dysplasia
• Morbid obesity (consider gastric bypass)
2019_Book_The SAGES Manual Of Foregut Surgery
Current Surgical Therapy 13th Ed

33. LARS
‘Lap. Nissen Fundoplication’

34. LARS
‘Lap. Nissen
Fundoplication’
Mobilize the esophagus : dissection
should be carried up into the chest
circumferentially around the esophagus
, avoid injuring the anterior and
posterior vagus nerves , at least 3 cm
and ideally 5 cm of esophagus comes
into the abdomen without tension
Crural dissection : Atraumatic,
peritoneal covering on the muscle of
the crura. Stripping the peritoneum off
the muscle will weaken the crural
repair

35. LARS
‘Lap. Nissen Fundoplication’
divide the short gastrics
Crural closure :crural stitches should be placed at a right angle
to a line bisecting the triangle made by the two crura, meaning
that the stitches will look like they slant downward to the
patient’s left. This prevents unnecessary tension on the left
crus , nonabsorbable 0 sutures
Fundoplication :short, floppy wrap, no more than 3 cm in
length

38. Complications
• Acute wrap herniation
• Dysphagia
• Gas bloat syndrome
• Recurrent GERD
• Esophageal or gastric dysmotility
• Anatomic failures

39. ARS outcomes
study involved 2,655 patients
,During a mean follow-up period of
5.1 years
• 80% possibility of long-term
freedom from symtoms
• 4% acute complications of
fundoplication
• 17.7% recurrence
ACG Clinical Guideline for the Diagnosis and Management of
Gastroesophageal Reflux DiseaseAm J Gastroenterol 2022;117:27–56

40. Patient counselling
Pt has to be counselled regarding expectations
To be realistic
Must be informed about postop sequelae

41. Thank you