This document discusses the surgical management of gastroesophageal reflux disease (GERD). It begins by defining GERD and explaining that it is caused by a defective lower esophageal sphincter. While proton pump inhibitors are usually prescribed, they do not address the underlying cause. Surgical fundoplication procedures like Nissen and Toupet fundoplication are discussed in detail, as they significantly reduce acid exposure and improve quality of life compared to medical management. Complications, indications, contraindications and follow up are also outlined. The document provides a comprehensive overview of the surgical treatment of GERD.
2. Introduction
• GERD is a common and chronic GI disorder.
• GERD is the failure of the antireflux barrier,
allowing abnormal reflux of gastric contents
into the esophagus .
• It is a mechanical disorder caused by a
defective lower esophageal sphincter (LES), a
gastric emptying disorder, or failed esophageal
peristalsis.
3. Introduction
• Patients with GERD are routinely prescribed PPIs.
• PPIs suppress normal acid production in the
stomach to increase the PH. This is effective for
healing esophagitis and heartburn, but less
effective for regurgitation and the non-acidic
symptoms of GERD.
• PPIs do not address the reason that reflux occurs,
i.e., a dysfunctional LES.
• In GERD, the LES is prone to abnormal opening
due to gastric distension, transient relaxation, or
hypotensive resting tone.
4. Medical vs Surgical Rx
• Fundoplication results in significantly less acid
exposure and significantly increased LES
pressure
• Fundoplication has demonstrated improved
QOL compared to that of medically treated
patients and is associated with high patient
satisfaction rates
• Cost differences: controversial
5. Aim of treatment
• Prevention of reflux without limiting the
dynamic nature of the LES to open for gastric
venting or swallowing.
6. Indications
• Objectively proven GERD
• Failed medical Rx (heartburn, severe
regurgitation not controlled with acid
suppression, or medication side effects)
• Patient opt for surgery despite successful
medical management (quality of life
considerations, lifelong need for medication
intake, cost of medications, etc.)
7. Indications
• Presence of complications of GERD (e.g.,
Barrett’s esophagus, esophagitis, peptic
stricture)
• Extra-esophageal manifestations (asthma,
hoarseness, cough, chest pain, aspiration)
• The development of a stricture represents
failed medical Rx: strictures are often
associated with a structurally defective
sphincter and loss of esophageal contractility
9. Preoperative evaluation
• Aim: To select the appropriate reflux patients for
surgical treatment in order to optimize outcomes.
• Counselling: for complications of treatment
• Typical symptoms (heartburn and/or regurgitation)
which have responded, at least partly, to PPI therapy,
will generally do well following surgery; patients with
atypical symptoms have a less predictable response.
• Objective signs of GERD: flexible OGD for any “mucosal
break”(an area of slough or erythema clearly
demarcated from adjacent normal-appearing mucosa )-
a reliable indicator of reflux esophagitis; BE, strictures,
masses; biopsy
10. Preoperative evaluation
• In the absence of endoscopic evidence of reflux, the
current gold-standard objective test to diagnose GERD is
the 24-hour ambulatory esophageal pH-metry
• 48-hour esophageal pH-monitoring: No additional benefit.
• Esophageal manometry: evaluates the strenght of the
propulsive force of the body of the esophagus to propel a
bolus of food through a newly reconstructed valve.
• With normal peristaltic contractions, consider 360° Nissen
FP (or a partial FP) though depends on patient and surgeon
preferences.
• With peristalsis absent, consider a partial FP (rule out
achalasia).
11. Preoperative evaluation
• Barium swallow:
• for better delineation of the anatomy.
• helpful in patients with motility disorders
• large hiatal hernias who have a shortened
esophagus, or for revision surgery after previous
antireflux surgery.
• Anatomic shortening may compromise the ability
to perform an adequate repair without tension,
and that this can lead to an increased incidence
of breakdown or thoracic displacement of the
repair.
12. Adjunct studies
• Video esophagography: structure (strictures,
masses, hiatal hernia, foreshortened esophagus,
diverticula) and function (reflux)
• CT scan of the chest and abdomen, small bowel
follow-through, gastric emptying study, and
colonoscopy
• Hiatal hernia: Lung function tests because of
compromised lung function and thorough cardiac
evaluation because of overlapping symptoms
13. Principles of Antireflux Surgery
• Aim: To safely create a new antireflux valve at the GEJ,
while preserving ability to swallow normally and belch.
Creates a flap valve which prevents regurgitation of
gastric contents into the esophagus due to an increase
in the pressure of the DES region.
The length of the reconstructed valve should be at
least 3 cm. This not only augments sphincter
characteristics in patients in whom they are reduced
before surgery, but prevents unfolding of a normal
sphincter in response to gastric distention
14. Principles of Surgical Therapy
• A laparoscopic approach is now used routinely in all patients
undergoing primary antireflux surgery.
• Some surgeons advocate the use of a single antireflux procedure for
all patients, whereas others advocate a tailored approach.
• Laparoscopic Nissen fundoplication as the procedure of choice for a
primary antireflux repair in all patients with normal or near normal
esophageal motility, and partial fundoplication for those with poor
esophageal body motility.
• Others, based on the good longer term outcomes reported
following partial fundoplication, advocate the routine use of a
partial fundoplication procedure, thereby avoiding any concerns
about constructing a fundoplication in individuals with poor
esophageal motility.
15. The ideal fundoplication
• A loose wrap
• Maintains the position of the gastric fundus close to the distal intra-
abdominal esophagus, in a flap valve arrangement
• An adequate length of the DES in the positive-pressure
environment of the abdomen by a method that ensures its
response to changes in intra-abdominal pressure.
• The reconstructed cardia should be able to relax on deglutition.
• Should not increase the resistance of the relaxed sphincter to a
level that exceeds the peristaltic power of the body of the
esophagus.
• Placed in the abdomen without undue tension, and maintained by
approximating the crura of the diaphragm above the repair
16. Primary Antireflux Repairs
• Nissen Fundoplication.
• The most common antireflux procedure.
• Previously done via an open abdominal or a chest
incision, now routinely undertaken laparoscopically.
• Originally a 360° fundoplication around the lower
esophagus for a distance of 4 to 5 cm, without division
of the short gastric blood vessels.
• Modification: only the gastric fundus used to envelop
the esophagus around a large (50 to 60F) bougie,
limiting the length of the fundoplication to 1 to 2 cm,
and dividing the short gastric vessels
17. Nissen fundoplication
• The patient is placed with the head elevated
approximately 30° in the modified lithotomy
position.
• The surgeon stands between the patient’s
legs, and the procedure is completed using
five abdominal ports.
• The gastrohepatic ligament is incised until the
phrenoesophageal ligament is visualized
18. Nissen fundoplication
• Opening of the phrenoesophageal ligament in a
left to right fashion and preservation of the
hepatic branch of the anterior vagus nerve
• The circumference of the diaphragmatic hiatus is
dissected and the esophagus is mobilized to allow
about 3 cm of intraabdominal esophagus by
careful dissection of the anterior and posterior
soft tissues within the hiatus with great care to
preserve both vagus nerves and the peritoneal
lining along the crura.
19. Nissen fundoplication
• The esophagus is held anterior and to the left and crural
closure posteriorly with interrupted non-absorbable
sutures.
• Following complete fundal mobilization, tension-free FP is
constructed either with or without division of the short
gastric blood vessels, according to surgeon preference.
• The posterior wall of the fundus is brought behind the
esophagus to the right side, and the anterior wall of the
fundus is brought anterior to the esophagus creating a 1.5
to 2-cm wrap with the most distal suture incorporating the
anterior muscular wall of the esophagus
• 50 to 60F bougie placement at the time of wrap
construction
21. Posterior Partial Fundoplication
• An alternative to the Nissen procedure developed to minimize the
risk of postFP side effects: dysphagia, inability to belch, and
flatulence.
• Commonest approach - a posterior partial or Toupet fundoplication.
• Some surgeons use this type of procedure for all patients
presenting for antireflux surgery.
• Others apply a tailored approach in which a partial fundoplication is
constructed in patients with impaired esophageal motility, in which
the propulsive force of the esophagus is thought to be insufficient
to overcome the outflow obstruction of a complete fundoplication.
• The Toupet posterior partial FP is a 270° gastric FP around the distal
4 cm of esophagus. It is usually stabilized by anchoring the wrap
posteriorly to the hiatal rim.
23. Anterior Partial Fundoplication
• An alternative approach to partial fundoplication.
• Following posterior hiatal repair, the anterior fundus is rolled over
the front of the esophagus and sutured to the hiatal rim and the
esophageal wall.
• Division of the short gastric vessels is never needed.
• Various degrees of anterior partial fundoplication have been
described—90°, 120°, 180°.
• The anterior 180° partial fundoplication provides a more robust FP
and achieves an excellent longer term outcome in approximately
90% of patients at follow-up of at least 10 years.
• With this procedure the fundus and esophagus are sutured to the
right side of the hiatal rim to create a flap valve at the
gastroesophageal junction, and to stabilize a 3-4 cm length of intra-
abdominal esophagus.
25. Collis Gastroplasty (PGT)
• When a shortened esophagus is encountered,
many surgeons choose to add an esophageal
lengthening procedure before fundoplication,
to reduce the tension on the gastro-
esophageal junction, believing this will
minimize the risk of failure due to
postoperative hiatus hernia.
27. Outcome after Fundoplication
• Relieves typical reflux symptoms (heartburn,
regurgitation, and dysphagia) in more than
90% of patients at follow-up intervals
averaging 2 to 3 years and 80% to 90% of
patients 5 years or more following surgery.
28. Postop Complication
• Dysphagia: Common. Generally resolves within 3
months, but can take up to 12 months.
Permanent in 5% of individuals following Nissen
fundoplication to require dietary modification
• Inability to belch & vomit: usually temporary (
first 3 to 6 months), but 80%-90% resolves by 12
months follow-up.
• Hyperflatulence: related to increased air
swallowing reflux disease, aggravated by the
inability to belch.
• Rx failure.
29. Recent advances
• Adding bulk to the LES
• tightening the sphincter (by plication/
radiofrequency ablation)
• Robotic surgery
30. Recent advances
• Sphincter augmentation with LINX system: use of
a flexible and expandable device that creates
resistance to abnormal opening of the sphincter.
Ease of removal.
• Complications:
Dysphagia: usually mild
Chest pain from suspected esophageal spasm.
Treated with sublingual nitroglycerin
inability to belch or vomit
Device erosion or migration: Not documented
35. Follow up
• Post op complications
• Complications of GERD (BE) postop: Seattle
protocol. Surveillance at regular intervals
because regression is rare
36. American Gastroenterological
Association Guidelines for Surveillance
After FP For BE
• VARIABLE SCORE
• Age >75 years 1
• Tachycardia (>100 beats/min) 1
• Leukocytosis (>10,000 white blood cells/mL) 1
• Pleural effusion 1
• Fever (>38.5° C) 2
• Noncontained leak (barium swallow or CT scan) 2
• Respiratory compromise (respiratory rate >30, increasing
oxygen requirement, or mechanical ventilation) 2
• Time to diagnosis >24 hours 2
• Presence of cancer 3
• Hypotension 3
37. PROGNOSIS
• Technique employed
Ant vs Post vs Nissen
Length
Short gastric vessel division
• For Barrett’s Esophagus
Presence of dysplasia
Degree of dysplasia
Length of BE segment
38. Conclusion
• GERD is the failure of the antireflux barrier,
allowing abnormal reflux of gastric contents
into the esophagus.
• Surgical management is more beneficial than
medical Rx in patients with typical symptoms
due to the added reflux control.
• Follow up is mandatory in patients with BE.
PPIs- proton pump inhibitors
LES – lower oesophageal sphincter
QOL – quality of life
Barrett’s CLE is commonly associated with a severe structural defect of the LES and often poor contractility of the esophageal body. Patients with BE are at risk of the development of an adenocarcinoma. Barrett’s esophagus should be considered to be evidence that the
patient has gastroesophageal reflux, and progression to antireflux surgery is indicated for the treatment of reflux symptoms, not cancer progression.
Rx - treatment
The important variables are:
the total time with pH < 4 as recorded by a probe placed 5 cm above the LES, and a
composite score comprised of the following 6 variables:
1. total esophageal acid exposure time
2. upright acid exposure time
3. supine acid exposure time,
4. number of episodes of reflux,
5. number of reflux episodes lasting more than 5 minutes and
6. the duration of the longest reflux episode
FP - fundoplication
esophageal shortening is present when a barium swallow X-ray identifies a sliding hiatal hernia that will not reduce in the upright position, or that measures more than 5 cm in length at endoscopy. When identified these surgeons usually undertake add a gastroplasty to the antireflux procedure. Opponents claim that esophageal shortening is overdiagnosed and rarely seen, and that the morbidity of adding a gastroplasty outweighs any benefits. These surgeons would recommend a standard antireflux procedure in all patients undergoing primary surgery.
Following a Nissen fundoplication the expected increase is to a level twice the resting gastric pressure (i.e., 12 mmHg for a gastric pressure of 6 mmHg). The extent of the pressure rise is often less following a partial fundoplication
Experience and randomized studies have shown that both the Nissen fundoplication and various partial fundoplication procedures are all effective and durable antireflux repairs, and generate an excellent outcome in approximately 90% of patients at longer term follow-up.
The efficacy of this relies on the close relationship between the fundus and the esophagus, not the “tightness” of the wrap.
2. The permanent restoration of 2 or more cm of abdominal esophagus ensures the preservation
of the relationship between the fundus and the esophagus. All of the popular antireflux procedures increase the length of the sphincter exposed to abdominal pressure by an average of at least 1 cm.
2. In normal swallowing, a vagally mediated relaxation of the distal esophageal sphincter and the gastric fundus occurs. The relaxation lasts for approximately 10 seconds and is followed by a rapid recovery to the former tonicity. To ensure relaxation of the sphincter, three factors are important: (a) Only the fundus of the stomach should be used to buttress the sphincter, because it is known to relax in concert with the sphincter; (b) the gastric wrap should be properly placed around the sphincter and not incorporate a portion of the stomach or be placed around the stomach itself, because the body of the stomach does not relax with swallowing; and (c) damage to the vagal nerves during dissection of the thoracic esophagus should be avoided because it may result in failure of the sphincter to relax.
4. The resistance of the relaxed sphincter depends on the degree, length, and diameter of the gastric fundic wrap, and on the variation in intra-abdominal pressure. A 360° gastric wrap should be no longer than 2 cm and constructed over a large (50 to 60F) bougie. This will ensure that the relaxed sphincter will have an adequate diameter with minimal resistance. A bougie is not necessary when constructing a partial wrap.
5. Leaving the fundoplication in the thorax converts a sliding hernia into a PEH, with all the complications associated with that condition. Maintaining the repair in the abdomen under tension predisposes to an increased incidence of recurrence. How common this problem is encountered is disputed, with some surgeons advocating lengthening the esophagus by gastroplasty and constructing a partial fundoplication, and others claiming that this issue is now rarely encountered.
*Rudolf Nissen
Technique: 1. Hiatal dissection and preservation of both vagi along their entire length
2. Circumferential esophageal mobilization
3. Hiatal closure, usually posterior to the esophagus
4. Creation of a short and floppy fundoplication over an esophageal dilator
If the vessels are divided, the upper one third of the greater curvature is mobilized by sequentially dissecting and divided these vessels, commencing distally and working proximally.
The fundoplication does not cover the anterior surface of the esophagus, and is stabilized by suturing the fundus to the side of the esophagus, and posteriorly to the right hiatal pillar.
This entails using a stapler to divide the cardia and upper stomach, parallel to the lesser curvature of the stomach, thereby creating a gastric tube in continuity with the esophagus, and effectively lengthening the esophagus by several centimeters. Following gastroplasty a fundoplication is constructed, with the highest suture is placed on the native esophagus when constructing a Nissen fundoplication.