current approach to assessment, investigation and treatment of reflux disease

1. Surgical approaches to
GERD
Dr Makanga
Continuous Medical Education, Tuesday, June 22, 2010

2. Pathophysiology
• Shortening of intra-abdominal esophagus
• Increase in angle of His
• Reduction of the thickness of esophageal wall
around the LES
– Vis a vis reduction of wall tension (La Place law)
• Increased intra-abdominal pressure
– Obesity

3. Indications for surgery
• Erosive esophagitis
• Stricture
• Barrett's esophagus
• Long term dependency on PPI for symptom
relief

4. Principles of anti-reflux surgery 1
• Single surgical approach will not suffice for all
patients
• Restoration of adequate intra-abdominal
esophagus
– Length is inversely correlated with the amount of
postoperative reflux
• The acuteness of the angle of His is restored by a
gastric wrap
• The gastric wrap reduces the esophageal orifice
diameter & increases wall tension

5. Principles of anti-reflux surgery 2
• Hiatal orifice diameter is reduced by
approximating the crural fibers, prevents
herniation of the repair
• Complete wraps:
– Better long-term control of reflux symptoms
– More postoperative dysphagia and are associated
with bloating

6. Pre-op assessment
• Establish that GERD is the underlying cause of
symptomatology
• Estimate risk of progressive disease
• Determine the presence or absence of
esophageal shortening
• Evaluate esophageal body function

7. Surgical approaches
• Laparoscopic
• Open
– Transthoracic
• Complete wrap – Nissen’s
• Partial wrap - Belsey Mark IV
– Trans-abdominal
• Complete wrap – Nissen’s
• Partial wrap
– Posterior (Toupet, Lind)
– Anterior (Dor, Thal)
– Hill gastropexy (combined anterior and posterior fundoplication)

8. Laparoscopic
• Currently the standard of care due to:
– Safety, short-term efficacy, patient satisfaction,
and shorter hospital stay
• For patients with normal esophageal
contractility and length

9. Transthoracic vs. transabdominal
• Thoracic
– For shortened esophagus
to mobilize intrathoracic
length
– More post-op pain and
resp compromise
– Antireflux protection not
as predictable* (Belsey)
• Abdominal
– Technically easier
– Offers versatility
– Difficult access in the
obese patient

10. Transthoracic total plication – Nissen’s

11. Transthoracic partial plication – Belsey
Mark IV

12. Transabdominal total plication –
Nissen’s

13. Toupet

14. Hill’s procedure

15. Refferences
• Maingot’s Abdominal Surgery
• Mastery of Cardiothoracic surgery
• Mastery of Surgery
• Up to Date Library 17.3
• Schwartz Surgery

16. GRATZI !