Surgery for Gastroesophageal Reflux Disease

Heartburn and Acid Reflux Cure Program

Treatments for Gastro Esophageal Reflux Disease

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Lev Khitin, md and David M. Brams, md

Contents

Introduction Pathophysiology of Gerd Symptoms of Gerd Indications for Surgery Contraindications to Surgery Preoperative Evaluation

Laparoscopic Fundoplication: Conduct of Operation

Results and Complications

Alternative Procedure

Cost

Summary

References introduction

Gastroesophageal reflux disease (GERD) is one of the most common problems seen in medical practice. Approximately 10% of the U.S. population experiences heartburn daily, and 40% of the population has heartburn monthly. Seven percent of the population (40 million individuals) use over-the-counter antacids, H-2 receptor antagonists, or proton pump inhibitors at least twice weekly to relieve GERD symptoms. Surgical management of GERD is an effective alternative to medical management of GERD, and it is being more commonly employed (1).

Antireflux surgery was first performed in the 1950s. Diagnostic modalities and technical details evolved during the ensuing 30 yr, yielding superb results from antireflux procedures. However, these procedures, which necessitated thoracotomy or laparotomy, were usually only employed in the most severe cases refractory to medical management. The advent of minimally invasive videoscopic surgery has revolutionized the surgical management of GERD. The transabdominal Nissen fundoplication, which has a greater than 90% effectiveness in treating GERD, became a laparoscopic procedure with equiva-

From: Clinical Gastroenterology: An Internist's Illustrated Guide to Gastrointestinal Surgery Edited by: George Y. Wu, Khalid Aziz, and Giles F. Whalen © Humana Press Inc., Totowa, NJ

lent results to the open Nissen, but with minimal postoperative pain and a rapid return to normal activities. The minimally invasive laparoscopic Nissen fundoplication (LNF) is now increasingly utilized in treating GERD (1,2).

LNF was initially performed only at referral centers. As experience with this procedure has grown, surgeons who perform advanced laparoscopy are routinely performing LNF in community hospitals. As with many laparoscopic procedures, there is a learning curve of 30 to 50 operations. When this curve is surmounted, operative times and complications decrease and long-term successful antireflux repair is achieved (2).

This chapter will discuss the pathophysiology of GERD, treatment options, indications for surgery, necessary preoperative evaluations, a description of LNF, alternative antireflux procedures, and LNF's results, complications, and costs.

pathophysiology of gerd

Gastroesophageal reflux is multifactorial in etiology. The three major determinants of GERD include transient lower esophageal sphincter (LES) relaxation with normal resting LES pressure, anatomical disruption of gastroesophageal junction associated with hiatal hernia, and hypotensive LES. The LES is not a discrete anatomic structure; rather, it is a high-pressure zone that exists because of the anatomic relationships of the distal esophagus, stomach, and diaphragm. The factors that contribute to the LES are as follows: intrinsic esophageal and gastric musculature, relationship of the esophagus to the gastric fundus, and relationship of the distal esophagus to the diaphragm (2,3).

The distal esophageal musculature is contracted in the resting state, but it completely relaxes on swallowing. The orientation of the musculature of the cardia of the stomach contributes to the LES. The relationship of the distal esophagus to the gastric fundus (which compresses the distal esophagus when the stomach is distended) also contributes to this high-pressure zone (4).

The relationship of the distal esophagus to the diaphragm stops reflux (Figs. 1-3). Normally, the distal esophagus rests within the abdomen. As the esophagus traverses the hiatus, the crura of the diaphragm compress the esophagus, increasing LES pressure. This compression is maximal during inspiration, when intrathoracic pressure decreases and risk of reflux is greatest. The intraabdominal pressure is also greater than that of the thorax. This high-pressure zone is transmitted to the distal intraabdominal esophagus, thus contributing to the LES pressure (4,5).

Pathologic reflux occurs if the elements contributing to the LES are dysfunctional. In the absence of a primary esophageal motility disorder, the most common cause of reflux and a low LES pressure is a Type I or sliding hiatal hernia (Fig. 4). A sliding hiatal hernia develops when there is a laxity of the phrenoesophageal attachments. High intraabdominal and negative intrathoracic pressures cause the distal esophagus and gastric cardia to migrate into the chest, lowering the LES pressure and allowing reflux to occur (2,4,5).

Antireflux procedures augment the LES pressure by returning the distal esophagus to abdomen. The relationship of the esophagus to the diaphragm and fundus is restored by repairing the hiatus and performing a fundoplication.

symptoms of gerd

GERD presents with symptoms related to exposure of gastric contents to the esophagus, pharynx, and lungs. Heartburn is the most common presenting symptom of GERD,

Fig. 2. Normal anatomy of esophageal hiatus: overview.

Fig. 3. Normal anatomy of esophageal hiatus: upper gastrointestinal contrast study.

occurring in 80% of patients. Chronic acid reflux can lead to esophagitis. In severe cases of esophagitis, stricture may develop leading to dysphasia. Belching and regurgitation occur in 50% of patients with GERD. Thirty percent of patients present with abdominal pain. Occasionally, patients present with minimal heartburn but with severe extra-esoph-ageal manifestations of GERD. Chronic respiratory symptoms, such as chronic cough, recurrent pneumonias, episodes of nocturnal choking, and asthma may occur. Chest pain may be an atypical symptom of GERD. Fifty percent of patients in whom a cardiac cause of the chest pain has been excluded will have increased acid exposure as the etiology (1,2).

Fig. 4. Type I hiatal or sliding hiatal hernia: coronal section.

indications for surgery

The majority of patients with heartburn can be managed through modification of lifestyle and through medical management. These should be optimized prior to consideration of surgery.

Caffeine, tobacco, and alcohol all decrease the LES pressure and cause reflux. Large meals late at night often results in nocturnal reflux symptoms. Their elimination will often improve GERD. Obesity increases intrabdominal pressure. Weight loss will often effectively decrease reflux. H2-blockers and proton pump inhibitors potently neutralize gastric secretions stopping heartburn and healing esophagitis (1).

When lifestyle modifications and medications are ineffective or poorly tolerated, surgery should be considered. In addition, in patients who are good surgical risks, LNF is an excellent alternative to lifelong medication (6).

Patients with esophageal injury because of acid reflux (including esophagitis, ulceration, stricture, and Barrett's metaplasia) should be considered for surgery. Although these complications can be controlled with medication, cessation of treatment often leads to recurrence. Regurgitation despite acid suppression is a clear indication for surgery (1,6).

Healthy patients are able to tolerate general anesthesia and laparoscopy, and they should be considered candidates for surgery. In particular, patients less than 50 yr old should consider surgery as an alternative to lifetime medication. Elderly patients are usually best treated medically (1,5,6).

contraindications to surgery

There are few absolute contraindications to LNF except those precluding laparoscopy or general anesthesia. Although LNF has been done successfully in patients older than 70 yr of age, the risk of surgery will often outweigh the benefit of avoiding medication. There are several relative contraindications to surgery. Obesity increases the technical difficulty of LNF, and is often a cause for conversion to an open procedure. Obesity will also increase the risk of long-term failure of the fundoplication with recurrence of symptoms. Morbid obesity is better treated with medical management or with gastric bypass surgery. Previous upper abdominal or gastric surgery increases the difficulty of LNF necessitating an open approach (1-3,5,6).

preoperative evaluation

Prior to surgery, the patient should undergo ambulatory esophageal pH testing, esophageal motility testing, and upper gastrointestinal (GI) endoscopy. Most patients will have an upper GI series (Fig. 5).

The success of LNF in eradicating GERD is dependent on the presence of acid reflux. Ambulatory 24-h pH testing will accurately characterize the severity of GERD, and allows the correlation of symptoms with acid reflux. The absence of acid reflux or poor correlation between symptoms and reflux is a predictor of poor outcome of surgery (2,5,6).

Esophageal motility testing is essential to rule out esophageal motility disorder as causing symptoms. An LNF done in the presence of a motility disorder can lead to severe dysphagia. Patients with poor motility may benefit from a partial fundoplication (2,5,6).

Upper GI endoscopy should be performed to document the presence of esophagitis or Barrett's esophagus both visually and through biopsies. Barrett's esophagus is a potentially premalignant columnar metaplasia of the distal esophagus that can progress to adenocarcinoma. Patients with Barrett's esophagus need lifetime surveillance endoscopy to identify potential progression to severe dysplasia, which is an indication for esophagectomy (2,3).

laparoscopic fundoplication: conduct of operation

Selection of the antireflux procedure and approach is based on an assessment of esophageal contractility and length. A transabdominal approach is used for patients with normal esophageal contractility and length. Patients who present with long-standing disease associated with poor esophageal function, a short esophagus, or stricture should undergo an open antireflux procedure tailored to their underlying anatomic and physiologic abnormalities. Those with weak esophageal contractions may be treated with a partial 270° fundoplication such as the transabdominal Toupet (Fig. 6) or transthoracic Belsey IV fundoplication in order to avoid the increased outflow resistance associated with a 360° Nissen fundoplication. Patients with poor contractility or questionable esophageal length can be approached transthoracically. If the esophagus is too short after it is mobilized from diaphragm to aortic arch, a Collis gastroplasty is done to provide additional esophageal length and to avoid placing the repair under tension. Finally, if the disease has resulted in esophageal body failure, Barrett's metaplasia with high grade dysplasia, or esophageal adenocarcinoma, an esophagectomy is required (2,3,5).

Toupet Fundoplication UpperToupet Fundoplication Trocar
Fig. 5. Type I hiatal or sliding hiatal hernia: upper GI contrast study.

Laparoscopic Nissen fundoplication (Fig. 7) is the procedure of choice in the majority of patients presenting with GERD. General anesthesia is required. The patient is placed in a low lithotomy position. Pneumoperitoneum and five laparoscopic trocars are placed (Fig. 8). The Nissen fundoplication (laparoscopic or open) is performed in what can be summarized as four major steps:

  1. Crural Dissection: Crura of the diaphragm are circumferentially dissected from the distal esophagus and stomach by dividing the phrenoesophageal attachments. The lower esophagus is completely mobilized, returning the distal esophagus to the abdomen without tension. The vagus nerves are preserved.
  2. Fundic mobilization: The gastric fundus is completely mobilized by division of the short gastric vessels and retrogastric attachments.
  3. Crural closure: The crura of the diaphragm are loosely approximated posteriorly.
  4. Fundoplication: A short, loose 360° fundoplication is created by wrapping the anterior and posterior walls of the fundus around the distal esophagus and vagus nerves. This loose wrap is 1.5 to 2 cm in length (2,5,6).

Fig. 6. 270° (Toupet) fundoplication.

Fig. 7. 360° (Nissen) fundoplication.

In the presence of altered esophageal motility, where the propulsive force of the esophagus is not sufficient to overcome the outflow obstruction of a complete fundoplication, a partial 270° Toupet fundoplication can be performed. This procedure is identical to the

Midline Laparot Open Fundoplic

Midline Laparot Open Fundoplic

Laparoscopic Fundoplication

Fig. 8. Incision locations for Belsey IV and open fundoplications, trocar positions for laparoscopic fundoplication.

Laparoscopic Fundoplication

Left Thoracotomy Belsey IV

Fig. 8. Incision locations for Belsey IV and open fundoplications, trocar positions for laparoscopic fundoplication.

Nissen fingoplication except that the stomach is sutured to the esophagus and crura, leaving the anterior esophagus uncovered and able to fully distend (4).

Operative time is 2-3 h. The patient begins liquids that night and is discharged the following morning. Most patients return to sedentary work in 2 wk. Patients are advised to avoid heavy lifting and straining for 6-8 wk to decrease the risk of herniation of the fundoplication into the chest. Patients are given a diet progressing to solid foods over 2 wk (5).

Nissen fundoplication is extremely effective in treating GERD. Typical symptoms of GERD (heartburn, regurgitation, and dysphagia) are alleviated in 90 to 95% of patients. With the open technique, 90% of patients have no recurrence of symptoms at 10 yr. The first LNF was done in 1991; therefore, 10-yr data is not available. However, the LNF is identical to the open procedure, and 5-yr data for LNF is similar to that seen in the open Nissen fundoplication (3,5).

Recurrence of symptoms is reported to occur in 3.4% after 3 yr in a meta-analysis by Perdikis. Recurrent reflux may be caused by inadequate technical repair, shortening of the esophagus or inadequate esophageal mobilization leading to excessive tension and retraction of the fundoplication into the chest, or weakening of the musculofascial structures by aging, atrophy, or obesity. Recurrent symptoms can usually be treated medically (2,6).

Less than 1% of patients require further surgical intervention for recurrent reflux. This subgroup consists mainly of patients who had severe esophagitis, esophageal stricture, and ulceration prior to surgery, and whose fundoplication failed. Failed fundoplication can take several forms: disrupted wrap, "slipped" fundoplication onto the proximal stomach, and recurrent hiatal hernia with intrathoracic migration of the fundoplication (Fig. 9) (5,6).

Conversion rate to open surgery is approx 2%, and early reoperation is necessary in 0.5%. Morbidity following LNF averages 3-10%. Pulmonary complications are more results and complications

Fundopl ¡cation

Fig. 9. Intrathoracic migration of fundoplication.

common and morbidity is higher after a thoracic operation than after transabdominal surgery. Pitfalls unique to the laparoscopic approach include pneumothorax and surgical emphysema, occurring in 1 to 2% of patients. Death is rare, whether the procedure is open or closed. In a recent collective review, 4 of 2453 (0.2%) patients died. Deaths that have been reported were caused by visceral perforation, superior mesenteric vessel thrombosis, and myocardial infarction (5,6).

The most serious operative complication is instrumental perforation of a hollow vis-cus. Perforations can also occur in the stomach or distal esophagus caused by passage of the bougie used to size the fundoplicaiton. If recognized at the time of surgery, a perforation can be repaired without added morbidity. Unrecognized perforations will be manifested by postoperative toxicity (fever, oliguria, hypoxia, tachycarida, and peritoneal signs). Suspicion of a perforation should necessitate radiological examination or reexploration in a timely fashion (5,6).

Postoperative hemorrhage is unusual, but can arise from the liver, short gastric vessels, or spleen. Splenic injury necessitating splenectomy has been virtually eliminated with the advent of laparoscopic fundoplication (5,6).

Dysphagia is the most common postoperative complaint occurring in 30% of patients. Dysphasia is usually worse with solids, is self-limited, and is caused by postoperative edema at the fundoplication. Persistent postoperative dysphagia occurs in approx 9% of patients after laparoscopic repair and in 3% after open. The majority of patients are asymptomatic by 8 wk. An esophagram and endoscopy may help to define the underlying problem. Gentle dilation of the fundoplication will usually alleviate symptoms (5,6).

Gastric distension ("Gas bloat") was common after the early variation of the open Nissen fundoplication. It is relatively uncommon today because of routine creation of a short "floppy" fundoplication that allows the patients to belch to a limited degree. Patients undergoing antireflux surgery habitually swallow air to clear the esophagus of reflux contents, and this habit continues after antireflux surgery. Gas-binding agents and prokinetics may be helpful when patients complain of bloating and increased flatulence (5,6).

Diarrhea and nausea occur in up to 8%. Most of these symptoms disappear after several weeks, and medical therapy is usually not required. Postoperative diarrhea is thought to be caused by rapid gastric emptying, change of diet, or incidental vagotomy. Severely affected patients may be treated with antidiarrheals (1,4).

alternative procedure

Lapraoscopic vs Open Fundoplication

LNF has been compared to the open Nissen fundoplication as well as to the Belsey IV. LNF has equivalent control of symptoms to open Nissen, and superior results to the Belsey IV. LNF has less perioperative morbidity and a shorter recovery time. Convalescence is faster after laparoscopy: return to normal life being 14 vs 31 d and return to work being 21 vs 44 d (1,2).

Partial vs Complete Fundoplication (Table 1)

In contrast to the 360° fundoplication typical of a Nissen fundoplication, antireflux protection also occurs when the fundus is incompletely wrapped around the lower esophagus. Table 1 lists some of the common antireflux procedures and a description of their conformation. Partial fundoplication results in less postoperative bloating and dysphagia. However, partial fundoplication has a higher incidence of recurrent reflux and, therefore, is not routinely used. Partial fundoplication is typically reserved for patients with abnormal esophageal motility, such as scleroderma and achalasia. Partial fundoplication has been linked to a greater overall level of patient satisfaction 6 mo after surgery. Fewer patients had difficulty swallowing, inability to belch, or had excessive flatus in the partial fundoplication patients. These benefits may be offset by recurrent GERD. In addition, the prevalence of these symptoms in patients following Nissen fundoplication is highly dependent on the technical aspects of the procedure that can be minimized given ideal technique (4).

Angelchik Procedure

The Angelchik procedure is no longer performed. It involves placing a doughnut shaped silicone prosthesis around the intraabdominal esophagus. After it is tied in place,

Table 1 Partial Fundoplications

Type

Eponym

Year Described

Description

Total

Nissen

1956

360° wrap

"Floppy" Nissen

1977

360° short (< 2 cm) wrap

Rosettil

1965

360° with short gastric vessels not divided

Partial

Belsey Mark IV

1967

270° transthoracic

Toupet

1963

180° posterior wrap

Dor/Watson

1962

180°/120° anterior wrap

Modified Toupet

1982

270° posterior wrap

Lind

1965

270° posterior with crural closure

Guarner

1975

270° posterior with gastropexy

Thal

1964

90° anterior wrap

Other

Allison

1951

Hiatal closure with esophagogastropexy

Hill

1967

Esophagogastropexy with 180° anterior wrap

the prosthesis prevents the hiatal hernia from recurring and mildly constricts the lower esophagus with increase in the sphincter pressure. Although insertion of the prosthesis is easier than fundoplication, patients often require reoperation to remove the prosthesis because of migration, esophageal compression, ulceration, or erosion. More than 100,000 of these procedures have been performed (5).

cost

Although medical therapy and surgery both control GERD, the cost of LNF is a single initial expense, whereas the cost of medical therapy is lifelong. Charges for surgery include hospital charges of approx $5000 and professional fees of $2000. When one compares the cost of proton-pump inhibitors with surgery, open Nissen fundoplication becomes a cost-effective treatment option compared with medical treatment in patients with refractory GERD if treatment continues more than 4 yr. LNF shifts this so-called break point toward 1.4 yr, mainly because of a shorter hospital stay (7-9).

summary

  1. GERD is a common condition and majority of patients are managed effectively by medical therapy.
  2. Antireflux surgery restores the mechanically defective esophageal sphincter and is an effective treatment in patients suffering from severe GERD, which is unresponsive to medical therapy.
  3. Laparoscopic Nissen fundoplication is the superior antireflux procedure for the majority of patients requiring surgery for GERD, but it is technically demanding and should be performed by properly trained and experienced surgeons.
  4. The outcome of laparoscopic Nissen fundoplication is excellent and morbidity is minimal. It offers a cost effective alternative to medical therapy in healthy patients with refractory symptoms.

references

  1. Katz PO. Treatment of gastroesophageal reflux disease: use of algorithms to aid in management. Am J Gastroenterol 1999;94:11. Suppl.
  2. Soper N. Laparoscopic management of hiatal hernia and gastroesophageal reflux. Curr Probl Surg 1999;36:765-838.
  3. Perdikis G, Hinder RA, Lund RJ, et al. Laparoscopic Nissen fundoplication: where do we stand? Surg Laparosc Endosc 1997;7:17-21.
  4. Swanstrom LL. Partial fundoplication for gastroesophageal reflux disease: indications and current status. J Clin Gastroenterol 1999;29:127-132.
  5. Bowrey DJ, Peters JH. Laparoscopic esophageal surgery. Surg Clin N Am 2000;80:1213-1242.
  6. Klingler PJ, Bammer T, Wetscher GJ, et al. Minimally invasive surgical techniques for the treatment of gastroesophageal reflux disease. Digest Dis 1999;17:23-36.
  7. Heikkinen TJ, Haukipuro K, Koivulkangas P, et al. Comparison of costs between laparoscopic and open Nissen fundoplication: a prospective randomized study with a 3-mo follow-up. J Am College Surg 1999;188:368-376.
  8. Narain PK, Moss JM, DeMaria EJ. Feasibility of 23-h hospitalization after laparoscopic fundoplication. J Laparoendoscop Adv Surg Tech 2000;10:5-11.
  9. Van Den Boom G, Go PM, Hameeteman W, et al. Cost effectiveness of medical versus surgical treatment in patients with severe or refractory gastroesophageal reflux disease in the Netherlands. Scand J Gastroenterol 1996;31:1-9.

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Responses

  • kevin
    Can you have an operation for reflux?
    4 years ago
  • monica
    Is hypotensive les a contraindication for reflux surgery?
    1 year ago

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