GASTROESOPHAGEAL REFLUX DISEASE/GERD

Laparoscopic Antireflux Surgery

“Heartburn is a common problem in the Western world. Approximately 7% of the population experience symptoms of heartburn daily. An abnormal esophageal exposure to gastric juice is probably present in 20-40% of this population, meaning this population have GERD”.

 

INTRODUCTION

The role of operative treatment for Hiatal Hernias and Gastroesophageal Reflux Disease (GERD) changed dramatically during the 1990s. Today, laparoscopic antireflux surgery has assumed a significant role in the treatment of both of these diseases. The introduction of minimally invasive techniques for the treatment of hiatal hernias and GERD has lowered the threshold for surgical treatment and renewed interest in the treatment outcomes.

The principles for laparoscopic Nissen Fundoplication (which is the most common and effective type of antireflux surgery) are the same as in open surgery, but the benefits of being performed by minimally invasive means do not have a point of comparison. Laparoscopic fundoplication is considered the “gold standard” for the surgical treatment of GERD nowadays.

GERD symptoms are common in the general population, affecting more than 40% of Americans at least once per month. Patients with GERD may have typical or atypical symptoms.

SIGNS AND SYMPTOMS
DIAGNOSIS & TREATMENT
INDICATIONS & CONTRAINDICATIONS
LAPAROSCOPIC VS. OPEN ANTIREFLUX SURGERY (AND/OR HIATAL HERNIA REPAIR)
SURGICAL TECHNIQUE (SIMPLIFIED)

Typical symptoms

  • Heartburn 80%
  • Regurgitation (Food coming back to mouth) 55%
  • Dysphagia (Difficulty swallowing) 25%
  • Water brash
  • Sour taste
  • Chest pain
  • Abdominal Pain

Atypical symptoms (mainly related to respiratory response to gastric contents in the airway)

  • Chronic nausea
  • Asthma
  • Cough
  • Hoarse throat
  • Dental erosions
  • Wheezing

DIAGNOSIS

The main factor related to GERD is a defective LES (Lower Esophageal Sphincter), nevertheless, many other factors exist that can lead to GERD without relation to the adequate function of this “valve”, and therefore, tests to assess the function of the LES, esophageal body, and stomach may be necessary for the majority of patients with GERD symptoms.

Since the physical examination of patients with GERD symptoms rarely contributes to confirmation of diagnosis, some of these tests are required.

PREOPERATIVE PHYSIOLOGIC AND/OR IMAGING TESTS

 

  • EGD (esophagogastroduodenoscopy or upper endoscopy)**
  • pH Monitoring (considered the “gold standard” for the diagnosis of GERD)**
  • Esophageal manometry **
  • Contrast radiographs (barium swallow, upper gastrointestinal series)
  • Acid infusion test
  • Scintigraphy or scanning

 

 

**These tests are mandatory in almost all patients, the rest, are reserved for atypical symptoms or atypical response to medication.

TREATMENT

As mentioned earlier, the best, long-lasting and most effective treatment for GERD is surgery, which involves in the making of a “new valve” or sphincter at the end part of the esophagus using the upper part of the stomach (a stomach wrap, Nissen fundoplication).

INDICATIONS FOR SURGERY:

  • Objective evidence of GERD plus:
  • Complications of GERD not responding to medical therapy (e.g, esophagitis, stricture, recurrent aspiration or pneumonia, Barrett’s esophagus). Barrett’s esophagus is one of the most serious complications of GERD, since it may progress to cancer!
  • GERD symptoms interfering with lifestyle, despite medical therapy
  • Hiatal hernia with GERD
  • Need for continuous drug therapy in a patient desiring discontinuation of medications (e.g., financial burden, non-compliance, lifestyle choice, young age, etc.)
  • Presence of extraesophageal manifestations of GERD may indicate the need for surgery (e.g., cough, wheezing, aspiration, hoarseness, sore throat, otitis media, etc.)

 

CONTRAINDICATIONS

Absolute

 

  • Inability to tolerate general anesthesia
  • High Bleeding Risk

 

 

Relative

 

  • Previous abdominal surgery close to the hiatal region
  • Severe obesity
  • Esophageal shortening

 

 

 

ADVANTAGES OF LAPAROSCOPIC ANTIREFLUX SURGERY

  • Very small incisions (5)
  • Fast recovery time (one or two-night hospital stay, depends on the case)
  • Minimal postoperative pain
  • Lower morbidity rate
  • Lower hospital stay
  • Return to normal activity and return to work in a shorter period of time (complete recovery in 5 to 7 days)
  • Decreased risk of wound infection and hernia formation
  • Minimal scarring

 

OUTCOMES/COMPLICATIONS

Results of laparoscopic antireflux surgery are encouraging with low rates of perioperative morbidity and mortality. Conversion rate from laparoscopic to open procedure is higher in inexperienced hands; the conversion rate in Dr. Rosales’ experience is less than 3%. Perioperative complications requiring reoperation such as stomach (wrap) migration or esophageal perforation occur in less than 1%.

The overall satisfaction rates regarding symptoms after the procedure range from 90 to 100% and a significant improvement in quality of life a few weeks after having the procedure.

 

SURGICAL TECHNIQUE (SIMPLIFIED)

Under general anesthesia, a 5 mm abdominal incision is made at the left subcostal region (below the ribcage), CO2 is introduced to the cavity, then 4 more incisions are made in the abdomen (one of 10mm and the rest of 5mm) to introduce the rest of the instruments; the junction between the esophagus and stomach is dissected in its whole circumference previous ligation of some vessels that attach the upper part of the stomach is done, we look for a hiatal hernia, if present, we repair it (See Laparoscopic Hiatal Hernia Repair). We proceed to do the 360° stomach wrap around the esophagus fixing it with suture material, incisions are closed with suture, and the procedure is completed.

NISSEN FUNDOPLICATION

Incisions for Laparoscopic Antireflux Surgery

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