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Fundoplication for Gastroesophageal Reflux Disease
Gastroesophageal reflux disease (GERD) is the most common disorder of the esophagus and gastroesophageal junction. While transient reflux of stomach contents into the esophagus occurs physiologically, according to the Montreal Classification, the criteria for GERD are met when reflux causes troublesome symptoms and/or complications. With 60% of American adults reporting intermittent heartburn symptoms, GERD is a serious health concern in the Western world. For the 20% of Americans who describe weekly reflux symptoms, GERD increases the risk for esophageal stricture, Barrett esophagus, and esophageal cancer, while significantly affecting health-related quality of life and work productivity.
The modern era of GERD therapy has brought advances in diagnosis and treatment, and, subsequently, a better understanding of the pathophysiology of GERD. The single most important factor in the development of GERD is an incompetent lower esophageal sphincter. Progressive dilation plus deterioration of the gastroesophageal flap-valve mechanism results in loss of the anatomic antireflux barrier and allows for acid and bile reflux. The goal of antireflux surgery is to reestablish the competency of the lower esophageal sphincter while preserving the patient's normal swallowing capacity.
Acid suppression therapies in the form of histamine H 2 receptor antagonists and proton pump inhibitors (PPIs) have brought both symptomatic relief and effective resolution of esophageal inflammation. While these approaches may ameliorate some of the long-term sequelae of GERD, medical therapy must be continued indefinitely and does not address nonacid reflux. Antireflux surgery provides an anatomic and physiologic cure with durable symptomatic relief and prevention of the adverse consequences of ongoing esophageal exposure to caustic refluxate.
The current gold standard for the operative treatment of GERD is the laparoscopic Nissen fundoplication. This well-established procedure has proved to be both durable and safe over a period of more than 25 years. Following the introduction of the laparoscopic approach in 1991 by Dallemagne and Geagea, the number of Nissen fundoplications performed annually increased threefold. While efficacy of medical therapy and concerns regarding potential complications of fundoplication have led to a recent decline in the number of operations performed annually in the United States, the pendulum may be swinging back with increasing concerns over the sequelae of chronic acid suppression.
Since Rudolf Nissen's original fundoplication in 1937, performed to protect a gastroesophageal anastomosis, the Nissen fundoplication has undergone many modifications. The principles of modern Nissen fundoplication are designed to most closely replicate the normal physiology of the gastroesophageal flap valve, including secure crural closure and the creation of a short, 360-degree “floppy” wrap around 2 to 3 cm of intraabdominal esophagus. This chapter discusses the indications and technical aspects of laparoscopic and open fundoplication for the treatment of GERD.
Clinical Features
As with all operations, proper patient selection is essential for a successful outcome. A thorough history and physical examination, as well as appropriate laboratory tests, should be completed to establish a diagnosis of GERD and eliminate other potential causes of symptoms. Patients should be queried regarding classic GERD symptoms including heartburn, regurgitation, and dysphagia. The frequency and timing of reflux symptoms, the relationship to meals, symptom exacerbation in the supine or upright position, and difficulty swallowing should be noted. The response and the duration of medical therapy are also recorded, as this information has prognostic significance following fundoplication.
In addition, patients may have atypical symptoms such as chronic cough, asthma, pulmonary disease, odynophagia, hoarseness, and chest pain. These patients should undergo cardiac evaluation, including a chest radiograph, electrocardiogram, and, if indicated, pulmonary function tests, in addition to the standard diagnostic evaluation for gastroesophageal reflux. Patients with atypical symptoms and those who fail to respond to medical therapy may show less improvement in symptoms after Nissen fundoplication than those with typical GERD symptoms. Box 19.1 includes a list of classic and atypical GERD symptoms.
Box 19.1
Signs and Symptoms of Gastroesophageal Reflux Disease
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Typical
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Heartburn
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Regurgitation
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Water brash
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Chest pain
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Dysphagia
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Atypical
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Cough
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Dental erosions
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Hoarseness
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Asthma
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Preoperative Evaluation
The preoperative evaluation of patients with GERD should be thorough. At a minimum, patients should undergo esophagogastroduodenoscopy (EGD). Performance of an esophageal motility study (EMS) is currently a preoperative standard to detect esophageal motility disorders that may lead to troublesome postoperative dysphagia. Although it has been dogma that patients with ineffective esophageal motility (IEM) (mean distal peristaltic amplitude <30 mm Hg or >20% loss of peristalsis) should undergo a partial fundoplication to prevent postoperative dysphagia, recent studies demonstrate that postoperative dysphagia after Nissen fundoplication is no greater with IEM than with normal esophageal motility. We routinely perform a preoperative EMS because it also allows documentation of a motility “baseline” for comparison should postoperative dysphagia develop. In addition, it has been reported that up to a third of patients with achalasia report symptoms of heartburn and EMS can help rule out this disease.
Twenty-four hour ambulatory pH monitoring is essential for the evaluation of patients with nonerosive reflux disease, extraesophageal, or atypical symptoms, and those who do not respond to PPI therapy. Patients with typical reflux symptoms and erosive esophagitis (or Barrett esophagus and peptic stricture) do not routinely need a pH study to prove the diagnosis of reflux preoperatively. In a multivariate analysis of factors predicting a good response to antireflux surgery, the best outcomes (98% good to excellent results) occurred in patients who had symptom relief with PPIs, typical GERD symptoms, and a positive 24-hour pH study.
Other new diagnostic modalities that have become increasingly important in the diagnosis and understanding of GERD physiology are the BRAVO pH probe and multichannel intraluminal impedance (MII). The wireless (noncatheter based) BRAVO probe monitors distal esophageal pH and transmits the data to a small external recorder worn on the belt for a duration of 48 to 96 hours. It has the advantage of being more comfortable than standard 24-hour pH probes. In addition, data suggest that 48-hour BRAVO monitoring may have greater sensitivity for GERD than does standard 24-hour monitoring. MII has also gained significant popularity for detecting both acid and nonacid GERD. MII measures electrical resistance (impedance) between a series of electrodes on a catheter placed across the gastroesophageal junction and up the esophagus. Air within the esophageal lumen causes an increase in impedance, whereas the presence of liquid refluxate within the esophageal lumen causes a decrease in impedance. By determining the temporal sequence of impedance events, one can establish the directional flow of gas and liquid within the esophagus (i.e., distal flow: swallow; proximal flow: reflux event or belch). By coupling this technology with data from a standard pH probe, one can correlate both acid and nonacid refluxate with patient symptomatology. Standardization of reference ranges for normal patients and in patients with reflux, and improvement of the software used for data interpretation, have moved this technology from a research tool to clinical practice. However, the role of this technology in determining which patients will best respond to surgery is still being studied. Those with significant symptoms and concomitant reflux events (acid or nonacid) while taking acid-suppression therapy may be the ideal patients for surgical therapy.
Impedance planimetry has emerged as a novel physiologic assessment tool and been applied to evaluating the esophagogastric junction (EGJ) in a variety of pathologic conditions, including the diagnosis of GERD. Available commercially as the EndoFLIP device (EndoFLIP model EF-325N, Crospon Ltd., Galway, Ireland), the functional lumen imaging probe (FLIP) is a catheter-based system that provides a geometric evaluation of luminal structures by measuring 16 adjacent cross-sectional areas while simultaneously recording intraballoon pressure using a solid-state pressure transducer. When placed across the EGJ, dividing the minimum cross-sectional area by the intraballoon pressure allows a calculation of the distensibility index (DI) of the EGJ. Kwiatek and colleagues compared FLIP measurements of the EGJ DI in GERD patients and asymptomatic controls and found GERD patients to have a 2 to 3 times more distensible EGJ.
Indications for Surgery
Although several innovative methods for treating GERD have achieved modest popularity over the past 5 years, the indications for antireflux surgery have changed little, and a fundoplication remains the “gold standard” to which all other procedures should be compared. Box 19.2 lists the primary indications for antireflux surgery.
Box 19.2
Primary Indications for Antireflux Surgery
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Patients with esophageal and/or extraesophageal GERD symptoms that are responsive but not completely eliminated by PPIs
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Patients with heartburn eliminated by PPIs but continued volume reflux (regurgitation)
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Patients with well-documented reflux events preceding symptoms such as chest pain, cough, or wheezing
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Patients with GERD complications such as peptic stricture, Barrett esophagus, or vocal cord injury while taking PPIs twice a day
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Patients with well-documented GERD who desire to stop chronic PPI use despite excellent symptom control (e.g., side effects, lifestyle, expense)
GERD, Gastroesophageal reflux disease; PPI, proton pump inhibitors.
There is rarely an indication for antireflux surgery in patients with uncomplicated GERD who are satisfied with medical therapy (single- or double-dose PPI), unless there are concerns or side effects related to the use of these medications. Such patients are usually maintained on medical therapy as long as their symptoms are well controlled and are advised to pursue lifestyle modifications and most importantly weight loss to mitigate the physiologic challenges to EGJ competence. In contrast, antireflux surgery should be seriously considered in patients with severe GERD whose symptoms are not controlled by medical therapy, patients who would prefer to avoid lifelong acid-suppression therapy, and those with complicated GERD (Barrett esophagus, refractory esophagitis, stricture). In the latter group of patients, surgery may not be necessary if repeat EGD reveals healing of the esophagus or a 24-hour pH probe while taking medications confirms the absence of acid reflux. However, because elimination of excessive reflux is difficult to achieve in those patients with complications of GERD, a marker of disease severity, consideration should be given to antireflux surgery. Preoperative endoscopic or medical treatment of esophageal stricture or peptic ulcer disease must be accomplished before surgery. In a patient with esophageal stricture, preoperative dilation to at least 16 mm (48 French) is advisable to minimize the chance that the customary postoperative dysphagia (a result of edema and early postoperative esophageal dysmotility) will be compounded by a tight stricture. If preoperative dilation to 16 mm is successful—several sessions are sometimes necessary—it is usually possible to extend the dilation intraoperatively to 18 or 20 mm, the standard-size dilators used by surgeons for calibrating the fundoplication. Laparoscopic antireflux surgery has also been increasingly used in the treatment of GERD following lung transplantation, as acid suppression alone has been shown to be inadequate in preventing allograft injury secondary to aspiration of nonacid refluxate.
In certain subgroups of patients with severe GERD, fundoplication may not be the optimal antireflux surgery. Medically complicated, morbidly obese (body mass index >35 kg/m 2 ) patients with significant GERD may be better served by undergoing Roux-en-Y gastric bypass as these patients have high failure rates following Nissen fundoplication. Patients with Barrett esophagus and high-grade dysplasia or adenocarcinoma should be treated by mucosal ablation or esophageal resection. Severe strictures that are not responsive to dilation therapy should also be treated by esophageal resection. Patients with low-grade dysplasia should be treated with high-dose PPIs for 3 months, after which they should undergo repeat biopsy. Fundoplication may be considered in such patients if subsequent pathology shows no progression to high-grade dysplasia or carcinoma. Finally, GERD patients with previous gastric surgery should be approached cautiously. GERD in patients after gastric bypass, partial or sleeve gastrectomy, and vertical banded gastroplasty cannot be treated by fundoplication because the fundus has been anatomically disrupted by the prior surgery.
Once a decision is made to perform a surgical antireflux procedure on a patient with GERD, the next step is to decide which type of fundoplication to perform. Recent data support the concept that Nissen fundoplication is an effective therapy for GERD and is not associated with significant long-term dysphagia, even in patients with IEM. These data, combined with data suggesting that partial fundoplication is associated with high long-term failure rates, have led to a significant decrease in the application of partial fundoplication in patients with GERD, regardless of esophageal peristaltic function. Currently, partial fundoplication is reserved for patients with a “named” esophageal motility disorder, such as achalasia or scleroderma, those with both IEM and significant dysphagia, and those patients undergoing revision of a prior 360-degree fundoplication for refractory dysphagia. Despite the recent trend toward complete (Nissen) fundoplication in most patients, contrasting data suggest that long-term satisfactory results may be achieved with partial fundoplication. Consequently, the debate regarding the role of partial fundoplication in the treatment of GERD persists, although the majority of experienced American surgeons prefer to perform complete fundoplication in most patients.
Open Versus Laparoscopic Nissen Fundoplication
Laparoscopic Nissen fundoplication was first reported by Dallemagne et al. in 1991. Since then, several large clinical series of Nissen fundoplication have been reported, including longitudinal studies with long-term follow-up that demonstrate the results of both open and laparoscopic fundoplication to be equivalent. Several randomized clinical trials published in the past decade reached the same conclusion. The laparoscopic approach is associated with shorter hospital stays, less postoperative pain, fewer wound-related complications, and earlier return to work. Despite these advantages, selection of the open versus the laparoscopic approach should depend on surgeon experience and the patient's previous surgical history. The intraoperative steps of surgical repair are relatively similar in both approaches. Laparoscopic Nissen fundoplication, however, requires that the surgeon possess advanced laparoscopic skills.
The approach to reoperative Nissen fundoplication should be individualized with the goal being long-term success of the procedure, since at the end of the day that is what will restore quality of life, independent of the approach. Most first-time redo procedures can be done laparoscopically, and several large series have demonstrated equivalent results with laparoscopic and open reoperation. Laparoscopic reoperation after open surgery, although feasible, may be tedious because the intraabdominal adhesions associated with open surgery may be formidable. It is important when planning a reoperation to consider why the prior procedure failed and address the cause of failure. An unrecognized short esophagus is one such potential cause, and a Collis gastroplasty may be an important addition during the reoperation in some patients. In the multiply reoperative foregut, consideration should be given to an alternative approach, such as an open thoracic or thoracoscopic approach or resection of the stomach or esophagus.
Principles of Nissen Fundoplication
Basic surgical principles guide the successful performance of Nissen fundoplication, regardless of the approach (laparoscopic or open). Box 19.3 lists the fundamental principles of Nissen fundoplication.
Box 19.3
Primary Principles of Nissen Fundoplication
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Careful positioning to protect patient and surgeon from neuromuscular injury
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Safe entry into the abdomen
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Circumferential hiatal dissection near the crura, limiting manipulation and avoiding injury to the esophagus
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Circumferential dissection of the esophagus under direct vision, with preservation of the vagus nerves
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Adequate mobilization of the esophagus (or Collis gastroplasty) to attain 2–3 cm of intraabdominal esophagus without inferior traction
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Complete mobilization of the gastric fundus including division of the short gastric vessels and any posterior attachments to the pancreas
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Closure of hiatal defect by reapproximation of the diaphragmatic crura.
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Creation of a short (2 cm), “floppy” (tension-free) fundoplication around the distal esophagus only and anchored to the esophagus
Laparoscopic Nissen Fundoplication
Position and Port Placement
Pneumatic sequential compression devices are applied to the calves, and 5000 units of subcutaneous heparin may be administered before the induction of general anesthesia, with placement of a Foley catheter, if indicated. The patient is placed in a split-leg position with both arms tucked and secured to the operating table. A vacuum beanbag mattress can aid in supporting the arms and perineum to prevent patient migration during repositioning of the operating table. The surgeon stands between the patient's legs with the primary monitor over the patient's head. The first assistant stands to the patient's right, and the scrub technician stands to the patient's left. The first step involves safe entry into the abdomen, which is achieved in most patients by inserting a Veress needle at the umbilicus and establishing pneumoperitoneum. In patients with a history of prior abdominal surgery, either an open cut-down approach or alternative Veress location can be used.
A five-port (one or two 10-mm ports and three or four 5-mm ports) technique is used ( Fig. 19.1 ). Additional ports may be placed as necessary. A camera port, to accommodate a 5-mm or 10-mm laparoscope, is placed just superior and to the left of the umbilicus, approximately 12 cm below the xiphoid and approximately 2 to 3 cm to the left of midline. A 30- or 45-degree laparoscope is placed through this port. The laparoscopic camera may be managed by the first assistant, a dedicated camera operator, or with a robotic camera holder. A thorough abdominal exploration with the laparoscope is routinely performed before initiating dissection. All secondary ports are placed under direct vision. After positioning the patient in steep reverse Trendelenburg, allowing the omentum and abdominal organs to fall away from the diaphragm, a second port (10 mm) is placed approximately 10 cm from the xiphoid process along the left costal margin for the surgeon's right hand. The 10-mm port accommodates an SH or V-20 size needle to allow for intracorporeal suturing. The third port, for liver retraction, is a 5-mm port placed on the right costal margin 12 to 15 cm from the xiphoid (depending on the size of the liver). A 5-mm articulating liver retractor is placed through the right lateral port under laparoscopic visualization, and the left lateral lobe of the liver is retracted anteriorly and superiorly to expose the hiatus ( Fig. 19.2 ). The right crus and caudate lobe of the liver should be clearly visible through the gastrohepatic ligament or pars flaccida if the liver retraction is adequate. Alternatively, the liver can be retracted with a Nathanson retractor placed just inferior and to the right of the xiphoid process. The liver retractor is stabilized with an endoscopic instrument holder attached to the operating table. The fourth port (5 mm), for the assistant, is generally placed midway between the liver retractor and the camera port. Finally, based on the location of the inferior edge of the liver after securing the retractor, a 5-mm port is placed to the right of midline, at the level of the 10-mm dissecting port, so that instruments in the surgeon's left hand triangulate the hiatus without hitting the falciform ligament or left lobe of the liver.
In the absence of a dedicated camera holder, the assistant can stand on the left side of the patient and control the laparoscope with the left hand. Should this be necessary, the fourth port is moved from the right upper quadrant to a location along the left costal margin, at least 5 cm below the 10 mm port used for the surgeon's right hand.
Exposure
An atraumatic grasper is used by the assistant to provide retraction of the stomach. The phrenoesophageal fat pad along the lesser curvature just below the EGJ is used for inferior retraction to minimize the risk of gastric or esophageal injury. The operating surgeon uses an atraumatic grasper in the left hand and an ultrasonic scalpel or advanced energy device in the right hand.
Dissection
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