Laparoscopic antireflux surgery
Gastroesophageal reflux disease (GORD), is a multifaceted disease defined by consensus as “chronic symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the oesophagus”
Probably it is the most prevalent condition affecting the gastrointestinal tract, with up to a third on individuals experiencing GORD weekly. Clinical oesophagitis will be present in 30-50% of the GORD population. The presence of Barret’s mucosa is more prevalent on men, and Caucasians are more likely to be affected.
Interestingly oesophagitis patients are less likely to have helicobacter pylori infection.
The cause of GORD is the abnormal exposure of the oesophageal mucosa to gastric secretions. The oesophagogastric junction (OGJ) is the natural barrier that prevents from this happening. The components of the OGJ are the lower oesophageal sphincter (LOS) which is a 3-4 cm segment of smooth muscle, the hiatus and the anatomy of the gastric cardia and the angle of his.
The principal cause of GORD is incompetence of the OGJ that can be caused by a number of factors
-Transient LOS relaxation: This occurs in up to 90% of normal subjects. It doesn’t need to be associated with hiatus hernia
-LOS hypotension with normal anatomy: Normally there is reflux when the pressure of the LOS is 0-4 mmHg, also in the absence of hiatus hernia. The drop in pressure usually secondary to food (fat, chocolate, ethanol), drugs (theophylline, nitrates, Ca channels blockers…), habits (smoking).
-Anatomical distortion: mainly secondary to the presence of a hiatus hernia that affects the shape of the gastroesophageal flap valve (fig 1)
-Impaired oesophageal clearance
Fig 1.- Hiatus Hernia
Symptoms of GORD
The typical GORD symptoms are heartburn, regurgitation and retrosternal pain but sometimes patients present with atypical extraoesophageal symptoms as asthma (more than 29% of asthma patients, without GORD symptoms have abnormal pH studies). Also chronic cough may be secondary to reflux in 7 to 40% cases.
The clear-cut diagnosis is when patients present with typical symptoms and have good response to proton pump inhibitors. Very often patients present with typical symptoms which don’t respond to ppi’s
Complications of GORD
1.-Oesophagitis: it is the most common complication and can it range from some small erosions to ulcerations reaching the deep muscularis mucosae (fig 2).
2.-Stricture (70% of oesophageal strictures are peptic.
3.-Barrets (present in 10-12 % of patients with GORD)
Fig 2. severe oesophagitis
Barret’s oesophagus is the displacement of the squamocolumnar junction, proximal to the esophagogastric junction, with the presence on intestinal metaplasia. In about 50% of this patients the epithelium will be non-dysplastic or with low grade dysplasia.
The medical management of GORD will be based in the following pillars
-Lifestyle/diet modifications: Weight loss, smoking, alcohol, coffee, tea,
-Antiacid drugs. (With Mg or aluminium)
-Procinetics: Domperidone, Metoclopramide
-H2 antagonists: Ratitidine, Cimetidine
-Proton pump inhibitors: Omeprazol, lansoprazole, esomeprazole
Initially all patients should be treated medically and Surgical Treatment should be considered mainly when there is volume reflux with or without airway symptoms, when there is lack of response to PPI’s, when the patient is averse to lifestyle changes, and finally in the presence of Barret’s oesophagus.
Before surgery patients should be evaluated very carefully. When the patients present with typical symptoms an OGD plus minus 24hrs pH testing should be enough but in the presence of atypical, extraoesophageal or non-responding symptoms, a more comprehensive work up is needed, including oesophageal impedance, 48-72 hours Bravo monitoring or even pharyngeal pH monitoring and pepsin test.
The surgical treatment for GORD has been traditionally, since the times of open surgery, based in the following principles
-Achievement of an adequate intrabdominal length of oesophagus.
-Closure of the diaphragmatic crus.
-Anchoring the OGJ in the abdomen
-Restoring the acute angle of His
The laparoscopic fundoplication is the standard technique to achieve those principles. It consists in wrapping the fundus of the stomach around the lower part of the oesophagus, and depending whether this is done to an extent of 360 180 or 90 degrees, the name of the operation will be Nissen, Toupet or Dor fundoplication (fig 3). All have been done for more than 50 years and laparoscopically for the last 20. Please see video section
Fig 3. 180 degree Toupet Fundoplication
How do we choose the type of wrap?
The “ideal wrap” will be the one that allows good control of the reflux with minimal side effects (dysphagia, gas bloating, ability to burp and vomit). Now it is more than 20 years since the initial laparoscopic fundoplications were performed and it seems that there is a proportionate increase in short term dysphagia scores with increasing degree of wrap, and a corresponding proportionate increase in dilatations and reoperations for dysphagia, though this differences in dysphagia scores diminish with time. But it seems to be a significant larger percentage of patients free of reoperation and dilatation after partial wrap .(BJS 2011;98:1414-1421).
It looks like that partial wraps (Toupet, Dor) seem to be associated with less postoperative side effects, but the question that we need to answer is whether the antireflux effect of those partial wraps is similar to the full Nissen wrap. A number of studies (Surg Endosc 2010 24;924-932, Surg Endosc 1997 11;625-631) seem to support that, provided that the partial wrap is constructed properly, that in the case of Toupet (fig 3) means at least to have a length of 3 cm, the antireflux effect is similar.
Whatever the wrap we choose and whet her we elect to divide the short gastric vessels to free the fundus or not, the operation is safe in experienced hands, and in my experience, (since 1997) can be completed laparoscopically, in nearly all patients (99.8%), using in most cases small 3mm and 5mm instruments and even being able to go home the day of the procedure.
Are there any contraindications?
Apart from the general surgical contraindications there are some specific considerations for this operation
-Age: Obviously unless symptoms are very severe and debilitating (regurgitation, non-responding severe GORD) old patients should in principle be managed medically.
-Obesity: Obesity is not a contraindication for this operation but in obese patients with severe non-responding GORD we should consider a Roux-en-Y gastric bypass that apart from correcting the obesity would also accomplish an excellent control of the reflux.
-Previous failed antireflux surgery: Whether the previous surgery was performed open or laparoscopic this won’t be a contraindication. Obviously the chances of success diminish with further surgical attempts.
At some point when the hiatus has been touched many times and has become fibrotic and non-accessible, other surgical options as the antrectomy with Roux-en-Y reconstruction (duodenal exclusion), that also can be done laparoscopically, can be the answer.See video section
-Short oesophagus: In some patients with long-standing severe reflux and inflammation it can be an ascension of the OGJ into the chest, this can seldom be overcome with careful dissection and mobilization of the lower oesophagus achieving a satisfactory length of intrabdominal oesophagus, necessary as mentioned before.
As mentioned before most patients will be discharged within 24 hours. A common concern is the type of diet that this patients should be on. As a general rule , from the second day they can start a soft diet, and from there the speed of recovery will depend on the existence of postoperative symptoms that are very inconsistent and , unlike the more uniform features of the postop laparoscopic cholecystectomy, very often they are not non associated to the complexity of the operation,.
Postoperatively and for the first three months very often patients present with symptoms, mainly dysphagia and chest pain, both due to oedema and dysmotility. What needs to be done at that stage is mainly reassurance plus minus obtaining a barium swallow. We must know that the most dramatic early complication it is herniation of the stomach into the chest, this has been reported up to in a 2% of cases, much less in my own experience (2:500). This will present with vomiting and chest pain and can be suspected on the chest X ray and confirmed on a thoracoabdominal CT scan. This requires urgent intervention, reduction of the stomach from the chest and re-do of the fundoplication. This can be achieved laparoscopically. See video section
If there are symptoms of reflux within the first 3 months this would not be considered a recurrence but at technical failure of the procedure.
The symptoms that appear after 3 months need to be considered more seriously and investigated them properly with barium swallow and ogd plus minus pH metry. If recurrence of the GORD is found this can be secondary to the wrap undone, slipped or herniated, and needs to be corrected
The only symptom that consistently has been found to be worse after fundoplication is abdominal bloating. Therefore patients presenting this symptom preoperatively need proper counselling and warning that it is unlikely to disappear.
In summary laparoscopic surgery for GORD is very effective when it is properly indicated and performed in experienced hands. I have been performing it since 1997 on a weekly basis. Since 2002 I favour the partial 180 degree Toupet wrap. I have converted to open surgery only one case (in 1998) and my complication rate is minimal. This together with the biliary surgery is my main NHS practice and hence my optimal results.
For more information visit video section