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Keywords
Fundoplication, gastroesophageal reflux
disease (GERD), laparoscopy.
Introduction
Laparoscopy has dramatically changed operations
for gastroesophageal reflux disease (GERD), making them increasingly
common in the last decade. As experience with laparoscopic
antireflux procedures has increased, operating times, conversion
rates, perioperative complications, and hospital length-of-stay
have all decreased. Though long-term outcomes data are not
yet available, it is clear that the laparoscopic approach
to this procedure is equally effective compared with the open
approach. In addition, the benefit to the patient in terms
of post-operative recovery is indisputable (1-4).
Preoperative Evaluation and Patient
Selection
The most important component of successful
antireflux operations is proper patient selection. The nature
of the gastro-esophageal pathophysiology must be understood
preoperatively. This is achieved by 1) complete preoperative
evaluation with the goals of diagnosing reflux and excluding
other esophageal or gastric pathology, 2) determining the
severity of the reflux, and 3) defining the anatomy. These
three objectives can generally be accomplished using the following
tests.
TWENTY-FOUR HOUR PH MONITORING
Standard pH Monitoring (Figure
1)
Twenty-four hour pH monitoring is the gold standard for defining
and quantifying gastroesophageal reflux (5,6). It confirms
the diagnosis of reflux, reveals where reflux episodes are
temporally associated with symptoms and thus presumed to be
the cause, and it quantifies reflux severity (7). Pre-operative
pH-monitoring data serve as a baseline for comparison in the
occasional patient with persistent symptoms after antireflux
surgery. This is particularly beneficial given the fact that
postoperative symptoms are rarely sufficient to determine
whether or not abnormal reflux is occurring (8,9).
STATIONARY ESOPHAGEAL MANOMETRY
Stationary esophageal manometry provides information regarding
the lower esophageal sphincter (LES) and esophageal body motility.
The presence of a hypotensive LES is a strong indicator of
an abnormal valve mechanism, and correlates well with a significant
amount of GER, though it is not a substitute for pH monitoring
to confirm GERD (10). Though a normal LES pressure signifies
some preservation of sphincter function, many patients with
severe GERD will have a LES pressure in the normal range and
may still benefit from an antireflux operation.
It was once thought that a total fundoplication (e.g. Nissen)
would cause too much resistance at the cardia, thus resulting
in dysphagia in patients with impaired peristalsis. However,
we and others have demonstrated that a properly constructed
loose total fundoplication does not result in a higher incidence
of dysphagia than a partial fundoplication in these patients
(11,12). Additionally, partial fundoplications are less reproducible
and provide an inferior reflux barrier (8). The absolute indications
for partial fundoplication continue to be debated, though
we tend to perform them in patients with the most severe defects
in peristalsis, such as those with scleroderma.
UPPER GASTROINTESTINAL SERIES
Upper gastrointestinal series (UGI) defines the anatomy of
the distal esophagus, the gastroesophageal junction and its
relationship to the diaphragmatic hiatus, and the stomach.
Moreover, spontaneous reflux on UGI is almost always associated
with abnormal reflux. Two findings may significantly impact
surgical strategy: 1) the presence of a peptic stricture and/or
esophageal shortening (Figure 2A), and 2) a large hiatal or
paraesophageal hernia (Figure 2B). These findings can increase
the complexity and technical demands of the operation.
ENDOSCOPY
Endoscopy is important for investigating lesions and ruling
out occult disease in the upper alimentary tract. The presence
of erosive esophagitis or Barrett’s esophagus confirms
the diagnosis of GERD and suggests severe disease. Esophagitis
is not, however, an absolute indication for operation, as
more than 90% of esophagitis can be relieved with medical
therapy (13). Conversely, the presence of esophagitis and
complicated reflux disease despite medications is a strong
indication for surgical intervention. However, the majority
of patients with symptomatic reflux disease do not have evidence
of esophagitis, and remain candidates for antireflux surgery
(14). When the patient has known Barrett’s esophagus,
biopsies to rule out dysplasia should be performed prior to
operation.
OTHER CONSIDERATIONS
GERD and Airway Disease
Because there is no specific diagnostic test available, establishing
a link between GERD and respiratory problems such as cough,
asthma, and laryngitis has been difficult. The initial approach
to these patients is to first establish the diagnoses of GERD
using standard 24-hour pH monitoring. Though a positive study
suggests an association, it does not prove causation, as the
incidence of GERD in patients with airway disease is high.
Pellegrini et al. were the first to consider the idea of proximal
esophageal acid exposure as stronger evidence of micro-aspiration
(15), one mechanism by which reflux may cause airway complications.
Measurement of pharyngeal reflux by using a four-channel catheter
to perform pharyngeal 24-hour pH monitoring predicts response
to medical (16) and surgical (17) therapy. However, some patients
have evidence of pharyngeal reflux with normal esophageal
acid exposure (18), further confounding the evaluation of
these atypical patients.
Laryngoscopy is often used in conjunction with pharyngeal
pH monitoring to diagnose gastroesophageal-laryngeal reflux
as a cause of respiratory symptoms. Laryngeal injury is evaluated
and graded, though biopsies are not generally useful. Documented
laryngeal injury without objective evidence of pharyngeal
reflux suggests another source. The presence of both laryngeal
injury and pharyngeal reflux has been found to correlate with
true gastroesophageal-laryngeal reflux (19).
Obesity
Obesity is common among patients with GERD and is an identified
risk factor (20). Certainly obesity makes antireflux operations
technically more difficult, and may decrease its efficacy.
Though there are reports of equivalent results in the overweight
and obese (21), morbid obesity (BMI > 35) appears to be
a significant risk factor for antireflux surgery failure (22).
For the morbidly obese patient with significant reflux who
has failed weight loss programs, a Roux-en-Y gastric bypass
is the procedure of choice. This operation provides excellent
long-term relief of GERD (23,24) and has the added benefit
of long-term weight loss and the associated health benefits.
Advancing Age
The incidence and severity of GERD increase with age (25-28).
Since our population is aging there will be more elderly candidates
for surgical intervention in the future. Because of the effectiveness
of medical therapy and the perceived increased risks of operation,
antireflux surgery is often denied to elderly patients. On
one hand this is justified, given evidence that morbidity
and mortality after antireflux surgery increases with age
(29). On the other hand, in properly selected candidates,
elderly patients (mean age 71 years) had equivalent outcomes
after antireflux surgery when compared to a younger patient
group (mean age 44 years) (30). Therefore, although advancing
age should not prevent candidacy for antireflux surgery, it
should be performed only if comorbidities common to the elderly
population (e.g. cardiac, pulmonary, etc.) do not preclude
safe operation and the disease severity justifies the risk.
OPERATIVE TECHNIQUE
There are several operations that have been proven to restore
the competency of the cardia. Within each of these, there
are many techniques that can be used to accomplish this goal.
The most common operation performed today is the Nissen fundoplication.
The left crus approach to this operation was developed at
the University of Washington and allows for early division
of the gastrosplenic ligament, which helps avoid splenic injury
from traction on the short gastric vessels during gastric
mobilization. Using this technique, no injuries requiring
splenectomy occurred in over a 1000 patients undergoing laparoscopic
Nissen fundoplication at our institution.
PATIENT POSITIONING
The OR table is prepared by taping a beanbag
in place on the table with a gel pad on top. The patient is
placed in stir-ups in low lithotomy position. The anterior
superior iliac spine should be no more than 10 cm cephalad
to the hip break in the table. The legs are positioned to
keep the hip in a neutral unflexed position to ensure free
range-of-motion of all laparoscopic instruments. The knees
are flexed at a right angle to the thighs. Both arms are tucked
at the patient’s sides. The beanbag is then molded to
provide a seat that maintains the patient’s position
while in extreme reverse Trendelenburg. The patient is checked
for stability in this position prior to the sterile prep.
The video cart is placed at the head of the table on the patient’s
right. All cords to the video cart, cautery, ultrasonic shears,
suction and irrigation exit the operative field near the patient’s
right shoulder (Figure 3).
PORT PLACEMENT
Five ports are typically used. All ports are placed prior
to positioning in extreme reverse Trendelenburg. When possible,
a minimal distance of ten centimeters between port sites should
be maintained. It has been our practice for the placement
of the surgeon’s left and right hand ports to be equidistant
from the esophageal hiatus forming an equilateral triangle
with the laparoscope port, which is placed 2 cm left lateral
to the midline and 10 cm from the costal margin (Figure 3).
The assistant’s right hand port completes an equilateral
triangle with the surgeon’s right hand port and the
laparoscope port, while the liver retractor port completes
another equilateral triangle with the surgeon’s left
hand port and the laparoscope port. Though small adjustments
are sometimes necessary based on variations in body habitus,
we have found that this technique produces consistently reliable
port positioning.
DISSECTION
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Video
Clip 1: Dissection of the phreno-gastric
ligament and the short gastric vessels.
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The surgeon stands between the patient’s
legs and the assistant on the patient’s left side. A
laparoscopic fundoplication can be divided into a series of
steps. Each step must be completed for a successful operation.
The following describes the left crus approach, though other
approaches, i.e. the right crus, are equally effective as
long as each step is completed.
A liver retractor is used to elevate the left lateral segment
of the liver. The first step of the left crus approach is
release of the angle of His by division of the phreno-gastric
ligament, thereby exposing the left crus. This approach facilitates
the safe division of the short gastric vessels and mobilization
of the fundus. These vessels are usually divided using an
ultrasonic scalpel device (Video Clip 1).
Once the gastro-splenic ligament has been completely divided,
the phreno-esophageal membrane is identified as a white line
reflected onto the distal esophagus. This membrane is then
incised separating the esophagus from the left crus (Video
Clip 2). The superior aspect of the gastro-hepatic ligament
is divided to expose the right crus. Care is taken to avoid
trauma to the nerve of Laterjet, which is a potential mechanism
of gastroparesis and gas bloat syndrome. It should be remembered
that accessory or replaced left hepatic vessels may be found
in the gastro-hepatic ligament. A large vessel found in this
location should be preserved if possible. The phreno-esophageal
ligament is divided posteriorly and anteriorly until the esophagus
is encircled. Care is taken to identify the vagus nerves and
keep them associated with the esophageal wall.
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Figure
4 |
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Video
Clip 2: Dissection of the phreno-gastric
ligament and the short gastric vessels.
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Once circumferential dissection of the phreno-esophageal membrane
is complete, a Penrose drain is placed around the esophagus
and vagus nerves to facilitate retraction (Video Clip 2).
The mediastinum is entered and dissection of the esophagus
away from its mediastinal attachments performed until at least
3 cm of esophagus is available in the abdomen for a tension-free
fundoplication. Care should be taken during this part of the
dissection to avoid injury to the pleura, aorta, and pericardium.
Aortic branches to the esophagus need to be clipped or, alternatively,
divided with the ultrasonic shears.
The hiatal hernia is repaired by approximating he crura posteriorly
with 2-0 silk sutures (Video Clip 3; Figure 4). A 50- to 60-French
bougie passed transorally by anesthesia personnel to correctly
determine the degree of closure of the diaphragmatic hiatus.
PERFORMING THE FUNDOPLICATION (Figure 5)
The following principles must be applied for successful Nissen
fundoplication:
1. The fundoplication is constructed in a symmetric fashion.
Distorted geometry can result in an ineffective fundoplication
or post-operative dysphagia (Figure 6). Symmetry is achieved
by using equal portions of anterior and posterior fundus for
the fundoplication (Video Clip 4).
2. The fundoplication is constructed without tension, using
the gastric fundus over the distal esophagus just proximal
to the gastroesophageal junction (Video Clip 5). The use of
a 50- to 60-French bougie inside the esophagus during its
construction assists in performing a "floppy" Nissen
fundoplication.
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| Figure
5 |
Video Clip
3: Hiatal closure posteriorly.
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Video Clip
4: Ensuring symmetry
of the fundoplication.
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Figure
6 |
3. After construction of the fundoplication
it is fixed to the esophagus to remain in that position permanently
(Video Clip 6). This requires adequate intra-abdominal esophageal
length, as well as correct identification of the gastroesophageal
junction. Intra-operative endoscopy can be a useful adjunct
for accurately defining the GE junction when its location
is in unclear with the laparoscopic view (31).
4. A total fundoplication, such as the Nissen fundoplication,
measures 2.5-3 cm in length anteriorly. Longer fundoplications
have higher rates of dysphagia without providing better control
of reflux (32).
5. Length and floppiness are assessed with laparoscopic instruments
prior to the conclusion of the operation (Video Clip 7).
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| Video
Clip 5: Hiatal closure
posteriorly.
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Video
Clip 6: Fixation of the
fundoplication.
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Video
Clip 7: Assessing floppiness
and length using laparoscopic instruments.
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Video
Clip 8: Esophago-gastroscopy
demonstrating flap valve grade prior to laparoscopic
Nissen fundoplication and post-operatively.
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INTRA-OPERATIVE ENDOSCOPY
Intraoperative endoscopy can be very useful
for examining the geometry of the fundoplication and determining
the grade of flap valve (Video Clip 8). If results are suboptimal,
manipulation of the wrap under direct endoscopic vision can
provide the information necessary to improve the fundoplication
intraoperatively (31).
COMPLICATIONS
Overall (minor and major) complication rates are currently
about the same (or lower) as for the open procedure (10%-20%)
(30,33,34). Individual complications are listed in Table 1.
| Complication |
Incidence (%) |
Reference(s) |
| Pneumothorax |
0-2 |
33, 34 |
| Liver Trauma |
Minor: common
Major: rare |
34 |
| Port-site hernia |
0.18-3 |
33, 44-46 |
| Splenic injury |
0.24 |
30, 33, 34 |
| Splenectomy |
.06-2.3 |
30, 33, 34 |
| Vagus injury |
Unknown |
34 |
| Perforation |
0.7-1.1 |
30, 33, 34, 48-50 |
| Fundoplication herniation |
1.3 (after primary repair) |
30, 33, 34, 40, 41, 43, 51-54 |
| Gas bloat |
Unknown |
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| DVT |
0.17 |
33, 34 |
| Ileus |
6.9 |
34 |
| Urine retention |
2 |
34 |
| Table
1 |
MORTALITY
Overall mortality for primary antireflux procedures performed
laparoscopically is generally reported to be between 0% and
1% (30,33). Population studies demonstrate a substantial increase
in mortality for those patients over 60 years of age, rising
to 8.3% for patients over 80 years (30). In addition, with
surgeon experience mortality decreases from 1.3% (< 5 cases)
to nil (> 49 cases) (30). Most deaths occur due to pre-existing
comorbidities such as pulmonary disease and cardiac disease.
The few patients that die as a direct complication of the
procedure have unrecognized bowel perforation. This emphasizes
the need for careful patient selection, advanced laparoscopic
and esophageal surgical skill, and the importance of recognizing
complications intraoperatively.
OUTCOMES
Close adherence to patient selection and technical principles
as described above leads to excellent results, providing symptom
control in 90-95% of patients. It has been demonstrated that
after a properly performed fundoplication there is significant
increase in LES pressure, fewer transient LES relaxations
(35,36), restoration of the flap valve (36), enhancement of
gastric emptying (37), and correction of the hernia, if present
(38,35,39,36). These changes 1) restore the physiology of
the LES mechanism, 2) improve the competency of the cardia,
and 3) preserve the ability to swallow normally.
SYMPTOM RECURRENCE
Overall, laparoscopic antireflux surgery has been demonstrated
to be effective at alleviating symptoms in 85% to 95% of patients
with excellent patient satisfaction. However, there are a
certain number of patients in whom symptoms recur. The precise
recurrence rate is difficult to determine, and depends on
the experience of the surgeon as well as the definition of
recurrence or failure. Recurrent reflux symptoms (e.g. heartburn,
regurgitation, etc.) and dysphagia are the two most common
indications of antireflux surgery failure. Most persistent
or recurrent symptoms that occur within the first 6 to 8 weeks
after operation do not represent reflux, are self-limited,
and generally require only assurance. Significant reflux symptoms
after this should be investigated with repeat 24-hour pH testing,
endoscopy, UGI, and manometry with comparison to pre-operative
baseline values. Many patients with symptoms after an operation
are incorrectly assumed to have recurrent GERD, but when appropriately
studied are found to be normal (32,37). If an anatomic abnormality
is identified in conjunction with recurrent symptoms, reoperation
is often required for correction.
POST-OPERATIVE DYSPHAGIA
Current studies indicate a 2% to 5% incidence of post-operative
dysphagia, depending on the type of antireflux procedure performed
(33,40). In the immediate post-operative period, some degree
of dysphagia is expected. This is usually the result of tissue
edema after esophageal and gastric mobilization and is self-limited.
Dysphagia is minimized using a specialized post-operative
diet that progresses from liquids to solid food during the
course of the first four to six weeks.
However, 2.5% of patients having primary antireflux procedures
have dysphagia that persists for more than two months (33,41).
Several technical factors have been identified as important
for preventing chronic dysphagia including 1) division of
the short gastric vessels (40), 2) avoiding an excessively
tight closure of the crus, 3) limiting the length of the fundoplication
to no more than 2-3 cm in length anteriorly (32), and 4) avoiding
faulty position and geometry of the fundoplication (Figure
6)(41-43).
If dysphagia continues for more than six
or eight weeks it should be investigated. A contrastesophagogram
is the first diagnostic test. The esophagogram will demonstrate
whether herniation of the wrap (Figure 7) or other geometric
abnormality is present. If an anatomic abnormality is present,
conservative measures can be tried but reoperation and reconstruction
of the fundoplication is usually necessary. Endoscopy by someone
with experience in fundoplication anatomy is the best test
to identify an anatomic problem. If endoscopic findings are
normal, gentle dilation and time is usually successful.
SUMMARY
Laparoscopic antireflux surgery is safe and effective. The
most important component of successful antireflux operations
is proper patient selection. The key components of the work-up
include careful evaluation of symptoms, esophagogram, manometry,
24-hour pH testing, and endoscopy. Post-operative symptom
recurrence, dysphagia, and acute herniation can be reduced
by careful attention to technical details including complete
fundus mobilization, full esophageal dissection, meticulous
closure of the diaphragmatic crura, and intra-abdominal fixation
of the fundoplication. Excellent outcomes after laparoscopic
antireflux operations can be expected in 85% to 95% of patients.
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