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Key Points
Surgical therapy restores the mechanical barrier of the lower esophageal sphincter
and prevents reflux of gastric contents into the esophagus.
(EGJ) to the abdominal cavity, full mobilization of the gastric fundus, snug crural
closure, and a short tension-free fundoplication.
The Nissen fundoplication is the procedure of choice for the treatment of GERD in
Partial fundoplications should be reserved for patients with achalasia, and those
whose esophageal manometry reveals amplitudes less than 30 mmHg.
Redo surgery for identifiable mechanical failure after fundoplication can result in a
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Introduction
gastroesophageal reflux disease (GERD) is a serious health concern in the Western world.
In Europe, epidemiologic studies put the prevalence of GERD between 9% and 42%.1 In
Asia, the prevalence of GERD is lower than in the United States. However, rates
of GERD now approach those seen in Western countries. In Japan, the incidence of
increases the risk of esophageal stricture, Barrett's esophagus (BE), and esophageal
cancer, and has a negative impact on work productivity and quality of life.3, 4, 5 The
modern era of GERD therapy have brought advances in diagnosis and treatment, and
therapies in the form of type 2 histamine receptor antagonists and proton pump inhibitors
(PPIs) have brought both symptomatic relief and effective resolution of esophageal
mucosal damage, which may help to ameliorate some of the long-term effects of GERD.
Medical therapy demands lifelong use in the majority of patients with GERD and fails to
prevent the reflux of bile or gastric contents. Antireflux surgery (ARS) can provide a
permanent anatomic and physiologic cure that provides resolution of symptoms and helps
prevent the adverse consequences of ongoing esophageal exposure to gastric contents.
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It was not until the early 1900s when radiologic studies became ubiquitous that hiatal
hernia was recognized as a pathologic entity. Early attempts at repair centered on hernia
reduction and hiatal closure without fundoplication. Because the underlying defect of the
lower esophageal sphincter (LES) was not repaired, surgery failed to control symptoms,
and the procedure was not widely embraced.
In 1951, Philip Allison and Norman Barrett established the causal relationship among hiatal
hernia, gastroesophageal reflux, and erosive esophagitis. Allison described the crural sling
and clasp musculature as the anatomic correlate to the LES and the primary mechanism
that prevents pathologic reflux. His method to restore the antireflux mechanism included
reduction of the herniated cardia with suture fixation to the abdominal surface of the
diaphragm followed by loose closure of the hiatus. Unfortunately, his attempts at surgical
repair fell short and he had a long-term recurrence rate of 49% at 20 years.
anastomosis in a young man with a penetrating esophageal ulcer. During follow-up, Nissen
noted that the patient's reflux symptoms were eradicated. Some years later, and
disappointed with contemporary hiatal hernia repairs, Nissen performed a fundoplication
on a man with an incarcerated paraesophageal hernia. The clinical outcome was excellent.
He published the first description of this procedure in 1956, thereby ushering in the
modern era of antireflux surgery.6
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propulsive action of the esophagus clears ingested material and physiologic reflux; this
peristaltic activity serves to limit the contact time of these substances with the esophageal
mucosa. Second, the LES is a region of high pressure located at the esophagogastric
junction and is the primary mechanism that prevents pathologic reflux. The tonic
opposition of the collar sling musculature (greater curvature) and the clasp fibers (lesser
curvature) at the level of the cardia creates this region of high pressure (Figure 1). This
area is commonly referred to as the gastroesophageal flap valve based on the endoscopic
the source of refluxate and prevent elevated gastric pressure with subsequent retrograde
"decompression" into the esophagus.
All antireflux procedures can be divided into two broad groups: total (360 degrees) and
partial (less than 360 degrees) fundoplications. Now regarded as the primary surgical
option for the treatment of GERD, the Nissen fundoplication is a well-established total
antireflux procedure proven both durable and safe over a period of 20 years. Since its
The current technique emphasizes return of the esophagogastric junction into the
vessels to achieve complete mobilization of the gastric fundus, snug crural closure, and a
proximal stomach, which serves to re-create the acute angle of His and distal high-
pressure zone. As intragastric pressure and volume increase, the enveloped distal
endoscope, a nipple valve the length of the fundoplication becomes evident (Figure
2).9, 10, 11
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In those with erosive esophagitis, PPIs will enable complete mucosal healing in 90% of
patients. However, if the medication is stopped, esophagitis will return within 1 year in
80% of patients.12 This highlights the limitation of medical therapyit does not address
recently demonstrated that acid-suppression therapy does not affect the total number of
reflux episodes; rather, the refluxate is rendered less acidic and is not detected with
standard pH monitoring. Other than acid, undefined characteristics of refluxed gastric fluid
may be contributing to ongoing esophageal mucosal damage. This may explain the failure
With the widespread use of effective medical therapy, peptic stricture is now relatively
approximately 13% developed stricture.13 Overall, the reported incidence ranges between
10% and 25%. Therapy for stricture begins with PPIs, which have been shown to
effectively treat esophagitis, reduce the need for dilations, and alleviate
disease. These patients may benefit from surgical intervention. In a study of 74 patients
with peptic stricture refractory to medical therapy, Klingler et al.15 showed that
laparoscopic antireflux surgery (LARS) diminished the need for further dilations fivefold
and significantly reduced dysphagia scores. Dysphagia scores dropped from a mean of 6.8
to 3.7 (p <.0001). Ninety-one percent of patients reported satisfaction with the procedure.
Barrett's Esophagus
Barrett's esophagus (BE) occurs most frequently in those with long-
the chronic and injurious effects of reflux. The presence of BE represents a 40 to 60 times
a person without BE. Whether BE represents an indication for surgery in and of itself has
been intensely debated. Many surgeons feel that LARS is the best way to prevent ongoing
exposure to all forms of reflux and thus reduce the risk of dysplasia and cancer. Although
of BE represents long-standing severe GERD, these patients should be referred for surgery
Our understanding of GERD has expanded to include its effects not just in the esophagus
but also in the upper aerodigestive tract. Laryngopharyngeal reflux can manifest as
fail to resolve with medical therapy in more than 40% of patients. Surgery is a viable
option in patients with laryngopharyngeal symptoms that have proximal reflux events
antireflux surgery in patients with laryngopharyngeal reflux symptoms and asthma is less
Proper patient selection is the key to successful surgical treatment of GERD. Beginning
with a history and physical exam, symptoms are classified as either typical or atypical.
symptoms include hoarseness, chest pain, laryngospasm, globus sensation, cough, and
exacerbation with supine or upright position, and difficulty swallowing are noted. As a
Symptoms have a limited positive predictive value in the initial presentation of GERD18 and
in those patients with postoperative symptoms.19
having a vagal nerve injury after a primary antireflux operation. The goal of preoperative
testing is to verify that symptoms are the result of GERD, and assess for any complicating
factors such as short esophagus, stricture, BE, or cancer that may change the operative
Twenty-four-hour pH Monitoring
forGERD. This test should be performed to establish the diagnosis of GERD, particularly in
any patient with a nondiagnostic EGD or atypical symptoms of GERD. An abnormal finding
would be a drop below a pH of 4 for more than 4% of a 24-hour period. A DeMeester score
is calculated to grade GERD severity. The test is performed with the patient off all
pattern of reflux; some patients may exhibit positional reflux (upright, supine, mixed).
Possibly supplanting the cumbersome catheter based pH monitoring system is the BRAVO
no need for retrieval. The pH sensor transmits a signal to a portable recording device,
which is then downloaded. Designed to free patients from the inhibition imposed by a
nasal catheter, the BRAVO system has been widely accepted by patients and physicians in
the diagnosis ofGERD. It is equal to or better at detecting acid when compared with a
catheter-based system. Additionally, the BRAVO probe is able to extend the period of
ambulatory monitoring, which may improve the diagnostic accuracy.20
Barium Swallow
The barium swallow is useful in the diagnosis of structural abnormalities such as stricture,
view of the action of the esophagogastric junction. However, the ability of the esophogram
hernia to note during esophogram are reducibility and size. A nonreducing hernia may
predispose to failure of ARS. A larger (>5 cm) hiatal hernia indicates long-standing disease
with associated mediastinal scarring and possible shortened esophagus. The challenge is to
reduce the large hernia (which may require extensive mediastinal dissection) and provide
enough intraabdominal esophageal length so as not to put tension on the fundoplication.
Tension with subsequent mediastinal herniation is the most common form of mechanical
Esophagogastroduodenoscopy (EGD)
All patients considered for ARS must undergo EGD, which can establish a diagnosis
of GERDin the case of severe, erosive esophagitis. In addition, retroflexed endoscopic view
gastroesophageal flap valve and identify a hiatal hernia. Furthermore, EGD is necessary to
dilate strictures. Although esophagitis on endoscopy has traditionally been used to confirm
a diagnosis ofGERD, studies suggest that all patients regardless of their endoscopic exam
with a normal DeMeester scores had a significantly less favorable outcome than those with
abnormal scores [odds ratio (OR) 9.02, p <.01). It is important to perform barium swallow
before EGDin patients who complain of dysphagia. This may alert the endoscopist to
diverticula, hiatal hernia, webs, or other structural abnormalities that may be treated
Manometry
and locates and measures the upper and lower esophageal sphincter and their resting
shorter than 2 cm, abdominal length shorter than 1 cm, and a resting pressure less than 6
mmHg. A hypotensive LES is the most common finding in patients with GERD. If one
component of the triad is defective, there is a 69% to 76% prevalence of GERD. Having all
motility disorders such as achalasia or diffuse esophageal spasm that would complicate or
>30 mmHg, the pressure needed to pass a food bolus past a Nissen fundoplication, then a
partial type fundoplication should be considered. A partial fundoplication may diminish the
undetected by pH testing alone. This technology allows the detection of nonacid and
weakly acid (a drop in pH of one unit with a nadir above pH 4) reflux in addition to
traditional acid reflux events. In addition, this technology enables one to determine the
duration and proximal extent of reflux episodes. Utilizing a thin catheter similar to a pH
probe, six sequential electrode pairs measure the impedance to electrical current between
them. As these electrode pairs are bridged with refluxate, the impedance decreases,
indicating an event. With respect to antireflux surgery, impedance testing may present the
opportunity to identify nonacid reflux events as a cause of symptoms that are refractory to
medical therapy. It is theorized that these patients would benefit from LARS much like
patients with typical acid reflux. Although prospective studies are lacking, MII-pH holds
Other Factors
In addition to objective measures, one should assess the patient's ability to tolerate an
operation physically and emotionally. The surgeon must evaluate patient compliance and
understanding of the procedure and possible side effects. Setting expectations is a major
component of the preoperative workup. Preexisting psychiatric diagnoses have been linked
with failed antireflux surgery24. Velanovich et al. showed that 95% of patients without
psychiatric diagnosis were satisfied with ARS, whereas only 11% of psychiatric patients
found the surgery to be helpful25. Patients who have stress aerophagia or who have eating
The popularization of laparoscopic fundoplication has been fueled by both patient demand
earlier return to solid food, and better cosmesis than the open approach. 26 In addition, a
laparoscopic approach may provide better visualization of the hiatus and allow extended
dissection into the mediastinum. Randomized clinical trials comparing open and
overall satisfaction26, 27, 28 (Tables 1 and 2). Although laparoscopic Nissen fundoplication
has largely overtaken its open counterpart, it is an operation that requires advanced
laparoscopic skills and has a significant learning curve. In the early phase of the learning
esophageal perforation and bleeding are higher, conversion rates to laparotomy are
higher, and operative time is longer.29 Although the perioperative complications are
higher, the long-term quality of life score as well as objective functional outcomes are
similar for operations performed in the early and late phases of the learning curve. 30
Regardless of the procedure chosen, the reconstruction must provide a functional barrier
to reflux while producing the fewest side effects possible. Additionally, three essential
goals must be met: (1) adequate intraabdominal esophageal length to allow a tension-free
fundoplication, and (3) closure of any associated hiatal defect. Partial-type fundoplications
are now reserved for those undergoing myotomy for achalasia and those with severe
hypomotility on manometry. The "tailored approach," which calls for partial wraps in those
with esophageal motility disorders has lost favor, being supplanted by the favorable results
obtained with total fundoplications even in those with esophageal motility disorders.
However, practices differ in many parts of the world, with similar outcomes using different
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The key to success with antireflux surgery resides in proper patient selection. Many
patients with moderate to severe GERD are candidates for LARS especially with the advent
of minimally invasive techniques that promise low morbidity, shorter hospital stays, and
greater than 90% success rates in experienced hands. Although many patients find relief
of their symptoms with PPIs, as many as 10% of medically treated patients still suffer
severe erosive esophagitis, PPIs heal 90% of patients, but the condition recurs within 1
year in 80% after drug withdrawal. Along with residual symptoms, intolerance to
pursue LARS. Medication failure is perhaps the most common reason to refer for surgical
management. Additionally, many patients weigh the long-term cost and lifestyle
adjustments as factors when deciding whether to pursue surgery. The patients most likely
to benefit from LARS are those who have abnormal 24-hour pH testing scores, typical
symptoms, and a good response to medical therapy.31
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Contraindications to Surgery
Antireflux surgery is contraindicated in patients who cannot tolerate general anesthesia or,
coagulopathy and severe cardiopulmonary disease both preclude surgery. In patients with
previous foregut surgery or in those who have had prior upper abdominal surgery, the
laparotomy. Adhesions and large fatty left liver lobe are the primary reasons for
conversion to open procedure.
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Operative Techniques
Total Fundoplications
Laparoscopic Nissen Fundoplication (360-Degree Fundoplication)
After general anesthesia has been induced, the patient is positioned in the low lithotomy
position. The surgeon operates from between the patient's legs. An assistant helps retract
the liver from the right. Placing the patient in steep reverse Trendelenburg position helps
to retract the abdominal contents away from the esophageal hiatus (Figure 3).
gaining access to the posterior mediastinum. With sharp dissection, the right and left
diaphragmatic crura are defined, and the esophagogastric junction is returned to its proper
hernia, it is reduced with the mediastinal dissection. The diaphragmatic crura are then
approximated with nonabsorbable suture posterior to the esophagus. The tightness of the
closure is calibrated such that there is a snug fit around the esophagus, but a laparoscopic
instrument can easily pass through the hiatus.
A harmonic scalpel allows efficient division of the short gastric vessels. This enables
Finally, the fundus is passed posterior to the esophagus, wrapped 360 degrees, and
sutured anteriorly using nonabsorbable sutures (Figure 4). Use of the "shoeshine"
maneuver prior to completing the fundoplication ensures that the stomach is not twisted
and that the proper portion of the stomach is employed in the repair; the surgeon grasps
both ends of the fundus and pulls it back and forth behind the esophagus to ensure
adequate mobility and no tension (Video 1). Most surgeons calibrate the fundoplication
postoperative dysphagia; however, some debate the advantage of wrap calibration in light
of the added risk of perforation upon passage of the dilator (Figure 5). At completion, the
fundoplication should be 2 cm in length (Video 2).
There is some evidence that the wrap itself is less likely to be the cause of persistent
dysphagia (>6 weeks); rather, the hiatal closure appears to play a critical role in the
patients identified as having crural stenosis with an intact wrap were effectively treated
with pneumatic dilation, lending credence to the hypothesis that too tight of a crural
closure (or accumulated scar tissue) leads to constriction of the esophagus with resulting
dysphagia. Three patients in this group required reoperation. In all, the authors found a
tight hiatal closure effectively narrowing the esophagus. Those patients with transthoracic
migration of the wrap (n = 27) underwent reoperation. All were found to have complete or
partial wrap migration into the mediastinum with evidence of constriction at the hiatus. In
almost 60% of these patients, the crural closure was intact but inadequate in preventing
wrap migration. Only five patients of the 50 had problems with the wrap itself (discovered
at reoperation) that accounted for their dysphagia. These findings point to the importance
of proper hiatal closure in preventing persistent or late-onset postoperative dysphagia.32
The Hill repair is not a fundoplication per se, but a recalibration of the antireflux barrier.
The Hill repair aims to secure the esophagogastric junction into the abdominal cavity,
recalibrate the LES, and re-create the acute angle of His. This is accomplished by
without tension, crural closure, and suture fixation of the right and left phrenoesophageal
bundles to the preaortic fascia. The tightness of the sutures is calibrated using
intraoperative manometry (Figure 6).
In about 10% of patients undergoing LARS, there will not be adequate intraabdominal
esophageal length. Because the most common cause of failure after antireflux surgery is
related to transdiaphragmatic herniation, at least 2.5 cm of tension-free intraabdominal
adequate length to be achieved. However, despite these efforts, some patients require an
tubularized portion of stomach that acts as a continuation of the esophagus (Figure 7). The
fundoplication is subsequently performed around the neoesophagus.
The short esophagus may be suggested in the preoperative workup; however, the final
diagnosis can only be made intraoperatively. Four findings have been established to
correlate with the presence of short esophagus: (1) large nonreducing hiatal hernia, (2)
esophageal stricture, (3) Barrett's esophagus, and (4) an LES at 35 cm or less from the
incisors by manometry.
Although there is excellent symptomatic relief of GERD symptoms after combined Collis
patients treated with Collis gastroplasty, recurrent erosive esophagitis owing to pathologic
acid exposure was found in an alarming 80% of patients. Despite the high incidence of
ongoing mucosal damage, 65% of patients with recurrent disease reported significant
should undergo follow-up with objective testing and be placed on PPIs if there is an
must be understood that many of these patients have advanced GERD with a severely
damaged esophagus and severe, medically refractory volume reflux; in this setting, the
Partial Fundoplications
employed after Heller myotomy in patients with achalasia. After the crura is closed, the
fundus is passed posterior to the esophagus similar to the approach used for the
laparoscopic Nissen fundoplication. The limbs of the fundoplication are then sutured
together to the anterior esophagus, taking care to avoid the anterior vagal trunk (Figure
8). Mounting evidence in the surgical literature weighs heavily against the continued use of
partial fundoplication as a primary therapy for medically refractory GERD.35, 36, 37, 38
associated with a high symptomatic failure rate.37 In addition, Toupet fundoplication has
of GERD.36A study by Heider et al.39 showed that, compared to partial fundoplication, most
patients with dysmotility have improved esophageal peristalsis after undergoing an LNF.
This suggests that GERD-related esophageal injury plays a role in causing dysmotility, and
that abolishing pathologic reflux corrects the motility disorder.
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Postoperative Care
Possibly the most attractive feature of laparoscopic surgery is the prompt recovery time.
The hospital stay is generally 1 to 4 days. Some centers perform LARS as a day surgery in
selected patients. Following an initial trial with clear liquids, patients begin a pureed diet
herniation. If there is concern that an occult perforation occurred during surgery, then a
barium swallow is performed before a diet is started. Typically, patients are maintained on
a soft diet for 4 to 6 weeks and then transitioned to solid foods as tolerated. Bread and
meat should be avoided for the first 6 weeks, as these items are notoriously troublesome
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bleeding, and missed visceral injury. Esophageal and gastric perforations occur in
approximately 1.5% of cases; if detected, they are repaired primarily, and drains are
rarely indicated. Splenic injury can take the form of infarction or bleeding. Superior pole
infarction can occur with ligation of the short gastric arteries and does not require
Cautery injury can result in delayed intestinal perforation and peritonitis. Meticulous
dissection and gentle retraction can help prevent injury. It is paramount that the
abdominal survey before closure can help identify any signs of bleeding or visceral injury.
Late Complications
Although Nissen fundoplication has greater than 90% success in eliminating reflux
symptoms, over time a proportion of patients develop new or recurrent foregut symptoms.
Some dysphagia, gas bloating, and mild residual esophagitis are common in the early
postoperative period, but these symptoms generally resolve within 3 months; severe or
persistent symptoms may indicate failure and the need for further investigation.
mechanical causes of failure vary significantly among studies, but transthoracic herniation
One of the reasons for pursuing LARS is to offer patients, especially the young, freedom
from daily medication dependence. However, data suggest that many patients are using
antisecretory medications after ARS. Some construe this as surgical failure. Closer
examination of prescribing patterns reveals that many patients are receiving antisecretory
medication for symptoms unrelated to the presence of recurrent GERD. Lord et
al.19showed that only 24% of 86 symptomatic, medically treated patients post-ARS had
abnormal distal esophageal acid exposure. This study indicates that many patients with
foregut symptoms after ARS are taking antisecretory medication based on symptoms alone
and not on objective evidence to support their use. In this study, the authors found a very
poor positive predictive value of symptoms, including moderate to severe heartburn and
regurgitation, and the presence of abnormal acid exposure. Latent, preexisting foregut
failure of the wrap should not be assumed when addressing post-ARS symptoms.
Symptoms after ARS should be investigated to rule out esophageal motility disorders,
gastroparesis, delayed gastric emptying, irritable bowel syndrome, gastritis, and nonulcer
A "slipped" or misplaced fundoplication occurs when the proximal stomach (instead of the
stomach proximal to the narrowing caused by fundoplication. The slippage is usually the
result of transthoracic herniation and represents one of the most common forms of failure.
unrecognized short esophagus (Figure 9). Twisting of the wrap is a technical error that can
result in a poor outcome. Twisting results from employing the distal greater curvature
stomach and episodic emesis and abdominal pain. Endoscopically, twisted wraps appear as
obliquely running folds with respect to the endoscope. These patients require reoperation.
A focused evaluation of postoperative symptoms begins with reviewing all prior records
and objective testing. Again, repeat 24-hour pH testing, EGD, manometry, and
the LES length, position, and resting pressure, manometry can determine the integrity of
pH testing will confirm recurrent reflux but will not identify the anatomic mechanism of
failure. Esophagram is a very valuable test in the workup of fundoplication failure. This
Redo Surgery
In our practice, we consider patients for redo surgery if they present with persistent or
recurrent foregut symptoms or if they develop symptoms not present prior to surgery.
Surgical intervention is carried out in those who have an identifiable anatomic abnormality
challenging in even the most experienced hands. To provide a durable repair, the cause of
perforation is the complication most feared when performing redo surgery secondary to
Smith and colleagues51 reported a 2.8% failure rate requiring reoperation in a series of
1892 patients undergoing antireflux surgery over a 13-year period; of the failures, 73%
required reoperation within the first 2 years of surgery. The most common mechanism of
failure was transdiaphragmatic wrap herniation (61%). The laparoscopic approach was
used in the majority of these patients and the conversion rate to laparotomy was 8%.
Similarly, Dutta et al.52 reported a reoperation-related conversion rate of 7%.
satisfaction rates after reoperative antireflux surgery are quite respectable. Almost 90% of
patients have an outstanding or acceptable outcome with redo fundoplication. In a
retrospective review of 118 patients, one study demonstrated that symptomatic response
rates approach those of primary surgery.53 Redo laparoscopic ARS is feasible with
acceptable complication rates and good success rates. It can provide a clinically effective
means in the management of recurrent GERD symptoms.
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Long-Term Results
Laparoscopic ARS is safe, effective, and durable. When selecting patients for surgery, it is
has shown that LARS prevents the progression of Barrett's esophagus into dysplasia or
adenocarcinoma. Some series demonstrate a trend toward decreased cancer risk, but
these findings are weakened by retrospective design and sample size.54, 55, 56 Esophageal
Mortality rates associated with LARS are very low, ranging from 0.008% to 0.8%57 in large
series. In fact, many large, single-institution retrospective studies reported zero mortality.
morbidity rate of 2%. These data came from large, academic referral centers and private
the time. This study did not mention splenectomy. In another large retrospective study of
over 5000 patients undergoing ARS, splenectomy occurred in 2.3%, esophageal laceration
in 1.1%, and the mortality was 0.8%. The study period was 1992 to 1997, during the
events were significantly more likely in the surgeon's first 15 cases. This speaks to the
need for specialized training to guide the surgeon through the learning curve and ideally
avoid perforations and other disastrous complications.58
Predictors of Outcome
Campos et al.31 identified three main predictors of good outcome in a study of 199 patients
excellent results. The most likely to benefit from LARS were those who had abnormal 24-
hour pH testing scores, typical symptoms, and a good response to medical therapy. The
strongest indicator of good surgical outcome was the 24-hour pH study [OR 5.4, 95%
toGERD, symptoms correlation with reflux events were strong indicators of good outcome.
Most large studies for LARS report high patient satisfaction rates at least 5 years out. A
study published by Anvari et al. showed an impressive follow up of 181 patients at 5 years
from Belgium where the first laparoscopic Nissen fundoplication was performed by
Results demonstrate that at 10 years, 89.5% of patients were symptom free. Only 9%
In most patients, the long-term management of GERD can be achieved with medical or
surgical therapy. Several randomized controlled trails have compared surgical to medical
therapy. Unfortunately, each investigation is limited by sample size and variables that
make interpreting and comparing the results challenging. For example, the largest of the
studies was performed in veterans who, as a group, are quite different from the general
population. From this, it is difficult to determine whether the results are generalizable.
The first randomized controlled trial investigating medical versus surgical therapy is the
Veterans Administration GERD Study Group trial, which provided the longest follow-up
data. This trial demonstrated the superiority of surgery over histamine receptor blockade
and lifestyle modifications in the treatment of typical GERD symptoms and esophagitis in
247 veterans.60 The 10-year follow-up of this study demonstrated that 62% of surgical
acid exposure were equivalent between the two groups.13 To some, the results of this
follow-up study were misconstrued to imply that surgical therapy for GERD is ineffective. It
is important to remember that this was an intention to treat analysis, and several of the
patients who were originally randomized to surgery, never received this therapy and thus
subjects both on and off medical therapy; compared to the medically treated patients,
those who underwent antireflux surgery had only a slight increase in GERD-related
symptoms off medication. Furthermore, they had significantly lower symptom scores off
medication than their medically treated counterparts. The implication is that surgery is
effective in maintaining symptom control, and that many patients are placed
on PPI therapy for nonGERD-related reasons.
medical treatment under a strict set of symptomatic and endoscopic "failure" criteria.
However, if the dosage of PPI was increased to accommodate for breakthrough symptoms
in the medically treated subjects, the two therapies were found to be equivalent.
A recent randomized controlled trial that examined medical versus surgical treatment
comes from Mahon et al.62 in the United Kingdom. Three-month follow-up showed
significantly less acid exposure to the distal esophagus by pH testing in the surgical arm.
significantly improved over the PPI group. The dosage of PPIs was titrated to abolish all
reflux symptoms. Long-term results of this study will be eagerly awaited.
In all, there have been few randomized controlled trials that use consistent criteria to
evaluate medical and surgical therapy. However, certain conclusions can be drawn.
Surgery in the properly selected patient can achieve excellent and durable symptom
control and can ameliorate long-term effects of esophageal acid exposure. For a multitude
of reasons, LARSdoes not necessarily free patients from medication dependence.
Respiratory and atypical symptoms that stem from GERD have been shown in several
studies to be improved by LARS over medical therapy. One recent study by Ciovica et
al.63showed a significant improvement in 126 patients with preoperatively documented
respiratory symptoms and GERD treated with PPIs. The patients then underwent LARS.
Cough, sore throat, hoarseness, and laryngeal symptoms improved postoperatively and
remained improved at 12 months. In another study with 21 GERD patients with respiratory
symptoms, relief was obtained in 66% of patients and 19% showed improvement of
respiratory symptoms. The medically treated control group only showed a 14%
well controlled in the LARS group but unaffected in the medically treated group. This offers
good supporting evidence that reflux reaches the upper airways and triggers respiratory
symptoms.64
although much less impressive than improvement in typical GERD symptoms. Ninety-three
study of 39 patients with GERD-triggered asthma that systemic steroid use significantly
decreased afterLARS. Allen and Anvari67 examined the effect of LARS on cough in patients
with GERD. Cough was significantly improved at 5-year follow-up.
refluxate, whether acid, nonacid, or alkaline, from reaching the larynx and airway.
esophageal injury is another mechanism by which LARS alleviates symptoms. Patients with
however, these studies indicate that LARS may be superior to medical therapy at
alleviating atypical and respiratory symptoms.
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Cost-Effectiveness
Several conflicting studies have surfaced recently that address the cost-effectiveness
ofLARS versus medical therapy with PPIs. For example, a Veterans Administration
with PPIs was superior to LARS in terms of quality adjusted life years (QALY) and cost over
10 years. They projected that medical therapy would total $8,798 versus $10,475 for
operation at 10 years, and QALY would be 4.59 versus 4.55 in the surgical group. In
contrast, a recent British study by Cookson et al.69 has shown that laparoscopic Nissen
fundoplication is cost-effective after 8 years compared with maintenance therapy with PPIs
in patients with severe GERD. A previous study by Heikkinen et al.28 from Finland showed
that total cost was actually lower for Nissen fundoplication mostly owing to earlier return
to work.
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Conclusion
From Rudolph Nissen's first fundoplication to the current endeavors in endoscopic therapy,
surgery has established itself as a safe, durable, and effective therapy for typical GERD.
reconstruction of the antireflux barrier that translates into effective symptom control and
fundoplication should serve as the standard for surgical and endoscopic therapies directed
at the treatment ofGERD.
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Video 1: A B Cinepak.
Use of the "shoeshine" maneuver prior to completing the
fundoplication ensures that the stomach is not twisted and that
the proper portion of the stomach is employed in the repair. The
surgeon grasps both ends of the fundus and pulls it back and
forth behind the esophagus to ensure adequate mobility and no
tension.
;
,
.
, 2 .
There is some evidence that the wrap itself is less likely to be the cause of persistent
dysphagia (>6 weeks); rather, the hiatal closure appears to play a critical role in the
Granderath et al. 32 categorized 50 patients referred for post- ARS dysphagia. Fifteen of 18
patients identified as having crural stenosis with an intact wrap were effectively treated
with pneumatic dilation, lending credence to the hypothesis that too tight of a crural
closure (or accumulated scar tissue) leads to constriction of the esophagus with resulting
dysphagia. Three patients in this group required reoperation. In all, the authors found a
tight hiatal closure effectively narrowing the esophagus. Those patients with transthoracic
migration of the wrap ( n = 27) underwent reoperation. All were found to have complete
or partial wrap migration into the mediastinum with evidence of constriction at the hiatus.
In almost 60% of these patients, the crural closure was intact but inadequate in
preventing wrap migration. Only five patients of the 50 had problems with the wrap itself
(discovered at reoperation) that accounted for their dysphagia. These findings point to the
The Hill repair is not a fundoplication per se, but a recalibration of the antireflux barrier.
The Hill repair aims to secure the esophagogastric junction into the abdominal cavity,
recalibrate the LES , and re-create the acute angle of His. This is accomplished by
bundles to the preaortic fascia. The tightness of the sutures is calibrated using
intraoperative manometry ( Figure 6 ).
In about 10% of patients undergoing LARS , there will not be adequate intraabdominal
esophageal length. Because the most common cause of failure after antireflux surgery is
patients, maximal esophageal mobilization reaching up to the aortic arch will enable
adequate length to be achieved. However, despite these efforts, some patients require an
The short esophagus may be suggested in the preoperative workup; however, the final
diagnosis can only be made intraoperatively. Four findings have been established to
correlate with the presence of short esophagus: (1) large nonreducing hiatal hernia, (2)
esophageal stricture, (3) Barrett's esophagus, and (4) an LES at 35 cm or less from the
incisors by manometry.
Although there is excellent symptomatic relief of GERD symptoms after combined Collis
intact fundoplication and can result in mucosal damage. 33, 34 In a follow-up study of
patients treated with Collis gastroplasty, recurrent erosive esophagitis owing to pathologic
acid exposure was found in an alarming 80% of patients. Despite the high incidence of
ongoing mucosal damage, 65% of patients with recurrent disease reported significant
should undergo follow-up with objective testing and be placed on PPI s if there is an
must be understood that many of these patients have advancedGERD with a severely
damaged esophagus and severe, medically refractory volume reflux; in this setting, the
Partial Fundoplications
employed after Heller myotomy in patients with achalasia. After the crura is closed, the
fundus is passed posterior to the esophagus similar to the approach used for the
laparoscopic Nissen fundoplication. The limbs of the fundoplication are then sutured
together to the anterior esophagus, taking care to avoid the anterior vagal trunk ( Figure
8 ). Mounting evidence in the surgical literature weighs heavily against the continued use
of partial fundoplication as a primary therapy for medically refractory GERD . 35, 36, 37, 38
associated with a high symptomatic failure rate.37 In addition, Toupet fundoplication has
most patients with dysmotility have improved esophageal peristalsis after undergoing
an LNF . This suggests that GERD -related esophageal injury plays a role in causing
dysmotility, and that abolishing pathologic reflux corrects the motility disorder.
Care
Possibly the most attractive feature of laparoscopic surgery is the prompt recovery time.
The hospital stay is generally 1 to 4 days. Some centers perform LARS as a day surgery in
selected patients. Following an initial trial with clear liquids, patients begin a pureed diet
herniation. If there is concern that an occult perforation occurred during surgery, then a
barium swallow is performed before a diet is started. Typically, patients are maintained on
a soft diet for 4 to 6 weeks and then transitioned to solid foods as tolerated. Bread and
meat should be avoided for the first 6 weeks, as these items are notoriously troublesome
approximately 1.5% of cases; if detected, they are repaired primarily, and drains are
placed to minimize the risk of peritonitis or mediastinitis. Pneumothorax is usually self-
limited because CO 2 is rapidly reabsorbed from the pleural space. Chest tube placement is
rarely indicated. Splenic injury can take the form of infarction or bleeding. Superior pole
infarction can occur with ligation of the short gastric arteries and does not require
Cautery injury can result in delayed intestinal perforation and peritonitis. Meticulous
dissection and gentle retraction can help prevent injury. It is paramount that the
abdominal survey before closure can help identify any signs of bleeding or visceral injury.
Late Complications
Although Nissen fundoplication has greater than 90% success in eliminating reflux
symptoms, over time a proportion of patients develop new or recurrent foregut symptoms.
Some dysphagia, gas bloating, and mild residual esophagitis are common in the early
postoperative period, but these symptoms generally resolve within 3 months; severe or
persistent symptoms may indicate failure and the need for further investigation.
reoperation. 41, 42, 43, 44 Reported mechanical causes of failure vary significantly among
studies, but transthoracic herniation occurs in 10% to 60% of failures and "slipped"
fundoplication, missed motility disorders, and paraesophageal hernias are other modes
of LARS failure 41, 45, 46, 47, 48, 49, 50 ( Table 3 ).
One of the reasons for pursuing LARS is to offer patients, especially the young, freedom
from daily medication dependence. However, data suggest that many patients are using
antisecretory medications after ARS . Some construe this as surgical failure. Closer
examination of prescribing patterns reveals that many patients are receiving antisecretory
al. 19 showed that only 24% of 86 symptomatic, medically treated patients post- ARS had
abnormal distal esophageal acid exposure. This study indicates that many patients with
foregut symptoms after ARS are taking antisecretory medication based on symptoms alone
and not on objective evidence to support their use. In this study, the authors found a very
poor positive predictive value of symptoms, including moderate to severe heartburn and
regurgitation, and the presence of abnormal acid exposure. Latent, preexisting foregut
failure of the wrap should not be assumed when addressing post- ARS symptoms.
Symptoms after ARS should be investigated to rule out esophageal motility disorders,
gastroparesis, delayed gastric emptying, irritable bowel syndrome, gastritis, and nonulcer
A "slipped" or misplaced fundoplication occurs when the proximal stomach (instead of the
stomach proximal to the narrowing caused by fundoplication. The slippage is usually the
result of transthoracic herniation and represents one of the most common forms of failure.
unrecognized short esophagus ( Figure 9 ). Twisting of the wrap is a technical error that
can result in a poor outcome. Twisting results from employing the distal greater curvature
(antrum) of the stomach as the fundoplication; this results in a two-compartment, twisted
stomach and episodic emesis and abdominal pain. Endoscopically, twisted wraps appear as
obliquely running folds with respect to the endoscope. These patients require reoperation.
A focused evaluation of postoperative symptoms begins with reviewing all prior records
and objective testing. Again, repeat 24-hour pH testing, EGD , manometry, and
the LES length, position, and resting pressure, manometry can determine the integrity of
pH testing will confirm recurrent reflux but will not identify the anatomic mechanism of
failure. Esophagram is a very valuable test in the workup of fundoplication failure. This
Redo Surgery
In our practice, we consider patients for redo surgery if they present with persistent or
recurrent foregut symptoms or if they develop symptoms not present prior to surgery.
Surgical intervention is carried out in those who have an identifiable anatomic abnormality
challenging in even the most experienced hands. To provide a durable repair, the cause of
perforation is the complication most feared when performing redo surgery secondary to
Smith and colleagues 51 reported a 2.8% failure rate requiring reoperation in a series of
1892 patients undergoing antireflux surgery over a 13-year period; of the failures, 73%
required reoperation within the first 2 years of surgery. The most common mechanism of
failure was transdiaphragmatic wrap herniation (61%). The laparoscopic approach was
used in the majority of these patients and the conversion rate to laparotomy was 8%.
Similarly, Dutta et al. 52reported a reoperation-related conversion rate of 7%.
satisfaction rates after reoperative antireflux surgery are quite respectable. Almost 90% of
retrospective review of 118 patients, one study demonstrated that symptomatic response
rates approach those of primary surgery. 53 Redo laparoscopic ARS is feasible with
acceptable complication rates and good success rates. It can provide a clinically effective
means in the management of recurrent GERD symptoms.
Laparoscopic ARS is safe, effective, and durable. When selecting patients for surgery, it is
has shown that LARS prevents the progression of Barrett's esophagus into dysplasia or
adenocarcinoma. Some series demonstrate a trend toward decreased cancer risk, but
these findings are weakened by retrospective design and sample size. 54, 55, 56 Esophageal
Mortality rates associated with LARS are very low, ranging from 0.008% to 0.8% 57 in
large series. In fact, many large, single-institution retrospective studies reported zero
demonstrated a morbidity rate of 2%. These data came from large, academic referral
centers and private practice experience. Early wrap herniation, pneumothorax, gastric
perforation, and hemorrhage were the most common serious complications, each occurring
around 1% of the time. This study did not mention splenectomy. In another large
retrospective study of over 5000 patients undergoing ARS , splenectomy occurred in 2.3%,
esophageal laceration in 1.1%, and the mortality was 0.8%. The study period was 1992 to
fundoplication. Adverse events were significantly more likely in the surgeon's first 15
cases. This speaks to the need for specialized training to guide the surgeon through the
learning curve and ideally avoid perforations and other disastrous complications. 58
Predictors of Outcome
Campos et al. 31 identified three main predictors of good outcome in a study of 199
good to excellent results. The most likely to benefit fromLARS were those who had
abnormal 24-hour pH testing scores, typical symptoms, and a good response to medical
therapy. The strongest indicator of good surgical outcome was the 24-hour pH study [OR
5.4, 95% confidence interval (CI) = 1.915.3]. In studies with respiratory symptoms
related to GERD , symptoms correlation with reflux events were strong indicators of good
outcome.
Most large studies for LARS report high patient satisfaction rates at least 5 years out. A
study published by Anvari et al. showed an impressive follow up of 181 patients at 5 years
from Belgium where the first laparoscopic Nissen fundoplication was performed by
Results demonstrate that at 10 years, 89.5% of patients were symptom free. Only 9%
In most patients, the long-term management of GERD can be achieved with medical or
surgical therapy. Several randomized controlled trails have compared surgical to medical
therapy. Unfortunately, each investigation is limited by sample size and variables that
make interpreting and comparing the results challenging. For example, the largest of the
studies was performed in veterans who, as a group, are quite different from the general
population. From this, it is difficult to determine whether the results are generalizable.
The first randomized controlled trial investigating medical versus surgical therapy is the
Veterans Administration GERDStudy Group trial, which provided the longest follow-up
data. This trial demonstrated the superiority of surgery over histamine receptor blockade
and lifestyle modifications in the treatment of typical GERD symptoms and esophagitis in
247 veterans. 60 The 10-year follow-up of this study demonstrated that 62% of surgical
acid exposure were equivalent between the two groups. 13To some, the results of this
follow-up study were misconstrued to imply that surgical therapy for GERD is ineffective. It
is important to remember that this was an intention to treat analysis, and several of the
patients who were originally randomized to surgery, never received this therapy and thus
subjects both on and off medical therapy; compared to the medically treated patients,
those who underwent antireflux surgery had only a slight increase in GERD -related
symptoms off medication. Furthermore, they had significantly lower symptom scores off
medication than their medically treated counterparts. The implication is that surgery is
effective in maintaining symptom control, and that many patients are placed
on PPI therapy for non GERD -related reasons.
to medical treatment under a strict set of symptomatic and endoscopic "failure" criteria.
However, if the dosage of PPI was increased to accommodate for breakthrough symptoms
in the medically treated subjects, the two therapies were found to be equivalent.
A recent randomized controlled trial that examined medical versus surgical treatment
comes from Mahon et al. 62 in the United Kingdom. Three-month follow-up showed
significantly less acid exposure to the distal esophagus by pH testing in the surgical arm.
significantly improved over the PPI group. The dosage of PPI s was titrated to abolish all
reflux symptoms. Long-term results of this study will be eagerly awaited.
In all, there have been few randomized controlled trials that use consistent criteria to
evaluate medical and surgical therapy. However, certain conclusions can be drawn.
Surgery in the properly selected patient can achieve excellent and durable symptom
control and can ameliorate long-term effects of esophageal acid exposure. For a multitude
of reasons, LARS does not necessarily free patients from medication dependence.
Surgical Results in Patients with Atypical Symptoms
Respiratory and atypical symptoms that stem from GERD have been shown in several
respiratory symptoms and GERD treated with PPI s. The patients then underwent LARS .
Cough, sore throat, hoarseness, and laryngeal symptoms improved postoperatively and
remained improved at 12 months. In another study with 21 GERD patients with respiratory
symptoms, relief was obtained in 66% of patients and 19% showed improvement of
respiratory symptoms. The medically treated control group only showed a 14%
well controlled in the LARSgroup but unaffected in the medically treated group. This offers
good supporting evidence that reflux reaches the upper airways and triggers respiratory
symptoms. 64
although much less impressive than improvement in typical GERD symptoms. Ninety-three
study of 39 patients with GERD -triggered asthma that systemic steroid use significantly
decreased afterLARS . Allen and Anvari 67 examined the effect of LARS on cough in
patients with GERD . Cough was significantly improved at 5-year follow-up.
refluxate, whether acid, nonacid, or alkaline, from reaching the larynx and airway.
esophageal injury is another mechanism by which LARS alleviates symptoms. Patients with
however, these studies indicate thatLARS may be superior to medical therapy at alleviating
atypical and respiratory symptoms.
Cost-Effectiveness
Several conflicting studies have surfaced recently that address the cost-effectiveness
of LARS versus medical therapy with PPI s. For example, a Veterans Administration
over 10 years. They projected that medical therapy would total $8,798 versus $10,475 for
operation at 10 years, and QALYwould be 4.59 versus 4.55 in the surgical group. In
contrast, a recent British study by Cookson et al. 69 has shown that laparoscopic Nissen
with PPI s in patients with severe GERD . A previous study by Heikkinen et al. 28 from
Finland showed that total cost was actually lower for Nissen fundoplication mostly owing to
earlier return to work.
From Rudolph Nissen's first fundoplication to the current endeavors in endoscopic therapy,
surgery has established itself as a safe, durable, and effective therapy for typical GERD .
reconstruction of the antireflux barrier that translates into effective symptom control and
prevention of GERD -related complications. The results achieved with the Nissen
fundoplication should serve as the standard for surgical and endoscopic therapies directed
at the treatment of GERD .