ANTIREFLUX SURGERY

Vicky S. Budipramana

Department of Surgery
Div. Digestive Surgery
Medical Faculty , Airlangga University
Surabaya
ANATOMY

Liebermann-M, Riedo I. Interrelation between functional and

muscular lower esophageal sphincter. Dig Surg 1986;3:101.
 GERD
GERD gastroesophageal junction incompetency, the underlying mechanism is:
Hiatal hernia (HH),
Decreased resting lower esophageal sphincter (LES) pressure,
Intermittent inappropriate LES relaxations
Combination of these factors
The greater the gastric acid secretion is, the higher the risk of esophagitis
The longer the duration of esophageal exposure to acid, the larger the mucosal erosive
lesions and complications, the greater the risk of Barrett's epithelium development.

Fiorruci S, Santucci L; Gastric acidity and gastroesophageal reflux

patterns in patients with esophagitis. Gastroenterology 1992;103:855-861.
 GERD BARRETTS ESOPHAGUS

Esophageal defence mechanisms :

The production of growth factors: EGF and TGFa.
Bicarbonates from saliva + esophageal secretion
Mucus of the esophagus

Low prevalence of Barrett's esophagus in patients with ZE syndrome

mucosal protection afforded by an increased content of both salivary and
gastric EGF.

Strader D, Benjamin S, et al; Esophageal function and

occurrence of Barrett's esophagus in Zollinger-Ellison
syndrome. Digestion 1995;56:347-356.
ACG Clinical Guideline: Diagnosis and Management of

Barretts Esophagus, 2015

Am J Gastroenterol
advance online publication, 3 November 2015
ACG Clinical Guideline: Diagnosis and
Management of
Barretts Esophagus, 2015

Am J Gastroenterol
advance online publication, 3 November 2015
 GERD: Indication for surgery
a) Symptomatic erosive GERD with adequate response to proton
pump inhibitors (PPIs)
b) Evidence of large hiatal hernia or lower esophageal sphincter (LES)
dysfunction
c) Intolerance to medical treatment
d) Severe symptoms, especially with nocturnal reflux and
regurgitation
Revista de Gastroenterologa de Mxico (English Edition)
Volume 82, Issue 3, JulySeptember 2017, Pages 234-247
 Esomeprazole vs Laparoscopic antireflux
surgery (GERD: Multicenter clinical trial, Europe, 554 patients)
at 5 years)

Estimated remission rates:

92% (95% CI, 89%-96%) vs. 85% (95% CI, 81%-90%) (P = .048).
5% and 11% for dysphagia (P < .001),
28% and 40% for bloating (P < .001),
40% and 57% for flatulence (P < .001).
13% and 2% for acid regurgitation (P < .001),
16% and 8% for heartburn (P = .14)

JAMA. 2011 May 18;305(19):1969-77

 Goals of Antireflux Surgery

To restore the normal functions of the EGJ by wrapping the fundus

around the esophagus either partially or totally.
Reduction of a hiatal hernia (if present) by repairing the enlarged
opening of the diaphragm
Restoration of the angle at which the esophagus enters the stomach
Increase in the pressure of the muscle that controls the valve
between the stomach and the esophasgus
 Problems in Fundoplication
surgery
Difficulty swallowing because the stomach is wrapped too high on
the esophagus or is wrapped too tightly.
The esophagus sliding out of the wrapped portion of the stomach so
that the valve is no longer supported.
Bloating and discomfort from gas buildup because the person is not
able to burp.
Excess gas.
 Total fundoplication : Nissen (360)
Partial fundoplications :
Thal (270 anterior)
Belsey (270 anterior, transthoracic)
Dor (anterior 180200)
Lind (300 posterior)
Toupet fundoplications (posterior 270)
 181 Laparoscopic Nissen fundoplication patients Symptoms
preoperatively and at 6 months, 2 years, and 5 years

Manometry: (p < 0.0001) increase in lower esophageal sphincter pressure

24-hours pH recording (p < 0.0001) drop in duration of acid reflux
Symptom score drops (p < 0.0001)
Lower esophageal sphincter tone dropped between 6 months and 5 years after
surgery, but was still an effective antireflux barrier
Patient satisfaction with surgery dropped over the 5-year followup but remained high,
at 86%,

J Am Coll Surg. 2003 Jan;196(1):51-7;

 Nissen Fundoplication

A cohort with 11 years follow-up, in 312 consecutive patients after

Laparoscopic Nissen Fundoplication (response to Acid Reducing
Medication and typical symptoms):

Successful (75.3%), failures (24.7%)

Surg Endosc. 2007 Nov;21(11):1978-84.

 The Nissen-Rossetti
The Nissen Rossetti fundoplication differs from the usual Nissen
fundoplication in not having the divide the short gastric vessels
during the fundic wrap creation.
All the other operative steps are similar.
This reduces the operative time and also decreases the blood loss in
the surgery and decreased post operative pain

Ann Med Surg (Lond). 2015 Dec; 4(4): 384387

 Lortat-Jacob procedure, 1948

- Fixation of the right margin of the gastric fundus to the left margin
of the esophagus

- Reattachment of the gastric fundus to the sub-diaphragmatic

peritoneum

Goutallier P. The Lortat-Jacob procedure. In: Giuli R, McCallum

RW, eds. Benign lesions of the esophagus and cancer. Berlin:
Springer-Verlag, 1989.
Collis gastroplasty
Collis-Nissen, 1977

Adler Richard H (1990). "Collis Gastroplasty: Origin and Evolution"

(PDF). The Annals of Thoracic Surgery. 50 (5): 839842.
 Nissen vs Toupet
Gas bloat is more prevalent in the complete Nissen fundoplication than in
the partial Toupet type (31.19% vs 23.91%, RR: 1.31, 95% CI: [1.05, 1.65],
p = 0.02).
The inability to burp is more prevalent in the complete fundoplication
14.9% vs 8.4% (95% CI: p = 0.03).
Flatulence 74.58%/67.24%
Epigastralgia in 25.42%/31.03%

Revista de Gastroenterologa de Mxico, Volume 82, Issue 3,

JulySeptember 2017, Pages 234-247
180 vs. 360 Fundoplication

Revista de Gastroenterologa de Mxico (English Edition)

Volume 82, Issue 3, JulySeptember 2017, Pages 234-247
Belsey Mark IV

Autumn 2013 Volume 18, Issue 3, Pages 215229

 Belsey Mark IV
The open Belsey Mark IV fundoplication (BMIV) is performed via a left posterolateral thoracotomy
an incomplete 240 anterior fundal wrap
avoiding gas bloat syndrome, Belching or burping
Result in 892 pt:
Good result 84%
10 years recurrence rate 14.7%
Belsey Mark IV diminished:
The improvement of laparoscopic anterior 180 Dor and posterior 270 Toupet
Using Thoracoscopy much more difficult than open thoracotomy

Autumn 2013 Volume 18, Issue 3, Pages 215229

Stretta Procedure
 Stretta procedure

558 patients underwent the Stretta procedure:

Significant improvement in GERD symptom control (from 50% to 90%)
Patient satisfaction (from 23% to 86% at a mean follow up of 8 mo.
The onset of GERD relief was in less than 2 mo in most patients (69%).
Off all antisecretory drugs at one year follow-up (96% pre-procedure
vs. 51%)

World J Gastroenterol. May 7, 2006; 12(17): 2641-2655

Published online May 7, 2006.
 Stretta procedure
"No evidence for efficacy of radiofrequency ablation for treatment of
gastroesophageal reflux disease: a systematic review and meta-
analysis.". Clinical Gastroenterology and Hepatology. 2015; 13 (6):
105867

In 2015 an American Society for Gastrointestinal Endoscopy guideline

noted that the quality of evidence was low for Stretta and called for
better research to be conducted (Sages 2015)
LINX PROCEDURE
 LINX PROCEDURE

85 patients, LINX procedure at 14 centers in the U.S. and The Netherlands.

Evaluated at 5 years for quality of life, reflux control, PPI use and side effects:

83% (95% CI, 73%-91%) of patients had a 50% reduction in GERD Health Related Quality of
Life (HRQL) scores.
89.4% (95% CI, 81%-95%) had at least a 50% reduction in average daily PPI dose.
89% of patients had 11,9% decreased heartburn
Patient dissatisfaction decreased from 95% before treatment to 7.1%

Ganz RA, et al. 5-year study confirms long-term safety,

efficacy of LINX procedure for GERD
Clin Gastroenterol Hepatol. 2015
 Linx Procedure vs. Nissen
Cohort 24 patients

Post operative dysphagia 50% vs. 0% (p=0.01)

Abdominal bloating or hyperflatulence 0% vs. 33%
Operative time 64 min vs. 90 min (p<0.001)

Eric G, D Phil, et al; Massachusetts General Hospital 2012-2013,

Society of American Gastrointestinal and Endoscopic Surgeons (SAGES)
Transoral Incisionless
Fundoplication (TIF)
The EsophyX device (EndoGastric
Solutions, Redmond, WA, United
States)

The Medigus Ultrasonic Surgical

Endostapler system (MUSE,
Medigus Ltd., Omer; Israel)
Transoral Incisionless
Fundoplication (TIF)
Symptomatic responses TIF

World J Gastrointest Pharmacol Ther. May 6, 2016; 7(2): 179-189

 Limitation of TIF
In the last few years TIF has only been done in clinical trials enrolling
patients with typical gastro-esophageal reflux symptoms responsive
or partially responsive to PPI therapy
With only small hiatal hernia (< 3 cm)
who refused long-term medication, or were intolerant to PPIs, or
required high doses of antisecretory maintenance therapy

World J Gastrointest Pharmacol Ther. May 6, 2016; 7(2): 179-189

 TIF Outcome
Overall outcomes showed that the TIF procedure can be an effective
and safe alternative therapeutic option to surgery in selected patients
in the series with three- to six-year follow-up
TIF resulted slightly inferior to Nissen fundoplication, but similar to
partial posterior (Toupet) or anterior (Dor-Thal) fundoplication
Without surgery-related side effects.

World J Gastrointest Pharmacol Ther. May 6, 2016; 7(2): 179-189

 TIF
American Society for Gastrointestinal Endoscopy guideline noted that
the quality of evidence was low for Transoral incisionless
fundoplication (TIF)

Sages, 2015
 SUMMARY

SAGES RECOMMENDATION

(Society of American Gastrointestinal and Endoscopic Surgeons)

 RECOMMENDATION (SAGES-
2010)
1. Partial fundoplication is associated with less postoperative
dysphagia, fewer reoperations, and similar patient satisfaction
and effectiveness compared with total fundoplication up to five
years after surgery (Level-1, Grade A).

2. Posterior fundoplication is superior to the anterior by achieving

better reflux control without increased incidence of
postoperative dysphagia (Level-1, Grade-A)
3. When the fundus can be wrapped around the esophagus without
significant tension, no division of the short gastric artery.
(Level-1, Grade A).

4. Crural closure should be strongly considered during fundoplication

when the hiatal opening is large and mesh reinforcement may be
beneficial in decreasing the incidence of wrap herniation (Grade B).
5. Higher failure rates in obese patient (BMI >35 kg/m2) the
underlying problem (obesity) and its associated comorbidities
Gastric bypass should be the procedure of choice (Grade B).

6. The placement of an esophageal dilator during the creation of

laparoscopic fundoplication is advisable as it leads to decreased
postoperative dysphagia (Grade B).
Thank you .