Gastroesophageal reflux disease (GERD) is caused by the chronic reflux of gastric acid from the stomach to the esophagus. This may be the result of an incompetent lower esophageal sphincter (LES) or poor gastric emptying. GERD is an anatomic and physiologic problem that may lead to surgical consultation for treatment of either the symptoms or sequelae of reflux. It was first recognized as a clinical entity in the 1930s. Today, it is the most prevalent upper gastrointestinal disorder in the Western world.¹

GERD gives rise to a spectrum of symptoms that range in intensity from mild to severe. Up to 80% of patients present with so-called typical symptoms of GERD. These include heartburn, regurgitation, sour taste, and intermittent dysphagia but no evidence of esophageal inflammation or injury. Approximately 20% of patients present with atypical symptoms, namely, chest pain, hoarseness, nocturnal choking, chronic cough, asthma, shortness of breath, and pneumonia. For some, GERD causes severe medical disabilities, such as recurrent aspiration, ulceration, end-stage lung disease, or recurrent esophageal stricture. Left untreated, these complications may lead to disability and rarely mortality. For most, however, GERD is a non-life-threatening condition and patients suffering from this disease seek treatment mainly to improve their quality of life.

The treatment options for GERD range from lifestyle change and medical therapy to antireflux surgery based on the severity of the patient’s symptoms or presence of complications. Long-term treatment with proton pump inhibitor (PPI) therapy is highly effective in terms of symptoms but may require indefinite duration because 82% of patients have recurrent symptoms within 6 months of discontinuation. When conservative treatment fails, several interventions are possible. Herein, we describe both the open Nissen fundoplication and the laparoscopic adaptation, the current surgical standard for the treatment of GERD. These operations were designed to fix the anatomic and physiologic problems that give rise to GERD.

The Nissen fundoplication consists of hiatal closure and a 360-degree wrap of stomach posteriorly around the distal esophagus to augment and restore the function of the LES. The laparoscopic adaptation is associated with reduced morbidity compared with the open approach; however, a history of previous abdominal operation with dense scar and adhesion still poses a significant challenge. Since its conception,² the Nissen fundoplication has been a successful operation with excellent long-term outcomes. The morbidity associated with the upper midline incision of the open approach; however, limited its application to patients with symptoms refractory to medical therapy and severe complications of GERD.

The laparoscopic adaptation, first reported in 1991,³ revitalized interest in the surgical treatment of GERD. Factors underlying this increased interest included the rising incidence of GERD in Western countries, the decreased morbidity and mortality of the minimally invasive approach, poor compliance or dissatisfaction with long-term medical treatment, recognition of an association between GERD and esophageal cancer, and curative potential of the surgery. Patient demand for a permanent treatment led many surgeons to acquire expertise in the minimally invasive approach. The learning curve for laparoscopic fundoplication is relatively short, reaching a plateau at 20 cases for the individual surgeon^4,5 and 50 cases for an institution.⁶ A two-surgeon collaborative approach can further reduce the learning curve.⁷ The long-term results of open and laparoscopic fundoplication appear to be equivalent, with larger series showing a sustained benefit in 95% of patients at 5 years and approximately 90% at 10 years.¹

A recent survey of 2261 consecutive cases over a 20-year period cites a conversion rate of 3.2%, a 5% rate of reoperation within 1 year, 9.6% within 10 years, and 1.4% beyond 10 years. The latter figure may not carry much value since less than one-third of the patients were followed beyond 10 years.⁸ Patient selection is critical. Those that benefit most from medical therapy have the best long-term results.

General indications for antireflux surgery include esophageal ulceration, severe esophagitis, Barrett esophagitis, severe pulmonary symptoms, recurrent stricture, dysplasia, and failure or inability to comply with medical therapy. To be considered for this surgery, the patient must have normal esophageal motility and a normal-length esophagus. Patients with foreshortened esophagus likely will require a Collis extension coupled with this procedure.

It is essential to conduct an adequate preoperative evaluation to confirm the diagnosis because the symptoms of GERD overlap substantially with the primary esophageal motility disorders, which require different therapies for treatment (see Part 4). Experience with the open technique is a prerequisite because rapid conversion to the open procedure may be required if the laparoscopic approach fails or in the event of a serious complication. Depending on specific anatomic considerations, other procedures described in this section also may be necessary (e.g., a Nissen–Collis procedure or partial fundoplication). Obesity is associated with GERD; however, for patients with a body mass index greater than 40, bypass or other weight-loss procedures have superior results.⁹

Patients referred for surgical treatment of GERD often have long-standing symptoms and have pursued at least medical and often lifestyle changes without success or satisfaction. Lifestyle changes include dietary modifications that reduce the consumption of fatty foods, peppermint, and alcohol, cessation of tobacco smoking, and weight loss.

The evaluation for antireflux procedures is best accomplished by studies designed to exclude related disorders of the esophagus ¹⁰ (Table 39-1). These are the barium or cine esophagram (upper gastrointestinal series), endoscopy (esophagogastroduodenoscopy [EGD]), esophageal manometry, and esophageal pH probe analysis. If the findings are inconclusive, esophageal and gastric-emptying studies, and even provocative testing may be useful.

Barium Esophagram

The barium swallow or esophagram is the diagnostic modality of choice for the evaluation of dysphagia and chest pain likely to be related to the esophagus. It is a sensitive diagnostic modality for achalasia and diffuse esophageal spasm but not for nutcracker esophagus or scleroderma, the latter representing secondary esophageal motility disorders. Only 40% of patients with classic GERD symptoms have a positive esophagram. Spontaneous regurgitation or moderate-to-severe reflux of contrast material to the esophagus confirms GERD.

Cine Esophagram

The cine esophagram is a dynamic video contrast study that records the transfer of contrast material from the oral cavity to the pharynx, showing the coordinated motion of the tongue, palate, epiglottis, laryngeal and pharyngeal walls, inferior constrictors, and upper esophageal sphincter. This study is indicated for patients with atypical chest pain and normal findings on barium esophagram.

Esophagogastroduodenoscopy

Fiberoptic EGD is the most important tool for the diagnosis and management of esophageal disease. It is usually performed with topical anesthesia and IV conscious sedation in an outpatient setting (see Chapter 14). We routinely perform EGD before surgery for GERD to assess esophageal length, define and treat any strictures, exclude other pathology such as cancer, evaluate Barrett esophagitis, and determine the presence of a hiatal hernia (esophageal or paraesophageal).

Esophageal Manometry

Esophageal manometry provides information about the motor function of the esophagus and its sphincters (upper and lower) at rest and during swallowing. Conventional manometry is performed using a water-perfused catheter which has pressure sensors located at several points along the length of the catheter. These catheters produce limited data, however, because of the large gaps between the sensors. A new generation of catheters has been developed for high-resolution manometry (HRM). The HRM catheters are equipped with intraluminal pressure transducers. They enable the clinician to simultaneously measure the entire esophagus (from hypopharynx to stomach). This not only increases the accuracy of the test but also provides more information. The data generated from these catheters is visualized on a spatiotemporal color plot, called a Clouse plot, which is more intuitive and easier for clinicians to interpret.¹¹

Patients who undergo Nissen fundoplication must have a relatively normally functioning esophagus. Impaired motility increases the risk for obstructive symptoms postoperatively. One exception is the entity known as esophageal stunning that is caused by prolonged acid exposure and reflected in decreased motility of the distal esophagus. This entity occasionally may be confused with diffuse esophageal spasm. At rest, the normal LES is a 3- to 4-cm high-pressure zone in the distal esophagus. It relaxes with a food bolus, permitting food to pass into the stomach. The LES has three components: resting pressure at midrespiration, overall length, and abdominal length (the lower limits of normal are 6 mm Hg, 2 cm, and 1 cm, respectively). If just one of these values is low, the LES will not function properly. Esophageal manometry is most useful for identifying nonobstructive causes of dysphagia because it is sensitive to pressure changes and does not provide information about the passage of food. It provides a definitive diagnosis of achalasia, diffuse esophageal spasm, nutcracker esophagus, hypertensive LES, and scleroderma, all of which are contraindications to Nissen fundoplication.

Esophageal pH Probe Monitoring

Ambulatory esophageal pH monitoring was introduced in 1985 for the diagnosis of GERD. The patient must cease H₂-blocker therapy 48 hours before monitoring and PPI therapy 2 weeks in advance of study. The basic instrument consists of a tube with a number of pH channels. This tube is placed in the esophagus for 24 hours. The tube is positioned such that the first probe is located 5 cm above the LES (determined by manometry). The second is connected to the skin, and both are connected to a portable data recorder. The pH is sampled and recorded every second. In general, the patient is asked to eat a regular diet and carry out normal daily activities. A diary is used to document meals, symptoms, and sleep time. A composite reflux score is calculated, and a value above 14.7 represents pathologic exposure to acid. Ninety-five percent of individuals score under 14.7. The composite reflux score has a sensitivity of 90% and specificity of 85% for GERD. It is especially useful in diagnosing reflux with atypical pulmonary symptoms such as chronic cough, wheezing, asthma, and recurrent pneumonia. It can be used to assess the efficacy of medical therapy or the success of surgical therapy. It should be used to confirm GERD in all patients before antireflux procedures. This test does not detect “alkaline reflux,” that is, reflux owing to bile with a pH >7. It is considered the single most useful objective test for evaluating GERD¹² (Table 39-2).

Newer devices have been developed that cause less discomfort to the patient. The wireless Bravo capsule (Bravo, pH Monitoring System, Medtronic, Inc., Minneapolis, MN), for example, is clipped to the esophageal wall during endoscopy and is capable of transmitting pH data to a small external recorder for up to 48 hours. A new generation of commercially available catheters has been developed that measure pH and impedance simultaneously at multiple sites in the esophagus via a single multichannel intraluminal device, whereas other catheters measure HRM and impedance. These contribute to the understanding of the relationship between GERD and motility.

On occasion, findings on the aforementioned studies are inconclusive. Nuclear scintigraphy (esophageal and gastric emptying studies) uses food (e.g., cereal, eggs, or juice) labeled with radioactive technetium-99m or indium-111 to record the transit of food over time through the body. Abnormal studies demonstrate rapid or delayed emptying. Normal transit time through the esophagus is 10 to 17 seconds, and 50% of gastric emptying occurs within 15 to 90 minutes for liquids and 45 to 100 minutes for solids.

Provocative testing was developed because many patients, particularly those with atypical symptoms, may be asymptomatic at the time of testing. These studies reproduce the type of pain characteristic of GERD but do not provide insight into the underlying pathology. Of historical interest is the Bernstein acid perfusion test that was developed in 1958 to distinguish esophageal from other causes of chest pain. A tube is placed in the distal esophagus, and 0.1N hydrochloric acid is infused continuously at a rate of 5 to 10 mL/min for 10 to 30 minutes. The test is positive if the patient experiences pain when acid is introduced, and the pain abates with saline.

Laparoscopic Nissen Fundoplication

The critical steps of this operation are (1) placing the ports, (2) dividing the short gastric arteries, (3) hiatal dissection, (4) mobilization of the fat pad and assessment of esophageal length, (5) hiatal closure, and (6) fashioning and securing the wrap. The procedure is performed under general anesthesia. EGD should be performed by the surgeon at the time of the operation to confirm the anatomic findings, in particular, esophageal length. The bladder is decompressed, antibiotics are given, and prophylactic measures to prevent pulmonary embolus are instituted. The procedure can be performed in the supine or lithotomy position, with both arms tucked in at the sides.