Step 1
Surgical Anatomy
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Key anatomic structures that must be considered in antireflux surgery include the lower esophageal sphincter (LES), gastroesophageal junction (GEJ), esophageal hiatus, phrenic nerve, and vagus nerves.
Indications
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Gastroesophageal reflux disease (GERD) is a mechanical disorder associated with a defective LES mechanism, affecting as many as 2.5 million Americans.
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GERD is common in morbidly obese patients because of the high incidence of hiatal hernia and increased intra-abdominal pressure, which displaces the LES and increases the gastroesophageal gradient.
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Typical symptoms of GERD (heartburn, regurgitation, chest pain, water brash, and occasionally dysphagia), atypical symptoms (chronic cough, hoarseness, asthma exacerbations, laryngitis, recurrent pulmonary infections, and dental lesions), and the sequelae of chronic acid reflux (esophagitis, esophageal strictures, Barrett esophagus [BE], and esophageal cancer) have been well described.
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Indications for antireflux surgery include GERD refractory to medical management, lifelong acid suppression, adverse reactions to medical therapeutic agents, and complications arising from GERD. The presence of BE may be an indication for antireflux surgery because some studies have demonstrated regression of metaplastic changes following surgery.
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BE has been reported in up to 10% of patients with GERD, and it increases the incidence of esophageal adenocarcinoma.
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Up to 20% of patients with BE demonstrated resolution of intestinal metaplasia, and as many as 50% to 60% show regression of low-grade dysplasia with surgical control of reflux.
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Step 2
Preoperative Considerations
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A focused history and physical examination should be performed on all patients.
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Esophageal function tests should be performed. These motility studies evaluate peristalsis in the esophageal body and are useful for planning the type of fundoplication, exclusion of associated primary esophageal motor disorders, and defining the LES.
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Performance of 24-hour pH probe testing is done to quantitate the degree of acid reflux. Patients with objective evidence of reflux seen on endoscopy may not require pH probe testing.
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Esophagogastric duodenoscopy (EGD) should be performed to evaluate for mucosal changes, evaluate for the presence of a hiatal hernia, and exclude other pathologic conditions (e.g., stricture, BE, Cameron ulcers, or malignancy).
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Barium swallow provides anatomic information that may be correlated with information obtained from the other preoperative studies.
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Obese patients with reflux disease may be considered for bariatric surgery because Roux-en-Y gastric bypass performed in morbidly obese patients often achieves simultaneous goals of weight reduction and resolution of gastroesophageal reflux.
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With medical therapy, esophagitis resolves in 90% of cases; however, the underlying mechanical cause is unaltered, resulting in recurrence on withdrawal. Alkaline reflux–induced esophageal mucosal injury will not resolve with acid suppression.
Step 3
Operative Steps
Nissen Fundoplication
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Nissen fundoplication can be performed in most patients. Although esophageal dysmotility may be considered a relative contraindication to Nissen, most patients with altered motility can undergo a floppy Nissen fundoplication.
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Double-lumen intubation with right lung ventilation.
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Place patient in the right lateral decubitus position.
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A left lateral muscle-sparing thoracotomy incision is made in the seventh intercostal space.
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Exposure of the esophagus is achieved by dividing the inferior pulmonary ligament and incising the mediastinal pleura. Incision of the mediastinal pleura should continue to the level of the diaphragm. Circumferential dissection of the esophagus, encircling the esophagus with a Penrose drain, aids atraumatic retraction during dissection and avoids injury to the vagus nerves. The esophagus should be dissected down to the level of the pulmonary vein. Esophageal length is assessed following mobilization.
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The esophageal hiatus, the right and left crura, and the phrenoesophageal membrane are identified. The phrenoesophageal membrane is incised and the esophageal hiatus and crura are dissected to gain entry into the peritoneal cavity, with care being taken to preserve the left phrenic nerve.
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The stomach is retracted into the left chest, and the gastric fundus is mobilized by dividing the proximal short gastric vessels.
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The esophagogastric fat pad is excised.
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A tension-free 360-degree fundoplication is fashioned around the distal esophagus extending to the GEJ ( Fig. 32-1A ). The fundoplication should be 1.5 to 2.5 cm long and is created with a large esophageal Bougie (54-60 French) in place. The fundoplication is created using three interrupted sutures incorporating the esophagus and fundus (see Fig. 32-1B ). The fundoplication should be adequately floppy and should easily accommodate a finger between the esophagus and the wrap while the bougie is in place.
