Transthoracic Antireflux Surgery Procedures

Surgical Anatomy

  • 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.


  • Gastroesophageal reflux disease (GERD) is a mechanical disorder associated with a defective LES mechanism, affecting as many as 2.5 million Americans.

  • 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.

  • 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.

  • 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.

    • BE has been reported in up to 10% of patients with GERD, and it increases the incidence of esophageal adenocarcinoma.

    • 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.

Preoperative Considerations

  • A focused history and physical examination should be performed on all patients.

  • 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.

  • 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.

  • 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).

  • Barium swallow provides anatomic information that may be correlated with information obtained from the other preoperative studies.

  • 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.

  • 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.

Operative Steps

Nissen Fundoplication

Mar 13, 2019 | Posted by in CARDIOLOGY | Comments Off on Transthoracic Antireflux Surgery Procedures
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