J. BARRY MCKERNAN, MD, PhD, CHARLES R. FINLEY, MD
The laparoscopic treatment of GERD continues to enjoy widespread acceptance because laparoscopic fundoplication provides very effective long-term benefits for this patient population. It is interesting to look back on the days prior to the laparoscopic revolution. My own personal experience is likely similar to that of others in that I received approximately 1 referral a year for a patient requiring surgical treatment for GERD prior to the laparoscopic era, and these patients were usually “end-stage” reflux patients. We are now in the second decade of laparoscopic treatment for reflux, and some exciting new modalities are on the horizon as well as some “old” controversies still being bantered about. If one lesson can be learned from the treatment of groin hernias and applied to the treatment of GERD, it is that we should attempt to maintain standardization in the description of the disease itself and its treatment.
One of the common myths about laparoscopic fundoplication is that the short gastric vessels should be sacrificed. A recent prospective, double-blind, randomized trial with a 5-year follow-up showed that division of the short gastric vessels during laparoscopic Nissen fundoplication caused no significant improvement in any measured clinical outcome . Sato et al  found that postoperative dysphagia was not significantly affected by division of the short gastric vessels. We would strongly suggest that the true issue is adequate mobilization of the fundus. Adequate mobilization of the fundus to perform a “floppy” fundoplication includes mobilization of the posterior fundus, with particular attention paid to the attachments between the posterior fundus and the pancreas. Although it is said that short gastric vessel division results in a longer operative time, this has not been our experience, and it likely makes adequate posterior mobilization of the fundus as well as creation of the fundoplication itself easier to perform.
Is the Nissen more effective than the modified Toupet fundoplication? Thor and Silander  showed with open surgery that modified Toupet is more successful than Nissen fundoplication (95% vs 67% had good or excellent results) in controlling typical reflux symptoms. Laparoscopic Nissen fundoplication has been shown to be 96% successful in relieving the primary symptom for which the surgery is performed . We use Nissen fundoplication most frequently. Although we feel that either procedure results in excellent relief of reflux symptoms, Nissen fundoplication is slightly less time consuming to perform. Modified Toupet fundoplication is performed in patients with documented motility disorders (esophageal body pressures less than 30 mm Hg) or in patients who have difficulty swallowing even in the presence of “normal” manometry. Modified Toupet is also usually performed in association with an esophagomyotomy for achalasia. On the other hand, some would argue that a fundoplication should be applied selectively to patients undergoing Heller myotomy for achalasia .
The use of prosthetic materials at the gastroesophageal junction continues to be an active area of discussion. We prefer to avoid the use of pledgets in the creation of the fundoplication. If one chooses to use them, they should certainly not be left in contact with the esophagus, because they have been known to erode into the esophagus and the stomach. Currently, a wide variety of materials are available to either buttress the hiatal hernia closure or for its primary repair. We have been hesitant to utilize prosthetic mesh in the immediate area of the gastroesophageal junction for fear of erosion. It is widely believed that a hiatal hernia greater than 5 cm in size has an increased rate of recurrence. From the standpoint of standardization, all crural openings are measured intraoperatively. If tension is present on the closure of the crura, we prefer to perform a medial relaxing incision as described by Huntington (Figure 1) . In these cases, the diaphragm is incised just to the right of the right crus, using an angled laparoscope to visualize the right chest, care being taken to avoid the inferior vena cava. The crura are then approximated and the relaxing incision is closed with a biosynthetic material. This material is either sutured or stapled into place.
During Nissen fundoplication, a 50-French bougie dilator is used for calibration of the wrap. Fear is often voiced about possible esophageal perforation during passage of the dilator. An alternate method of calibration would be to use a technique such as the size of a known grasper between the wrap and the esophagus or a bougie that is passed over a previously placed nasogastric (NG) tube. In any event, it is very difficult to “eyeball” the proper diameter of a fundoplication. We have therefore chosen to emphasize a team approach, utilizing anesthesiologists quite familiar with the procedure and who are conscientious about both gently passing the dilator as well as observing its passage with us on our monitors.
Delayed gastric emptying is quite common in patients with GERD. In patients who present with significantly delayed gastric emptying with an intact fundoplication, we have found it helpful to dilate the pylorus endoscopically with a 56-French balloon for 3 minutes. If the patient improves symptomatically, the option of pyloroplasty is then discussed.
We perform intraoperative endoscopy (esophagogastroscopy) on all patients undergoing reoperative fundoplication, repair of paraesophageal hernia, or esophagomyotomy. Intraoperative endoscopy is also performed during any other case in which the exact location of the gastroesophageal junction is at all in question. Chang et al  noted that in approximately 10% of patients the GE junction is actually more cephalad than is apparent on laparoscopy.
An interesting new modality on the diagnostic front is the catheterless, 48-hour Bravo pH System (Medtronic, Minneapolis, MN, USA). The preoperative patient with no gross esophagitis on screening esophagogastroduodenoscopy (EGD) (often because by the time patients present for surgical repair they are taking maximum doses of proton pump inhibitors) or spontaneous reflux on upper gastrointestinal series has traditionally been subjected to the 24-hour pH probe as a last resort to confirm diagnosis prior to surgery. This has also been important for diagnosis in patients with principally extraesophageal symptoms, who recently have been receiving more accurate and timely diagnoses as many more internists, ENTs, and pulmonologists are becoming aware of the extraesophageal symptoms of GERD. However, it is difficult for patients to simulate a normal lifestyle and eating habits with the traditional catheter probe, and some are not able to tolerate its placement through the nasopharynx at all. With the Bravo System, a pH probe is placed comfortably and leaves no catheter visible at the patient’s nose to preclude normal activity (due to discomfort or embarrassment). However, some difficulty still exists in obtaining reimbursement for this procedure from some of the health coverage plans.
Lastly, endoscopic treatments of GERD have received much attention of late. These fall into several categories, including endoscopic suturing, submucosal injection of various agents or substrates, and the use of radiofrequency. The latter has received the most attention. The Stretta (Curon Medical, Sunnyvale, CA, USA) procedure delivers radiofrequency energy directly to the gastroesophageal junction through an endoscopic approach. Initial results are somewhat promising. However, many patients are not candidates because of exclusion criteria including the presence of a hiatal hernia greater than 2 cm, Barrett’s esophagus, dysphagia, or severe erosive esophagitis . Little doubt exists that, given the safety and long-term effectiveness of laparoscopic fundoplication, any endoscopic procedure must give predictable results, as well as be durable, cost effective, and relatively easy to perform to be a viable alternative for the patient who can otherwise tolerate general anesthesia.
Figure 1a, 1b, 1c. Relaxing incision is performed for the difficult crural closure utilizing the harmonic scalpel. The crura are closed posteriorly and the relaxing incision is closed with mesh. Reprinted with permission from Huntington TR, Laparoscopic Mesh Repair of the Esophageal Hiatus. J Am Coll Surg. 1997;184:399-400. Copyright 1997, American College of Surgeons.
A captured image from a 3-D animation showing lower esophageal sphincter. From "What Acid Reflux Disease Looks Like" available at www.prevacid.com.
Address reprint requests to: J. Barry McKernan, MD, PhD, 2001 Professional Pkwy, Ste 110, 820 S Wood St, Woodstock, GA 30188, Tel: 770 924 8808, Fax: 770 924 8266, E-mail: email@example.com
Clinical Professor of Surgery, Medical College of Georgia, Augusta, Georgia (Dr McKernan).
Clinical Instructor, Emory University School of Medicine, Atlanta, Georgia (Dr Finley).
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