LAPAROSOPIC VERSUS OPEN FOUDOPLICATION
Dr. ADIL K. SALLOM, MRCS, D.MAS
Member Royal College ofSsurgeons of Ireland
Project Submitted Towards Completion Of Diploma In Minimal Access Surgery, World Laparoscopy Hospital, Gurgaon, NCR Delhi, India. AUGUST 2007.
Key words :
GASTROESOPHAGEAL reflux disease is a very common condition for which most patients are treated with medical treatment like proton pump inhibitors and prokinetic agents. However, 20% of patients who develop complications or experience recurrent symptoms after discontinuing medical therapy require surgical treatment. Conventional surgical management of gastroesophageal reflux disease with fundoplication is effective, durable, and in some aspects superior to medical therapy. The ability to perform this procedure laparoscopically may further the applications of this treatment. Laparoscopic fundoplication has been shown to be safe and as effective as open fundoplication, and has become the preferred surgical option.
To compare the results of open and laparoscopic fundoplication:
Another most common symptom is regurgitation. Regurgitation is the return of gastric or esophageal fluid into the pharynx without nausea, retching, or abdominal contractions. Regurgitation often occurs at night while the patient is sleeping. When this results in a sudden awakening with hot fluid in the throat. It is often associated with coughing, choking, and shortness of breath due to aspiration of the regurgitated fluid. It can also occur after a large meal.
A third symptom is dysphagia, which is occurs in about one third of people with GERD. It can be caused by a peptic stricture due to oesophagitis.
The cause of GERD is multifactorial. GERD can be caused by a failure of intrinsic mechanisms of: the lower esophageal sphincter (LES), the function of the esophageal body, and the function of the gastric reservoir. Though the esophagus must be able to clear acid normally, and the stomach should be able to empty normally, a weak LES is the most important contributor to GERD.
To function appropriately, the LES must have a normal length, normal pressure, normal relaxation, and be located intra-abdominal below the diaphragmatic crura. There, the intra-abdominal pressure can assist the action of the LES. The LES pressure is commonly low in patients with GERD but sometime may be normal or even elevated. The most important factor causing GERD i s transieint relaxation of the LES, by far is the most important cause of reflux .
Gastric acid reflux is an essential component of GERD, but the reflux is a combination of gastric contents and duodenal contents in 50% (7). Acid-only reflux occurs in only 40%. Gastric juice contains both HCl and the enzyme pepsin, while duodenal juice contains alkaline bile acid, and pancreatic juice. Acid, pepsin, and bile salts all interact together and contribute to erosive esophagitis. It has been found that acid and bile, causing more severe mucosal damage to the esophagus than acid alone.
Barrettís esophagus is the metaplastic change of normal squamous epithelium to columnar epithelium, it is a premalignant condition. There is evidence that Barrett¹s esophageal mucosa is prone to develop adenocarcinoma of the esophagus. Barrett¹s mucosa places the patient at increased risk (30 fold to 350 fold) for the subsequent development of esophageal adenocarcinoma (9,10). In patients with Barrett¹s mucosa, the risk of developing carcinoma is about 1% per year.Previously, adenocarcinoma of the esophagus accounted for fewer than 8% of all esophageal tumors, but it now accounts for at least 50% of esophageal cancers. It has been suggested that this rising in incidence may be due to the increasing occurrence of Barrett¹s metaplasia. The increased prevalence of adenocarcinoma at the gastroesophageal junction is a matter of concern, and seems to be related to inadequate control of gastroesophageal reflux (10,11).
Treatment (non surgical) :
Non surgical treatment includes lifestyle modifications and medications (12-14). Lifestyle modifications include elevation of the head of the bed during sleeping and avoidance of eating for 2 to 3 hours before sleeping. Avoidance of fatty or spicy food, cessation of smoking,caffeine intake and alcohol , may significantly improve symptoms. However, lifestyle and dietary changes are successful in only 20% of patients.
Most symptomatic patients treat themselves with over the counter medications, such as antacids or H2-receptor antagonists. Only a small percentage of people who actually experience GERD consult a physician. H2-receptor antagonist use in standard doses can achieve symptomatic relief in 25% to 60% of patients, and endoscopic resolution of esophagitis in 50%. Use of high dose H2-receptor antagonists can result in healing rates of 45-75%.Proton pump inhibitors (PPI) are the most effective medical therapy to heal esophagitis and control symptoms. The standard doses of PPIis resolves symptoms in 80-90% of patients, and heals the esophagitis in upto 90%. Larger doses are mainly required in patients with high-grade esophagitis. However, GERD is a chronic condition and disease tend to relapse if the drug dose is stopped, decreased, or sometimes even if a dose is skipped. Esophagitis relapse up to 80% of the time within six months, both symptomatically and by endoscopy, if PPI therapy is stopped or the drug dose is decreased.
Surgical Treatment :
Refractory to medical treatment which occurs in about 10% of patients. These patients have persistent, symptomatic esophagitis that are resistant to medical treatment.
Present with complication of GERD that occurs in 20% of patients. These include continued esophagitis, grade 3 or 4 esophagitis, esophageal ulcers, esophageal stricture, and Barrettís esophagus.
In tolerance to medical treatment.
Atypical symptoms which are primarily pulmonary and laryngeal. These include asthma, chronic cough, hoarseness, laryngitis, chest pain, and recurrent aspiration. Although the outcome of surgery in patients with extraesophageal symptoms is, in general, less successful than in patients with typical symptoms, patients tend to require less corticosteroid treatment for asthma after surgery. The best surgical results are in those patients with a good response to PPIis.
A symptomatic hiatal hernia or paraesophageal hernia deserve consideration for surgical repair to correct the hernia.The indications for antireflux surgery have not really changed, but patient and physician acceptance of a minimal access surgical procedure has increased.
Evaluation of patient prior to surgery :
Antireflux surgery :
Antireflux surgery involves wrapping a portion of stomach (fundus) around LES with reduction of a hiatal hernia if present. This constructs a valve like mechanism to re-establish gastroesophageal junction competence. This creates a barrier to the reflux of gastric contents,so it provides relief of symptoms and prevents the complications associated with GERD.
Laparoscopic antireflux surgery is technically challenging and should be performed only by surgeons with good training and with high experience in advanced laparoscopic surgical technique. There are two types of fundoplications that are most commonly performed: Nissen and Toupet Fundoplications. The Nissen operation involves wrapping the fundus completely around the esophagus (360¤), producing a short, loose wrap. In the Toupet operation, the fundus is wrapped only part of the way around the esophagus (270¤), producing a short, even looser wrap. The type of operation is chosen based on the severity of reflux and complications involved, as well as the function of the esophagus. While the Toupet results in less difficulty with gas bloat syndrome and swallowing, the Nissen procedure is the most effective for controlling reflux. Therefore, the Toupet is generally best for patients whose reflux is less severe . The latter is utilized in the small percent of patients who have severe dysmotility of the esophageal body. The mortality of laparoscopic procedure is essentially zero, and the morbidity is around 5%, which is less than after open surgery. The conversion rate to an open surgical technique is also less than 2%.
Most patients experience a mild degree of dysphagia postoperatively , which is slightly more in laparoscopic procedure than that of open operation, but this resolves in more than 95% of patients within the first month. The long-term incidence of postoperative dysphagia is 2% or less which is the same in both procedure . Other symptoms that the patient may experience early after the surgery include early satiety, hyperflatulence, bloating, and diarrhea. These symptoms also tend to be transient and resolve with time. The success of the operation in preventing reflux as determined by a 24 hr. pH study one year postoperatively is 93% (18). Patients with Barrettís esophagus prior to surgery still need surveillance endoscopy after surgery to evaluate for the development of dysplasia.
Fundoplication is done as either an open or a laparoscopic procedure. The open procedure involves an incision of about 20- 25 cm in the abdomen, while the laparoscopic approach is a minimally invasive technique producing 4 to 5( 0.5-1cm) incisions. Although the laparoscopic approach offers many advantages over the open technique, such as a quicker recovery and less complications, it may not be appropriate for some patients, including those who have had previous abdominal surgery or who have some pre-existing medical conditions. In addition, some patients may have to be converted from the laparoscopic procedure to the open technique during surgery. However, this is uncommon and most patients (95%) can undergo the laparoscopic procedure without difficulty.
During the operation, the surgeon raises the liver to expose the junction between the stomach and the esophagus. A space is created behind the esophagus and the fundus of the stomach and freed from its attachment to the spleen(gastrosplenic ligament). The fundus is then pulled behind the esophagus and secured in place. Depending on the type of procedure, the wrap is either sutured to the esophagus itself (as in the Toupet), or it is sutured to the stomach on the other side of the wrap (as in the Nissen). If a hiatal hernia is present, it is repaired before.
In the laparoscopic procedure, surgeons use a trocar (a narrow tube-like instrument) to gain access to the abdomen. A laparoscope (a thin telescope connected to a video camera) is inserted through the trocar, giving the surgeon a magnified view of the patient's internal organs on a television monitor. Four additional trocars are then inserted to accommodate special instrumentation.So five trocars are used ,10 mm port camera is placed in midline 5cm above the umbilicus,5mm port is inserted in the right upper quadrant 8- 10 cm from the midline.The third 5- 10 mm port is placed in left upper quadrant -a mirror image of the right one. A further 5mm port is placed in the left anterior axillary line immediately below the costal margin .
Following the procedure, the incision(s) are closed with stitches or with surgical tape and bandages are applied.
Surgical Complications :
Perforation of the stomach or esophagus can occur in about 1% of patients. In rare cases, bleeding or perforation is not identified at the time of operation and a re-operation is necessary. Approximately 5% of patients require conversion to open surgery because of bleeding, perforation or other complications. In all, about 95% of all cases can be performed laparoscopically, while 5% of laparoscopic cases can result in a conversion to the open procedure.
2-Perforation of oesophagus.
3-Perforation of stomach.
These complication is rare and account less than 2%.Complications more in open procedure than that of laparoscopic procedure.
After Surgery :
When patients wake up from surgery, they often have a NG tube to decompress the area around the wrap. Their diet is restricted to liquids for the first day after the tube is removed. A soft diet is recommended for several weeks after surgery.
Hospital Stay and Recovery :
Most patients are able to return home the first or second day after laparoscopic surgery and 4 to 7 days after the open operation. Return to full activity usually takes 1 to 2 weeks following most laparoscopic anti-reflux repairs and 4 to 6 weeks after an open repair. For about 2 weeks after surgery, patient will need to take an acid reducing medication such as Zantac. A follow up appointment should be made with the surgeon 7 to 10 days after discharge so that your questions can be answered, and progress can be assessed and patient can be examined.
Since the operation creates a valve mechanism at the bottom of the esophagus to prevent reflux, it may also cause resistance to the passage of food causing more air to be swallowed than before surgery. Therefore, following fundoplication, patients often experience periods of gas-bloat syndrome. During these episodes, which can last up to 2 to 3 hours, an increase in swallowed air makes it difficult to belch or vomit. In addition, patients often experience abdominal distention, nausea and an increase in flatulence. The soft diet should help prevent this syndrome.
In addition, for about 6 weeks after the laparoscopic repair, patients may experience dysphagia (difficulty swallowing) due a post-surgical swelling at the wrapped site.
Although dysphagia is almost always temporary, 2% of patients experience long term symptoms. These patients may be treated with balloon stretching of the area.
For surgical management of GERD regardless of the way of access the main and popular procedure, that is wrapped of fundus around the oesophegus, is same in both laparoscopic and open surgery. The operating time is significantly shorter for laparoscopy group in comparison with the open repair group (99 versus 142 minutes)[2-4]. Estimated blood loss is more in open surgeries (120 vs 95 ml). Rate of conversion to open surgery is about 5%  and the most common reasons are due to failure to progress or due to the complication that occur during operation(oesophgeal perforation,gastric perforation,splenic injury) . Conversions happened more with surgeons with less experience in successful laparoscopic repair. complicaton,convertion rate decrease with increase experience of surgeon. In those patients who underwent laparoscopy, postoperative comfort is obviously more and the amount of narcotic used is significantly lesser than open group. Laparoscopic group have lower wound infection rate Length of hospital stay is obviously shorter in laparoscopic group (3 vs 7 days) and they returned to their work earlier(14 vs 30 days). Cosmetically, scars following laparoscopic surgery are much more acceptable and patients are more satisfied with their operation  . Temperory dysphagia is more in laprascopic procedure,but long term dysphagia is the same
GERD is an extremely common disease that affects millions of people. Most patients can control their symptoms of heartburn with lifestyle changes and medications. The major drawback to medical therapy is its inability to address the underlying problem of a structurally defective LES. At this time, only surgery can improve the function of the LES.
Laparoscopic fundoplication is an option that more patients and their physicians are accepting as an alternative to a lifetime of medication. It is effective therapy for patients with GERD, and for some patients, may be more effective than medical therapy at controlling their symptoms and allow them to resume a normal lifestyle. Laparoscopic antireflux surgery should be strongly considered in patients with poorly controlled reflux, young patients, those with complications from their reflux, and those with atypical reflux symptoms.
From a functional point of view, both techniques were equally effective except concerning belching ability and temporary dysphagia .
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