GERD - Surgery of Esophageal Disease - Fundoplication

 

Laparoscopic Oesophageal Procedure

ANATOMY AND PHYSIOLOGY OF THE GASTROESOPHAGEAL JUNCTION

The muscular aspects of the crural diaphragm be a consequence of the best diaphragmatic crus. The right crus comes from the anterior longitudinal ligament overlying the lumbar vertebrae. When muscular elements emerge in the tendon, two flat muscular bands type, that cross each other in scissor-like fashion, form the walls of the hiatus, and decussate with each other anterior towards the esophagus.

This distal end from the esophagus is anchored towards the diaphragm by the phrenoesophageal membrane, formed through the fused endothoracic and endoabdominal fascia. This elastic membrane positions circumferentially into the esophageal musculature, very close to the squamocolumnar junction which resides inside the diaphragmatic hiatus.

This configuration is actually altered throughout swallowinitiated peristalsis, a sequenced shrinkage associated with both the longitudinal as well as circular muscle accountable for bolus propulsion with the esophagus. With contraction from the esophageal longitudinal muscle, a esophagus reduces the length of and also the phrenoesophageal membrane is stretched; it's elastic recoil is then responsible for taking this squamocolumnar junction to its normal placement using each swallow. This really is, essentially, “physiologic herniation,” since the gastric cardia tents through the diaphragmatic hiatus with each swallow.

Amongst various laparoscopic methods being carried out with regard to oesophageal problems laparoscopic antireflux procedures have grown to be defacto standard,whilst procedures for achalasia and oesophageal diverticulum are quick gaining popularity. Procedures for malignancy are being carried in few centers of excellence.

Laparoscopic Fundoplication

GERD is among the most typical problems associated with western civilization,its frequency is increasing in India. Historically management was more focused toward drugs ,diet ,& lifestyle modification Along with growth and development of loose,brief floppy wrap and also intro of laparoscopic fundoplication it has quick become defacto standard for managment of GERD.

Gastro Esophageal Reflux Disease (GERD) is understood to be a failure of the anti reflux barrier, allowing abnormal reflux of gastric contents to the esophagus. It is a mechanical disorder which is caused by a defective lower esophageal sphincter, a gastric emptying disorder or failed esophageal peristalsis. Exposure of the oesophageal mucosa to acid, enzymes and other digestive secretions, leads to acute and chronic inflammation, with pain, and ulceration or stricture formation if untreated. Medical treatments are the first line of management. Esophagitis will heal in approximately 90% of cases with intensive medical therapy. However, symptoms recur in more than 80% of cases within twelve months of drug withdrawal. Since it is a chronic condition, medical therapy involving acid suppression and/or pro-motility agents are usually necesary throughout a patient’s life. Despite the fact that current medical management is very effective for most a small amount of patients do not get complete relief of symptoms. Currently, there is increasing curiosity about the surgical management of gastro-oesophageal reflux disease (GERD).

Symptoms:

  • Heart burn (Retrosternal burning)
  • Regurgitation
  • Pain
  • Respiratory symptoms

Diagnostic test:

  • Endoscopy
  • Barium swallow
  • Oesophageal transit +/- Manometry
  • pH monitoring

Indications for Surgical management of GRED

  1. Persistent complications because of GERD - You will find fewer patients comprising this population since the introduction of proton-pump inhibitors (PPIs), but these patients will consider surgery, because there is a clear “failure” of medical treatment.
  2. Barrett’s esophagus- Patients with Barrett’s esophagus usually have severe GERD, and surgery provides excellent charge of symptoms. More important, surgical treatments are the only real treatment which has demonstrated substantial rates of regression for Barrett’s epithelium.[1]
  3. Respiratory complications- Patients with pulmonary (recurrent pneumonia, asthma) or laryngeal (hoarseness, chronic cough, laryngitis) complications often don't react to medical treatment. Surgical therapy includes a higher effectiveness on this setting, likely because it addresses the reflux that leads to microaspiration. Nevertheless, we lack a diagnostic test that clearly links GERD to those problems; pH monitoring (esophagus and pharynx), laryngoscopy, and pulmonary function testing may help.
  4. Persistent regurgitation- PPIs often neutralize the acid and for that reason stop the heartburn, but regurgitation persists. The lifestyle effect of the symptom should not be understated, and surgical therapy provides excellent relief for these patients.
  5. Young patients- This population represents a relative indication for antireflux surgery. Patients with severe GERD who are younger than 40 years have a high probability of having progressive disease. Surgical therapy can offer long-term relief of GERD and it is complications in these patients, in addition to abate the costs associated with the utilization of PPIs. Still, many patients elect to wait until medical therapy fails before pursuing the surgical option, and this is an extremely reasonable course of action.
  6. Failure to respond to medical therapy- While seemingly representing the “perfect” surgical candidate, patients whose symptoms do not react to PPIs ought to be given caution. As a group, they've an inferior reaction to therapy likely because many of these people have a confounding diagnosis that will not respond to stopping the gastroesophageal reflux. All efforts to rule out cardiac, pulmonary, musculoskeletal, along with other gastrointestinal problems should therefore be sought

The choice of technique

The option of techniques typically been based on anatomic considerations, as well as the surgeon’s preference and expertise. Several techniques have been extensively proven and tested to be effective in controlling reflux with minimal unwanted effects. The All over or -Nissen- type fundoplication offers surfaced as the most widely recognized procedure for sufferers with normal esophageal motility.

First performed in early nineties by Dallemagne in Belgium, the conventional laparoscopic fundoplication is now named the therapeutic modality of choice in the surgical management of gastro-esophageal reflux. Since that time, several technical modifications happen to be introduced with various success. However up to now, advances in laparoscopic instrumentation and surgical skills make the standard, 360 degrees laparoscopic fundoplication the most effective antireflux procedure available.

Using a precise understanding of the anatomy of the gastroesophageal junction, comprehending the mechanics from the gastroesophageal junction and also establishing a precise proper diagnosis of gastro-esophageal reflux is completely essential for any kind of surgeon practicing these procedures.

Operative Steps

The patient is placed in a modified lithotomy placement with the head on the table tilted up 25 degrees. The operating surgeon stands between your patient’s legs as the camera operator stands towards the patient’s right and also the second assistant assumes a situation on the patient’s left. One 10-mm and three 5-mm trocars are put as shown in Figure 3. The laparoscope is introduced through a port put into the midline superior to the umbilicus. Placing the 5-mm trocars on each side of the midline allows for triangulation and avoids interference with the camera’s line of vision. Left lobe of the liver is retracted using a fan shaped retractor put through the anterior axillary port. We start the dissection first by dividing short gastric vessels to mobilse the fundus using ultrasonic scissors.

Left crus is then mobilized being careful to not damage the phreno oesophageal ligament. Gastrohepatic ligament is divided taking care to not injure the left hepatic artery arising from left gastric artery in 25% of patients. This exposes the best crus. The right crus will be mobilized by dividing the peritoneum overlying the anterior aspect. By blunt dissection across the medial side of right crus the medistinum is entered. Once oesophagus is visualized along with the crural confluence gentle blunt dissection avoiding problems for posterior vagus posterior to oesophagus enables circumferential mobilization of oesophagus.Care should be taten to not open the pleura.

An umbilical tape is put round the oesophagus to sling it and further help in retraction .Around 5-7cms length of intra abdominal oesophagus should be achieved after the above mobilization. Crural closure is essential to avoid the wrap through herniating to the mediastinum. This is done by placing figure of ‘8’ ethibond suture (2-0) gently approximating the crura. Care ought to be used to not excessively tighten up the crura which may result in dysphagia.

Three Sixty degree short floppy Fundal wrap is constructed after placing 50fr bougie through oesophagus into the stomach. The oesophagus ought to be enveloped by an untwisted fundus before suturing.

Floppiness of the wrap is ensured by the

  1. Shoe shine test
  2. Drop test.

The wrap is fixed using 2-0 ethibond sutures. The wrap ought to be 2-3 cms in length just above the O-G junction. Adequate mobilization assures 2-3cms length of intra abdominal oesophagus above the wrap. After completion the fundoplication suture line ought to be facing anteriorly. Ryles tube remains in situ and also bougie is withdrawn. Haemostasis is ensured before with drawing the ports.

LAPAROSCOPIC TOUPET PARTIAL FUNDOPLICATION

The mobilization is similar to Nissen’s.The major difference involves a 270 degree wrap in comparision to 360 degree wrap. The fundal edges are fixed towards the oesophagus and cru at the crural margins dilator is not required to callibrate this partial wrap.

RESULTS

Within their research “Predictors of outcome in 100 consecutive laparoscopic antireflux procedures” JACKSON Patrick G. GLEIBER Michael et al demonstrated that surgical strategies can reproducibly handle gastroesophageal reflux condition symptoms in more than 90% of patients. The optimal surgical candidate is a patient younger than 50 whose typical symptoms completely resolve with acid suppression therapy (6). Partial fundoplication provide less efficient reflux control and should be used in those with severe motility disorders, even this is being challenged because the Population of patients with GERD induced motility disorders have more severe grade of reflux which may recur with partial wrap (9, 10). Post operative complications occur in 8-10%, rate of conversions about 2%.Untoward side effects for example dysphagia has-been reported in 3-10% and usually resolves within A few months.

Mechanisms of failure

Dallemagne et al suggested technical quality was responsible for majority of the failures. Horgan and Pellegrini have figured most significant technical factors preventing recurrence were effective crural closure, trasns hiatal oesophageal mobilization, focus on the geometry of the fundoplication, and anchoring the wrap towards the oesophagus and surroundig tissues.

Paraesophageal hernias

The word hernia refers to a protrusion of all or part of an organ via a tear within the wall of the containing cavity. The diaphragm is really a muscular partition between the thorax and abdomen that functions by changing the size of the thoracic cavity during respiration. The esophagus, a collapsible tube approximately 10 inches long, extends from the pharynx to the stomach, piercing the diaphragm in its descent from the thoracic cavity to the abdominal cavity. The normal positioning from the esophagus as it passes with the diaphragm is illustrated in Figure 1. A paraesophageal hernia is definitely an anatomic defect at the junction from the esophagus and diaphragm that could occur in combination with sliding esophageal hernias. The defect may be congenital or may occur as the result of stretching the phrenoesophageal ligament with gradual enlargement of the hernia over a period of time and is most common in late middle-aged or elderly patients. Paraesophageal hernias take into account approximately 5% of hernias in the esophageal hiatus.

Kinds of HERNIA

Type I or Sliding Hernia.

Gastro-oesophageal junction migrates above the oesophageal hiatus. It's the most typical kind of hiatus hernia (95%).

Type II

True paraoesophageal hernia is characterized by normally positioned GE junction and an intrathoracically migrated stomach.

Type III

Combined hernia with sliding and a Para esophageal component. Symptomatic gastro-oesophageal reflux disease (GERD) is frequently associated with finding of a sliding hernia. A number of procedures like Nissen’s fundoplication and it is modification (the Toupet procedure), Hill’s procedure and Belsey transthoracic repair have been described. Nissen fundoplication is however, the easiest and most effective. Success has been achieved in performing the laparoscopic Nissen fundoplication, Hill’s repair and also Toupet procedure as well as thoracoscopic Belsey Mark IV. Laparoscopic Nissen Fundoplication shows the most promise and has the potential of becoming defacto standard. It provides the opportunity for correction from the underlying anatomical and functional deficiency related to GERD with lessened discomfort and hospitalisation.

Appropriate preoperative evaluation of oesophagogastric junction is essential prior to performing laparoscopic fundoplication. Failure of surgery to control symptoms happens in as much as 10 per cent of cases is a reflection that antireflux surgery continues to be inadvertently utilized for unrecognized cardiac, hepatobiliary, oesophageal or gastric etiologies.

Preoperative evaluation could be split into mandatory as well as selective tests.

Mandatory

  • Endoscopy UGI with/without biopsy
  • Oesophageal manometry

Selective

  • Barium swallow
  • 24 hours pH monitoring
  • Gastric studies

A minimum of 3 cm of esophagus must be mobilized to the abdomen to ensure adequate intraabdominal length with regard to fixation. If your hiatal hernia is present the crura are approximated with 2 to 3 sutures of No. 1-0 non-absorbable suture. The short gastric vessels are routinely divided along the upper one-third of stomach using harmonic scalpel. A 2 cm wrap is adequate with incorporation of oesophagus into the wrap to avoid slippage. Postoperatively a chest X-ray is acquired within the rescue room to exclude a pneumothorax. Patients are begun on clear liquids on the day of surgery and soft diet the following day. Average period of stay is A couple of days. Intraoperative complications may include problems for visceral organs, bleeding, pneumothorax and vagal injury. Postoperative complications include wrap slippage.

CONCLUSIONS:

Laparoscopic antireflux surgery is an effective therapy for patients with gastroesophageal reflux and hiatus hernia may be more effective than medical therapy with enhancing standard of living.