Shortness of breath
5.3.1 Atypical Symptoms
Atypical or extraesophageal symptoms of GERD arise from the respiratory tract and are most commonly thought to be caused by microaspiration of gastric contents. They can be divided into laryngeal symptoms such as hoarseness, throat pain and Globus sensation; and pulmonary symptoms including cough, shortness of breath and asthma (either with or without associated chronic lung injury). Although aspiration is the most likely route of injury, distal esophageal acid exposure may activate the vagus nerve. Due to common innervation of the trachea and esophagus, this may result in bronchospasm and cough. Atypical symptoms are much more difficult to elicit an etiology for as they can also occur from respiratory or pulmonary causes. Furthermore, extraesophageal GERD symptoms less commonly resolve with proton pump inhibitor (PPI) therapy. This is attributed to persistent microaspiration causing ongoing injury, even when acid production is suppressed by medical therapy . When patients present with extraesophageal symptoms and GER, it is our practice to refer patients for evaluation by a laryngologist or pulmonologist. If a nongastrointestinal cause cannot be identified it is appropriate to proceed with LARS.
Patients referred for surgical evaluation will occasionally experience dysphagia related to their GERD. In this patient population, the most common cause is esophageal mucosal inflammation and damage. The inflammatory changes can manifest as diffuse esophageal inflammation, a Schatzki ring or a peptic stricture. Although the incidence of peptic strictures has significantly decreased in the age of PPI therapy, they are considered pathognomonic for long-standing reflux. If found on upper endoscopy, peptic strictures should always be biopsied to rule out intestinal metaplasia, dysplasia or malignancy. Similarly to peptic strictures, Schatzki rings also arise in the distal esophagus. They can be differentiated on endoscopy by the appearance of submucosal fibrotic bands as opposed to the mucosal scarring seen in peptic stricture disease. Both should be dilated to relieve obstruction but Schatzki rings do not need to be biopsied unless there is a visible mucosal abnormality. Some patients with dysphagia in the setting of GERD have no identifiable anatomic etiology. In these cases the dysphagia usually resolves with control of reflux. Patients who present with sudden dysphagia to solids and liquids without anatomic abnormalities should be evaluated for neuromuscular or autoimmune disorders.
5.4 Preoperative Work-Up
Many patients present for surgical evaluation with a longstanding diagnosis of GERD based on typical symptoms and response to PPI therapy. However, there are four key diagnostic tests to help establish a diagnosis of GERD as well as evaluate gastroesophageal anatomy and function. These tests can help guide surgeon decision making and predict the success of an antireflux operation.
5.4.1 pH Monitoring
The gold standard test to diagnosis GERD is a 24-hour ambulatory pH study. This is performed using a thin nasoesophageal catheter. The catheter is positioned with the distal probe approximately 5 cm above the LES, whose location is determined using esophageal manometry . Another option for assessment is ambulatory pH monitoring performed using an endoscopically placed wireless pH sensor. Both studies record data on the duration and number of acid episodes (defined as pH < 4), including the number of episodes lasting longer than 5 min and the percentage of time spent in reflux during upright and supine position (Fig. 5.1). Based on these results a composite DeMeester score may be calculated. Abnormal distal esophageal acid exposure is defined as >4–5% of time spent with pH < 4 or a DeMeester score of 14.7 or higher. Symptom correlation is also recorded by having the patient press a button to track reflux-related symptoms. If >50% of episodes correlate with patient symptoms then drops in pH are considered positive. A strong correlation with symptoms can occasionally be helpful in equivocal cases. It is important to note that patients sometimes modify their behavior and eating patterns when the catheter is in place. Therefore, a comprehensive interpretation of the study is necessary to help predict the effectiveness of LARS.
Sample pH study tracing demonstrating episodes of reflux when pH drops below 4, indicated by dotted line
High-resolution manometry tracing demonstrating normal swallow, peristalsis and lower esophageal sphincter relaxation
5.4.2 Esophageal Manometry
Esophageal manometry should be performed on all patients being evaluated for LARS . High resolution esophageal manometry has become increasingly prevalent and has improved the sensitivity and specificity of testing. A transnasal catheter with pressure-sensing devices is passed down the esophagus and into the stomach. The patient performs 10 swallows which are displayed as a color-contour plot based on pressure recordings (Fig. 5.2). This study assesses function of the esophageal body by measuring amplitude and efficacy of swallow-induced peristalsis. The length, location and pressure of the LES is evaluated along with sphincter relaxation during swallowing. Manometry can identify esophageal motility disorders and therefore identify patients who may be at higher risk for postoperative dysphagia. It can also help screen patients with atypical symptoms who may have an underlying primary motility abnormality, such as achalasia or scleroderma.
Upper gastrointestinal series X-ray showing hiatal hernia with stomach above the level of the diaphragm
Preoperative endoscopy is necessary to evaluate the esophageal mucosa, the GE junction flap valve and check for the presence of a hiatal hernia. If the patient has esophageal complications of GERD (e.g. esophagitis, ulcerations, peptic stricture or Barrett’s esophagus), ambulatory pH testing might not be required. Patients with atypical symptoms such as dysphagia should be evaluated for additional anatomic abnormalities. Depending on the findings, biopsies can be taken or strictures can be dilated, making upper endoscopy diagnostic as well as therapeutic.
5.4.4 Barium Esophagram
Contrast radiographs of the upper gastrointestinal tract help delineate anatomy and identify the presence of a hiatal hernia or paraesophageal hernia (PEH) (Fig. 5.3). A large PEH or shortened esophagus can add to the complexity of the operation and should be identified preoperatively. Although sometimes the radiologist will comment on reflux of contrast into the distal esophagus, barium esophagram is not a reliable way to diagnose GERD. If the anatomy and function of the esophagus is clear with EGD , manometry and pH monitoring, then one can consider dropping the UGI. However, many other pathologies can be identified such as esophageal diverticula, peptic strictures, achalasia, esophageal dysmotility, gastroparesis and malignancy.
5.4.5 Impedance Testing
Esophageal impedance testing is a technique for assessing episodes of nonacid reflux. Similarly to pH monitoring, this outpatient study is performed using a thin, flexible catheter placed through the nares into the esophagus. Impedance catheters detect changes in resistance based on the flow of an electrical current. By recording different levels of impedance the catheter can help analyze movement of gas and liquid in the esophagus . Combined impedance-pH testing has been reported to be more sensitive than pH testing alone. However, these tests require a lot of education and human oversight, and often contradict the gold standard pH monitoring. Therefore, a normal impedance study portion and normal pH portion should be treated with caution. As such, more research is needed to determine the role of impedance in guiding surgical therapies for GERD [4, 5].
5.5 Additional Preoperative Considerations
There are several additional factors which should be considered prior to LARS. Obese patients have been shown to have a high failure rate with hiatal hernia repair and fundoplication [6–8]. For morbidly obese patients (Body mass index >40) we typically consider Roux-en-Y gastric bypass as an alternative antireflux operation . Gastric bypass can aid in weight loss and reverse medical comorbidities while also eliminating acid exposure in the distal esophagus. Other preoperative considerations include patients with severe cardiopulmonary disease who may not tolerate general anesthesia or pneumoperitoneum. Previous operations on the stomach may make dissection at the hiatus more difficult or preclude construction of the fundoplication.
5.5.2 Partial Versus Complete Fundoplication
There has been a long history of controversy over the optimal fundoplication to provide superior treatment of reflux while mitigating postoperative side effects of dysphagia and gas-bloat. The most commonly seen options include 180-degree anterior (Dor fundoplication ), 270-degree posterior (Toupet fundoplication ) and 360-degree esophagogastric fundoplication (Nissen fundoplication ).
The anterior Dor fundoplication has generally been found to be less effective for reflux control, with more patients requiring reoperations for symptomatic GERD [10–13]. However, debate remains on differences in outcomes between Toupet and Nissen fundoplications. Short-term data appears to favor partial fundoplication with fewer side effects and similar control of reflux compared to complete fundoplication [10, 14–21]. In 2010 Shan and colleagues reviewed 32 studies, including nine randomized controlled trials, comparing laparoscopic Nissen fundoplication with laparoscopic Toupet fundoplication. In patients with normal esophageal motility, no difference in postoperative dysphagia was found between groups. In patients with abnormal esophageal motility, laparoscopic Nissen fundoplication was found to be associated with higher rates of dysphagia. The study also found increased rates of postoperative gas-bloat and inability to belch in patients who underwent Nissen fundoplication. The authors concluded that laparoscopic Toupet fundoplication offers equivalent symptom relief with reduced adverse results compared to laparoscopic Nissen fundoplication .
However, long-term outcomes have trended in favor of the Nissen, with similar rates of dysphagia and some studies showing re-emergence of symptoms after partial fundoplication [23–25]. A very recent meta-analysis published by Du et al. reviewed eight randomized controlled trials comparing laparoscopic Nissen fundoplication and laparoscopic Toupet fundoplication . There were no significant differences found with regard to hospital length of stay, perioperative complications, patient satisfaction or control of reflux symptoms. Although postoperative dysphagia was noted to be more prevalent after Nissen fundoplication, subgroup analysis showed that the difference between groups disappeared over time. A comparative outcome study of 161 patients undergoing partial and complete fundoplications showed a significantly increased prevalence of heartburn after laparoscopic Toupet fundoplication . Quality of life results were collected using patient questionnaire with a mean follow-up of 88 months.
Multiple studies have also attempted to determine whether the type of fundoplication constructed should be tailored based on the patient’s preoperative esophageal motility [27–29]. In patients with GERD and esophageal dysmotility it has been reasoned that a complete fundoplication will lead to greater postoperative dysphagia. Booth et al. performed a randomized controlled trial comparing outcomes of Nissen and Toupet fundoplication based on preoperative esophageal manometry . Patients were stratified based on effective and ineffective esophageal motility. While there were no differences between groups for heartburn and regurgitation, dysphagia was more frequent after Nissen fundoplication at 1 year follow-up. However there was no difference seen in postoperative symptoms between the effective and ineffective motility groups. Based on these findings, the authors did not recommend tailoring the type of fundoplication based on preoperative manometry results. In our experience, performing a complete fundoplication in patients with esophageal dysmotility provides effective control of GERD symptoms without an increase in the development of dysphagia . We utilize a partial fundoplication only in those patients with aperistalsis or severe ineffective esophageal motility.
Despite a large volume of literature, there is still no consensus regarding the fundoplication which provides maximal reflux control with the least side-effects. This is attributed to highly variable patient characteristics, patient selection and operative technique between studies. Based on current evidence, the Society of American Gastrointestinal and Endoscopic Surgeons guidelines for treatment of GERD do not currently recommend a modified approach based on esophageal motility . Surgeons should perform the fundoplication that they are most comfortable with until further consensus has been achieved.
5.5.3 Barrett’s Esophagus
Chronic distal esophageal exposure to acid reflux can lead to histologic change of the distal esophageal mucosa from stratified squamous epithelium to intestinal columnar epithelium. Biopsy results will show intestinal metaplasia, known as Barrett’s esophagus. Endoscopically Barrett’s is described as red “tongues” of mucosa extending proximally from the GE junction. If Barrett’s esophagus is suspected, biopsies should be taken to establish the diagnosis as well as evaluation for the presence of dysplasia or malignancy. The incidence of esophageal adenocarcinoma is increased by about 40-fold in these patients compared to the general population. Although intestinal metaplasia in the distal esophagus is a complication of long term GERD, the presence of Barrett’s itself is not an indication for surgery. Some evidence suggests that LARS may cause regression of intestinal metaplasia, however current studies are not conclusive [33–35]. For patients with Barrett’s esophagus without GER symptoms there is no evidence that anti-reflux surgery will decrease patient risk of esophageal adenocarcinoma [36, 37].
5.6 Surgical Management
Surgical therapy should be considered in patients who have an objective diagnosis of GERD based on preoperative testing and inadequate symptom and disease control despite maximal medical therapy. Other indications include patients with extra-esophageal manifestations or complications of GERD such as peptic stricture, esophageal ulcerations, or recurrent aspiration [38–42]. Occasionally patients will have adequate symptoms control with medical management but request surgery to avoid prescriptions or medication side effects.
5.7 Operative Technique
We routinely administer preoperative antibiotics to reduce the risk of surgical site infection and preoperative subcutaneous heparin to reduce risk of venous thromboembolic events. Sequential compression devices are placed prior to induction. After initiation of general anesthesia, a Foley is inserted and the patient is placed in a modified low lithotomy position with all extremities well padded. The surgeon stands between the patient legs to obtain optimal ergonomics and the assistant stands at the patient’s left. Steep reverse Trendelenburg is utilized to facilitate exposure of the hiatus and displace the abdominal viscera inferiorly. An 11 mm incision is made at the left costal margin lateral to the mid-clavicular line. A Veress needle is inserted and used to establish pneumoperitoneum. The abdomen is entered under visualization with a bladed optical access port. Three additional 5 mm ports are then placed (Fig. 5.4). The camera port is placed 2 cm to the left of the midline and 10 cm below the costal margin. The assistant drives camera and operates through the left inferior port. The primary surgeon operates through the left upper quadrant and left subcostal port. A Nathanson liver retractor is placed through a small subxyphoid incision.
Port placement for laparoscopic foregut surgery with patient in split-leg position. C camera port, A assistant port, SR surgeon right hand, SL surgeon left hand, LR liver retractor
Intraoperative anatomy visualizing the hiatus, esophagus, right and left crus
Our dissection is first begun at the left crus by dividing the phrenogastric membrane. The lesser sac is entered at the inferior edge of the spleen and the short gastric vessels are ligated and divided to mobilize the gastric fundus. This is carried superiorly until the previously dissected left crus is encountered. After the fundus is mobilized to expose the left crus, the phrenoesophageal membrane is incised. The mediastinum is carefully entered through the phrenoesophageal membrane between the left crus and esophagus. The dissection is continued superiorly as well as anteriorly by dividing the peritoneum overlying the anterior crus. The gastrohepatic ligament is then divided to the level of the right crus. The right phrenoesophageal membrane is divided and right crural dissection is performed in a similar fashion to the left side (Fig. 5.5). A retroesophageal window is created and a penrose drain is placed around the esophagus. This is used to safely retract the esophagus during the mediastinal dissection and creation of the fundoplication. The esophagus is mobilized until at least 3 cm of intra-abdominal esophagus is achieved. During this dissection, care must be taken to preserve the anterior and posterior vagal nerves. The hiatus is closed posteriorly using permanent interrupted sutures and approximated to allow a 52-French bougie (Fig. 5.6). The crural fascia is incorporated into the closure rather than the muscle fibers alone. Closure begins posteriorly where the left and right crura join and then proceeds anteriorly. The esophagus should maintain straight orientation without excessive angulation and the bougie should pass easily. The repaired hiatus should allow passage of a closed laparoscopic instrument between the esophagus and crura.
Closure of the diaphragmatic hiatus with interrupted sutures
5.7.1 Creation of a Nissen Fundoplication
The Nissen fundoplication is the most commonly performed fundoplication worldwide . It augments the intrinsic function of the LES by increasing resting pressure and decreasing transient relaxation, as well as by recreating the angle of His. The most common technical failure when constructing a Nissen fundoplication is incorrect fundoplication anatomy. It is critical for proper construction of the fundoplication that the two gastric fundus flaps are symmetrically wrapped around the distal esophagus. To maintain appropriate orientation, it is our practice to place a marking suture 3 cm distal to the GE junction and 2 cm from the greater curvature on the posterior fundus. The posterior fundus is then passed through the retroesophageal window from the patients left to right side. The marking suture is used to identify the correct site. The anterior fundus to the left of the esophagus is similarly grasped 2 cm from the greater curvature and 3 cm from the GE junction. By identifying two points equidistant from the greater curvature and GE junction we decrease the chance of constructing a fundoplication using the body of the stomach. This error creates a redundant portion in the posterior wrap which can compress the esophagus and result in dysphagia. Anterior and posterior portions of the fundus are positioned on the anterior aspect of the esophagus and secured together using three or four interrupted permanent sutures (Fig. 5.7). Care is taken to avoid entrapment of the anterior vagal nerve. The fundoplication is constructed to a length of approximately 2.5–3 cm. Similar to the hiatal repair, it should allow easy passage of a 52-French bougie. To prevent herniation through the hiatus we anchor the wrap to the esophagus and diaphragm. Two coronal sutures are placed to secure the right and left gastric flaps and a single caudal suture to secure the posterior wrap. We prefer these coronal sutures to incorporating the esophagus with the fundoplication in order to reduce the chance of including the vagus nerve with the closure.
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