Notes on the Surgical Treatment of GERD

Fig. 12.1

Giovanni Battista Morgagni (1682–1771) was an Italian anatomist, regarded as the father of modern anatomical pathology. (Public domain reproduced from Wikipedia.org)

It is interesting to note that the first description of a HH was performed by X-ray. In that same year, the first surgical intervention for HH was described [16]. Eppinger in 1911 summarized the literature on diaphragmatic hernia and reported that of 635 cases of herniation through various portions of the diaphragm, only 11 involved the esophageal hiatus [15]. Akerlund in 1926 proposed the term HH and classified it in the three types we use today [7]. Bernstein in 1947 reviewed the HH theme and concluded that one of the reasons for the low number of diagnoses was that HH could be missed by autopsy as muscles are relaxed and intra-abdominal pressure decreased [17]. The technique of X-ray examination with the patient in the upright posture generally also fails to visualize these hernias. Examination in a reclining or even Trendelenburg position with application of manual pressure to the upper abdomen is necessary to demonstrate HH. These hernias may disappear as soon as the patient is brought back into the upright posture, or the increased abdominal pressure is released [16].

The first elective surgical repair of HH entitled “diaphragmatica” repair was reported in 1919 by Angelo Soresi [18], although the physiopathological link between HH and gastroesophageal reflux was only established in the second half of the twentieth century by Allison in Leeds and Barrett in London. We feel that the modern age of antireflux surgery was initiated by the English surgeon Allison (Fig. 12.2) who in 1951 repositioned the stomach into the abdomen and approximated the crural fibers behind the esophagus [19].

../images/473262_1_En_12_Chapter/473262_1_En_12_Fig2_HTML.jpg — Fig. 12.2

Philip R. Allison (1908–1974) a thoracic surgeon from Leeds, UK. (Reproduced with permission ©Nuffield Department of Surgical Sciences, University of Oxford)

Allison’s 20-year follow-up showed good results with improvement of symptoms in 80% of patients. Modern attempts to correct HH without other procedure such as a fundoplication failed to control GERD adequately [20]. HH repair, however, was granted as a necessary part of anatomical restoration to control GERD.

Angle of His Restoration: Early Attempts to Control GERD

Parallel to hiatal hernia repair, some surgeons focused on the angle of His as antireflux mechanism (Fig. 12.3) [21].

../images/473262_1_En_12_Chapter/473262_1_En_12_Fig3_HTML.jpg — Fig. 12.3

Wilhelm His (1831–1904) a German anatomist that described the angle named after him. (Public domain reproduced from Wikipedia.org)

Barrett [22] (Fig. 12.4) and latter Lortat-Jacob [23] (Fig. 12.5) were pioneers on the restoration of the cardioesophageal (His) angle as an element for GERD prevention.

../images/473262_1_En_12_Chapter/473262_1_En_12_Fig4_HTML.jpg — Fig. 12.4

Norman R. Barret (1903–1979) a thoracic surgeon who is primarily remembered for describing Barrett’s esophagus. (Reproduced from Researchgate under CC BY 2.0 license)

../images/473262_1_En_12_Chapter/473262_1_En_12_Fig5_HTML.jpg — Fig. 12.5

Jean-Louis Lortat-Jacob (1908–1922) a French surgeon also recognized as the first one to reconstruct the alimentary tract after an esophagectomy in France and to perform the first anatomic hepatectomy

As a consequence, the angle of His gained importance as an indispensable antireflux mechanism. It is important to note that while Allison focused on the reduction of HH and adequate closure of the diaphragmatic sling, Barrett prioritized restoration of the cardioesophageal angle as a critical element in preventing reflux [7].

The Rise of the Fundoplication

It is impossible to talk about the history of GERD surgery without citing the key role of Rudolph Nissen (Fig. 12.6). Nissen was born in Schlesien in 1896, began his career in German in 1921, and died in Basel in 1981. Of historical importance are his work in thoracic surgery such as the first successful pneumonectomy in man; however, it was his antireflux operation that made him famous worldwide [24–28].

../images/473262_1_En_12_Chapter/473262_1_En_12_Fig6_HTML.jpg — Fig. 12.6

Rudolph Nissen (1896–1981) a German surgeon that also acted in Turkey, the Unites States, and Switzerland. (Reproduced from Images from the History of Medicine – National Library of Medicine)

The Nissen technique was first introduced during the operation of a young patient with a distal esophageal ulcer penetrating the pericardium. After resection of the distal esophagus and cardia, the anastomosis was protected wrapping the distal esophagus with the posterior wall of the stomach. The patient had an excellent recovery and did not develop esophagitis. It is of notice that the short gastric blood vessels were not ligated, and the hiatus was not approximated. As such, the ideal antireflux operation was not perfected yet [25–28].

The Technical Evolution of the Fundoplication

André Toupet (Fig. 12.7) played an important role in the development of many operations, but he is recognized for the antireflux procedure that bears his name. Unlike Nissen who performed a 360-degree wrap, Toupet proposed a 270-degree posterior wrap, which would produce less postoperative dysphagia than Nissen fundoplication [29].

../images/473262_1_En_12_Chapter/473262_1_En_12_Fig7_HTML.jpg — Fig. 12.7

André Toupet (1915–2015) a Parisian surgeon that also developed 20 new instruments and 40 procedures. (Reused with permission ©French Academie Nationale de Chirurgie)

Other authors such as Jacques Dor [30] and Vicente Guarner [31] also proposed different partial fundoplications [32]. Dor proposed an anterior 180-degree fundoplication, while Guarner used a posterior partial fundoplication with closure of the hiatus.

Studies comparing Lortat-Jacob [23], Toupet, and Nissen procedures proved that isolated restoration of the cardioesophageal angle has inferior outcomes as compared to a fundoplication [33–35]. History showed that correction of a single natural antireflux mechanism is not enough.

Some authors have performed a Nissen fundoplication without a hiatoplasty, neglecting the diaphragm as an antireflux mechanism. The results showed a large number of HH recurrences and consequently very poor control of reflux. This experience further strengthened the role of the diaphragm as an antireflux mechanism. In 1965 Nissen and Rossetti proposed a variation of the technique in overweight patients, using the anterior wall of the stomach to wrap the distal esophagus [27]. The follow-up of 590 cases showed 90% relief of symptoms [36, 37]. Other technical changes were made but were eventually abandoned such as the addition of pyloroplasty or vagotomy [38–42].

Two modifications, however, showed improvement in results especially decreasing the rate of dysphagia and gas symptoms. Donahue et al. made the Nissen valve “floppy,” with a loose wrapping of the esophagus [43]. The advantages of a loose “floppy” wrap in avoiding the gas bloat syndrome have been well documented, and it was an important historical learning (Fig. 12.8) [44].