Surgical Treatment of GERD

Surgical management of gastroesophageal reflux disease has evolved from relatively invasive procedures requiring open laparotomy or thoracotomy to minimally invasive laparoscopic techniques. Although side effects may still occur, with careful patient selection and good technique, the overall symptomatic control leads to satisfaction rates in the 90% range. Unfortunately, the next evolution to endoluminal techniques has not been as successful. Reliable devices are still awaited that consistently produce long-term symptomatic relief with correction of pathologic reflux. However, newer laparoscopically placed devices hold promise in achieving equivalent symptomatic relief with fewer side effects. Clinical trials are still forthcoming.

Key points

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Surgical management of gastroesophageal reflux disease has evolved from relatively invasive procedures requiring open laparotomy or thoracotomy to minimally invasive laparoscopic techniques.
•

Although side effects may still occur after gastroesophageal reflux disease operations, with careful patient selection and good technique, the overall symptomatic control leads to satisfaction rates in the 90% range.
•

Newer laparoscopically placed devices hold promise in achieving equivalent symptomatic relief with fewer side effects.

Historical review

Philip Allison first emphasized the association between reflux esophagitis and hiatal hernia in 1951. This lead surgeons to explore surgical options in the management of gastroesophageal reflux disease (GERD) and hiatal hernia. Although it is now clear that lower esophageal sphincter (LES) competence is a multifactorial system, initial operations focused on hiatal hernia repair.

Allison first attempted simple reduction of the herniated stomach with repair of the hiatal hernia. Results, however, were unsatisfactory. The next iteration incorporated augmentation of the LES. It was first described by Rudolph Nissen in 1956. Originally, the anterior and posterior walls of the fundus were used for the fundoplication without division of the short gastric vessels; this was wrapped around 6 cm of distal esophagus just above the gastroesophageal junction and approximated using 4 or 5 interrupted sutures, of which one or more incorporated the anterior wall of the esophagus. The fundoplication was performed over a 36-Fr esophageal bougie dilator. Of note, Nissen did not repair the crura in his original description.

The original Nissen fundoplication had relatively unacceptable postoperative incidences of dysphagia and gas-bloat. It was thought that the fundoplication was “too long and too tight.” In an effort to minimize these, modifications were made to the original Nissen fundoplication without decreasing its effectiveness in preventing pathologic reflux. Donahue and coworkers described using a larger 50-Fr esophageal bougie during the creation of the fundoplication in association with hiatal hernia repair. Following this, DeMeester and his group described several other measures that improved the postoperative outcome of fundoplication. These measures included using a larger 60-Fr esophageal bougie, decreasing the length of the gastric wrap to 1 cm, and dividing the short gastric vessels to use the gastric fundus in constructing a “floppy” wrap. The final step was to insert an index finger along the esophagus while the 60-Fr bougie was in place to ensure that the wrap was sufficiently “floppy” ( Fig. 1 ). The Nissen fundoplication enhances LES competence by placing the distal 2 cm of the esophagus in the intra-abdominal position, restoring the interaction of the distal esophagus with the diaphragmatic hiatus, and augmenting the distal esophageal musculature with the fundoplication. Although much is made of the fundoplication, it consists of all 3 components working in concert, allowing for correction of pathologic reflux and symptomatic improvement. Rossetti and Hell modified the Nissen by using only the anterior wall of the gastric fundus. Despite these modifications and success in eliminating reflux, the Nissen fundoplication has been associated with side effects of bloating, dysphagia, and diarrhea.

Other surgical options have been described but are not nearly as popular as the modified Nissen fundoplication. André Toupet in 1963 described a posterior 270° wrap as an alternative to the Nissen fundoplication to decrease the incidence of postoperative bloating and dysphagia ( Fig. 2 ). The results vary in comparison with the Nissen fundoplication. Certainly, although dysphagia is less compared with the Nissen, long-term durability is a problem. Currently, the Toupet posterior fundoplication is generally reserved for patients with abnormal esophageal motility with similar results to the Nissen fundoplication, although there are some groups that advocate its routine use. Dor created a 180° anterior fundoplication used primarily in combination with Heller esophagomyotomy for achalasia; it can be used as a primary surgical treatment for GERD. Recent data do not show a difference in outcome between the anterior partial fundoplication and the posterior partial fundoplication.

For patients with severe esophagitis leading to stricturing, there was concern that recurrent hiatal hernia could occur because of esophageal foreshortening. Because of this, Collis created an “esophageal lengthening” procedure to insure an intra-abdominal esophagus, consisting of placing a dilator in the esophagus and gastric cardia, then dividing the gastric cardia from the angle of His parallel to the dilator for a distance of 2 to 3 cm. The fundoplication was then completed around this “neo-esophagus” and the hiatal defect was repaired. In the 1960s, Belsy described an imbricating partial fundoplication completed in the left thoracic cavity ( Fig. 3 ). These operations all required a laparotomy or left thoracotomy for completion.

For decades, these operations have been the mainstay of surgical treatment of hiatal hernia and GERD. However, their application was relatively uncommon compared with the prevalence disease despite evidence of their superiority to medical management of reflux, attributed primarily to concern over side effects and the relatively invasive nature of these surgical treatments.

Historical review

Philip Allison first emphasized the association between reflux esophagitis and hiatal hernia in 1951. This lead surgeons to explore surgical options in the management of gastroesophageal reflux disease (GERD) and hiatal hernia. Although it is now clear that lower esophageal sphincter (LES) competence is a multifactorial system, initial operations focused on hiatal hernia repair.

Allison first attempted simple reduction of the herniated stomach with repair of the hiatal hernia. Results, however, were unsatisfactory. The next iteration incorporated augmentation of the LES. It was first described by Rudolph Nissen in 1956. Originally, the anterior and posterior walls of the fundus were used for the fundoplication without division of the short gastric vessels; this was wrapped around 6 cm of distal esophagus just above the gastroesophageal junction and approximated using 4 or 5 interrupted sutures, of which one or more incorporated the anterior wall of the esophagus. The fundoplication was performed over a 36-Fr esophageal bougie dilator. Of note, Nissen did not repair the crura in his original description.

The original Nissen fundoplication had relatively unacceptable postoperative incidences of dysphagia and gas-bloat. It was thought that the fundoplication was “too long and too tight.” In an effort to minimize these, modifications were made to the original Nissen fundoplication without decreasing its effectiveness in preventing pathologic reflux. Donahue and coworkers described using a larger 50-Fr esophageal bougie during the creation of the fundoplication in association with hiatal hernia repair. Following this, DeMeester and his group described several other measures that improved the postoperative outcome of fundoplication. These measures included using a larger 60-Fr esophageal bougie, decreasing the length of the gastric wrap to 1 cm, and dividing the short gastric vessels to use the gastric fundus in constructing a “floppy” wrap. The final step was to insert an index finger along the esophagus while the 60-Fr bougie was in place to ensure that the wrap was sufficiently “floppy” ( Fig. 1 ). The Nissen fundoplication enhances LES competence by placing the distal 2 cm of the esophagus in the intra-abdominal position, restoring the interaction of the distal esophagus with the diaphragmatic hiatus, and augmenting the distal esophageal musculature with the fundoplication. Although much is made of the fundoplication, it consists of all 3 components working in concert, allowing for correction of pathologic reflux and symptomatic improvement. Rossetti and Hell modified the Nissen by using only the anterior wall of the gastric fundus. Despite these modifications and success in eliminating reflux, the Nissen fundoplication has been associated with side effects of bloating, dysphagia, and diarrhea.

Other surgical options have been described but are not nearly as popular as the modified Nissen fundoplication. André Toupet in 1963 described a posterior 270° wrap as an alternative to the Nissen fundoplication to decrease the incidence of postoperative bloating and dysphagia ( Fig. 2 ). The results vary in comparison with the Nissen fundoplication. Certainly, although dysphagia is less compared with the Nissen, long-term durability is a problem. Currently, the Toupet posterior fundoplication is generally reserved for patients with abnormal esophageal motility with similar results to the Nissen fundoplication, although there are some groups that advocate its routine use. Dor created a 180° anterior fundoplication used primarily in combination with Heller esophagomyotomy for achalasia; it can be used as a primary surgical treatment for GERD. Recent data do not show a difference in outcome between the anterior partial fundoplication and the posterior partial fundoplication.