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Laparoscopic Antireflux
Procedures
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Laparoscopic Antireflux Procedures |
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Overview |
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First performed in the early nineties by Dallemagne in Belgium, the standard
laparoscopic fundoplication is now recognized as the therapeutic modality of
choice in the surgical management of gastro-esophageal reflux. Since then,
several technical modifications have been introduced with
various success. However to date, advances in laparoscopic instrumentation
and surgical skills make the standard, 360 degrees laparoscopic fundoplication the most effective procedure antireflux procedure
available.
Having a precise knowledge of the anatomy of the
gastroesophageal junction, understanding the mechanics of the
gastroesophageal junction and establishing an accurate diagnosis of
gastro-esophageal reflux is absolutely essential for any surgeon performing
these procedures.
In the majority of patients, gastro-esophageal reflux
is universally recognized as a malfunction of the gastro-esophageal complex.
However, LES dysfunction is not its sole etiology, and a misdiagnosis will
certainly generate catastrophic postoperative complications. Thus, a full
anatomical and functional evaluation of the gastro-esophageal complex should
be performed for each patient. The following diagnostic procedures are found
to be invaluable in the preoperative management of these patients.
The function of the GE complex
depends primarily on the following:
1. Esophageal Primary Motility (Amplitude and
Progression)
2. Lower Esophageal Sphincter (LES)
3. Gastric Emptying Mechanism
The following, step by
step, management and diagnostic studies should be completed for each
potential surgical candidate. None of the studies
mentioned herein are by themselves one hundred percent sensitive in
accurately diagnosing gastro-esophageal reflux. It is the combination of
all these results that will help the surgeon decide if the patient is
indeed a surgical candidate.
 | Documenting the GE Reflux: A meticulous history should be obtained
(past medical history, medications taken, age at onset of reflux,
length of reflux, supine or upright reflux, past medical treatment and
results). |
| UGI Series: The presence of a hiatal hernia, spontaneous
reflux and other associated anatomical anomalies (stricture, short
esophagus, etc.) should be checked. |
| UGI Endoscopy:
The esophageal and gastric mucosa
should be evaluated for associated lesions and the degree of
esophageal injury from the reflux should be reported according to the
following scale: |
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GRADE |
ESOPHAGEAL DAMAGE |
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1 |
Mucosal
Damage: Erythema without Ulcerations |
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2 |
Mucosal
Damage: Erythema with Ulcerations |
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3 |
Transitional Submucosal Damage: Chronic Ulcerations with Fibrosis |
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4 |
Transmural Damage: Stricture |
If esophagitis is demonstrated, a biopsy
should be performed to document the presence of Barrett's Esophagus,
with or without cellular atypia/dysplasia. In addition, the length of the
intra-abdominal portion of the lower esophagus can be estimated by UGI
endoscopy (from diaphragmatic cruras to GE junction estimated as the
patient sniffs).
| Esophageal Manometric Studies:
This analysis of the endoluminal pressure of the esophagus and
gastroesophageal junction should provide the following data to the
surgeon: |
- 1. Primary esophageal motility: Presence,
progression and amplitude
- 2. Lower Esophageal Sphincter Analysis: Resting
pressure and length.
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Manometric Studies |
Normal Readings |
Abnormal Readings supporting
GER |
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LES
Length-Total |
3.6
cm (mean) |
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LES
Length-Intra-abdominal |
2.0
cm (mean) |
<
than 1 cm |
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LES
Resting Pressure |
13 mm Hg (mean) |
< than 6 mm H |
| 24 Hr. pH Study:
This 24 Hr. monitoring of the acid and bilious content and pH of the
esophagus (biochemical electrode placed 5 cm above the GE junction) is
a sensitive modality which will accurately report the acid/bile
exposure of the lower esophagus over 24 hours. It should be reported
as follows: |
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Esophageal Acid Contact/ Exposure |
Clinical Correlation |
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4.2 % to 7% |
Normal Recording |
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12% to 15% |
Erosive
Esophagitis |
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Around 26% |
Transmural
Esophagitis - R/o Barrett's Esophagus - Stricture |
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Combined Acid-Bile Exposure |
Transmural
Esophagitis - R/o Barrett's Esophagus - Stricture |
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Choice of Antireflux Procedure |
Laparoscopic antireflux procedures only differ by the degree of
resistance they created across the newly created GE junction. A 360 deg.
fundoplication or Nissen fundoplication can be usually performed in all
patients with a normal primary esophageal peristalsis or normal manometric
studies. In patients with altered or abnormal primary esophageal
peristalsis (as seen in patients with long term gastro-esophageal reflux),
a Toupet or 270 Deg. fundoplication may be the procedure of choice. The
lesser pressure gradient across the GE junction may compensate for the
lack of a propulsive esophageal strength against the resistance created by
the fundoplication. The Rossetti Type Anti Reflux Procedure is no longer
performed by our surgical team.
See the section on Laparoscopic Fundoplication with esophageal
lengthening for the management of a "Short Esophagus".
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