Laparoscopic Antireflux Procedures
Society American Gastrointestinal
SAGES Guidelines: GERD
LAPAROSCOPIC MANAGEMENT OF GE REFLUX
Gastroesophageal reflux disease (GERD) has long been recognized as
a significant public health concern. GERD Occurs in many Americans,
with nearly 44% experiencing monthly "heartburn" and 18% of these
individuals using nonprescription medication for this problem. GERD is
a chronic progressive disorder, often prompting patients to seed
medical advice for further treatment.
Surgical treatment of GERD is well established and provides well
recognized benefits. This document outlines the indications for and
appropriate surgical treatment of GERD. This document is not intended
to debate the issues of diagnosis and medical management of GERD,
which are dealt with elsewhere.
GERD is defined as the failure of the antireflux barrier, allowing
abnormal reflux of gastric contents into the esophagus. It is a
mechanical disorder which is caused by a defective lower esophageal
sphincter, a gastric emptying disorder or failed esophageal
peristalsis. These abnormalities result in a spectrum of disease
ranging from "heartburn" to esophageal tissue damage with subsequent
complications. While the exact nature of the antireflux barrier is
incompletely understood, the current view is that the lower esophageal
sphincter (LES), the diaphragmatic crura, and the phreneosophageal
ligament are key components.
In the appropriate clinical setting, the diagnosis of GERD relies
on the demonstration of ONE of the following:
presence of documented (photographic or histologic) esophageal
mucosal injury (esophagitis)
reflux during 24-hour intraesophageal pH monitoring.
Additional studies may be used for confirmation in difficult cases
(e.g., contrast radiographic studies, symptom mapping with provocative
tests, gastric emptying studies).
Medical therapy is the first line of management for GERD.
Esophagitis will heal in approximately 90% of cases with intensive
medical therapy. However, medical management does not address the
condition’s mechanical etiology; thus symptoms recur in more the 80%
of cases within one year of drug withdrawal. In addition, while
medical therapy may effectively treat the acid-induced symptoms of
GERD, esophageal mucosal injury may continue due to ongoing alkaline
reflux. Since GERD is a chronic condition, medical therapy involving
acid suppression and/or promotility agents may be required for the
rest of a patient’s life. The expense and psychological burden of a
life time of medication dependence, undesirable life style changes,
uncertainty as to the long term effects of some newer medications, and
the potential for persistent mucosal changes despite symptomatic
control, all make surgical treatment of GERD an attractive option.
Surgical therapy, which addresses the mechanical nature of this
condition, is curative in 85-93% of patients. Chronic medical
management may be most appropriate for patients with limited life
expectancy or comorbid conditions which would prohibit safe surgical
Two controlled trials which compared medical and surgical therapy
of GERD favored surgical therapy. In the most recent prospective
randomized comparison, surgical treatment was significantly more
effective than medical therapy (ranitidine and metoclopromide) in
improving symptoms and endoscopic signs of esophagitis for periods of
up to two years. Other longitudinal studies report good to excellent
long term results in 80-93% of surgically treated patients.
SURGICAL TREATMENT OF GERD
|Preoperative Work-up |
Before considering surgical
treatment of GERD, it is recommended that patients undergo:
- esophagogastroduodenoscopy (with
biopsy, where appropriate – see below)
- esophageal manometric
In selected cases, the following
investigations may prove helpful:
- 24-hour intraesophageal pH
- barium cineradiography.
While not always available, these investigations should not only
confirm the diagnosis, but also lead to appropriate selection of
patients for surgical repair. In particular, biopsies from areas of
suspected Barrett’s epithelium may document the presence of severe
dysplasia or carcinoma. In such settings, an antireflux procedure
alone would be inappropriate and other interventions such as resection
or close endoscopic surveillance might be indicated. Upper
gastrointestinal endoscopy may also identify other esophagogastric
mucosal abnormalities, suggesting symptomatic etiologies other than
GERD. Additionally, a normal 24-hour intraesophageal pH study should
strongly suggest an alternate diagnosis and lead to additional
diagnostic investigations. Finally, abnormal peristalsis on esophageal
manometric study may suggest a significant risk of dysphagia following
|Indications for Surgery
Surgical therapy should be considered in those individuals with
documented GERD (see above) who:
have failed medical
opt for surgery
despite successful medical management (due to life style
considerations including age, time or expense of medications, etc.)
have complications of
GERD (e.g. Barrett’s/stricture; grade 3 or 4 esophagitis)
symptoms (asthma, hoarseness, cough, chest pain, aspiration) and
reflux documented on 24 hour pH monitoring.
In patients with Barrett’s changes and severe dysplasia, the risk
of underlying malignancy may suggest consideration of esophagectomy,
rather than antireflux surgery.
|Surgical Techniques |
The primary goal of surgical intervention for GERD is to
re-establish the antireflux barrier without creation of undue side
effects. In addition, most surgeons feel it is necessary to:
position the LES
within the abdomen where the sphincter is under positive (intraabdominal)
close any associated
Various safe and effective surgical techniques have been developed
to realize the above goals. The choice of technique has typically been
based upon anatomic considerations, as well as the surgeon’s
preference and expertise. Many of these techniques have been
extensively tested and proven to be effective in controlling reflux
with minimal side effects. The Nissen fundoplication has emerged as
the most widely accepted procedure for patients with normal esophageal
motility. For patients with compromised esophageal motility, one of
the various partial fundoplications (e.g., Toupet fundoplication) is
recommended to decrease the possibility of postoperative dysphagia.
The success of an antireflux procedure depends upon the surgeon’s
familiarity and training with the specific technique and his/her
ongoing involvement in the pre-and post-operative care. The choice of
procedure and methods of access (open or laparoscopic) should be
determined by the surgeon’s experience and training more than by the
technique itself. Special mention of the laparoscopic approaches for
the treatment of GERD follows.
|Laparoscopic Treatment of GERD
Laparoscopic antireflux procedures rely on videoscopic technologies
to allow surgeons to reproduce the accepted "open" procedures in a
minimally invasive fashion. The benefits of a laparoscopic approach
are analogous to those realized with laparoscopic cholecystectomy and
include a shorter and more comfortable recovery with an earlier return
to normal activities. Several reports in the literature document the
feasibility, safety, and favorable results of laparoscopic antireflux
The indications for laparoscopic treatment of GERD are the same as
those outlined earlier in this document. Laparoscopic antireflux
surgery should only be offered by surgeons skilled and privileged in
the equivalent open antireflux procedure. Safe and effective
laparoscopic treatment of GERD requires advanced laparoscopic skills
such as intracorporeal knot tying, the use of angled scopes to achieve
multiple viewing angles, and two-handed organ and tissue manipulation.
Therefore, appropriate training in advanced laparoscopic course which
details the specific laparoscopic antireflux technique and teaches the
appropriate advanced skills. Such a course should provide
documentation of attendance and skills taught. Before attempting such
a procedure independently, the surgeon should be preceptored by a
surgeon experienced in the procedure. Finally, laparoscopic antireflux
surgery requires a well trained operating team familiar with the
equipment, instruments and techniques of antireflux surgery.
Gastroesophageal reflux disease (GERD) is a significant health
concern. Medical management is expensive and may be necessary
lifelong. Effective surgical therapy is available and, if performed by
experienced surgeons, is successful in greater than 90% of patients.
Laparoscopic techniques which reproduce their "open" counterpart are
also available. When performed by appropriately trained surgeons,
these laparoscopic approaches appear to hasten the patient’s recovery
and return to normal function.
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Reproduced with Permission