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Ростовский Государственный Медицинский Университет

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Книга_1050_Библиотеки_им_академика_М_И_Перельмана

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toGERDduetotheincreasedvolumeanddurationofgastriccontentsthat canpotentiallyrefluxintotheesophagus.

■ AfundoplicationistheuseofthegastricfundustorecreatetheLESvalve function.Variousfundoplicationconfigurationsexist(e.g.,Nissen,Dor, Toupet)anddifferbythenumberofdegreesthatencircletheesophagus,the locationofthewrap,andtheapproachusedtocreatethefundoplication.

DIFFERENTIALDIAGNOSIS

■ Pepticulcerdisease

■ Esophagealmotilitydisorder(e.g.,achalasia)

■ Malignancy(e.g.,esophagealorgastric)

■ Anatomicabnormality(e.g.,hiatalhernia)

■ Eosinophilicesophagitis

■ Coronaryarterydisease

■ Biliarycolic

■ Pancreatitis

■ Functionalheartburn

■ Hypersensitiveesophagus

■ Functionaldyspepsia

■ Otherfunctionalboweldiseases(i.e.,inflammatorybowelsyndrome[IBS])

PATIENTHISTORYANDPHYSICALFINDINGS

■ Themostcommongastroesophagealrefluxsymptomsreportedareheartburn, acidregurgitation,anddysphagia.Thereisagrowingawarenessofmore atypicalpresentations,mostofwhicharerelatedtolaryngealorpulmonary manifestationssuchascough,chestpain,hoarseness,wheezing,globus sensation,andaspiration.

■ Itisimportanttoaskthepatienttoexplainthesensationstheyarehaving whentheyusetheterm“heartburn.”Heartburn,asrelatedtoGERD,isa retrosternalburningorcausticsensation.Somepatientsincorrectlyusethe termheartburntodescribeepigastricpain(associatedwithpepticulcer disease,gastritis,andfunctionaldyspepsia),rightupperquadrantpain (fromcholelithiasisorotherhepatobiliarydiseases),orchestpain(from coronaryarterydisease).Itishelpfultoaskpatientstopointontheirbody astowheretheyhavediscomfortwhentheynotethattheyhaveheartburn. Classicheartburndoesnotradiatetothebacknorisitusuallydescribedas apressuresensation.

■ Regurgitationsymptomscanincludegastricfluidregurgitation,knownas waterbrash,and/orpartiallydigestedfood.Regurgitationoffoodparticles canalsobeassociatedwithesophagealclearanceproblemssuchasan esophagealdiverticulumorachalasia.

■ Dysphagiafromareflux-associatedstrictureisusuallyworsewithsolidsthan liquids.Ifbothareequallybothersome,aneuromusculardisordermustalso beconsidered.

■ Airway-relatedsymptoms(e.g.,cough,wheezing,voicechanges)canbe presentaloneorinconjunctionwithesophagealsymptoms.

■ DiseasestatesthataresometimesrelatedtoGERDareidiopathicpulmonary fibrosis,asthma,andrecurrentpneumonia.

■ PatientspresentingtoasurgeontodiscussGERDtreatmenthaveoftenalready trialedantacidmedications.Itisimportanttoquerythepatient’sresponseto thesemedications.Ifthepatientdoesnothaveatleastsymptomatic improvementtoantacidtherapy,alternativediagnosesshouldbeconsidered. Heartburnwillalmostalwaysimprovewithantacidtherapy,atleastpartially, withindaystoafewweeks.Similarly,theywillnoticeworseningofheartburn symptomswithcessationofantacidtherapy.Airwaysymptomsmaytake longer(2to3months)andmaynotrespondatall(evenwhenGERDisthe etiology).

■ PhysicalexaminationfindingsareoftenlimitedinapatientwithGERD.Inall patientswithgastroesophagealcomplaints,itisimportanttoqueryabout weightlossandhematemesisandtoexamineforlymphadenopathy,asthese couldrepresentanunderlyingmalignancy.

IMAGINGANDOTHERDIAGNOSTICSTUDIES

■ Diagnostictestingtoconfirmobjectiveevidenceofabnormalgastroesophageal refluxisimperativebeforeconsideringsurgicalmanagementforGERD.A recentstudyrevealedthat42%ofpatientsreferredforantirefluxsurgeryhada normalpHstudywhentestedobjectively.3Thefollowingstudiesareessential toconfirmthediagnosisofGERD,theunderlyingfunctionalityoftheLES andesophagus,andinvestigateanyanatomicconsiderationsnecessaryfor successfuloperativeoutcomes:

■ pHmonitoring(FIG1)assessesdistalesophagealpHoveraperiodoftime (routinely24to48hours)andacompositeDeMeesterscoreiscalculated. AnabnormalDeMeesterscoreisgreaterthan14.7.4Factorscontributingto thisscoreincludepercenttotaltimepHlessthan4,percentuprighttimepH lessthan4,percentsupinetimepHlessthan4,numberofrefluxepisodes, numberofrefluxepisodesmorethan5minutes,andlongestrefluxepisode.

■ UpperendoscopyevaluatesforesophagealinjuryandBarrett’sesophagus secondarytoGERDwhileexcludingmalignantpathologywithbiopsiesas necessary.Endoscopyallowsthesurgeontoevaluateforthepresenceofa hiatalherniaaswellastovisuallyinspecttheLES.

■ Esophagealmanometry(FIG2)assessesLESpressureandrelaxationaswell asesophagealmotility.Patientswithesophagealmotilitydisorderscan easilybemislabeledashavingGERDbasedonsymptoms.Understanding apatient’sesophagealmotilityisnecessarytoplansuccessfulantireflux surgery.

■ Esophagogramevaluatesgastroesophagealanatomyandabnormalitiessuchas hernia,stricture,diverticula,motility,ortumors.

■

Ancillaryteststhatmayalsobeusefulincludelaryngoscopy,gastricemptying scintigraphy,andimpedancetesting.

SURGICALMANAGEMENT

■ Thereisrarelyanabsoluteindicationforantirefluxsurgeryinapatientwith GERD.Medicalmanagement,includingacidsuppressiontherapyand lifestylemodifications(e.g.,dietarychanges,weightloss),isusually sufficienttomanagemostpatients’GERDsymptoms.Manyfactorsmustbe consideredinmakingthedecisiontoproceedwithantirefluxsurgery.These includesymptomseverity,symptomcontrolwithmedicaltherapy, complicationsofGERD(e.g.,severeesophagitis,esophagealstricture, Barrett’sesophagus,chronicrespiratorycomplaints),andthegeneralized healthofthepatient.

■ Patientsbestsuitedforanantirefluxprocedurearethosewithdocumentedand confirmedGERDforwhommedicalandlifestylechangesarenotproviding adequatequality-of-lifeimprovement.Whenthequality-of-lifeimpairment justifiesacceptingtheriskofsurgery,antirefluxsurgeryisindicated.

PreoperativePlanning

Positioning

■ Patientcanbepositionedineithermodifiedlithotomypositionorsupine dependingonsurgeonpreference.Lithotomypositionrequiresmoretimeand equipmentandhasmorerisksofnerveinjury.However,lithotomyposition providessuperiorergonomicsforthesurgeon.Botharmsshouldbetuckedto notinterferewithinstrumentationandthepatientshouldbeadequately stabilizedonthebedtosafelyaccommodatesteepreverseTrendelenburg (whichallowsorganstonaturallyfallawayfromthehiatusandleftupper quadrant).

■

Standardtrocarplacementincludesthreeworkingtrocars,afourthtrocarforthe camera,andafifthforliverretraction.FIG3illustratesstandardtrocar placement,surgeon,andassistantpositioning.

■ Elevationoftheleftlaterallobeoftheliverisnecessarytovisualizethe esophagealhiatus.Thisismostcommonlyaccomplishedwitharetraction deviceofthesurgeon’schoice.

TECHNIQUES

TAKEDOWNTHELEFTPHRENOGASTRICLIGAMENT

■ Afterobtaininglaparoscopicaccesstotheabdomenandplacementoftrocarsand theliverretractor,thephrenogastricligamentisdivided,exposingtheleft crus.Thisismosteasilyaccomplishedbytractiononthegastroesophageal (GE)junctionfatpadandthegastricfundus(FIG4).Manysurgeonsstarton therightsidebydividingthegastrohepaticligamentandright phrenoesophagealligament.Wehavefoundthatitissafertofirstapproach thehiatusfromtheleft,whichprovidesbettervisualization,butboth

approachesareacceptable.

LIGATEANDDIVIDETHESHORTGASTRICVESSELS

■ Theshortgastricvesselsbetweenthegreatercurvatureofthestomachandthe spleenareligatedanddividedfromthegastricmidbodytotheangleofHis (FIG5).Themostsuperiorshortgastricvesselscanbedifficulttoexpose. Caremustbetakentoavoidcapsuletearstothespleenduringthismaneuver. Moreposteriorshortgastricvesselsandretroperitonealadhesionsmustalso bereleasedtofacilitatefullmobilizationofthefundus(FIG6).

EXPOSETHEENTIRELEFTCRUS

■ Theleftphrenoesophagealmembraneisopenedalongitslength(FIG7).

OPENGASTROHEPATICLIGAMENT

■ Therightcrusisexposedbyopeningthegastrohepaticligamentwidely,taking caretoavoidinjurytonerveofLatarjet(FIG8).

ENTERTHERIGHTPHRENOESOPHAGEAL MEMBRANE

■ Therightphrenoesophagealmembraneisidentifiedoverlyingtherightcrusand isdividedtoexposethecruralfibersbeneath.Therightphrenoesophageal membraneisopenedalongitslength(FIG9).

CONNECTLEFTANDRIGHTHIATALDISSECTIONS

■ Theleftandrightdissectionsofthephrenoesophagealmembraneareconnected bothanteriorlyandposteriorlywithcautionsoasnottoinjuretheanteriorand

posteriorvagusnerves.APenrosedrainisplacedaroundtheesophagustoaid ingastroesophagealjunctionretractionandesophagealexposure(FIG10).

ESOPHAGEALMOBILIZATION

■ Theareolarconnectivetissuesurroundingtheesophagusisexposedand dissectedfreebyretractingtheGEjunctionwiththePenrosedrainto mobilizeadequateintraabdominalesophageallength(minimumof3cm) (FIG10).Theanteriorandposteriorvagusnervesaswellasthepleuraare protectedduringthisdissection.

POSTERIORCRUSREAPPROXIMATION

■ Therightandleftcruraarereapproximatedposteriorlywithheavypermanent suture(FIG11)sothatthehiatuscomfortablyacceptsa52-Frintraesophageal bougie.

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