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36 Khitin and Brams
Fig. 3. Normal anatomy of esophageal hiatus: upper gastrointestinal contrast study.
occurring in 80% of patients. Chronic acid reflux can lead to esophagitis. In severe cases
of esophagitis, stricture may develop leading to dysphasia. Belching and regurgitation
occur in 50% of patients with GERD. Thirty percent of patients present with abdominal
pain. Occasionally, patients present with minimal heartburn but with severe extra-esophageal manifestations of GERD. Chronic respiratory symptoms, such as chronic cough,
recurrent pneumonias, episodes of nocturnal choking, and asthma may occur. Chest pain
may be an atypical symptom of GERD. Fifty percent of patients in whom a cardiac cause
of the chest pain has been excluded will have increased acid exposure as the etiology (1,2).
Chapter 4 / Surgery for GERD 37
Fig. 4. Type I hiatal or sliding hiatal hernia: coronal section.
INDICATIONS FOR SURGERY
The majority of patients with heartburn can be managed through modification of
lifestyle and through medical management. These should be optimized prior to consideration of surgery.
Caffeine, tobacco, and alcohol all decrease the LES pressure and cause reflux. Large
meals late at night often results in nocturnal reflux symptoms. Their elimination will
often improve GERD. Obesity increases intrabdominal pressure. Weight loss will often
effectively decrease reflux. H2-blockers and proton pump inhibitors potently neutralize
gastric secretions stopping heartburn and healing esophagitis (1).
When lifestyle modifications and medications are ineffective or poorly tolerated,
surgery should be considered. In addition, in patients who are good surgical risks, LNF
is an excellent alternative to lifelong medication (6).
Patients with esophageal injury because of acid reflux (including esophagitis, ulceration, stricture, and Barrett’s metaplasia) should be considered for surgery. Although
these complications can be controlled with medication, cessation of treatment often
leads to recurrence. Regurgitation despite acid suppression is a clear indication for
surgery (1,6).
Healthy patients are able to tolerate general anesthesia and laparoscopy, and they
should be considered candidates for surgery. In particular, patients less than 50 yr old
should consider surgery as an alternative to lifetime medication. Elderly patients are
usually best treated medically (1,5,6).
38 Khitin and Brams
CONTRAINDICATIONS TO SURGERY
There are few absolute contraindications to LNF except those precluding laparoscopy
or general anesthesia. Although LNF has been done successfully in patients older than
70 yr of age, the risk of surgery will often outweigh the benefit of avoiding medication.
There are several relative contraindications to surgery. Obesity increases the technical
difficulty of LNF, and is often a cause for conversion to an open procedure. Obesity will
also increase the risk of long-term failure of the fundoplication with recurrence of symptoms. Morbid obesity is better treated with medical management or with gastric bypass
surgery. Previous upper abdominal or gastric surgery increases the difficulty of LNF
necessitating an open approach (1–3,5,6).
PREOPERATIVE EVALUATION
Prior to surgery, the patient should undergo ambulatory esophageal pH testing,
esophageal motility testing, and upper gastrointestinal (GI) endoscopy. Most patients
will have an upper GI series (Fig. 5).
The success of LNF in eradicating GERD is dependent on the presence of acid
reflux. Ambulatory 24-h pH testing will accurately characterize the severity of GERD,
and allows the correlation of symptoms with acid reflux. The absence of acid reflux
or poor correlation between symptoms and reflux is a predictor of poor outcome of
surgery (2,5,6).
Esophageal motility testing is essential to rule out esophageal motility disorder as
causing symptoms. An LNF done in the presence of a motility disorder can lead to severe
dysphagia. Patients with poor motility may benefit from a partial fundoplication (2,5,6).
Upper GI endoscopy should be performed to document the presence of esophagitis or
Barrett’s esophagus both visually and through biopsies. Barrett’s esophagus is a potentially premalignant columnar metaplasia of the distal esophagus that can progress to
adenocarcinoma. Patients with Barrett’s esophagus need lifetime surveillance endoscopy to identify potential progression to severe dysplasia, which is an indication for
esophagectomy (2,3).
LAPAROSCOPIC FUNDOPLICATION: CONDUCT OF OPERATION
Selection of the antireflux procedure and approach is based on an assessment of
esophageal contractility and length. A transabdominal approach is used for patients with
normal esophageal contractility and length. Patients who present with long-standing
disease associated with poor esophageal function, a short esophagus, or stricture should
undergo an open antireflux procedure tailored to their underlying anatomic and physiologic abnormalities. Those with weak esophageal contractions may be treated with a
partial 270° fundoplication such as the transabdominal Toupet (Fig. 6) or transthoracic
Belsey IV fundoplication in order to avoid the increased outflow resistance associated
with a 360° Nissen fundoplication. Patients with poor contractility or questionable esoph-
ageal length can be approached transthoracically. If the esophagus is too short after it is
mobilized from diaphragm to aortic arch, a Collis gastroplasty is done to provide additional esophageal length and to avoid placing the repair under tension. Finally, if the
disease has resulted in esophageal body failure, Barrett’s metaplasia with high grade
dysplasia, or esophageal adenocarcinoma, an esophagectomy is required (2,3,5).
Chapter 4 / Surgery for GERD 39
Fig. 5. Type I hiatal or sliding hiatal hernia: upper GI contrast study.
Laparoscopic Nissen fundoplication (Fig. 7) is the procedure of choice in the majority
of patients presenting with GERD. General anesthesia is required. The patient is placed
in a low lithotomy position. Pneumoperitoneum and five laparoscopic trocars are placed
(Fig. 8). The Nissen fundoplication (laparoscopic or open) is performed in what can be
summarized as four major steps:
1. Crural Dissection: Crura of the diaphragm are circumferentially dissected from the distal
esophagus and stomach by dividing the phrenoesophageal attachments. The lower
esophagus is completely mobilized, returning the distal esophagus to the abdomen without tension. The vagus nerves are preserved.
2. Fundic mobilization: The gastric fundus is completely mobilized by division of the short
gastric vessels and retrogastric attachments.
3. Crural closure: The crura of the diaphragm are loosely approximated posteriorly.
4. Fundoplication: A short, loose 360° fundoplication is created by wrapping the anterior
and posterior walls of the fundus around the distal esophagus and vagus nerves. This
loose wrap is 1.5 to 2 cm in length (2,5,6).
40 Khitin and Brams
Fig. 6. 270° (Toupet) fundoplication.
Fig. 7. 360° (Nissen) fundoplication.
In the presence of altered esophageal motility, where the propulsive force of the esophagus is not sufficient to overcome the outflow obstruction of a complete fundoplication,
a partial 270° Toupet fundoplication can be performed. This procedure is identical to the
Chapter 4 / Surgery for GERD 41
Fig. 8. Incision locations for Belsey IV and open fundoplications, trocar positions for laparoscopic
fundoplication.
Nissen fingoplication except that the stomach is sutured to the esophagus and crura,
leaving the anterior esophagus uncovered and able to fully distend (4).
Operative time is 2–3 h. The patient begins liquids that night and is discharged the
following morning. Most patients return to sedentary work in 2 wk. Patients are advised
to avoid heavy lifting and straining for 6–8 wk to decrease the risk of herniation of the
fundoplication into the chest. Patients are given a diet progressing to solid foods over
2 wk (5).
Nissen fundoplication is extremely effective in treating GERD. Typical symptoms of
GERD (heartburn, regurgitation, and dysphagia) are alleviated in 90 to 95% of patients.
With the open technique, 90% of patients have no recurrence of symptoms at 10 yr. The
first LNF was done in 1991; therefore, 10-yr data is not available. However, the LNF is
identical to the open procedure, and 5-yr data for LNF is similar to that seen in the open
Nissen fundoplication (3,5).
Recurrence of symptoms is reported to occur in 3.4% after 3 yr in a meta-analysis by
Perdikis. Recurrent reflux may be caused by inadequate technical repair, shortening of the
esophagus or inadequate esophageal mobilization leading to excessive tension and retraction of the fundoplication into the chest, or weakening of the musculofascial structures by
aging, atrophy, or obesity. Recurrent symptoms can usually be treated medically (2,6).
Less than 1% of patients require further surgical intervention for recurrent reflux.
This subgroup consists mainly of patients who had severe esophagitis, esophageal
stricture, and ulceration prior to surgery, and whose fundoplication failed. Failed
fundoplication can take several forms: disrupted wrap, “slipped” fundoplication onto
the proximal stomach, and recurrent hiatal hernia with intrathoracic migration of the
fundoplication (Fig. 9) (5,6).
Conversion rate to open surgery is approx 2%, and early reoperation is necessary in
0.5%. Morbidity following LNF averages 3–10%. Pulmonary complications are more
42 Khitin and Brams
Fig. 9. Intrathoracic migration of fundoplication.
common and morbidity is higher after a thoracic operation than after transabdominal
surgery. Pitfalls unique to the laparoscopic approach include pneumothorax and surgical
emphysema, occurring in 1 to 2% of patients. Death is rare, whether the procedure is
open or closed. In a recent collective review, 4 of 2453 (0.2%) patients died. Deaths that
have been reported were caused by visceral perforation, superior mesenteric vessel
thrombosis, and myocardial infarction (5,6).
The most serious operative complication is instrumental perforation of a hollow vis-
cus. Perforations can also occur in the stomach or distal esophagus caused by passage
of the bougie used to size the fundoplicaiton. If recognized at the time of surgery, a
perforation can be repaired without added morbidity. Unrecognized perforations will be
manifested by postoperative toxicity (fever, oliguria, hypoxia, tachycarida, and peritoneal signs). Suspicion of a perforation should necessitate radiological examination or
reexploration in a timely fashion (5,6).
Chapter 4 / Surgery for GERD 43
Postoperative hemorrhage is unusual, but can arise from the liver, short gastric vessels, or spleen. Splenic injury necessitating splenectomy has been virtually eliminated
with the advent of laparoscopic fundoplication (5,6).
Dysphagia is the most common postoperative complaint occurring in 30% of patients.
Dysphasia is usually worse with solids, is self-limited, and is caused by postoperative
edema at the fundoplication. Persistent postoperative dysphagia occurs in approx 9% of
patients after laparoscopic repair and in 3% after open. The majority of patients are
asymptomatic by 8 wk. An esophagram and endoscopy may help to define the underlying
problem. Gentle dilation of the fundoplication will usually alleviate symptoms (5,6).
Gastric distension (“Gas bloat”) was common after the early variation of the open
Nissen fundoplication. It is relatively uncommon today because of routine creation of a
short “floppy” fundoplication that allows the patients to belch to a limited degree. Patients
undergoing antireflux surgery habitually swallow air to clear the esophagus of reflux contents, and this habit continues after antireflux surgery. Gas-binding agents and prokinetics
may be helpful when patients complain of bloating and increased flatulence (5,6).
Diarrhea and nausea occur in up to 8%. Most of these symptoms disappear after
several weeks, and medical therapy is usually not required. Postoperative diarrhea is
thought to be caused by rapid gastric emptying, change of diet, or incidental vagotomy.
Severely affected patients may be treated with antidiarrheals (1,4).
ALTERNATIVE PROCEDURE
Lapraoscopic vs Open Fundoplication
LNF has been compared to the open Nissen fundoplication as well as to the Belsey IV.
LNF has equivalent control of symptoms to open Nissen, and superior results to the
Belsey IV. LNF has less perioperative morbidity and a shorter recovery time. Convalescence is faster after laparoscopy: return to normal life being 14 vs 31 d and return to work
being 21 vs 44 d (1,2).
Partial vs Complete Fundoplication (Table 1)
In contrast to the 360° fundoplication typical of a Nissen fundoplication, antireflux
protection also occurs when the fundus is incompletely wrapped around the lower esophagus. Table 1 lists some of the common antireflux procedures and a description of their
conformation. Partial fundoplication results in less postoperative bloating and dysphagia. However, partial fundoplication has a higher incidence of recurrent reflux and,
therefore, is not routinely used. Partial fundoplication is typically reserved for patients
with abnormal esophageal motility, such as scleroderma and achalasia. Partial
fundoplication has been linked to a greater overall level of patient satisfaction 6 mo after
surgery. Fewer patients had difficulty swallowing, inability to belch, or had excessive
flatus in the partial fundoplication patients. These benefits may be offset by recurrent
GERD. In addition, the prevalence of these symptoms in patients following Nissen
fundoplication is highly dependent on the technical aspects of the procedure that can be
minimized given ideal technique (4).
Angelchik Procedure
The Angelchik procedure is no longer performed. It involves placing a doughnut
shaped silicone prosthesis around the intraabdominal esophagus. After it is tied in place,
44 Khitin and Brams
Table 1
Partial Fundoplications
Type Eponym Year Described Description
Total Nissen 1956 360° wrap
“Floppy” Nissen 1977 360° short (< 2 cm) wrap
Rosettil 1965 360° with short gastric vessels not divided
Partial Belsey Mark IV 1967 270° transthoracic
Toupet 1963 180° posterior wrap
Dor/Watson 1962 180°/120° anterior wrap
Modified Toupet 1982 270° posterior wrap
Lind 1965 270° posterior with crural closure
Guarner 1975 270° posterior with gastropexy
Thal 1964 90° anterior wrap
Other Allison 1951 Hiatal closure with esophagogastropexy
Hill 1967 Esophagogastropexy with 180° anterior wrap
the prosthesis prevents the hiatal hernia from recurring and mildly constricts the lower
esophagus with increase in the sphincter pressure. Although insertion of the prosthesis
is easier than fundoplication, patients often require reoperation to remove the prosthesis
because of migration, esophageal compression, ulceration, or erosion. More than 100,000
of these procedures have been performed (5).
COST
Although medical therapy and surgery both control GERD, the cost of LNF is a single
initial expense, whereas the cost of medical therapy is lifelong. Charges for surgery
include hospital charges of approx $5000 and professional fees of $2000. When one
compares the cost of proton-pump inhibitors with surgery, open Nissen fundoplication
becomes a cost-effective treatment option compared with medical treatment in patients
with refractory GERD if treatment continues more than 4 yr. LNF shifts this so-called
break point toward 1.4 yr, mainly because of a shorter hospital stay (7–9).
SUMMARY
1. GERD is a common condition and majority of patients are managed effectively by
medical therapy.
2. Antireflux surgery restores the mechanically defective esophageal sphincter and is an
effective treatment in patients suffering from severe GERD, which is unresponsive to
medical therapy.
3. Laparoscopic Nissen fundoplication is the superior antireflux procedure for the majority
of patients requiring surgery for GERD, but it is technically demanding and should be
performed by properly trained and experienced surgeons.
4. The outcome of laparoscopic Nissen fundoplication is excellent and morbidity is minimal. It offers a cost effective alternative to medical therapy in healthy patients with
refractory symptoms.
Chapter 4 / Surgery for GERD 45
REFERENCES
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J Gastroenterol 1999;94:11. Suppl.
2. Soper N. Laparoscopic management of hiatal hernia and gastroesophageal reflux. Curr Probl Surg
1999;36:765–838.
3. Perdikis G, Hinder RA, Lund RJ, et al. Laparoscopic Nissen fundoplication: where do we stand? Surg
Laparosc Endosc 1997;7:17–21.
4. Swanstrom LL. Partial fundoplication for gastroesophageal reflux disease: indications and current
status. J Clin Gastroenterol 1999;29:127–132.
5. Bowrey DJ, Peters JH. Laparoscopic esophageal surgery. Surg Clin N Am 2000;80:1213–1242.
6. Klingler PJ, Bammer T, Wetscher GJ, et al. Minimally invasive surgical techniques for the treatment
of gastroesophageal reflux disease. Digest Dis 1999;17:23–36.
7. Heikkinen TJ, Haukipuro K, Koivulkangas P, et al. Comparison of costs between laparoscopic and
open Nissen fundoplication: a prospective randomized study with a 3-mo follow-up. J Am College
Surg 1999;188:368–376.
8. Narain PK, Moss JM, DeMaria EJ. Feasibility of 23-h hospitalization after laparoscopic fundoplication.
J Laparoendoscop Adv Surg Tech 2000;10:5–11.
9. Van Den Boom G, Go PM, Hameeteman W, et al. Cost effectiveness of medical versus surgical
treatment in patients with severe or refractory gastroesophageal reflux disease in the Netherlands.
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