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Review

PART 1 Oral cavity, pharynx and esophagus

GI Motility online (2006) doi:10.1038/gimo56


Published 16 May 2006

Surgical therapy for gastroesophageal reflux disease


Renee C. Minjarez, M.D. and Blair A. Jobe, M.D.
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Key Points

Gastroesophageal reflux disease is a widespread public health concern. It can lead

to the development of Barrett's epithelium, which confers a higher risk of

esophageal adenocarcinoma.

Surgical therapy restores the mechanical barrier of the lower esophageal sphincter

and prevents reflux of gastric contents into the esophagus.

Current surgical techniques emphasize return of the esophagogastric junction

(EGJ) to the abdominal cavity, full mobilization of the gastric fundus, snug crural

closure, and a short tension-free fundoplication.

Esophageal stricture and erosive esophagitis can be treated successfully with

antireflux surgery (ARS).

Inasmuch as the finding of Barrett's esophagus (BE) represents long-standing

severeGERD, these patients should be referred for surgery based on symptom

control and disease-related complications. There is insufficient evidence to

support ARS in the prevention of esophageal adenocarcinoma.

The best predictors of a good surgical outcome are typical symptoms,

objectification of reflux events, and correlation of these events with symptoms.


Indications for operation include symptoms not well controlled by medication,

intolerance to medication, atypical symptoms not well controlled by medication,

complicated GERD, and desire for freedom from medication.

The Nissen fundoplication is the procedure of choice for the treatment of GERD in

patients with or without esophageal dysmotility. Evidence suggests dysmotility is

improved after fundoplication.

Partial fundoplications should be reserved for patients with achalasia, and those

whose esophageal manometry reveals amplitudes less than 30 mmHg.

The most common cause of mechanical fundoplication failure is transhiatal

herniation into the chest.

In experienced hands, the laparoscopic Nissen fundoplication has over a 90%

satisfaction rate at 5 years. Recently available 10-year data indicate satisfaction

rates remain high at 88%.

Redo surgery for identifiable mechanical failure after fundoplication can result in a

good outcome in the majority of patients and can often be performed

laparoscopically.

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Introduction

With nearly half of Americans experiencing heartburn symptoms at least monthly,

gastroesophageal reflux disease (GERD) is a serious health concern in the Western world.

In Europe, epidemiologic studies put the prevalence of GERD between 9% and 42%.1 In

Asia, the prevalence of GERD is lower than in the United States. However, rates

of GERD now approach those seen in Western countries. In Japan, the incidence of

esophagitis is reported to be between 14% and 16%. 2 Gastroesophageal reflux disease

increases the risk of esophageal stricture, Barrett's esophagus (BE), and esophageal

cancer, and has a negative impact on work productivity and quality of life. 3, 4, 5 The modern

era of GERD therapy have brought advances in diagnosis and treatment, and subsequently

a better understanding of the pathophysiology of GERD. Improved medical therapies in the

form of type 2 histamine receptor antagonists and proton pump inhibitors (PPIs) have

brought both symptomatic relief and effective resolution of esophageal mucosal damage,

which may help to ameliorate some of the long-term effects of GERD. Medical therapy

demands lifelong use in the majority of patients with GERD and fails to prevent the reflux
of bile or gastric contents. Antireflux surgery (ARS) can provide a permanent anatomic and

physiologic cure that provides resolution of symptoms and helps prevent the adverse

consequences of ongoing esophageal exposure to gastric contents.

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History of Antireflux Surgery

It was not until the early 1900s when radiologic studies became ubiquitous that hiatal

hernia was recognized as a pathologic entity. Early attempts at repair centered on hernia

reduction and hiatal closure without fundoplication. Because the underlying defect of the

lower esophageal sphincter (LES) was not repaired, surgery failed to control symptoms,

and the procedure was not widely embraced.

In 1951, Philip Allison and Norman Barrett established the causal relationship among hiatal
hernia, gastroesophageal reflux, and erosive esophagitis. Allison described the crural sling

and clasp musculature as the anatomic correlate to the LES and the primary mechanism

that prevents pathologic reflux. His method to restore the antireflux mechanism included

reduction of the herniated cardia with suture fixation to the abdominal surface of the

diaphragm followed by loose closure of the hiatus. Unfortunately, his attempts at surgical

repair fell short and he had a long-term recurrence rate of 49% at 20 years.

In 1939, Rudolf Nissen improvised a fundoplication to protect an esophagogastric

anastomosis in a young man with a penetrating esophageal ulcer. During follow-up, Nissen

noted that the patient's reflux symptoms were eradicated. Some years later, and

disappointed with contemporary hiatal hernia repairs, Nissen performed a fundoplication

on a man with an incarcerated paraesophageal hernia. The clinical outcome was excellent.

He published the first description of this procedure in 1956, thereby ushering in the

modern era of antireflux surgery.6

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Principles of Surgical Repair

Three mechanisms prevent excessive esophageal exposure to refluxate. First, the

propulsive action of the esophagus clears ingested material and physiologic reflux; this

peristaltic activity serves to limit the contact time of these substances with the esophageal

mucosa. Second, the LES is a region of high pressure located at the esophagogastric

junction and is the primary mechanism that prevents pathologic reflux. The tonic

opposition of the collar sling musculature (greater curvature) and the clasp fibers (lesser
curvature) at the level of the cardia creates this region of high pressure (Figure 1). This

area is commonly referred to as the gastroesophageal flap valve based on the endoscopic

appearance during retroflexion. Finally, proper gastric emptying is required to eliminate

the source of refluxate and prevent elevated gastric pressure with subsequent retrograde

"decompression" into the esophagus.

Figure 1: Opposing sling and clasp muscle fibers. The longitudinal


muscle layer of the stomach has been cut away to show the opposing
sling and clasp muscle fibers.

These fibers sit in tonic opposition until a swallow triggers


receptive relaxation. It is thought that progressive stretching of
these fibers leads to valve incompetence and subsequent
gastroesophageal reflux disease (GERD). Antireflux procedures
restore the anatomic barrier by re-creating the one-way valve of
the lower esophageal sphincter (LES). (Source: Jobe BA, et al.
Endoscopic appraisal of the gastroesophageal valve after
antireflux surgery. Am J Gastroenterol 2004;99(2):241 with
permission from Blackwell Publishing.)

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All antireflux procedures can be divided into two broad groups: total (360 degrees) and

partial (less than 360 degrees) fundoplications. Now regarded as the primary surgical

option for the treatment of GERD, the Nissen fundoplication is a well-established total

antireflux procedure proven both durable and safe over a period of 20 years. Since its

introduction in 1991, the number of laparoscopic Nissen fundoplications (LNFs) has


increased annually.7, 8The Nissen fundoplication has undergone many modifications aimed

at minimizing postoperative side effects and improving the longevity of the repair.

The current technique emphasizes return of the esophagogastric junction into the

abdominal cavity by transhiatal esophageal mobilization, division of the short gastric

vessels to achieve complete mobilization of the gastric fundus, snug crural closure, and a

short, tension-free fundoplication designed to re-create the distal high-pressure zone. By

performing a fundoplication, the distal esophagus is essentially "submerged" into the

proximal stomach, which serves to re-create the acute angle of His and distal high-

pressure zone. As intragastric pressure and volume increase, the enveloped distal

esophagus is compressed, thereby preventing reflux. When viewed with a retroflexed

endoscope, a nipple valve the length of the fundoplication becomes evident (Figure

2).9, 10, 11

Figure 2: a. An endoscopic view of a 360-degree fundoplication.

b. The fundic wrap viewed from a retroflexed endoscope appears


as a nipple valve. c. The body of the valve takes on a "stacked
coils" appearance and should run perpendicular to the
endoscope. (Source: Jobe BA, et al. Endoscopic appraisal of the
gastroesophageal valve after antireflux surgery. Am J
Gastroenterol 2004;99(2):241 with permission from Blackwell
Publishing.)

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Antireflux Surgery and the Complications of Gastroesophageal Reflux


Disease

Esophagitis and Peptic Stricture

In those with erosive esophagitis, PPIs will enable complete mucosal healing in 90% of

patients. However, if the medication is stopped, esophagitis will return within 1 year in

80% of patients.12 This highlights the limitation of medical therapyit does not address the
mechanical etiology of GERD. Multichannel intraluminal impedance studies have recently

demonstrated that acid-suppression therapy does not affect the total number of reflux

episodes; rather, the refluxate is rendered less acidic and is not detected with standard pH

monitoring. Other than acid, undefined characteristics of refluxed gastric fluid may be

contributing to ongoing esophageal mucosal damage. This may explain the failure of

medical therapy in some patients with reflux disease.

With the widespread use of effective medical therapy, peptic stricture is now relatively

uncommon. In a large Veterans Administration study of typical GERD patients,

approximately 13% developed stricture.13 Overall, the reported incidence ranges between

10% and 25%. Therapy for stricture begins with PPIs, which have been shown to

effectively treat esophagitis, reduce the need for dilations, and alleviate

dysphagia.14 ThePPIs successfully treat 90% of patients; however, 80% experience a

recurrence if medical therapy is withdrawn. A number of patients require dilation or

multiple dilations to treat recalcitrant dysphagia, especially if they have long-standing

disease. These patients may benefit from surgical intervention. In a study of 74 patients

with peptic stricture refractory to medical therapy, Klingler et al. 15 showed that

laparoscopic antireflux surgery (LARS) diminished the need for further dilations fivefold

and significantly reduced dysphagia scores. Dysphagia scores dropped from a mean of 6.8

to 3.7 (p <.0001). Ninety-one percent of patients reported satisfaction with the procedure.

Twelve percent of patients required ongoing medication for residual symptoms or

dyspepsia. Laparoscopic antireflux surgery is as effective as medical therapy in treating

stricture and reduces dysphagia and the need for dilation.

Barrett's Esophagus
Barrett's esophagus (BE) occurs most frequently in those with long-

standing GERDsymptoms. It is intestinal metaplasia of the esophageal lining in response to

the chronic and injurious effects of reflux. The presence of BE represents a 40 to 60 times

increase in the risk of a patient developing esophageal adenocarcinoma when compared to

a person without BE. Whether BE represents an indication for surgery in and of itself has

been intensely debated. Many surgeons feel that LARS is the best way to prevent ongoing

exposure to all forms of reflux and thus reduce the risk of dysplasia and cancer. Although

several retrospective studies have demonstrated regression of BE or low-grade dysplasia

after antireflux surgery,16, 17 there is no conclusive evidence that surgery prevents or

decreases the risk of developing adenocarcinoma. Inasmuch as the finding

of BE represents long-standing severe GERD, these patients should be referred for surgery

based on symptom control and disease-related complications.

Asthma and Atypical Symptoms

Our understanding of GERD has expanded to include its effects not just in the esophagus

but also in the upper aerodigestive tract. Laryngopharyngeal reflux can manifest as

hoarseness, cough, wheeze, aspiration pneumonia, pulmonary fibrosis, and laryngeal

dysfunction. Initially, treatment consists of high-dose PPIs. However, atypical symptoms

fail to resolve with medical therapy in more than 40% of patients. Surgery is a viable

option in patients with laryngopharyngeal symptoms that have proximal reflux events

based on pH monitoring. The overall symptomatic response rate with laparoscopic

antireflux surgery in patients with laryngopharyngeal reflux symptoms and asthma is less

than for patients with only typical GERD symptoms.


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Preoperative Evaluation and Objective Testing

Proper patient selection is the key to successful surgical treatment of GERD. Beginning

with a history and physical exam, symptoms are classified as either typical or atypical.

TypicalGERD symptoms include heartburn, regurgitation, belching, and dysphagia. Atypical

symptoms include hoarseness, chest pain, laryngospasm, globus sensation, cough, and

wheezing. Frequency and timing of reflux symptoms, relationship to meals, symptom

exacerbation with supine or upright position, and difficulty swallowing are noted. As a

diagnostic tool, symptoms alone cannot provide or exclude a diagnosis of GERD.

Symptoms have a limited positive predictive value in the initial presentation of GERD18 and

in those patients with postoperative symptoms. 19

Routine preoperative objective evaluation includes 24-hour pH monitoring, manometry,

esophagogastroduodenoscopy (EGD), and barium swallow. Gastric emptying studies may


reveal gastroparesis in those with symptoms of nausea and vomiting or those suspected of

having a vagal nerve injury after a primary antireflux operation. The goal of preoperative

testing is to verify that symptoms are the result of GERD, and assess for any complicating

factors such as short esophagus, stricture, BE, or cancer that may change the operative

intervention. The best predictor of a good surgical outcome is objectification of reflux

events and correlation of these events with symptoms.

Twenty-four-hour pH Monitoring

Twenty-four-hour esophageal pH monitoring is the most sensitive and specific test

forGERD. This test should be performed to establish the diagnosis of GERD, particularly in

any patient with a nondiagnostic EGD or atypical symptoms of GERD. An abnormal finding

would be a drop below a pH of 4 for more than 4% of a 24-hour period. A DeMeester score

is calculated to grade GERD severity. The test is performed with the patient off all

antisecretory medications. Twenty-four-hour pH studies also provide insight into the

pattern of reflux; some patients may exhibit positional reflux (upright, supine, mixed).

Possibly supplanting the cumbersome catheter based pH monitoring system is the BRAVO

probe (Medtronic, Shoreview, MN), a pH-sensing capsule endoscopically secured in the

distal esophagus. It boasts minimal discomfort and it detaches spontaneously, so there is

no need for retrieval. The pH sensor transmits a signal to a portable recording device,

which is then downloaded. Designed to free patients from the inhibition imposed by a nasal

catheter, the BRAVO system has been widely accepted by patients and physicians in the

diagnosis ofGERD. It is equal to or better at detecting acid when compared with a

catheter-based system. Additionally, the BRAVO probe is able to extend the period of

ambulatory monitoring, which may improve the diagnostic accuracy. 20

Barium Swallow

The barium swallow is useful in the diagnosis of structural abnormalities such as stricture,

nonreducible hiatal hernia, paraesophageal hernia, and diverticula. The esophogram

demonstrates extrinsic compression and mucosal abnormalities, and offers a real-time

view of the action of the esophagogastric junction. However, the ability of the esophogram

to detect GERD is limited, with a sensitivity of 34%.21 Important characteristics of hiatal

hernia to note during esophogram are reducibility and size. A nonreducing hernia may

predispose to failure of ARS. A larger (>5 cm) hiatal hernia indicates long-standing disease

with associated mediastinal scarring and possible shortened esophagus. The challenge is to

reduce the large hernia (which may require extensive mediastinal dissection) and provide

enough intraabdominal esophageal length so as not to put tension on the fundoplication.


Tension with subsequent mediastinal herniation is the most common form of mechanical

failure after surgery.

Esophagogastroduodenoscopy (EGD)

All patients considered for ARS must undergo EGD, which can establish a diagnosis

of GERDin the case of severe, erosive esophagitis. In addition, retroflexed endoscopic view

of the gastroesophageal junction can provide an assessment of the competency of the

gastroesophageal flap valve and identify a hiatal hernia. Furthermore, EGD is necessary to

rule out alternate causes of symptoms, such as malignancy, and

identify BE.22Esophagogastroduodenoscopy also offers the opportunity to identify and

dilate strictures. Although esophagitis on endoscopy has traditionally been used to confirm

a diagnosis ofGERD, studies suggest that all patients regardless of their endoscopic exam

should undergo pH testing. In a study by Khajanchee et al., 23 patients with esophagitis

with a normal DeMeester scores had a significantly less favorable outcome than those with

abnormal scores [odds ratio (OR) 9.02, p <.01). It is important to perform barium swallow

before EGDin patients who complain of dysphagia. This may alert the endoscopist to

diverticula, hiatal hernia, webs, or other structural abnormalities that may be treated

during the endoscopy or explain the patients symptoms.

Manometry

Manometry is performed in all patients undergoing evaluation for an antireflux procedure.

Manometry confirms aboral peristalsis, assess adequacy of esophageal peristaltic pressure,

and locates and measures the upper and lower esophageal sphincter and their resting

pressures. A mechanically defective LES is characterized by three parameters: total length

shorter than 2 cm, abdominal length shorter than 1 cm, and a resting pressure less than 6

mmHg. A hypotensive LES is the most common finding in patients with GERD. If one

component of the triad is defective, there is a 69% to 76% prevalence of GERD. Having all

three parameters be defective guarantees a dysfunctional LES. Manometry identifies

motility disorders such as achalasia or diffuse esophageal spasm that would complicate or

otherwise preclude an antireflux procedure. If the esophageal contraction amplitude is not

>30 mmHg, the pressure needed to pass a food bolus past a Nissen fundoplication, then a

partial type fundoplication should be considered. A partial fundoplication may diminish the

chance of developing dysphagia postoperatively.

Multichannel Intraluminal Impedance-pH

Recent research utilizing a technology called combined multichannel intraluminal

impedance and pH-metry (MII-pH) has demonstrated that many reflux events go

undetected by pH testing alone. This technology allows the detection of nonacid and
weakly acid (a drop in pH of one unit with a nadir above pH 4) reflux in addition to

traditional acid reflux events. In addition, this technology enables one to determine the

duration and proximal extent of reflux episodes. Utilizing a thin catheter similar to a pH

probe, six sequential electrode pairs measure the impedance to electrical current between

them. As these electrode pairs are bridged with refluxate, the impedance decreases,

indicating an event. With respect to antireflux surgery, impedance testing may present the

opportunity to identify nonacid reflux events as a cause of symptoms that are refractory to

medical therapy. It is theorized that these patients would benefit from LARS much like

patients with typical acid reflux. Although prospective studies are lacking, MII-pH holds

promise in enhancing the understanding of atypical symptoms, laryngopharyngeal

symptoms, and persistent symptoms in patients on maximal medical therapy.

Other Factors

In addition to objective measures, one should assess the patient's ability to tolerate an

operation physically and emotionally. The surgeon must evaluate patient compliance and

understanding of the procedure and possible side effects. Setting expectations is a major

component of the preoperative workup. Preexisting psychiatric diagnoses have been linked

with failed antireflux surgery24. Velanovich et al. showed that 95% of patients without

psychiatric diagnosis were satisfied with ARS, whereas only 11% of psychiatric patients

found the surgery to be helpful25. Patients who have stress aerophagia or who have eating

disorders such as bulimia should be approached cautiously (if at all).


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Minimally Invasive Antireflux Surgery

The popularization of laparoscopic fundoplication has been fueled by both patient demand

and growing familiarity among surgeons with advanced laparoscopic techniques. In

general,LNF is associated with a shorter hospital stay, decreased postoperative pain,

earlier return to solid food, and better cosmesis than the open approach. 26 In addition, a

laparoscopic approach may provide better visualization of the hiatus and allow extended

dissection into the mediastinum. Randomized clinical trials comparing open and

laparoscopic Nissen fundoplication have found no difference in long-term symptom relief,

esophageal acid exposure, esophageal sphincter pressure, postoperative dysphagia, and

overall satisfaction26, 27, 28 (Tables 1 and 2). Although laparoscopic Nissen fundoplication has

largely overtaken its open counterpart, it is an operation that requires advanced

laparoscopic skills and has a significant learning curve. In the early phase of the learning

curve, generally considered the first 25 to 30 cases, intraoperative complications such as

esophageal perforation and bleeding are higher, conversion rates to laparotomy are
higher, and operative time is longer. 29 Although the perioperative complications are higher,

the long-term quality of life score as well as objective functional outcomes are similar for

operations performed in the early and late phases of the learning curve. 30

Table 1: Laparoscopic versus open fundoplication results of four


randomized controlled trials

Full size table

Table 2: Laparoscopic versus open Nissen fundoplication results of four


randomized controlled trials

Full size table

Regardless of the procedure chosen, the reconstruction must provide a functional barrier

to reflux while producing the fewest side effects possible. Additionally, three essential

goals must be met: (1) adequate intraabdominal esophageal length to allow a tension-free

fundoplication, (2) mobilization of the fundus to facilitate a torsion and tension-free

fundoplication, and (3) closure of any associated hiatal defect. Partial-type fundoplications

are now reserved for those undergoing myotomy for achalasia and those with severe

hypomotility on manometry. The "tailored approach," which calls for partial wraps in those

with esophageal motility disorders has lost favor, being supplanted by the favorable results

obtained with total fundoplications even in those with esophageal motility disorders.

However, practices differ in many parts of the world, with similar outcomes using different

techniques. Regardless of technique, emphasis should be placed on safety, reducing side


effects, and performing the most durable repair to prevent gastric refluxate from entering

the esophagus.

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Indications for Operation

The key to success with antireflux surgery resides in proper patient selection. Many

patients with moderate to severe GERD are candidates for LARS especially with the advent

of minimally invasive techniques that promise low morbidity, shorter hospital stays, and

greater than 90% success rates in experienced hands. Although many patients find relief

of their symptoms with PPIs, as many as 10% of medically treated patients still suffer

breakthrough symptoms of GERD and up to 50% of patients require lifelong medication. In

severe erosive esophagitis, PPIs heal 90% of patients, but the condition recurs within 1
year in 80% after drug withdrawal. Along with residual symptoms, intolerance to

medication and the development of GERD-related complications represent reasons to

pursue LARS. Medication failure is perhaps the most common reason to refer for surgical

management. Additionally, many patients weigh the long-term cost and lifestyle

adjustments as factors when deciding whether to pursue surgery. The patients most likely

to benefit from LARS are those who have abnormal 24-hour pH testing scores, typical

symptoms, and a good response to medical therapy. 31

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Contraindications to Surgery

Antireflux surgery is contraindicated in patients who cannot tolerate general anesthesia or,

in the case of the laparoscopic approach, a pneumoperitoneum. An uncorrectable

coagulopathy and severe cardiopulmonary disease both preclude surgery. In patients with

previous foregut surgery or in those who have had prior upper abdominal surgery, the

laparoscopic approach can be attempted initially. Most repairs are completed

laparoscopically; however, these patients do have a higher risk of conversion to

laparotomy. Adhesions and large fatty left liver lobe are the primary reasons for

conversion to open procedure.

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Operative Techniques

Total Fundoplications
Laparoscopic Nissen Fundoplication (360-Degree Fundoplication)

After general anesthesia has been induced, the patient is positioned in the low lithotomy

position. The surgeon operates from between the patient's legs. An assistant helps retract

the liver from the right. Placing the patient in steep reverse Trendelenburg position helps

to retract the abdominal contents away from the esophageal hiatus (Figure 3).

Figure 3: A typical operating room setup for performing laparoscopic


antireflux surgery (LARS).

Setup consists of placing the patient in the lithotomy position


with the surgeon operating from between the patient's legs. This
allows easy access to the foregut and hiatus. The assistant
stands to the left of the patient. (Source: Courtesy of B.A. Jobe,
M.D.)

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After dividing the gastrohepatic omentum, the phrenoesophageal membrane is opened,

gaining access to the posterior mediastinum. With sharp dissection, the right and left
diaphragmatic crura are defined, and the esophagogastric junction is returned to its proper

intraabdominal position with circumferential esophageal mobilization. If there is a hiatal

hernia, it is reduced with the mediastinal dissection. The diaphragmatic crura are then

approximated with nonabsorbable suture posterior to the esophagus. The tightness of the

closure is calibrated such that there is a snug fit around the esophagus, but a laparoscopic

instrument can easily pass through the hiatus.

A harmonic scalpel allows efficient division of the short gastric vessels. This enables

complete mobilization of the gastric fundus in anticipation of a tension-free fundoplication.

Finally, the fundus is passed posterior to the esophagus, wrapped 360 degrees, and

sutured anteriorly using nonabsorbable sutures (Figure 4). Use of the "shoeshine"

maneuver prior to completing the fundoplication ensures that the stomach is not twisted

and that the proper portion of the stomach is employed in the repair; the surgeon grasps

both ends of the fundus and pulls it back and forth behind the esophagus to ensure

adequate mobility and no tension (Video 1). Most surgeons calibrate the fundoplication
over an esophageal dilator in order to prevent a tight a closure with subsequent

postoperative dysphagia; however, some debate the advantage of wrap calibration in light

of the added risk of perforation upon passage of the dilator (Figure 5). At completion, the

fundoplication should be 2 cm in length (Video 2).

Figure 4: Nissen fundoplication.

This intraoperative view is looking superiorly toward the hiatus


and shows a complete Nissen fundoplication wrapping
posteriorly around the distal esophagus. The grasper to the left
(patient's right) points to three sutures holding the two ends of
the fundus securely over the distal esophagus. The liver is seen
being retracted superiorly by a laparoscopic liver retractor, an
essential piece of equipment for exposing the hiatus. The
grasper in the middle shows the course of the esophagus as it
enters the abdomen. The crura are not seen in this picture.
(Source: Courtesy of B.A. Jobe, M.D.)

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Figure 5: Intraoperative view of an esophageal perforation.

The blue bougie has perforated the esophagus. Perforations are


immediately repaired and followed closely postoperatively. A
postoperative barium swallow may be necessary to exclude a
leak. There is also usually a period in which the patient remains
NPO (nothing by mouth) to allow the perforation to heal.
(Source: Courtesy of John Hunter, M.D.)

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Video 1: Shoeshine A and B Cinepak.


Use of the "shoeshine" maneuver prior to completing the
fundoplication ensures that the stomach is not twisted and that
the proper portion of the stomach is employed in the repair. The
surgeon grasps both ends of the fundus and pulls it back and
forth behind the esophagus to ensure adequate mobility and no
tension.

View movie file: Video 1: Shoeshine A and B Cinepak.

Video 2: Final Nissen 2 Cinepak New.

Most surgeons calibrate the fundoplication over an esophageal


dilator to prevent a tight a closure with subsequent
postoperative dysphagia; however, some debate the advantage
of wrap calibration in light of the added risk of perforation upon
passage of the dilator. At completion, the fundoplication should
be 2 cm in length.

View movie file: Video 2: Final Nissen 2 Cinepak New.

There is some evidence that the wrap itself is less likely to be the cause of persistent

dysphagia (>6 weeks); rather, the hiatal closure appears to play a critical role in the

development of this infrequent complication. Based on radiologic and EGD studies,

Granderath et al.32 categorized 50 patients referred for post-ARS dysphagia. Fifteen of 18

patients identified as having crural stenosis with an intact wrap were effectively treated

with pneumatic dilation, lending credence to the hypothesis that too tight of a crural

closure (or accumulated scar tissue) leads to constriction of the esophagus with resulting

dysphagia. Three patients in this group required reoperation. In all, the authors found a

tight hiatal closure effectively narrowing the esophagus. Those patients with transthoracic

migration of the wrap (n = 27) underwent reoperation. All were found to have complete or
partial wrap migration into the mediastinum with evidence of constriction at the hiatus. In

almost 60% of these patients, the crural closure was intact but inadequate in preventing

wrap migration. Only five patients of the 50 had problems with the wrap itself (discovered

at reoperation) that accounted for their dysphagia. These findings point to the importance

of proper hiatal closure in preventing persistent or late-onset postoperative dysphagia. 32

Hill Posterior Gastropexy

The Hill repair is not a fundoplication per se, but a recalibration of the antireflux barrier.

The Hill repair aims to secure the esophagogastric junction into the abdominal cavity,

recalibrate the LES, and re-create the acute angle of His. This is accomplished by

esophageal mobilization, return of the esophagogastric junction to the abdominal cavity

without tension, crural closure, and suture fixation of the right and left phrenoesophageal

bundles to the preaortic fascia. The tightness of the sutures is calibrated using

intraoperative manometry (Figure 6).

Figure 6: The Hill repair.

The anterior and posterior phrenoesophageal bundles ("the


esophagogastric junction") are sutured to the preaortic fascia
after esophageal mobilization and hiatal closure. Tightening of
the sutures is performed in conjunction with intraoperative
manometry to calibrate the fundoplication tightness.
(Source: Courtesy of B.A. Jobe, M.D.)

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Collis Gastroplasty for Short Esophagus

In about 10% of patients undergoing LARS, there will not be adequate intraabdominal

esophageal length. Because the most common cause of failure after antireflux surgery is

related to transdiaphragmatic herniation, at least 2.5 cm of tension-free intraabdominal

esophagus must be present in order to perform a proper Nissen fundoplication. In most

patients, maximal esophageal mobilization reaching up to the aortic arch will enable
adequate length to be achieved. However, despite these efforts, some patients require an

esophageal lengthening procedure such as a Collis gastroplasty. This procedure creates a

tubularized portion of stomach that acts as a continuation of the esophagus (Figure 7). The

fundoplication is subsequently performed around the neoesophagus.

Figure 7: Collis gastroplasty.

The Collis gastroplasty is an esophageal lengthening procedure


that addresses a shortened esophagus. First, an anvil is passed
alongside an esophageal dilator through the fundus (a). This
guides an EEA stapler used to create a sealed "buttonhole"
(b,c). Through this transgastric circular window, a linear cutting
stapler is then placed and fired parallel to the esophageal dilator
(d,e) essentially converting a cuff of proximal stomach into the
distal esophagus. The wrap is then performed around the
neoesophagus. EEA, end-to-end anastomotic stapling device;
GIA, gastrointestinal anastomotic stapling device.
(Source: Horvath KD, et al. The short esophagus:
pathophysiology, incidence, presentation, and treatment in the
era of laparoscopic antireflux surgery. Ann Surg
2000;232(5):630640., with permission from Lippincott,
Williams & Wilkins.)

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The short esophagus may be suggested in the preoperative workup; however, the final

diagnosis can only be made intraoperatively. Four findings have been established to

correlate with the presence of short esophagus: (1) large nonreducing hiatal hernia, (2)

esophageal stricture, (3) Barrett's esophagus, and (4) an LES at 35 cm or less from the

incisors by manometry.

Although there is excellent symptomatic relief of GERD symptoms after combined Collis

gastroplasty and Nissen fundoplication, long-term results demonstrate that the

neoesophagus (tubularized portion of stomach) continues to secrete acid proximal to an


intact fundoplication and can result in mucosal damage. 33, 34 In a follow-up study of

patients treated with Collis gastroplasty, recurrent erosive esophagitis owing to pathologic

acid exposure was found in an alarming 80% of patients. Despite the high incidence of

ongoing mucosal damage, 65% of patients with recurrent disease reported significant

symptomatic improvement compared to preoperative scores. 34 Accordingly, patients should

undergo follow-up with objective testing and be placed on PPIs if there is an abnormal

level of acid exposure regardless of the presence or absence of symptoms. It must be

understood that many of these patients have advanced GERD with a severely damaged

esophagus and severe, medically refractory volume reflux; in this setting, the efficacy of

Collis gastroplasty and fundoplication in ameliorating chronic symptoms is outstanding.

Partial Fundoplications

Toupet Fundoplication (270-Degree Fundoplication)

The Toupet fundoplication is a 270-degree posterior fundoplication that is most commonly

employed after Heller myotomy in patients with achalasia. After the crura is closed, the

fundus is passed posterior to the esophagus similar to the approach used for the

laparoscopic Nissen fundoplication. The limbs of the fundoplication are then sutured

together to the anterior esophagus, taking care to avoid the anterior vagal trunk (Figure

8). Mounting evidence in the surgical literature weighs heavily against the continued use of

partial fundoplication as a primary therapy for medically refractory GERD.35, 36, 37, 38

Figure 8: Toupet repair.

In the Toupet repair, the fundus is wrapped 270 degrees around


the distal esophagus. Securing the fundoplication entails
suturing the fundus on either side of the esophagus.
Identification of the anterior vagal branch helps prevent
incorporation into a suture. Suturing the lateral aspects of the
wrap to the crural edges stabilizes the repair. (Source:Peters,
JH, DeMeester, T (eds). Minimally Invasive Surgery of the
Foregut. St Louis, MO: Quality Medical Publishing; 1994, with
permission)

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Studies of laparoscopic Toupet fundoplication have demonstrated comparable short-term

results to Nissen fundoplication; however, in long-term follow-up, the Toupet repair is

associated with a high symptomatic failure rate. 37 In addition, Toupet fundoplication has

been demonstrated to be inadequate in the treatment of the most severe forms

of GERD.36A study by Heider et al.39 showed that, compared to partial fundoplication, most

patients with dysmotility have improved esophageal peristalsis after undergoing an LNF.

This suggests that GERD-related esophageal injury plays a role in causing dysmotility, and

that abolishing pathologic reflux corrects the motility disorder.

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Postoperative Care

Possibly the most attractive feature of laparoscopic surgery is the prompt recovery time.

The hospital stay is generally 1 to 4 days. Some centers perform LARS as a day surgery in

selected patients. Following an initial trial with clear liquids, patients begin a pureed diet

on postoperative day 1. Liberal use of preemptive antiemetics helps to control

postoperative nausea and vomiting, a common cause of early wrap disruption or

herniation. If there is concern that an occult perforation occurred during surgery, then a

barium swallow is performed before a diet is started. Typically, patients are maintained on

a soft diet for 4 to 6 weeks and then transitioned to solid foods as tolerated. Bread and

meat should be avoided for the first 6 weeks, as these items are notoriously troublesome

to swallow. Frequently, there is some dysphagia in the early postoperative period;

however, this should resolve within 6 to 8 weeks.

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Complications of Nissen Fundoplication

Intraoperative and Early Complications

Intraoperative complications include esophageal perforation, pneumothorax, splenic injury,

bleeding, and missed visceral injury. Esophageal and gastric perforations occur in

approximately 1.5% of cases; if detected, they are repaired primarily, and drains are

placed to minimize the risk of peritonitis or mediastinitis. Pneumothorax is usually self-

limited because CO2 is rapidly reabsorbed from the pleural space. Chest tube placement is

rarely indicated. Splenic injury can take the form of infarction or bleeding. Superior pole

infarction can occur with ligation of the short gastric arteries and does not require
intervention. Splenic bleeding may require conversion to a laparotomy and urgent

splenectomy. The rate of splenectomy should be less than 1% in experienced hands.

Cautery injury can result in delayed intestinal perforation and peritonitis. Meticulous

dissection and gentle retraction can help prevent injury. It is paramount that the

instruments be in view during the laparoscopic procedure to avoid an occult injury. An

abdominal survey before closure can help identify any signs of bleeding or visceral injury.

Overall, the complication rate associated with Nissen fundoplication is 13%. 40

Late Complications

Although Nissen fundoplication has greater than 90% success in eliminating reflux

symptoms, over time a proportion of patients develop new or recurrent foregut symptoms.

Some dysphagia, gas bloating, and mild residual esophagitis are common in the early

postoperative period, but these symptoms generally resolve within 3 months; severe or

persistent symptoms may indicate failure and the need for further investigation.

Of patients undergoing LARS, 2% to 6% eventually require reoperation.41, 42, 43, 44Reported

mechanical causes of failure vary significantly among studies, but transthoracic herniation

occurs in 10% to 60% of failures and "slipped" fundoplications are responsible in

approximately 15% to 30% of patients. Tight fundoplication, missed motility disorders,

and paraesophageal hernias are other modes of LARS failure41, 45, 46, 47, 48, 49, 50 (Table 3).

Table 3: Complications of Nissen fundoplication

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One of the reasons for pursuing LARS is to offer patients, especially the young, freedom

from daily medication dependence. However, data suggest that many patients are using

antisecretory medications after ARS. Some construe this as surgical failure. Closer

examination of prescribing patterns reveals that many patients are receiving antisecretory

medication for symptoms unrelated to the presence of recurrent GERD. Lord et al.19showed

that only 24% of 86 symptomatic, medically treated patients post-ARS had abnormal distal

esophageal acid exposure. This study indicates that many patients with foregut symptoms
after ARS are taking antisecretory medication based on symptoms alone and not on

objective evidence to support their use. In this study, the authors found a very poor

positive predictive value of symptoms, including moderate to severe heartburn and

regurgitation, and the presence of abnormal acid exposure. Latent, preexisting foregut

disorders may be unmasked by the eradication of reflux symptoms by ARS; therefore,

failure of the wrap should not be assumed when addressing post-ARS symptoms.

Symptoms after ARS should be investigated to rule out esophageal motility disorders,

gastroparesis, delayed gastric emptying, irritable bowel syndrome, gastritis, and nonulcer

dyspepsia, and to ensure the integrity of the fundoplication. Resuming medication

after ARSshould be based on objective evidence of GERD as measured by 24-hour pH

monitoring.

A "slipped" or misplaced fundoplication occurs when the proximal stomach (instead of the

distal esophagus) is wrapped with the fundoplication. Endoscopically, there is a pouch of

stomach proximal to the narrowing caused by fundoplication. The slippage is usually the

result of transthoracic herniation and represents one of the most common forms of failure.

This may be the result of tension on the diaphragmatic closure secondary to an

unrecognized short esophagus (Figure 9). Twisting of the wrap is a technical error that can

result in a poor outcome. Twisting results from employing the distal greater curvature

(antrum) of the stomach as the fundoplication; this results in a two-compartment, twisted

stomach and episodic emesis and abdominal pain. Endoscopically, twisted wraps appear as

obliquely running folds with respect to the endoscope. These patients require reoperation.

Figure 9: Mechanisms of fundoplication failure.

a: Total disruption of the fundoplication with herniation of the


fundus into the mediastinum. b: Herniation of the fundus into
the chest through the fundoplicationa slipped Nissen. This
complication is most likely caused by an unrecognized short
esophagus. c: The fundus has been wrapped around the body of
the stomacha technical error. d: Total herniation of the
fundoplication into the chest.

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A focused evaluation of postoperative symptoms begins with reviewing all prior records

and objective testing. Again, repeat 24-hour pH testing, EGD, manometry, and

esophagram are helpful studies to elucidate mechanisms of failure. By measuring

the LES length, position, and resting pressure, manometry can determine the integrity of

the fundoplication and gauge whether it is tight or located intrathoracically. Esophageal

function is evaluated for undiagnosed achalasia, diffuse esophageal spasm, or other

motility disturbances that might account for postoperative symptoms. Twenty-four-hour

pH testing will confirm recurrent reflux but will not identify the anatomic mechanism of

failure. Esophagram is a very valuable test in the workup of fundoplication failure. This

exam identifies fundoplication herniation or contrast retention secondary to a tight

fundoplication. Esophagogastroduodenoscopy is also very valuable in determining the

anatomic causes of fundoplication failure.

Redo Surgery

In our practice, we consider patients for redo surgery if they present with persistent or

recurrent foregut symptoms or if they develop symptoms not present prior to surgery.

Surgical intervention is carried out in those who have an identifiable anatomic abnormality

or a physiologic cause based on objective testing. Redo surgery can be technically

challenging in even the most experienced hands. To provide a durable repair, the cause of

the failure must be unequivocally identified so as to avoid a subsequent failure; this

mandates that the entire fundoplication be dismantled prior to reconstruction. A

laparoscopic technique is typically the initial approach, but a laparotomy is always an

option in difficult cases. Rarely, a thoracic approach may be necessary. Esophageal

perforation is the complication most feared when performing redo surgery secondary to

adhesions and scarring.

Smith and colleagues51 reported a 2.8% failure rate requiring reoperation in a series of

1892 patients undergoing antireflux surgery over a 13-year period; of the failures, 73%

required reoperation within the first 2 years of surgery. The most common mechanism of

failure was transdiaphragmatic wrap herniation (61%). The laparoscopic approach was

used in the majority of these patients and the conversion rate to laparotomy was 8%.

Similarly, Dutta et al.52 reported a reoperation-related conversion rate of 7%.

Although not as good as for a primary operation, it is important to mention that

satisfaction rates after reoperative antireflux surgery are quite respectable. Almost 90% of

patients have an outstanding or acceptable outcome with redo fundoplication. In a


retrospective review of 118 patients, one study demonstrated that symptomatic response

rates approach those of primary surgery.53 Redo laparoscopic ARS is feasible with

acceptable complication rates and good success rates. It can provide a clinically effective

means in the management of recurrent GERD symptoms.

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Long-Term Results

Safety, Morbidity, and Mortality

Laparoscopic ARS is safe, effective, and durable. When selecting patients for surgery, it is

important to understand that ARS is an elective procedure, meant to alleviate symptoms

and prevent long-term complications of GERD. As of yet, no randomized controlled trial

has shown that LARS prevents the progression of Barrett's esophagus into dysplasia or
adenocarcinoma. Some series demonstrate a trend toward decreased cancer risk, but

these findings are weakened by retrospective design and sample size. 54, 55, 56 Esophageal

cancer is a rare entity, posing difficulties in its study.

Mortality rates associated with LARS are very low, ranging from 0.008% to 0.8%57 in large

series. In fact, many large, single-institution retrospective studies reported zero mortality.

Carlson and Frantzides49 examined 10,000 antireflux operations and demonstrated a

morbidity rate of 2%. These data came from large, academic referral centers and private

practice experience. Early wrap herniation, pneumothorax, gastric perforation, and

hemorrhage were the most common serious complications, each occurring around 1% of

the time. This study did not mention splenectomy. In another large retrospective study of

over 5000 patients undergoing ARS, splenectomy occurred in 2.3%, esophageal laceration

in 1.1%, and the mortality was 0.8%. The study period was 1992 to 1997, during the

developmental phases of the laparoscopic approach to Nissen fundoplication. Adverse

events were significantly more likely in the surgeon's first 15 cases. This speaks to the

need for specialized training to guide the surgeon through the learning curve and ideally

avoid perforations and other disastrous complications. 58

Predictors of Outcome

Campos et al.31 identified three main predictors of good outcome in a study of 199 patients

undergoing LARS. At a median follow-up of 15 months, 87% of patients reported good to

excellent results. The most likely to benefit from LARS were those who had abnormal 24-

hour pH testing scores, typical symptoms, and a good response to medical therapy. The

strongest indicator of good surgical outcome was the 24-hour pH study [OR 5.4, 95%
confidence interval (CI) = 1.915.3]. In studies with respiratory symptoms related

toGERD, symptoms correlation with reflux events were strong indicators of good outcome.

Patient Satisfaction and Symptom Control

Most large studies for LARS report high patient satisfaction rates at least 5 years out. A

study published by Anvari et al. showed an impressive follow up of 181 patients at 5 years

postlaparoscopic Nissen fundoplication (Table 4).59 These patients agreed to undergo

objective testing including manometry and 24-hour pH testing. Significant improvements

in symptom scores, lower esophageal sphincter pressure (LESP), and normalization of

esophageal pH were maintained at 5 years postoperative. Ten-year results are emerging

from Belgium where the first laparoscopic Nissen fundoplication was performed by

Dallemagne et al.58 Of the 86 patients evaluated at 5 years, 69 returned for follow-up.

Results demonstrate that at 10 years, 89.5% of patients were symptom free. Only 9%

were taking PPIs, and 7% had undergone revision surgery.


Table 4: Results of laparoscopic Nissen fundoplication in 181 patients
followed for 5 years

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Antireflux Surgery vs. Medical Therapy

In most patients, the long-term management of GERD can be achieved with medical or

surgical therapy. Several randomized controlled trails have compared surgical to medical

therapy. Unfortunately, each investigation is limited by sample size and variables that

make interpreting and comparing the results challenging. For example, the largest of the

studies was performed in veterans who, as a group, are quite different from the general

population. From this, it is difficult to determine whether the results are generalizable.

The first randomized controlled trial investigating medical versus surgical therapy is the

Veterans Administration GERD Study Group trial, which provided the longest follow-up

data. This trial demonstrated the superiority of surgery over histamine receptor blockade

and lifestyle modifications in the treatment of typical GERD symptoms and esophagitis in
247 veterans.60 The 10-year follow-up of this study demonstrated that 62% of surgical

patients were on antisecretory medication. Rates of esophagitis and abnormal esophageal

acid exposure were equivalent between the two groups. 13 To some, the results of this

follow-up study were misconstrued to imply that surgical therapy for GERD is ineffective. It

is important to remember that this was an intention to treat analysis, and several of the

patients who were originally randomized to surgery, never received this therapy and thus

remained on antisecretory therapy. A symptom-based questionnaire was delivered to

subjects both on and off medical therapy; compared to the medically treated patients,

those who underwent antireflux surgery had only a slight increase in GERD-related

symptoms off medication. Furthermore, they had significantly lower symptom scores off

medication than their medically treated counterparts. The implication is that surgery is

effective in maintaining symptom control, and that many patients are placed

on PPI therapy for nonGERD-related reasons.

Lundell et al.61 examined medical versus surgical therapy in a well-designed randomized

controlled trial. At 5-year follow-up (n = 310), surgery was demonstrated to be superior to

medical treatment under a strict set of symptomatic and endoscopic "failure" criteria.

However, if the dosage of PPI was increased to accommodate for breakthrough symptoms

in the medically treated subjects, the two therapies were found to be equivalent.

A recent randomized controlled trial that examined medical versus surgical treatment

comes from Mahon et al.62 in the United Kingdom. Three-month follow-up showed

significantly less acid exposure to the distal esophagus by pH testing in the surgical arm.

At 12 months, surgical patient's gastrointestinal and general well-being scores were

significantly improved over the PPI group. The dosage of PPIs was titrated to abolish all

reflux symptoms. Long-term results of this study will be eagerly awaited.

In all, there have been few randomized controlled trials that use consistent criteria to

evaluate medical and surgical therapy. However, certain conclusions can be drawn.

Surgery in the properly selected patient can achieve excellent and durable symptom

control and can ameliorate long-term effects of esophageal acid exposure. For a multitude

of reasons, LARSdoes not necessarily free patients from medication dependence.

Surgical Results in Patients with Atypical Symptoms

Respiratory and atypical symptoms that stem from GERD have been shown in several

studies to be improved by LARS over medical therapy. One recent study by Ciovica et

al.63showed a significant improvement in 126 patients with preoperatively documented

respiratory symptoms and GERD treated with PPIs. The patients then underwent LARS.

Cough, sore throat, hoarseness, and laryngeal symptoms improved postoperatively and
remained improved at 12 months. In another study with 21 GERD patients with respiratory

symptoms, relief was obtained in 66% of patients and 19% showed improvement of

respiratory symptoms. The medically treated control group only showed a 14%

improvement in respiratory symptoms at 6-month follow up. Regurgitation symptoms were

well controlled in the LARS group but unaffected in the medically treated group. This offers

good supporting evidence that reflux reaches the upper airways and triggers respiratory

symptoms.64

Farrell et al.65 also found improvement in atypical symptoms in response to LARS, although

much less impressive than improvement in typical GERD symptoms. Ninety-three percent

of patients showed improvement and 48% complete resolution in atypical symptoms in 56

patients who underwent LARS. Hunter's group66 found in a retrospective study of 39

patients with GERD-triggered asthma that systemic steroid use significantly decreased

afterLARS. Allen and Anvari67 examined the effect of LARS on cough in patients with GERD.

Cough was significantly improved at 5-year follow-up.

In contrast to PPI therapy, LARS provides a mechanical barrier to reflux preventing

refluxate, whether acid, nonacid, or alkaline, from reaching the larynx and airway.

Theoretically, reducing vagally mediated bronchospasm from reflux-related distal

esophageal injury is another mechanism by which LARS alleviates symptoms. Patients with

atypical symptoms can be diagnostically and therapeutically challenging to the clinician;

however, these studies indicate that LARS may be superior to medical therapy at

alleviating atypical and respiratory symptoms.

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Cost-Effectiveness

Several conflicting studies have surfaced recently that address the cost-effectiveness

ofLARS versus medical therapy with PPIs. For example, a Veterans Administration

Cooperative study by Arguedas et al.68 demonstrated that long-term management

with PPIs was superior to LARS in terms of quality adjusted life years (QALY) and cost over

10 years. They projected that medical therapy would total $8,798 versus $10,475 for

operation at 10 years, and QALY would be 4.59 versus 4.55 in the surgical group. In

contrast, a recent British study by Cookson et al. 69 has shown that laparoscopic Nissen

fundoplication is cost-effective after 8 years compared with maintenance therapy with PPIs

in patients with severe GERD. A previous study by Heikkinen et al.28 from Finland showed

that total cost was actually lower for Nissen fundoplication mostly owing to earlier return

to work.
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Conclusion

From Rudolph Nissen's first fundoplication to the current endeavors in endoscopic therapy,

the treatment of GERD continues to undergo refinements on many fronts. Antireflux

surgery has established itself as a safe, durable, and effective therapy for typical GERD.

Long-term outcome studies have consistently demonstrated LARS to provide

reconstruction of the antireflux barrier that translates into effective symptom control and

prevention ofGERD-related complications. The results achieved with the Nissen

fundoplication should serve as the standard for surgical and endoscopic therapies directed

at the treatment ofGERD.

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