Gastroesophageal Reflux Disease

Abstract

Gastroesophageal reflux disease (GORD) is defined as troublesome symptoms and/or injury to the oesophageal mucosa consistent with acid exposure [1]. GORD is common, with an age-adjusted global prevalence of 9% but significant variation across the world [2]. The diagnosis can often be made on clinical grounds and is more likely if there is at least a partial response to a proton pump inhibitor (PPI) [3]. Indications for oesophageal testing have been recently updated in international consensus guidelines, which include guidelines where diagnosis is not clearly established [4]. Fundoplication is the use of the gastric fundus to create a high-pressure zone on or around the lower oesophagus and is usually performed laparoscopically. It can be considered in terms of the completeness of the wrap (generally from 90 to 360°), and if less than 360°, whether the wrap is brought anterior to the oesophagus, posterior, or both. The efficacy and side effect profiles of many of the approaches have been subjected to randomised trials: anterior 90 vs 360° [5]; anterior 180 vs 360° [6]; and posterior 270 vs 360° [7]. The relative merits of each have been recently reviewed by Morino and colleagues [8]. Fundoplication is at least as safe and effective as PPI in relieving the symptoms of GORD [9]. For PPI-refractory GORD, fundoplication is more effective than escalating medical therapy [10].

Introduction

Gastroesophageal reflux disease (GORD) is defined as troublesome symptoms and/or injury to the esophageal mucosa consistent with acid exposure [1]. GORD is common, with an age-adjusted global prevalence of 9% but significant variation across the world [2]. The diagnosis can often be made on clinical grounds and is more likely if there is at least a partial response to a proton pump inhibitor (PPI) [3]. Indications for oesophageal testing have been recently updated in international consensus guidelines, which include guidelines where diagnosis is not clearly established [4]. Fundoplication is the use of the gastric fundus to create a high-pressure zone on or around the lower oesophagus and is usually performed laparoscopically. It can be considered in terms of the completeness of the wrap (generally from 90 to 360°), and if less than 360°, whether the wrap is brought anterior to the oesophagus, posterior, or both. The efficacy and side effect profiles of many of the approaches have been subjected to randomised trials: anterior 90 vs 360° [5]; anterior 180 vs 360° [6]; and posterior 270 vs 360° [7]. The relative merits of each have been recently reviewed by Morino and colleagues [8]. Fundoplication is at least as safe and effective as PPI in relieving the symptoms of GORD [9]. For PPI-refractory GORD, fundoplication is more effective than escalating medical therapy [10].

Indications

• Established GORD, with ongoing troublesome symptoms or complications (e.g., reflux esophagitis).

• Trial of maximal medical therapy (MMT) or intolerance of medical therapy [11]. (MMT often interpreted as twice daily proton pump inhibitor (PPI)).

Contraindications (Relative)

• Unfit for general anaesthetic (e.g., major medical comorbidity).

• Unsafe (e.g., prior complex upper abdominal surgery or injury).

• Severe oesophageal dysmotility.

Pre-op Assessment (Diagnosis Established)

Assess safety to undergo GA/operation.

Preoperative education on the procedure and the likely postoperative course

• all patients will experience port site pain,

• many will get referred shoulder pain (capno-peritoneum and diaphragmatic manipulation/suturing),

• some get chest pain (oesophageal spasm, extensive hiatal dissection),

• likely one night as inpatient,

• diet upgraded from liquid to soft over time (weeks),

• in-depth discussion on possible side effects (especially gas-bloat and flatulence).

OT Setup

Instrumentation

• 3× 5 mm ports (one replaced with 12 mm if cut-down approach preferred or 10 mm camera required), 1× 8 mm port

• 5 mm 30 deg laparoscope (10 mm if using 12 mm port)

• Nathanson retractor—alternative is a ratcheted toothed grasper (requires via an additional 5 mm port in the epigastrium).

• 2× laparoscopic atraumatic graspers (e.g., Johan, DeBakey)

• Advanced energy device—author preference is Ligasure with Maryland-tip.

• Laparoscopic scissors, needle holder, and suction.

• Portex sling.

• Mechanical and chemical prophylaxis and antibiotics per local guidelines.

Surgical Technique

Essential Steps in Synthesis

• Optimal positioning.

• Consider patient safety, operative access, and surgeon ergonomics.

• Safe entry and appropriate port placement.

• Adequate view.

• Liver retraction to expose the entire hiatus.

• Fat retraction suture to expose the entire fundus and the superior pole of spleen.

• Mobilise fundus to allow a loose wrap. Separate from left diaphragm, usually with division of superior short gastrics.

• Dissect the hiatus, by dividing phrenoesophageal ligament, and mobilise the distal esophagus to achieve an adequate intra-abdominal length.

• Restore the normal anatomy, perform cruroplasty, reconstitute the phrenoesophageal attachment.

• Create the wrap. Fix the fundus to the diaphragm and oesophagus.

Description of the Technique

Patient’s Position

Lithotomy

• We favor the ergonomics of lithotomy with both arms out; Allen’s stirrups (padded leg supports) with reverse Trendelenburg; thighs horizontal.

• Surgeon between legs, camera operator seated on patient’s left, instrument nurse +/− assistant on right.

Alternative, Patient supine

• Surgeon on the patient’s left, assistant right side.

• Bed mount for Nathanson retractor on patient’s right.

Entry (Site for the Laparoscope)

• Approximately 5 cm below the costal margin in midclavicular line. Excellent view of the gastro-splenic region and the left crus of the diaphragm especially in obese patients. (Fig. 1).

• Optical entry or open cut-down with Hasson’s cannula.

Fig. 1

Port placement

Other Ports

Placed under vision after local anaesthetic infiltration.

Precise location per surgeon preference and varied slightly for patient anatomy.

We use:

Surgeon’s ports: 5 mm port—just right of midline for left hand; 8 (or 12) mm port left lateral upper quadrant, anterior to the tip of ninth rib for right hand.

• This port is used for needle and sling introduction and removal and as the exit site of the fat retraction suture.

Retraction port (assistant): 5 mm right upper quadrant

• Retraction and oesophageal sling manoeuvering,

• Liver retraction port: 5 mm sub-xiphisternal incision for Nathanson retractor. Alternatively, 5 mm port for ratcheted toothed grasper placed under left lobe of liver, attached to diaphragm 2 cm above the right crus.

Exposure to Commence Fundal Short Gastric Division (Fig. 2)

Liver retraction—Nathanson retractor or grasper (as above).

Fig. 2

Fat retraction and site of commencement of short gastric division

Omental retraction—Omental suture

• Via left lateral port, full length 2/0 polypropylene, artery clip on free end outside the body, multiple bites of omental fa, attached to superior greater curve overlying/covering the short gastric vessels. Needle removed via same port, port removed then reinserted with both arms of suture outside the port. Both suture arms secured with artery clip at skin level once adequate retraction. Retraction under vision monitoring the spleen, with cessation of retraction if any splenic movement.

• For obese patients, a retraction suture can be helpful on the lesser omentum to improve visualisation of the right crus and posterior hiatus.

Dissection

Limited division of superior short gastric vessels with Ligasure to allow sufficient mobility of fundus for the wrap.

• Assistant retracts the fundus to the right to expose short gastric vessels.

• If the gastro-splenic distance is very short, divide the peritoneum overlying the vessels as well as the peritoneal reflection from the fundus to the diaphragm first. This allows the vessels to lengthen and be divided with safety, avoiding physical or thermal injury to the stomach wall or splenic capsule.

Exposure and sharp division of the left phrenoesophageal ligament.

• Continue phrenoesophgeal ligament division anteriorly as far as possible to the right.

Expose the right crus.

• Assistant grasps anterior cardia fat pad and pushes to the left.

• Divide the superior lesser omentum with the Ligasure. It is rare to need to divide as low as the pars flaccida; open a few centimeters superiorly and preserve the hepatic branch/es of the vagus). Similarly, an aberrant left hepatic artery, if present, should be preserved.

Complete dissection of the right phrenoesophageal ligament

• Sharp and blunt dissection to meet the dissection from the left.

• Anterior and posterior vagi must be identified and preserved.

Bluntly dissect posteriorly.

• Typically, with the suction device using blunt dissection, aiming to be between the posterior oesophageal wall and the posterior vagus so that it is excluded from the wrap. This is because unlike the anterior vagus, the posterior vagus is not closely applied to the oesophageal wall. After coming through the hiatus it turns abruptly posteriorly so that the majority of its fibres can join the coeliac and superior mesenteric plexuses. In the uncommon scenario of the posterior vagus not easily separating from the oesophagus it can be included in the wrap.

Pass a sling around the esophagus

• Pass a blunt grasper behind the oesophagus from right to left. View the grasper tip anterior to the left crus and bring in the sling via the left lateral port, passing it behind the oesophagus but in front of the posterior vagus (see above). Both ends of the sling are taken out of the port and an artery forceps applied without tension.

• The two segments of the sling can be grasped close to the anterior oesophago-gastric junction by the assistant allowing the lower oesophagus to be manipulated.

Complete the anterior hiatal dissection

• With distal sling retraction, dissect the loose areolar tissue off the oesophagus. The anterior vagus usually runs on the oesophageal wall and is preserved.

Complete the posterior hiatal dissection

• Assistant lifts the sling anteriorly. Approach from the right aspect with the 30 deg scope angled to look to the left.

• Clear tissue posteriorly to identify the left crus through the window.

• If the posterior vagus was not included in the sling, it should be identified and pushed posteriorly.

• There should be a window for the wrap to be brought through.

Relax the sling and ensure an adequate intra-abdominal length of esophagus, which should be around 2 cm.

Closure of the Hiatus (Fig. 3)

Approximate the posterior right and left crura

• Use interrupted 2/0 Novofil incorporating crural muscle and overlying connective tissue (otherwise at risk of the suture cutting through). Note that the bulk of the left crus is anterior requiring only a modest bite with the suture, while the right crus is thinner and a larger bite should be considered (ensuring no injury to the inferior vena cava). The left crus is usually also longer (semi-circular) than the more vertical and straight right crus, often necessitating asymmetric bites to ensure an appropriately-shaped hiatus is created. 

• Closure should be enough for an anterior hiatal space that would allow two blunt graspers to be placed (without difficulty).

• Typically, one posterior suture is all that is required, if no hiatus hernia or minimal herniation is present. (Anterior hiatal suture closure is typically only required for giant hiatus hernias with large hiatal defect and attenuated left crus.)

Fig. 3

Approximation of the right and left crus posterior to oesophagus

Reconstruction of the Left Phrenoesophageal Ligament

This helps maintain an adequate intra-abdominal length of oesophagus and discourages herniation through the space, which, in our early experience, was the most common site for fundal hiatal herniation.

Assistant retracts the sling to the patient’s right to identify the left crus.

Approximate the oesophagus muscle wall to the left crus.

• 3/0 Prolene or PDS continuous suture from 6 o’clock to 1 o’clock position

• Modest bites of the left crural pillar and the oesophageal muscularis propria.

Fundoplication—Nissen or Toupet (Fig. 4)

Conceptually, the fundus is taken behind the oesophagus with the angle of His being the pivot point and not rotated or displaced

• Loosen the left omental retraction suture/s.

• Left-hand grasper posterior to the oesophagus, right-hand grasper places the apex of the fundus into the left grasper.

• Bring the left grasper through the window to position the fundus on the right aspect of the intra-abdominal oesophagus.

• The segment of fundus is brought through more easily by grasping along the line of the superior/greater curve portion rather than the lower/distal portion of the fundus as it appears on the right side of the oesophagus.

Fig. 4

(a) Fundus taken posterior to the oesophagus to the right—“toweling” maneuver to ensure no tension. (b) Completed fundoplication—Nissen (360 ). (c) Completed fundoplication—Toupet (270)

A two-handed “toweling” maneuver can help to set the fundus in position.

• The divided short gastric vessels should lie anteriorly on the right, and the wrap should sit in position without tension. (If not, consider dividing another short gastric vessel).

• The assistant grasps the right portion of the fundus while surgeon gets the sutures. At this time, a bougie can also be passed by the anaesthetist.

Oesophageal bougie passed by anaesthetist.

• We routinely calibrate the hiatal closure with a 48Fr (small female) to 54Fr (large male) bougie.

• Any tension on the sling is released. The anaesthetist announces that it is being pushed distally with slow, cautious passage through the distal oesophagus into the stomach, carefully watched by the surgeon with close communication.

• Bougie is left in place while suturing the fundus.

Nissen Fundoplication

Left and right fundus sutured together anterior to the oesophagus with 2 x nonabsorbable sutures (2/0 Novofil)

• Bites of the seromuscular layer of the stomach, the muscularis propria of the esophagus (avoiding the anterior vagus nerve), and the seromuscular layer of the right fundus that had been held by the assistant.

• The assistant grasps the cardial fat pad to push posteriorly and retract distally after the suture is placed and before the suture is tied.

• The suture is tied. There should be minimal to no tension. If there is high tension then the suture should be removed and redone following manipulation of the fundal wrap.

• A second interrupted suture, 2 cm distal to the first, performed in the same manner.

Toupet Fundoplication (the authors’ preferred option)

The right fundus is fixed to the hiatus and oesophagus followed by the left fundus fixed in the same way.

• At the 10 o’clock position, using a nonabsorbable suture (2/0 Novofil), a bite is taken of the oesophageal muscularis propria, the right crus and the fundus and tied.

• The assistant grasps the cardial fat pad to retract distally and push posteriorly to allow a good view of both fundal components and anterior oesophagus.

• A continuous suture is run picking up oesophagus and fundus for 2 cm and tied.

• This is then repeated on the left commencing at the 1 o’clock position.

• The anterior vagus is avoided and should lie between the two suture lines.

• Remove bougie.

• Gastropexy (after Nissan or Toupet fundoplication) using 2/0 Novofil interrupted suture to fix the fundus to the crura (7 o’clock on the right crus and 5 o’clock on the left crus). This may help to prevent recurrence, which usually occurs on the left and posteriorly.

Fundoplication—Anterior

Mobilization of oesophagus from the hiatus as described earlier

• There is rarely a need for the division of the short gastric branches.

• Ensure an adequate length of intra-abdominal oesophagus.

• There is no need for an oesophageal bougie.

Trial of wrapping anterior fundus across the oesophagus.

Fixation of the angle of His and left oesophagus

• Using a continuous nonabsorbable suture (2/0 Novofil), the angle of His is recreated by taking a bite of the lower antero-medial fundus and the left oesophago-gastric junction.

• The suture is progressed superiorly, between the antero-medial fundus and the left lateral oesophagus, up to the hiatus with the last bite including the left crus.

The fundus is folded 180° over the anterior oesophagus

• Starting superiorly, using a new nonabsorbable suture (2/0 Novofil), take a bite of stomach, oesophagus, and upper right crus at apex and suture tied.

• A continuous suture is progressed inferiorly, picking up the fundus, the right lateral oesophagus, and two further bites of the right crus.

• This is continued on the right lateral esophagus to the oesophago-gastric junction where the suture is tied.

Conclusion

Remove sling, retraction suture/s, Nathanson retractor under vision.

Complete evacuation of capnoperitoneum (reduces postoperative pain).

Ports removed under vision.

Skin closure and dressings per surgeon preference.

Complications and Management

Subcutaneous emphysema—ensure no airway compromise prior to extubation, then simple observation.

Capnothorax—due to pleural injury; observation is usually sufficient but evacuate capnothorax and capnoperitoneum if intra-operative cardiovascular or respiratory compromise.

Oesophageal spasm—see below (presents as severe chest pain in recovery or in the first few postoperative days).

Early dysphagia—best avoided with careful patient selection and intra-operative calibration of the wrap around a bougie; manage with restriction of diet (liquids); if severe then consider early endoscopy and/or reoperation.

Gas bloating—preoperative counseling (avoidance of excessive swallowing/aerophagia), postoperative counseling, cognitive behavioral therapy.

Excessive flatulence—as above.

Late dysphagia—possible causes include hiatus hernia or wrap failure allowing erosive oesophageal injury or stricture; at clinician’s discretion, swallow study, CT, or endoscopy. Also, consider non-GORD diagnoses such as oesophageal dysmotility or malignancy.

Post-op Care

Regular simple analgesia, stronger analgesia (e.g. opiate) as required but this isn't common.

Dull central chest pain is usually from oesophageal spasm.

• In patients with risk factors for ischaemic heart disease, exclude acute coronary syndrome.

• Treat with reassurance, sitting upright, slow deep breathing, and a trial of IV hyoscine butylbromide (Buscopan), sublingual glyceryl trinitrate, or an oral calcium channel blocker if no contraindications exist. Opiates are not always helpful and can cause vomiting; consider a small dose of anxiolytic (e.g., 1 mg midazolam).

Smooth extubation and aggressive prophylaxis against postoperative nausea and vomiting

• Avoid retching which may contribute to early failure of the repair.

• Respiratory exercises (e.g., incentive spirometry), chest physiotherapy.

• Mechanical and chemical prophylaxis for venous thromboembolism.

Liquid diet for 24 h, upgrade if tolerating to a minced and moist diet for 4 weeks, then cautious reintroduction of solids.