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Laparoscopic Antireflux Procedures

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Laparoscopic Antireflux Procedures
Overview
 

First performed in the early nineties by Dallemagne in Belgium, the standard laparoscopic fundoplication is now recognized as the therapeutic modality of choice in the surgical management of gastro-esophageal reflux. Since then, several technical modifications have been introduced with various success. However to date, advances in laparoscopic instrumentation and surgical skills make the standard, 360 degrees laparoscopic fundoplication the most effective procedure antireflux procedure available.

Having a precise knowledge of the anatomy of the gastroesophageal junction, understanding the mechanics of the gastroesophageal junction and establishing an accurate diagnosis of gastro-esophageal reflux is absolutely essential for any surgeon performing these procedures.

 Diagnosis of GERD

In the majority of patients, gastro-esophageal reflux is universally recognized as a malfunction of the gastro-esophageal complex. However, LES dysfunction is not its sole etiology, and a misdiagnosis will certainly generate catastrophic postoperative complications. Thus, a full anatomical and functional evaluation of the gastro-esophageal complex should be performed for each patient. The following diagnostic procedures are found to be invaluable in the preoperative management of these patients.

 Functional Analysis

The function of the GE complex depends primarily on the following:

1. Esophageal Primary Motility (Amplitude and Progression)

2. Lower Esophageal Sphincter (LES)

3. Gastric Emptying Mechanism

The following, step by step, management and diagnostic studies should be completed for each potential surgical candidate. None of the studies mentioned herein are by themselves one hundred percent sensitive in accurately diagnosing gastro-esophageal reflux. It is the combination of all these results that will help the surgeon decide if the patient is indeed a surgical candidate.

bulletDocumenting the GE Reflux: A meticulous history should be obtained (past medical history, medications taken, age at onset of reflux, length of reflux, supine or upright reflux, past medical treatment and results).
bulletUGI Series: The presence of a hiatal hernia, spontaneous reflux and other associated anatomical anomalies (stricture, short esophagus, etc.) should be checked.
bulletUGI Endoscopy: The esophageal and gastric mucosa should be evaluated for associated lesions and the degree of esophageal injury from the reflux should be reported according to the following scale:
GRADE  ESOPHAGEAL DAMAGE

1

Mucosal Damage: Erythema without Ulcerations

2

Mucosal Damage: Erythema with Ulcerations

3

Transitional Submucosal Damage: Chronic Ulcerations with Fibrosis

4

Transmural Damage: Stricture

If esophagitis is demonstrated, a biopsy should be performed to document the presence of Barrett's Esophagus, with or without cellular atypia/dysplasia. In addition, the length of the intra-abdominal portion of the lower esophagus can be estimated by UGI endoscopy (from diaphragmatic cruras to GE junction estimated as the patient sniffs).

bulletEsophageal Manometric Studies: This analysis of the endoluminal pressure of the esophagus and gastroesophageal junction should provide the following data to the surgeon:
1. Primary esophageal motility: Presence, progression and amplitude
2. Lower Esophageal Sphincter Analysis: Resting pressure and length.
Manometric Studies Normal Readings Abnormal Readings supporting GER
LES Length-Total  3.6 cm (mean)
LES Length-Intra-abdominal   2.0 cm (mean) < than 1 cm
LES Resting Pressure  13 mm Hg (mean)  < than 6 mm H

 

bullet24 Hr. pH Study: This 24 Hr. monitoring of the acid and bilious content and pH of the esophagus (biochemical electrode placed 5 cm above the GE junction) is a sensitive modality which will accurately report the acid/bile exposure of the lower esophagus over 24 hours. It should be reported as follows:
Esophageal Acid Contact/ Exposure Clinical Correlation
4.2 % to 7% Normal Recording
12% to 15% Erosive Esophagitis
Around 26% Transmural Esophagitis - R/o Barrett's Esophagus - Stricture
Combined Acid-Bile Exposure Transmural Esophagitis - R/o Barrett's Esophagus - Stricture

 

 Choice of Antireflux Procedure

Laparoscopic antireflux procedures only differ by the degree of resistance they created across the newly created GE junction. A 360 deg. fundoplication or Nissen fundoplication can be usually performed in all patients with a normal primary esophageal peristalsis or normal manometric studies. In patients with altered or abnormal primary esophageal peristalsis (as seen in patients with long term gastro-esophageal reflux), a Toupet or 270 Deg. fundoplication may be the procedure of choice. The lesser pressure gradient across the GE junction may compensate for the lack of a propulsive esophageal strength against the resistance created by the fundoplication. The Rossetti Type Anti Reflux Procedure is no longer performed by our surgical team.

See the section on Laparoscopic Fundoplication with esophageal lengthening for the management of a "Short Esophagus".


 

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