Perioperative management - Nissen fundoplication - general and visceral surgery
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Indications
Treatment of GERD is primarily non-surgical, i.e., by medication (proton pump inhibitors - PPI).
Treatment objectives in GERD include:
- If not asymptomatic, then at least satisfactorily controlled symptoms
- Return to normal quality of life and work
- Remission of any reflux esophagitis present
- Long-term maintenance of remission (symptoms, lesions)
- Prevention of complications
Surgical antireflux treatment is indicated in:
- PPI intolerance or wanted by patient in chronic reflux symptoms
- Massive reflux (e.g., of stomach content when erect, while bending over or during sleep, possibly with aspiration)
- Extra-esophageal GERD symptoms (reflux induced coughing, pharyngitis and asthma) not fully controlled by PPI or in PPI intolerance
- Persistent symptoms despite adequate PPI dosage and clearly confirmed GERS (e.g., in PPI resistance or accelerated PPIU metabolism)
- It is important that the correct diagnosis of reflux disorder is confirmed by subtle preoperative diagnostic work-up.
Contraindications
- Motility disorders of the esophagus without reflux (e.g., achalasia)
- Secondary reflux, for instance in gastric emptying disorders
- Esophagitis of other origin (infection, drug toxicity)
- Extra-esophageal disorders with reflux-like symptoms, e.g., CHD
- In confirmed tubular contraction disorders of the esophagus, Toupet or Nissen fundoplication should not be performed. One alternative would be anterior hemifundoplication (Dor) or sole gastropexy
Preoperative diagnostic work-up
Since there is no diagnostic gold standard for GERD, diagnostic work-up should primarily address the symptoms. Although the diagnostic steps most likely vary from department to department, surgical measures should be preceded by objective morphological and functional studies, in particular to document the indication.
1. Medical history
Lower reflux symptoms
- Heartburn
- Washburn/non-acid eructation
- Retrosternal pain
- Dysphagia
- Odynophagia (painful swallowing, rare)
Upper reflux symptoms
- Burning sensation in throat
- Regurgitation
- Irritating cough/morning hawking
- Breathy voice, hoarseness
- Asthma attacks
Symptoms triggered or worsened by: Ingestion, extended fasting phases, sweet foods, alcohol, stooped or supine body position. The symptoms may be episodic, intermittent or continuous.
Type, intensity and frequency of reflux symptoms do not permit any conclusion about the severity of the reflux disorder and the extent of the esophageal lesions.
Heartburn is the most sensitive symptom in GERD. If it is the main symptom, the probability of reflux is > 75%. If the heartburn is of minor importance because other symptoms are the main focus, other diseases are more likely (e.g., functional dyspepsia and ulcer). However, lack of heartburnb does not rule out GERD. Dysphagia, retrosternal complaints and respiratory symptoms might dominate the picture in reflux disorder, but still are nonspecific.
When obtaining the medical history, the medication/nonsurgical measures should also be asked and possible previous findings screened.
2. PPI test
No or less than full response to PPI administration indicates the presence of GERD. In case of failed high-dose PPI therapy the presence of GERD is rather unlikely.
However, the PPI test is only indicated in symptoms already indicative of GERD, but where endoscopy has been unremarkable. The PPI test should be administered with two or three times the standard dose recommended in GERD and for at least 2 weeks because without treatment reflux episodes may vary from day to day or are present just intermittently.
3. Endoscopy
The value of esophagogastroduodenoscopy in diagnostic work-up of GERD is undisputed and mandatory before any surgical procedure. It allows:
- Diagnosis of reflux esophagitis and assessment of its severity (also as treatment follow-up in esophagitis)
- Diagnosis of hiatal hernia
- Detection of complications (stricture, ulcer)
- Ruling out malignancy
Early endoscopy is indicated in unusually severe complaints and alarming symptoms such as anemia, dysphagia and weight loss. In all grossly evident pathologies histology must be obtained.
4. 24-hour esophageal pH monitoring
24-hour esophageal pH monitoring is the gold standard in objective confirmation of gastroesophageal reflux. It detects the circadian rhythm of reflux episodes, bodily activities, ingestion and body position. Correlation of the symptoms with the registered reflux episodes is possible by having the patient document his/her complaints, which increases the sensitivity of the pH monitoring. The result of the pH monitoring cannot yield the diagnosis of reflux esophagitis, since this requires endoscopy.
24-hour esophageal pH monitoring is indicated in:
- Preoperatively to document the indication for surgery
- Persistent reflux complaints despite adequate PPI medication
- In patients with unremarkable endoscopy - NERD patients (Non Erosive Reflux Disease)
- Recurrent reflux symptoms following antireflux surgery
In pH monitoring it must be noted that up to 25% of patients with reflux esophagitis and about 30% of the NERD patients display normal values; this is due to the fact that the amount of reflux may vary from day to day despite the definite presence of reflux disease.
5. Esophagus manometry
Esophagus manometry reliably verifies the competency (resting pressure, length) of the LES and the tubular motility of the esophagus. Contraction amplitudes of the tubular esophagus of less than 30 mmHg are regarded as hypomobile and an LES resting pressure below 5 mmHg as reduced.
Presently the role of manometry as sole diagnostic parameter in GERD is controversial and under discussion. While it does not have a place in primary diagnostic work-up of GERD, it may be useful in some cases to differentiate GERD from other motility disorders of the esophagus (e.g., achalasia).
It is absolutely recommended as part of the preoperative evaluation and documentation in terms of the selected surgical procedure. In confirmed tubular contraction disorders of the esophagus, Toupet or Nissen fundoplication should not be performed. One alternative would be anterior hemifundoplication (Dor) or sole gastropexy
6. Radiography/barium swallow
GERD diagnosis solely by barium swallow is not recommended for the following reasons:
- Since reflux is a physiologic phenomenon, its radiological presence does not necessarily denote pathologic significance.
- Reflux is intermittent and definite confirmation may only be obtained by long-term measurement and not by a radiological snapshot.
However, barium swallow still is the gold standard in the diagnosis of axial hiatal hernia and allows differentiation of other types of hernia. In addition, many surgeons regard the barium swallow as helpful in visualizing the gastroesophageal junction before planning their procedure. And in the work-up of postoperative problems following fundoplication, barium swallow often is indispensable because, e.g., wrap failure and telescope phenomenon hardly lend themselves to endoscopy.
7. Other study options
In some NERD patients it is sometimes helpful to demonstrate the presence of acid and non-acid reflux episodes by impedance measurement, while scintiscans of esophagus transit and gastric emptying are useful in the study of functional disorders of the esophagus and stomach.
Special preparation
- Single-shot i.v. antibiotic Perioperative administration in case of foreign body/mesh
- Mild laxative the day before surgery
Informed consent
General risks
- Bleeding
- Secondary bleeding
- Necessity of blood transfusions with corresponding transfusion risks
- Thromboembolism
- Wound infection
- Abscess
- Injury to adjacent organs (here: esophagus, stomach, liver, spleen)
Special risks
- Temporary postoperative dysphagia
- Persistent dysphagia Bougienage, rarely revision surgery
- Intraoperative pneumothorax, possibly chest tube
- Pericardial injury
- Denervation syndrome due to injury to the anterior or posterior vagal trunk (outcome: gastric emptying disorder, diarrhea)
- Recurrent reflux due to, e.g., ruptured wrap or insufficient hiatoplasty
- Recurrent hiatal hernia
- Telescope phenomenon
- Gas bloat syndrome (inability to eructate or vomit. Caution: May already be present before surgery! History!)
- Lack of success (despite correct indication and surgical technique)
When planning laparoscopic procedures, the patient should always be informed explicitly of the possible need for conversion to open laparotomy.
Anesthesia
Positioning
Operating room setup
Special instruments and fixation systems
Postoperative management
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