Indications
- Refractory GERD:
- Antireflux surgery is appropriate for patients requiring long-term therapy (> 1 year).
- Complicated GERD:
- Includes conditions such as LA grade C/D esophagitis or peptic stricture
- Incomplete Response to Medications:
- Surgery may benefit patients with initial responsiveness to PPIs but subsequent resistance
- Patient Preference:
- For those wishing to avoid lifelong proton pump inhibitor (PPI) therapy
- Associated Hiatal Hernias (Type II to IV):
- Hiatal hernias of these types independently justify surgical intervention
Note: Preoperative manometry is critical to exclude esophageal motility disorders like achalasia, as fundoplication in undiagnosed achalasia can lead to disastrous outcomes. Similarly, patients with autoimmune esophageal involvement (e.g., CREST syndrome in scleroderma) are not suitable for antireflux surgery.
Technique
- Minimally Invasive vs. Open Surgery:
- Laparoscopic fundoplication has been demonstrated to be superior to open surgery, and guidelines recommend it as the standard approach
- Type of Fundoplication Wrap:
- The controversy between total (Nissen) and partial posterior (Toupet) fundoplication has been explored in numerous studies, including randomized controlled trials (RCTs)
Evidence from Meta-Analysis by Broeders et al. (2010):
- Data Analyzed:
- Included RCTs published between 1997 and 2010, encompassing 404 laparoscopic Nissen and 388 laparoscopic Toupet procedures
- Key Findings:
- Postoperative Dysphagia:
- Higher incidence in Nissen fundoplication
- Need for Postoperative Dilations:
- More frequent after Nissen fundoplication
- Reoperation Rates:
- Higher in the Nissen group
- Gas Bloating and Inability to Burp:
- More commonly associated with Nissen fundoplication
- Reflux Control:
- Comparable between the two techniques for pathological acid exposure and reflux esophagitis
- Operative Time and Hospital Stay:
- No significant differences between the groups
- Conclusions:
- The meta-analysis provides Level 1a evidence favoring laparoscopic Toupet fundoplication for GERD treatment, citing lower rates of postoperative dysphagia and gas-related symptoms without compromising reflux control
Criticisms and Strengths:
- Criticisms:
- Follow-up periods in included studies were relatively short:
- Four studies followed patients for 12 months
- Two studies extended to 24 – 27 months
- Only one study provided a 60- month follow-up
- Studies were predominantly conducted in expert centers, potentially limiting generalizability
- Follow-up periods in included studies were relatively short:
- Strengths:
- Focused exclusively on posterior fundoplication (Nissen vs. Toupet), excluding the anterior fundoplication, which is now considered inferior
Conclusion: The evidence strongly supports the superiority of the 270° Toupet fundoplication over the 360° Nissen fundoplication for GERD management. Toupet offers a similar reduction in reflux symptoms with significantly lower rates of postoperative dysphagia and associated complications.
Mesh Augmentation in Hiatal Repair
The use of mesh reinforcement during hiatal hernia repair is a topic of ongoing debate. According to the German S2k guideline, routine reinforcement of the hiatus with foreign material is not recommended due to inconclusive evidence. Current studies primarily focus on patients with large hiatal hernias (> 5 cm²) or paraesophageal hernias, often excluding cases of GERD without hiatal herniaenefits and Risks**
- Advantages:
- Reduced recurrence rates of hiatal hernias with mesh reinforcement
- Risks:
- Severe complications, such as mesh migration into the esophagus, may necessitate complex corrective surgeries (e.g., Merendino procedure)
Given the low evidence level, the decision to use mesh should be made on a case-by-case basis. While some studies indicate potential benefits, there is significant variability in the types of mesh, fixation methods, materials, and positioning. Mesh implantation should be considered based on hernia size and further investigated in controlled studies .
Meta-Analysis by Rajkomar et al. (2023)**
A meta-analysis published in Hernia evaluated outcomes of laparoscopic repair of large hiatal hernias (LHH) with and without mesh augmentation .
- **Study Parame - Included 19 studies (6 RCTs and 13 observational studies) with 1,670 patients (846 with mesh, 824 without)
- Examined recurrence rates, reoperations, and complications
- Key Findings:
- Mesh reduced overall recurrence rates (OR 0.44, 95% CI 0.25–0.80, p = 0.007)
- No significant reduction in large recurrences (>2 cm) (OR 0.94, 95% CI 0.52–1.67, p = 0.83)
- Reoperation rates were not significantly reduced (OR 0.64, 95% CI 0.39–1.07, p = 0.09)
- Synthetic meshes were linked to cases of erosion into the esophagus
- Conclusion:
- Mesh appears to protect against complete recurrence but does not significantly reduce large recurrences or reoperation rates
- Patients must be informed about the risk of mesh erosion if synthetic materials are used
Robotics in Antireflux Surgery
Robotic-assisted surgery represents a significant advancement in minimally invasive procedures. It offers enhanced 3D visualization, seven degrees of instrument motion, tremor filtering, and superior precision.
- Benefits:
- of traditional laparoscopy with rigid instruments
- Early studies suggest comparable or superior outcomes in high-volume centers
Postoperative Dysphagia
Dysphagia, a common issue after fundoplication, has seen improved management with endoscopic dilation using large-bore bougies. Success is typically achieved after 1–2 sessions, and reoperation rates for persistent dysphagia remain low.
Hiatal Hernia Surface Area (HSA) Calculation
The HSA can be calculated using:
- Rhombus Formula:
- HSA = (R × S) / 2
- R = length of the crura from the crural commissure to the upper edge of the esophageal hiatus
- S = horizontal distance between the crura, including their thickness
- Granderath Method:
- Combines measurements of crural length (R) and arc (s) to calculate the dorsal crural commissure angle (Alpha):
- Alpha1 = arcsin(s / 2) / R
- Alpha0 = 2 × Alpha1
- Arc = π × R × Alpha0 / 180
- HSA = Arc × R / 2
- Combines measurements of crural length (R) and arc (s) to calculate the dorsal crural commissure angle (Alpha):
This method provides a precise estimation of hiatal surface area, particularly for complex or large hernias.