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Laparoscopic Surgery for reflux is indicated in the following situations:
Antireflux surgery is particularly beneficial if the reflux is affecting the lungs or throat. Many (if not most) cases of respiratory disease caused by aspiration of what may be tiny amounts of acid refluxate, typically during sleep, are undiagnosed as such. This may result in waking at night with what is thought to be an attack of "asthma". Whereas drug therapy is usually effective at eradicating heartburn, it is notoriously less effective at preventing secondary lung, throat and voice problems (dysphonia). Although laparascopic fundoplication is very low-risk surgery, it is not no-risk, and life-threatening complications are a possibility in this as in any sugical procedure.
See below for a discussion of the possible downsides of laparoscopic fundoplication.
The mainstay of drug therapy in patients with severe reflux are Losec, Zoton and Somac, which are all very similar. Although there are theoretical objections to taking these drugs for life, to date there is no firm evidence that there are any serious long-term side- effects, although this question has not yet been fully resolved.
The best operation for reflux is known as "fundoplication" and it involves loosely wrapping the fundus (dome) of the stomach around the defective valve.
In recent, years surgery for reflux disease has become much less traumatic and more effective. Many years ago the operations were major and involved an operation on the chest. Nowadays, an abdominal "key hole" operation is preferred in nearly all cases.
Anti-reflux surgery is a very low risk operation. However, significant complications do rarely occur, which may even require re-operation. Such complications occur in about 1% of patients. Less serious, but annoying complications may also occasionally occur, and these include temporary difficulty in swallowing (if the fundoplication is too tight), difficulty in burping which may result in a feeling of "gas-bloat", and inability to vomit. Modern refinements in surgical technique have reduced the frequency of these complications to about 5-10% of patients, and when they do occur they are now less severe and tend to disappear with the passage of time. Not all patients have a satisfactory outcome from surgery, and in fact about 5-10% of patients undergoing surgery fail to achieve long-term relief from reflux oesophagitis.
This operation represents a major breakthrough in surgical technique. The technique allows the same abdominal operation to be performed through a series of "keyhole" incisions, usually five or six, which are small enough to be covered with a Band-Aid. This dramatically reduces post-operative pain, days in hospital and time off work. The majority of patients requiring anti-reflux surgery are suitable for this technique, although occasionally a standard abdominal incision is required, which extends from the naval to the lower end of the sternum (breast bone). Most of the post-operative pain and time-in-hospital results from the abdominal cut (incision), rather than the internal operation - it is this incision which laparoscopic surgery avoids
Should you wish to know more about laparoscopic fundoplication, including speaking with someone who has had it performed, this can be arranged on request.
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Fundoplications are the most widely used form of antireflux surgery. Similar results have been obtained irrespective of whether the procedure is performed using an open conventional laparotomy approach or with the use of modern laparoscopic technology. Since the introduction of the Nissen total fundoplication procedure, there has been some concern about the incidence of troublesome mechanical complications, which occur in about 15% of cases. The most frequent postfundoplication symptoms are dysphagia, inability to belch and vomit, postprandial fullness, bloating and pain, and socially embarrassing flatus. The frequency which these symptoms have been reported varies considerably among series. Dysphagia is frequently reported during the early postoperative period, but seems to diminish with the passage of time, as do other post fundoplication symptoms.
Since an effective treatment for established severe postfundoplication symptoms is lacking, it is of vital importance to define factors that are associated with an enhanced risk of postoperative drawbacks. These factors might include: preoperative characteristics of the patient, motor function of the esophagus and stomach, presence of duodenogastric reflux, presence or absence of esophagitis, irritable bowel syndrome, technical aspects related to the type of fundoplication used, and surgeon-associated factors.
Some 10% of patients in whom an inadequate preoperative diagnosis of chronic gastroesophageal reflux disease (GERD) has been made are referred for repeat operations, when the index procedure was carried out when there was a primary motor disorder of the esophagus and/or gastroesophageal junction other than GERD.
Esophageal manometry has been recommended prior to antireflux surgery in all patients. Until recently, the choice of the surgical approach has been based on an assessment of esophageal contractility and function. For instance, a transabdominal approach with construction of a total fundoplication has been advocated in patients with normal esophageal contractility, while in those with poor contractility, a partial fundoplication has been advocated. This concept has been challenged by many recent studies. Mughai concluded that Nissen fundoplication can be safely performed in patients who are genuinely refractory to vigorous medical treatment, regardless of the subtleties of preoperative manometry or pH recording. Rydberg, in my own group, reported a series of patients who were allocated to different fundoplication procedures irrespective of the preoperative manometric findings. No relationship at all was found in the clinical outcome between postfundoplication complaints and preoperative manometric findings. We believe it can be concluded that a tailored approach to antireflux surgery, with the ultimate aim of optimizing the postoperative results based on a preoperative assessment of motor function in the esophagus and gastroesophageal junction, is not well founded.
Another area of controversy is whether preoperative or postoperative impairment in gastric emptying may be involved in the genesis of postfundoplication symptoms and whether it affects the risk of failure after fundoplication. Repeated studies have found no relationship between the symptomatic postoperative outcome and gastric emptying parameters. Clinical data would suggest that gastric emptying studies are not useful in relation to tailoring of the procedure and determining the extent and type of fundoplication.
Population-based incidence and prevalence studies of GERD have clearly demonstrated that the majority of patients presenting with severe long-standing reflux symptoms have no endoscopic signs of peptic lesions in the esophagus. These patients are characterized by having more prominent daytime acid reflux than those with more severe manifestations of the disease. These patients should not be denied antireflux surgery.
Quality-of-life assessment is a new tool in clinical research, and may be able to provide important additional information to that provided by the conventional assessment of efficacy variables. It has recently been found that dyspeptic symptoms are also quite prevalent preoperatively in reflux patients. Circumstantial evidence would indicate that similar patients might have a tendency to respond less favorably to a total fundic wrap, with perhaps more bloating-like complaints when assessed after the operation.
Persistent postoperative dysphagia is a problem with the early classic Nissen procedure, and has proved to be a continuing source of postprocedural morbidity with laparoscopic antireflux procedures. It has been emphasized that the length of the fundoplication should be reduced to 1.0–1.5 cm and that the short gastric vessels have to be divided to achieve complete mobilization of the gastric fundus and guarantee a tension-free wrap.
Well-designed studies have been unable to demonstrate the importance of dividing all short gastric vessels in order to minimize postoperative morbidity. The use of an esophageal bougie has not until recently been subjected to a prospective randomized trial. The presence of a 56-Fr bougie in the distal aspect of the esophagus during construction of 360° fundoplication has been shown to substantially reduce the incidence of long-term dysphagia.
The side effects of total fundoplication, the operation most widely used throughout the world, appear to be related to the construction of a supracompetent antireflux barrier at the gastroesophageal junction, the consequences of which include an inability to adequately vent air from the stomach. Recent studies have shown that partial fundoplication achieves the same level of acid reflux control as a total fundoplication and is accompanied by a lower frequency of mechanical complications, also allowing patients to vent air from the stomach more effectively. The procedure of partial fundoplication seems to minimize the frequency of postfundoplication complaints. Importantly, long-term follow-up data have shown that the results of the operation are durable and that it is effective in controlling gastroesophageal reflux.
