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Anti-reflux surgery

From Surgopaedia

Indications

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  • See 'GORD'

Principles

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  • Identify and preserve both vagal nerves
  • Reduce hiatal hernia
  • Restore 3-4cm of oesophagus below diaphragm
  • Repair hiatal defect - can be calibrated with bougie (52-60Fr)
  • Identify true GOJ for placement of wrap
  • Create valve with close apposition of gastric fundus and abdominal oesophagus

Pre-op workup

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  • Upper endoscopy - mandatory within last two years
    • If no evidence of reflux, needs 24-hr pH study
  • Oesophageal manometry - if Nissen planned
  • Oesophageal length evaluation?
  • Gastric emptying studies?
  • Barium swallow if hiatus hernia >5cm
    • Helps to estimate time taken in theatre

Operations:

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Some sources say best choice of operation is laparoscopic Nissen fundoplication - however controversial

  • Re-creation of a sphincter around the GOJ with a full 360-degree wrap of the fundus around the distal oesophagus
  • 360 degree Nissen fundoplication preferred due to greater long-term durability
  • Success rate >90%
  • See 'GORD' for predictors of operative success

Toupet fundoplication

  • Posterior 270 degree partial wrap
  • Additional tacking sutures to fix the stomach to the crura in the abdomen

Dor fundoplication

  • Anterior 180-200 degree wrap
  • Most often used in the setting of oesophageal myotomy

Collis gastroplasty

  • Oesophageal lengthening
  • Wedge fundectomy to create a few extra cm of length, around which the stomach can be wrapped
  • Need to continue PPIs due to gastric mucosa above the wrap

Options:

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  • Total vs partial
    • Nissen provides more reflux control, while partial wrap gives less side effects
    • Total generally preferred, except with significant oesophageal dysmotility or weak peristalsis
    • 360 degree wrap preferred when the reflux causes respiratory compromise, such as in lung transplant patients
    • Partial wrap preferred in patients with dysphagia or poor peristalsis on manometry
  • Abdominal vs thoracic
    • Abdominal preferred, except in hostile abdomen etc
  • Open vs lap
    • Lap has significant advantages in terms of recovery
  • Mesh
    • Biologic mesh can be used but only needed if there is tension on the crural repair - very large hernias
    • Less recurrence at 1 year, but no difference in recurrence rate at 5 years
  • Lengthening procedure
    • Collis gastroplasty or transabdominal wedge gastrectomy
    • Generally not needed if careful paraoesophageal dissection is undertaken
  • Division of short gastrics
    • Now thought to be unnecessary - leads to increased reflux long-term

Anaesthetic considerations:

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  • 30mL sodium citrate to decrease stomach acidity
  • ?RSI with cricoid pressure
  • Deep paralysis to increase working space
  • Minimise PONV

Technique:

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  • Low lithotomy and steep reverse Trendelenburg with surgeon between legs and assistant to patient's left
  • Access abdomen, ports centred on GOJ
    • 10mm LUQ optical, 10mm epigastric, 5mm in RUQ and LUQ, then 5mm sub-xiphoid for Nathanson
    • Place Nathanson liver retractor
  • Exposure and reduction/repair of hiatus hernia (see separate topic for hiatus hernia repair)
    • Mobilise oesophagus - need a minimum 3cm intra-abdominal oesophagus
    • Completely free oesophagus at crus circumferentially
    • Approximate crura posteriorly and anteriorly
      • Checking size - either ensure a 52Fr bougie can pass into stomach easily or just check by eye
      • Ethibond sutures
  • Fundoplication:
    • May need to mobilise fundus by dividing short gastric arteries
    • 360 degree
      • Posterior aspect of the fundus marked with a suture 3cm distal to GOJ and 2cm off the greater curvature
      • Posterior fundus passed behind the oesophagus from left to right
      • Anterior fundus on the left side of the oesophagus is then grasped (2cm from the greater curvature and 3cm from GOJ), and both portions of the fundus are positioned on the anterior aspect of the oesophagus
      • First suture is placed, then a 52Fr bougie passed into stomach, and the fundoplication is completed (3 or 4 interrupted permanent sutures)
      • Remove the bougie
      • Secure the fundoplication to the diaphragm with right and left coronal sutures (prevents slipping and herniation into mediastinum)
    • Toupet fundoplication
      • Wrap 180-270 degrees posteriorly
      • Pull fundus posteriorly
      • Initial gastro-oesophago-phrenic suture
      • 2x oesophago-gastric sutures
      • Suture to left crus
    • Dor/Thal fundoplication
      • No need to disrupt the posterior attachments of the oesophagus
      • Fold fundus over the anterior aspect of the oesophagus
      • Anchor to the hiatus and oesophagus
  • Short oesophagus
    • Need minimum 3cm intra-abdominal
    • First step - mobilisation in posterior mediastinum - can get enough length in most patients
    • Second step - vagotomy - 2cm per side - did not seem to lead to delayed gastric emptying according to Sabiston
    • Third step - stapled wedge gastroplasty - almost never needed

Post-op management

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  • Clear fluids day 0
    • NGT not used routinely
    • Minimise opioids, give anti-emetics
  • Free fluids day 1
    • Some say get a barium swallow day 1
  • Pureed diet day 2 and continue for 2/52
  • Soft diet 2/52 post-op
  • Aim full diet 6/52 post-op
  • Stop PPI after 1-6/52
    • Hann stops after 1/52
    • Janine seems to base on symptoms
    • Take level of Barrett's into account - if they have Barrett's, need to continue it
  • Dysphagia
    • Most patients get it - give mostly liquids somewhere between 2-12 weeks
    • Early dysphagia is thought to be due to post-operative oedema or even suture haematoma in stomach wall
    • If dysphagia persists after 12 weeks (3% of patients) or patient can't tolerate enough liquids to get home - get a barium swallow to assess the fundoplication
      • Could be due to overtight wrap, slippage or reherniation
      • Overtight wraps can be endoscopically dilated starting 6/52 post-op
      • If barium swallow looks ok, empiric dilatation of GOJ should be performed
  • Gas bloat syndrome - inability to burp, leads to distension
    • Can do CXR/AXR to confirm gastric distension
    • Usually self-limiting and subsides by 3/12 mark, but can consider endoscopic dilatation
    • Occasionally needs a post-op NGT

Complications

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  • Ileus (7%)
  • Pneumothorax (3%)
    • Caused by pleural violation during mediastinal dissection
    • When identified intra-operatively, close with a suture
    • Doesn't normally need intervention when identified post-op, unless patient has persistent hypoxia or symptoms
  • Gastric and oesophageal injuries (1%)
    • If identified at time of injury, repair with suture/staple
  • Dysphagia (2%)
  • Liver/splenic trauma (2%)
    • Control bleeding with direct pressure and haemostatic agents
    • Partial splenic infarction can occur during transection of short gastric vessels
  • Acute herniation

Failure of surgery

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  • Presentation
    • Typically presents with recurrent GORD
    • Dysphagia suggests oesophageal obstruction - recurrent hiatal hernia or slipped fundoplication. Re-operation is almost always necessary.
    • Persistent symptoms that never improved with surgery - revisit original diagnosis and workup
  • Implicated factors:
    • Oesophageal dysmotility
    • Gastroparesis (?iatrogenic vagal injury)
    • Anatomic failures - hiatal hernia, slipped fundoplication, incorrectly constructed fundoplication (created out of body instead of fundus)
  • Workup
    • Barium swallow
    • Gastroscopy
    • Oesophageal manometry and ambulatory pH
  • Management
    • Most patients effectively managed by reintroduction of PPI
  • Reoperation is difficult - should be done by specialist UGIS unit
    • Often dense adhesions with left lobe of liver
    • Unwrap completely and start again, may require oesophageal lengthening
    • RYGB is an option, especially in patients with obesity and diabetes
      • Allows gastric contents to travel away from GOJ, reducing reflux

Novel therapies - LINX antireflux device

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  • Generally used in patients with minimal or no hiatus hernia, but has been reported in case series with hiatus hernia too with good results
  • Magnetic beads placed around GOJ that stretch with slight pressure, mimicking and augmenting the natural LOS
  • >90% of patients had improved QoL and used less PPIs
  • Two thirds of patients had significantly less oesophageal acid exposure at 1 year
    • Similar outcomes to fundoplication patients, with significantly less regurgitation, gas bloat, and PPI use
  • 5 year follow-up - no device erosions or migrations, with good control of reflux symptoms


Endoscopic

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  • Transoral incisionless fundoplication
    • Uses fasteners to create an antireflux valve at GOJ
    • Doesn't seem to be as effective as surgery at stopping reflux
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