The Surgical Option in the Treatment of Gastroesophageal Reflux Disease: Rationale and Indications

Carlos A. Pellegrini, MD

Disclosures
In This Article

Rationale for a Change in Treatment Philosophy

Several important factors fostered a change from a more conservative to a more aggressive treatment of reflux disease -- that is, from simply controlling acid secretion to restoring the normal competence of the cardia. The first factor is the recognition that abnormal gastroesophageal reflux can lead to serious complications, and that some can be prevented or better treated by surgery. Second is the availability of more effective operations with fewer side effects, and last is the introduction of minimally invasive techniques.

It has become increasingly clear that abnormal gastroesophageal reflux, a relatively minor complaint in the majority of patients, can lead to the development of severe complications. Furthermore, as effective as proton pump inhibitors (PPIs) are, they have not been able to affect the evolution of some of these complications. For example, several studies have now shown that a number of airway problems previously thought to be idiopathic, such as laryngitis, chronic cough, hoarseness, and asthma, are in fact the result of microaspiration of refluxate into the airway in a large number of patients.[5] Furthermore, while PPIs are effective in controlling heartburn and in resolving esophagitis in these patients, they are less effective in the control of aspiration-induced problems. Restoring the competency of the cardia by means of surgical intervention emerged, therefore, as a reasonable alternative.

Barrett's esophagus, another serious complication of abnormal gastroesophageal reflux, is thought by many to depend on the presence of duodenal contents rather than acid.[6] Furthermore, some studies suggest that the evolution of Barrett's into dysplasia and cancer may be associated with further exposure to acid- and non-acid-refluxed contents.[7] Again, a mechanical correction of the cardia emerged here as a more sensible approach. While a successful operation does not necessarily lead to resolution of Barrett's (patients must remain under surveillance after surgery), the rationale for the operation is that the evolution of this epithelium into cancer may be delayed or arrested by stopping all acid- and non-acid reflux.

Advances in our knowledge of the pathophysiology of the cardia, and in particular of the elements responsible for maintaining competency of the gastroesophageal junction, led to refinements in the technique of the operation. For example, several studies have shown that a shorter fundoplication is as effective in preventing reflux as a longer one, but that it is associated with fewer side effects.[8] As a consequence, the length of the fundoplication has decreased from the 4-6 cm recommended in the 1980s to the current 2-2.5 cm. As a result, gas-bloat syndrome has become rare and most patients retain their ability to belch and to vomit. The importance of freeing the fundus of the stomach entirely (by dividing all short gastric vessels and the fundic attachments to the retroperitoneum) has also been recognized. A free fundus, a large window behind the gastroesophageal junction, and the construction of a geometrically correct fundoplication (using the posterior wall of the stomach) decreases the tension and thus the risk of early failure of the fundoplication. Furthermore, the combination of a "floppy" fundoplication (one that can accommodate a size-60 bougie) in addition to a perfect geometry (one that avoids torsion of the esophagus fixed to the fundoplication) decreases significantly the incidence of postoperative dysphagia. These modifications to the original technique have essentially eliminated the procedure's feared side effects while increasing its effectiveness to stop reflux and, presumably, its longevity as well.

These developments have also influenced substantially the strategic approach to the patient with reflux. Without the need for a large incision, and for retraction and manipulation of viscera, postoperative pain decreased substantially and recovery was hastened. In the past, patients suffered considerable postoperative pain, were not allowed intake of food for a few days, stayed in the hospital for a week, and returned to work 6-8 weeks after an uneventful operation. Today, however, abdominal pain is usually limited to the first day or two after surgery, patients can be discharged from the hospital within 2 days, and they can return to full activity within 2 weeks. Thus, antireflux operations have become more acceptable to patients and to their referring physicians. In turn, having the opportunity to perform the operation more often has increased the surgeon's experience, thus leading to better results.

In addition, the introduction of the telescope and its ability to magnify the image resulted in its own significant advantages. For example, with the telescope, it is now possible to expose and dissect the distal end of the esophagus and the posterior mediastinum in ways that we could not achieve before under direct vision from the abdominal incision. Thus, one of the main indications for thoracotomy in the performance of antireflux operations is gone, because the esophagus can be appropriately -- and safely -- mobilized from the abdomen through the esophageal hiatus. If needed, an elongation of the esophagus can also be achieved in this way. The use of angled scopes and magnification have improved overall exposure of the hiatus and its adjacent area, allowing us to perform a more delicate and precise dissection and a more accurate approximation of tissues. As a consequence, injury to the spleen, a relatively common complication of the traditional open approach, is now extraordinarily rare; blood loss is minimal, and construction of the fundoplication, precise.

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