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Operations
Written by Dr Sebastian Zeki
Preoperative evaluation No point doing pH studies if can see oesophagitis on endoscopy. Manometry provides alternative diagnoses, such as scleroderma or achalasia, for which antireflux surgery may be contraindicated. Manometry may lead to a modification of the surgical approach or a change in management. Evidence of markedly decreased LES pressure (less than about 10 mmHg) is correlated with improved surgical results and patient satisfaction. OGD to determine oesophageal length and size of hiatus hernia. Predictors of successful reflux surgery: Typical GORD symptoms. Abnormal readings on 24 hour pH monitoring. Response to PPIs. Endoscopic therapy for gastroesophageal reflux disease: Sewing/plication techniques
If mild-Try chewable simethicone tablets or charcoal caplets. Instruct patients not to drink with a straw or ingest carbonated beverages until symptoms resolve. Metoclopramide/ erythromycin (10 to 15 mg four times daily) may be helpful. Symptoms tend to lessen over time in most patients. If symptoms persist and have documented gastroparesis, pylorplasty can be considered. Conversion from full to partial fundoplication is alternative. Long term efficacy Compared To Medical Therapy — PPI’s as effective as surgery after 2 years follow-up Relative costs — Overall costs lower for medical therapy Response rates for fundoplication for airway diseases are < that done for typical gastroesophageal symptoms-70 % of patients get symptom improvement, while 33 % remain on medication but often at a far reduced dosage. Asthma — Surgery improved asthma related to GERD by 70% of patients, as does medical therapy. Postoperative management Dysphagia is common and lasts 2-12 weeks. The most common predictor of postoperative dysphagia is the presence of preoperative dysphagia. If the fundoplication is intact, the patient is unlikely to have persistent GORD- can be assessed with barium. 6-12% of dysphagics need dilatation- bougie dilatation well tolerated. Patients with dysphagia may need revision to partial fundoplication. Oesophageal spasm may cause dysphagia if pH studies/ barium is normal. Gas bloat syndrome is a sensation of intestinal gas with the inability to belch common post fundoplication. Gas bloat syndrome may be due to delayed gastric emptying and tight fundoplication. Gas bloat syndrome symptoms may be due to aerophagia or vagal dysfunction. Patient’s anatomy
Shortened esophagus Normal length but decreased motility Normal esophageal length and motility Indications: Persistent or recurrent symptoms despite medical therapy - These patients may not respond to surgery. Severe oesophagitis by endoscopy. Benign stricture. Barrett's columnar-lined epithelium (without severe dysplasia or carcinoma). Recurrent pulmonary symptoms (eg, aspiration, pneumonia) in association with GORD. Laryngeal disease. Abnormal pharyngeal acid on a double probe pH study when medical therapy has been maximized, is not tolerated, or is impractical. Nissen fundoplication — -Improvement in 90 %, 60% will need to remain on PPI -Technique: Gastric fundus encircles distal 6 cm of the esophagus. Can be done laparoscopically Complications Gastric or esophageal injury, splenic injury or splenectomy, pneumothorax, bleeding, pneumonia, fever, wound infections, bloating, and dysphagia. Major complication uncommon. Postoperative dysphagia (8 to 12 %) a problem with laparoscopy as difficult to determine looseness of wrap so often constructed over a large esophageal Bougie (48 to 60 Fr). Belsey Mark IV — Technique: Partial fundoplication performed by transthoracic approach, which allows full esophageal mobilization Recommended for patients with poor esophageal motility who might have other indications for a transthoracic approach (eg, obesity or a shortened esophagus). Hill gastropexy — Imbrication of the anterior and posterior lesser gastric curve around the esophagus with tethering of the complex to the median arcuate ligament and closure of the diaphragm. Intraoperative manometry is used to achieve a desired LES pressure. Angelchik prosthesis — The Angelchik prosthesis is a doughnut-shaped prosthesis placed about the distal esophagus. Surgical management of GORD
ENDO SURGICAL PLICATOR OTHER DEVICES — Several other suturing/plicating devices have been designed and are undergoing evaluation for the endoscopic treatment of GERD. These include the Syntheon AntiReflux Device, the EndoGastric Solutions Endoluminal Fundoplication System, and several new sewing devices such as the Olympus Eagle Claw. Syntheon AntiReflux Device — The Syntheon AntiReflux Device (ARD) delivers a single titanium implant into the cardia of the stomach, creating a serosa- to-serosa apposition and altering the anatomy of the proximal stomach in a fashion similar to that of the NDO device. EndoGastric Solutions — The EndoGastric Solutions Esophyx EndoLuminal Fundoplication System is designed to treat gastroesophageal reflux endoscop - cally via restoration of the angle of His at the gastroesophageal junction. It is available in Europe and FDA cleared in the United States. The Medigus endoscopy system — The Medigus endoscopy system combines a miniaturized video camera, a surgical stapler, and ultrasonic sights for alignment in a single instrument. The Hiz-Wiz device — The Hiz-Wiz device can create two plications, anteriorly and posteriorly just below the gastroesophageal junction.
