This document discusses the surgical management of gastroesophageal reflux disease (GERD). It begins by defining GERD and explaining that it is caused by a defective lower esophageal sphincter. While proton pump inhibitors are usually prescribed, they do not address the underlying cause. Surgical fundoplication procedures like Nissen and Toupet fundoplication are discussed in detail, as they significantly reduce acid exposure and improve quality of life compared to medical management. Complications, indications, contraindications and follow up are also outlined. The document provides a comprehensive overview of the surgical treatment of GERD.

1. SURGICAL MANAGEMENT OF
GASTRO-ESOPHAGEAL REFUX
DISEASE (GERD)
Nwafulume Obiora.
General Surgery, University of Nigeria
Teaching Hospital.

2. Introduction
• GERD is a common and chronic GI disorder.
• GERD is the failure of the antireflux barrier,
allowing abnormal reflux of gastric contents
into the esophagus .
• It is a mechanical disorder caused by a
defective lower esophageal sphincter (LES), a
gastric emptying disorder, or failed esophageal
peristalsis.

3. Introduction
• Patients with GERD are routinely prescribed PPIs.
• PPIs suppress normal acid production in the
stomach to increase the PH. This is effective for
healing esophagitis and heartburn, but less
effective for regurgitation and the non-acidic
symptoms of GERD.
• PPIs do not address the reason that reflux occurs,
i.e., a dysfunctional LES.
• In GERD, the LES is prone to abnormal opening
due to gastric distension, transient relaxation, or
hypotensive resting tone.

4. Medical vs Surgical Rx
• Fundoplication results in significantly less acid
exposure and significantly increased LES
pressure
• Fundoplication has demonstrated improved
QOL compared to that of medically treated
patients and is associated with high patient
satisfaction rates
• Cost differences: controversial

5. Aim of treatment
• Prevention of reflux without limiting the
dynamic nature of the LES to open for gastric
venting or swallowing.

6. Indications
• Objectively proven GERD
• Failed medical Rx (heartburn, severe
regurgitation not controlled with acid
suppression, or medication side effects)
• Patient opt for surgery despite successful
medical management (quality of life
considerations, lifelong need for medication
intake, cost of medications, etc.)

7. Indications
• Presence of complications of GERD (e.g.,
Barrett’s esophagus, esophagitis, peptic
stricture)
• Extra-esophageal manifestations (asthma,
hoarseness, cough, chest pain, aspiration)
• The development of a stricture represents
failed medical Rx: strictures are often
associated with a structurally defective
sphincter and loss of esophageal contractility

8. Contraindications to Surgical Rx
• Malignancy
• Drug-induced strictures
• Achalasia

9. Preoperative evaluation
• Aim: To select the appropriate reflux patients for
surgical treatment in order to optimize outcomes.
• Counselling: for complications of treatment
• Typical symptoms (heartburn and/or regurgitation)
which have responded, at least partly, to PPI therapy,
will generally do well following surgery; patients with
atypical symptoms have a less predictable response.
• Objective signs of GERD: flexible OGD for any “mucosal
break”(an area of slough or erythema clearly
demarcated from adjacent normal-appearing mucosa )-
a reliable indicator of reflux esophagitis; BE, strictures,
masses; biopsy

10. Preoperative evaluation
• In the absence of endoscopic evidence of reflux, the
current gold-standard objective test to diagnose GERD is
the 24-hour ambulatory esophageal pH-metry
• 48-hour esophageal pH-monitoring: No additional benefit.
• Esophageal manometry: evaluates the strenght of the
propulsive force of the body of the esophagus to propel a
bolus of food through a newly reconstructed valve.
• With normal peristaltic contractions, consider 360° Nissen
FP (or a partial FP) though depends on patient and surgeon
preferences.
• With peristalsis absent, consider a partial FP (rule out
achalasia).

11. Preoperative evaluation
• Barium swallow:
• for better delineation of the anatomy.
• helpful in patients with motility disorders
• large hiatal hernias who have a shortened
esophagus, or for revision surgery after previous
antireflux surgery.
• Anatomic shortening may compromise the ability
to perform an adequate repair without tension,
and that this can lead to an increased incidence
of breakdown or thoracic displacement of the
repair.

12. Adjunct studies
• Video esophagography: structure (strictures,
masses, hiatal hernia, foreshortened esophagus,
diverticula) and function (reflux)
• CT scan of the chest and abdomen, small bowel
follow-through, gastric emptying study, and
colonoscopy
• Hiatal hernia: Lung function tests because of
compromised lung function and thorough cardiac
evaluation because of overlapping symptoms

13. Principles of Antireflux Surgery
• Aim: To safely create a new antireflux valve at the GEJ,
while preserving ability to swallow normally and belch.
 Creates a flap valve which prevents regurgitation of
gastric contents into the esophagus due to an increase
in the pressure of the DES region.
 The length of the reconstructed valve should be at
least 3 cm. This not only augments sphincter
characteristics in patients in whom they are reduced
before surgery, but prevents unfolding of a normal
sphincter in response to gastric distention

14. Principles of Surgical Therapy
• A laparoscopic approach is now used routinely in all patients
undergoing primary antireflux surgery.
• Some surgeons advocate the use of a single antireflux procedure for
all patients, whereas others advocate a tailored approach.
• Laparoscopic Nissen fundoplication as the procedure of choice for a
primary antireflux repair in all patients with normal or near normal
esophageal motility, and partial fundoplication for those with poor
esophageal body motility.
• Others, based on the good longer term outcomes reported
following partial fundoplication, advocate the routine use of a
partial fundoplication procedure, thereby avoiding any concerns
about constructing a fundoplication in individuals with poor
esophageal motility.

15. The ideal fundoplication
• A loose wrap
• Maintains the position of the gastric fundus close to the distal intra-
abdominal esophagus, in a flap valve arrangement
• An adequate length of the DES in the positive-pressure
environment of the abdomen by a method that ensures its
response to changes in intra-abdominal pressure.
• The reconstructed cardia should be able to relax on deglutition.
• Should not increase the resistance of the relaxed sphincter to a
level that exceeds the peristaltic power of the body of the
esophagus.
• Placed in the abdomen without undue tension, and maintained by
approximating the crura of the diaphragm above the repair

16. Primary Antireflux Repairs
• Nissen Fundoplication.
• The most common antireflux procedure.
• Previously done via an open abdominal or a chest
incision, now routinely undertaken laparoscopically.
• Originally a 360° fundoplication around the lower
esophagus for a distance of 4 to 5 cm, without division
of the short gastric blood vessels.
• Modification: only the gastric fundus used to envelop
the esophagus around a large (50 to 60F) bougie,
limiting the length of the fundoplication to 1 to 2 cm,
and dividing the short gastric vessels

17. Nissen fundoplication
• The patient is placed with the head elevated
approximately 30° in the modified lithotomy
position.
• The surgeon stands between the patient’s
legs, and the procedure is completed using
five abdominal ports.
• The gastrohepatic ligament is incised until the
phrenoesophageal ligament is visualized

18. Nissen fundoplication
• Opening of the phrenoesophageal ligament in a
left to right fashion and preservation of the
hepatic branch of the anterior vagus nerve
• The circumference of the diaphragmatic hiatus is
dissected and the esophagus is mobilized to allow
about 3 cm of intraabdominal esophagus by
careful dissection of the anterior and posterior
soft tissues within the hiatus with great care to
preserve both vagus nerves and the peritoneal
lining along the crura.

19. Nissen fundoplication
• The esophagus is held anterior and to the left and crural
closure posteriorly with interrupted non-absorbable
sutures.
• Following complete fundal mobilization, tension-free FP is
constructed either with or without division of the short
gastric blood vessels, according to surgeon preference.
• The posterior wall of the fundus is brought behind the
esophagus to the right side, and the anterior wall of the
fundus is brought anterior to the esophagus creating a 1.5
to 2-cm wrap with the most distal suture incorporating the
anterior muscular wall of the esophagus
• 50 to 60F bougie placement at the time of wrap
construction

20. Nissen FP

21. Posterior Partial Fundoplication
• An alternative to the Nissen procedure developed to minimize the
risk of postFP side effects: dysphagia, inability to belch, and
flatulence.
• Commonest approach - a posterior partial or Toupet fundoplication.
• Some surgeons use this type of procedure for all patients
presenting for antireflux surgery.
• Others apply a tailored approach in which a partial fundoplication is
constructed in patients with impaired esophageal motility, in which
the propulsive force of the esophagus is thought to be insufficient
to overcome the outflow obstruction of a complete fundoplication.
• The Toupet posterior partial FP is a 270° gastric FP around the distal
4 cm of esophagus. It is usually stabilized by anchoring the wrap
posteriorly to the hiatal rim.

22. Toupet FP

23. Anterior Partial Fundoplication
• An alternative approach to partial fundoplication.
• Following posterior hiatal repair, the anterior fundus is rolled over
the front of the esophagus and sutured to the hiatal rim and the
esophageal wall.
• Division of the short gastric vessels is never needed.
• Various degrees of anterior partial fundoplication have been
described—90°, 120°, 180°.
• The anterior 180° partial fundoplication provides a more robust FP
and achieves an excellent longer term outcome in approximately
90% of patients at follow-up of at least 10 years.
• With this procedure the fundus and esophagus are sutured to the
right side of the hiatal rim to create a flap valve at the
gastroesophageal junction, and to stabilize a 3-4 cm length of intra-
abdominal esophagus.

24. Dor FP

25. Collis Gastroplasty (PGT)
• When a shortened esophagus is encountered,
many surgeons choose to add an esophageal
lengthening procedure before fundoplication,
to reduce the tension on the gastro-
esophageal junction, believing this will
minimize the risk of failure due to
postoperative hiatus hernia.

26. Collis gastroplasty

27. Outcome after Fundoplication
• Relieves typical reflux symptoms (heartburn,
regurgitation, and dysphagia) in more than
90% of patients at follow-up intervals
averaging 2 to 3 years and 80% to 90% of
patients 5 years or more following surgery.

28. Postop Complication
• Dysphagia: Common. Generally resolves within 3
months, but can take up to 12 months.
Permanent in 5% of individuals following Nissen
fundoplication to require dietary modification
• Inability to belch & vomit: usually temporary (
first 3 to 6 months), but 80%-90% resolves by 12
months follow-up.
• Hyperflatulence: related to increased air
swallowing reflux disease, aggravated by the
inability to belch.
• Rx failure.

29. Recent advances
• Adding bulk to the LES
• tightening the sphincter (by plication/
radiofrequency ablation)
• Robotic surgery

30. Recent advances
• Sphincter augmentation with LINX system: use of
a flexible and expandable device that creates
resistance to abnormal opening of the sphincter.
Ease of removal.
• Complications:
Dysphagia: usually mild
Chest pain from suspected esophageal spasm.
Treated with sublingual nitroglycerin
inability to belch or vomit
Device erosion or migration: Not documented

31. LINX device

32. LINX device: Negative predictors
• higher BMI
• structurally defective LES
• residual LES pressure

33. Roux-en-Y reconstruction
bile or gastric reflux
Morbid obesity,
diabetes

34. Roux-en-Y gastric bypass

35. Follow up
• Post op complications
• Complications of GERD (BE) postop: Seattle
protocol. Surveillance at regular intervals
because regression is rare

36. American Gastroenterological
Association Guidelines for Surveillance
After FP For BE
• VARIABLE SCORE
• Age >75 years 1
• Tachycardia (>100 beats/min) 1
• Leukocytosis (>10,000 white blood cells/mL) 1
• Pleural effusion 1
• Fever (>38.5° C) 2
• Noncontained leak (barium swallow or CT scan) 2
• Respiratory compromise (respiratory rate >30, increasing
oxygen requirement, or mechanical ventilation) 2
• Time to diagnosis >24 hours 2
• Presence of cancer 3
• Hypotension 3

37. PROGNOSIS
• Technique employed
Ant vs Post vs Nissen
Length
Short gastric vessel division
• For Barrett’s Esophagus
Presence of dysplasia
Degree of dysplasia
Length of BE segment

38. Conclusion
• GERD is the failure of the antireflux barrier,
allowing abnormal reflux of gastric contents
into the esophagus.
• Surgical management is more beneficial than
medical Rx in patients with typical symptoms
due to the added reflux control.
• Follow up is mandatory in patients with BE.

39. THANK YOU