Laparoscopic anti-reflux surgery : indications, techniques and physiological effects

Abstract

Gastro-oesophageal reflux disease (GORD) is a highly prevalent chronic disorder in which retrograde flow of gastric contents into the oesophagus causes troublesome symptoms or lesions. Proton pump inhibitor (PPI) therapy controls reflux disease in 95% of the patients and the remaining 5% have PPI-refractory GORD. Patients with PPI-refractory GORD, unwillingness to take lifelong medication or extra-oesophageal manifestations are candidates for anti-reflux surgery. Candidates for antireflux surgery with erosive reflux disease on upper endoscopy and/or pathological reflux in supine or bipositional body position with a positive symptom-reflux association during 24-h pH metry, have a classic indication for antireflux surgery. The aims of this study were (I) to explore indications for laparoscopic antireflux surgery, (II) to compare fundoplication techniques and (III) evaluate physiological effects. Consecutive cohort studies proved that candidates for antireflux surgery with isolated upright reflux, oesophageal acid hypersensitivity, negative symptom-reflux correlation or non-erosive reflux disease benefit from laparoscopic Nissen fundoplication (LNF) as much as those with classic indications for surgery. Consequently, indications for antireflux surgery should be broadened and fundoplication should not be withheld from these patients. On the other hand, patients with poor oesophageal peristalsis or high supine acid exposure before surgery should be counselled about their higher chance of recurrent reflux after LNF. A cohort study in 2040 patients demonstrated that tailoring the degree of fundoplication based on preoperative oesophageal motility is probably not necessary, since oesophageal peristalsis before surgery has no impact on postfundoplication dysphagia. A small cohort study found that LNF for failed endoluminal EsophyX fundoplication provides satisfactory reflux control, but is associated with a risk of gastric perforations during LNF and a high rate of postfundoplication dysphagia. The ten-year results of a randomised clinical trial (RCT) in 146 patients demonstrated that laparoscopic anti-reflux surgery reduces the reoperation rate for incisional hernia (2.5%versus13.0%) with similar long-term effectiveness compared with conventional fundoplication. Surgeon experience, however, affected early outcome of laparoscopic fundoplication and this pleads for centralisation of expertise. LNF is the most frequently performed operation for GORD. Dysphagia and gas-related symptoms are the main side-effects of LNF and a study that preformed impedance monitoring before and after LNF demonstrated that the latter are caused by a reduction in the number of gastric belches that is accompanied by an increase in oesophageal belching. Partial laparoscopic anterior (LAF) and Toupet fundoplication (LTF) have been proposed to reduce these symptoms. The 5-year results of 4 RCTs in 425 patients demonstrated that 90 LAF provides inferior long-term reflux control compared with LNF. In contrast, 180 LAF reduced dysphagia and gas-related symptoms compared with LNF, with similar long-term control of reflux symptoms. In a meta-analysis of RCTs, LTF was associated with fewer reinterventions (3.1%versus7.0%), less dysphagia and fewer gas-related symptoms, with similar reflux control compared with LNF. A subsequent impedance study shed light on the physiological origin of these findings and found that LNF and LTF similarly control acid and weakly acidic reflux, with a smaller reduction of gastric belches. Therefore, 180 LAF and LTF should be considered the surgical procedure of choice for GORD