Advances in the surgical treatment of reflux disease

Abstract

The studies presented in this thesis have addressed the advances of surgical treatment of gastro-oesophageal reflux disease (GORD). GORD is one of the most prevalent benign disorders of the upper gastrointestinal tract and involves a wide spectrum of disorders in which reflux of gastric content into the oesophagus leads to troublesome symptoms and/or lesions. GORD is diagnosed based on the presence and combination of typical symptoms such as heartburn and regurgitation with a favourable response to pharmacological therapy. Diagnostic tests to demonstrate the presence of GORD are 24-h pH monitoring and upper gastrointestinal endoscopy. Pharmacological treatment with proton pump inhibitors (PPIs) is the standard initial therapy for GORD. PPI therapy provides long-term control of GORD in up to 95 per cent of the patients. The remaining 5 per cent suffer from PPI-refractory GORD and are candidates for anti-reflux surgery. The first fundoplication for GORD was implemented by Rudolph Nissen and has become the most frequently performed operation for GORD. The procedure was performed by wrapping the fundus of the stomach posteriorly around the oesophagus with a 360° circumference. Laparoscopic fundoplication rapidly replaced conventional fundoplication. In this thesis the long-term outcome of conventional Nissen fundoplication and its laparoscopic counterpart are compared. There was no difference between the improvement of reflux symptoms at 17 years between both fundoplication. Laparoscopic anti-reflux surgery reduces the number of incisional hernia corrections compared to conventional upper midline incision, underlining the long-term benefit of laparoscopic surgery. Despite the good results after Nissen fundoplication, the procedure can result in post-fundoplication symptoms like difficulty in swallowing (dysphagia) and gas-related symptoms. Therefore, partial fundoplications such as the 270° posterior Toupet fundoplication and the 90° and 180° anterior fundoplication have been developed to reduce these postfundoplication symptoms while maintaining reflux control. This thesis reports several studies such as meta-analyses and mid- and long-term outcome of RCTs comparing anterior versus Nissen fundoplication. From these studies it can be concluded that laparoscopic 180° anterior fundoplication ensures durable control of reflux symptoms with minimal postfundoplication symptoms compared to laparoscopic Nissen fundoplication, which is associated with a higher rate of transient side effects up to 12 years. Furthermore, laparoscopic 90° anterior fundoplication is associated with inferior reflux control compared to 180° anterior and Nissen fundoplication. Finally, the two types of laparoscopic partial fundoplications (180° anterior fundoplication and Toupet fundoplication) were head-to-head compared in a randomised clinical trial. The one-year outcome of this RCT demonstrated that there is no difference between laparoscopic Toupet and laparoscopic 180˚ anterior fundoplication in controlling GORD symptoms and oesophageal acid exposure, with a low rate of postoperative side effects and high patient satisfaction. In conclusion, laparoscopic partial fundoplication is the current surgical therapy of choice for GORD, with no differences in short-term between laparoscopic 180˚ anterior fundoplication and 270˚ posterior fundoplication (Toupet).