A 51-year-old man seeks medical attention for intermittent chest pain. He describes the pain as “burning” and it has become increasingly frequent after meals over the last 4 to 6 months. In addition, he experiences regurgitation, and often wakes up at night with a feeling of choking. He has also noted hoarseness and cough. Proton pump inhibitors are very helpful for the heartburn and chest pain but do not improve the regurgitation. Long-term results have shown that a fundoplication provides control of reflux in about 90% of patients. To achieve these results the surgeon should focus on the technical elements of the operation, rather than on the eponyms. The technical elements of the operation are the following: (1) division of the short gastric vessels to achieve complete fundic mobilization; (2) extensive dissection of the distal esophagus in the posterior mediastinum to bring the gastroesophageal junction at least 3 cm below the diaphragm; (3) meticulous closure of the right and left pillar of the crus with non-absorbable sutures; (4) use of a bougie to decrease postoperative dysphagia; (5) a short fundoplication with three interrupted stitches placed at 1 cm of distance from each other (2-2.5 cm long). All these technical elements have been shown to positively impact long-term outcomes. Patients who are still symptomatic postoperatively must be thoroughly evaluated to identify the cause of failure, and treatment must be individualized.
Ciro Andolfi (The University of Chicago Medicine)
Marco G. Patti (The University of Chicago Medicine)
Editor Recruited By: Jeffrey Matthews, MD
The patient lies supine on the operating table in low lithotomy position with the lower extremities extended on stirrups with knees flexed 20-30 °; a bean bag is inflated to avoid sliding of the patient; an orogastric tube is placed to decompress the stomach; the surgeon stands between the patient's legs, while first and second assistant stand on the right and left side respectively. A five trocar technique is used for this procedure; a first trocar is placed 14 cm inferior to the xiphoid process, in the midline, for a 30° scope; a second trocar is placed in the left midclavicular line, at the same level with the first trocar, to introduce a Babcock clamp; a third trocar is placed in the right midclavicular line, at the same level of the other two trocars, and it is used for the insertion of a retractor to lift the liver; a fourth and a fifth trocar are placed under the right and left costal margins and they are used for the dissecting and suturing instruments.
Symptoms not controlled by medications, presence of a pathologic amount of reflux documented by 24-h pH monitoring.
There are no contraindications to a laparoscopic fundoplication as the patient is otherwise healthy.
Excluding placement and removal of trocars, we can consider seven major steps for this surgery.
1. Division of gastro-hepatic ligament; identification of the right crus of the diaphragm and posterior vagus nerve.
2. Division of peritoneum and phreno-esophageal membrane above the esophagus; identification of the left crus of the diaphragm and anterior vagus nerve.
3. Division of short gastric vessels.
4. Creation of a window between gastric fundus, esophagus and diaphragmatic crura; placement of Penrose drain around the esophagus, incorporating anterior and posterior vagus nerves.
5. Closure of the crura with interrupted 2-0 silk suture.
6. Insertion of the bougie (56 Fr) into the esophagus and across the esophageal junction.
7. Wrapping of gastric fundus around the lower esophagus; the two edges of the wrap are secured by three 2-0 silk interrupted sutures placed at 1 cm of distance from each other. The wrap should be no longer than 2-2.5 cm.
His work consisted of the following tests: 1) barium swallow which showed normal flow of contrast into the stomach and no hiatal hernia; 2) upper endoscopy which showed LA grade B esophagitis; 3) esophageal manometry which shows a hypotensive lower esophageal sphincter and normal peristalsis; and 4) ambulatory pH monitoring that shows a pathologic amount of reflux (score 76, normal being < 14.7), and strong correlation between episodes of reflux and symptoms. The essential investigations are barium esophagram, manometry, endoscopy and 24h pH monitoring.
In case of a severe impairment of esophageal peristalsis, a partial fundoplication should be considered. There are two options:
1.Partial posterior fundoplication: 240 - 270 degrees
2.Partial anterior fundoplication: 180 degrees
Intra-operative complications are pneumothorax, esophageal or gastric perforation, splenic injury, and vagal nerve injury. Post-operative complications are dysphagia and persistent or recurrent reflux, and symptoms. The patient started a soft diet the morning of the first post-operative day; it's important to avoid meat, bread and carbonate beverages for 2 weeks; 85% of patients are discharged within 23h and 95% within 48 hours.
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