Preprocedural Planning
It is important to obtain a detailed history and physical examination. Clinical predictors of response to antireflux surgery are lacking; thus, a thorough preoperative evaluation is needed for appropriate patient selection to ensure the best clinical outcome. [17]
Before surgical intervention, patients must undergo anatomic or physiogic testing to confirm that there is objective evidence of gastroesophageal reflux disease (GERD). Anatomic examination includes the use of esophagogastroduodenoscopy (EGD) with or without biopsy and contrast radiography (eg, upper gastrointestinal [GI] series). Physiologic examination may include 24-hour esophageal pH assessment, esophageal manometry, intraluminal impedance monitoring, gastric emptying testing, and the Bernstein acid test.
Esophagogastroduodenoscopy
EGD can be used to visualize evidence of reflux esophagitis (see the video below).
Lundell et al confirmed GERD in patients with typical symptoms accompanied by endoscopic evidence of a mucosal break (defined as "an area of slough or erythema clearly demarcated from adjacent normal-appearing mucosa"). [18] Endoscopic evidence of biopsy-proven benign peptic stricture or Barrett esophagus is also considered diagnostic evidence of GERD.
EGD can be used to obtain biopsies that may help to determine the extent of esophagitis, Barrett esophagus, or other pathology. Interestingly, the EGD findings may be normal in as many as 70% of patients with GERD.
24-hour pH testing
Although pH testing is considered the criterion standard for diagnosis of GERD, routine use may be of only marginal benefit. It is best used in the absence of endoscopic evidence of reflux or when the diagnosis is unclear. [19] This test allows the physician to quantify the number and duration of reflux episodes, differentiate between upright and supine reflux, and correlate these events with subjective symptoms. Either 24-hour ambulatory esophageal pH-metry or the 48-hour wireless esophageal pH-monitor probe can be used.
Esophageal manometry
Esophageal manometry tests the function of the esophagus by evaluating peristalsis and lower esophageal sphincter (LES) pressure. Specifics about the length, location, and tone of the LES can be characterized. This test also helps diagnose underlying motility disorders, which may be a contraindication to fundoplication.
Preoperative manometry testing suggestions vary. Many physicians advocate preoperative manometry testing, noting that approximately 10% of manometry findings alter surgical planning. [19] However, the literature does not support mandatory preoperative manometry testing. Rather, manometry may be considered in patients who do not respond to empiric medical treatment and have normal findings on endoscopy. [9, 20, 21, 22]
Contrast radiography
An upper GI series may be useful for anatomic delineation of the esophagogastric junction (EGJ) in relation to the hiatus. This allows detection of hiatal hernias, strictures, or shortened esophagus. Esophageal peristalsis can also be qualitatively assessed. [9]
Impedance monitoring
Impedance monitoring evaluates esophageal motility and function through assessment of directional bolus transit within the esophagus. This test is particularly helpful in evaluation of nonacidic reflux. [23]
Gastric emptying tests
Gastric emptying tests may be considered if patients have a history of diabetes, severe nausea or vomiting, or postprandial bloating. In addition, they may be helpful in cases of reoperation. Gastric emptying studies should not be routinely obtained, because there is only limited evidence in the literature to support a correlation between gastric emptying test results and postoperative outcomes from fundoplication. [9]
Equipment
An atraumatic liver retractor is necessary to elevate the liver for exposure of the hiatus. A self-retraining device is needed to hold the liver retractor if an additional assistant is not available. An appropriately sized bougie may be used by some surgeons. A coagulation device of choice (monopolar, bipolar, or ultrasonic) should be available. A flexible endoscope should be available for emergency use should the need arise for endoscopic evaluation of the esophagus or stomach. A curved instrument of choice or Penrose drain can be used to encircle the esophagus.
Patient Preparation
Anesthesia
General endotracheal anesthesia is used. A nasogastric or orogastric tube is often placed to assist in decompression of the stomach during the procedure.
Positioning
In the transabdominal approach, patients are placed in the supine position, with the arms tucked. Some surgeons ensure that patients are stable by using a beanbag or egg-crate foam. The bed is placed in the reverse Trendelenburg position to displace the bowel inferiorly. The surgeon is positioned between the patient’s legs, and the first assistant is on the patient’s left.
In the transthoracic or thoracoabdominal approach, the patient is positioned with the left side raised so that a midline laparotomy can be supplemented by a left anterolateral thoracotomy.
Monitoring & Follow-up
Patients are most commonly discharged between postoperative days 2 and 5. The authors recommend that patients abstain from lifting anything heavier than 10 lb for 6 weeks postoperatively.
Close follow-up is necessary to ensure patient compliance with diet and early identification of potential complications. In the authors' practice, patients are seen at 1 week, 2 weeks, 4 weeks, and 8 weeks postoperatively, then yearly after that.
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Rossetti-Nissen modified fundoplication.
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Nissen fundoplication.
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Toupet partial fundoplication.
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Hiatal dissection. Esophagus is encircled and retracted anteriorly, exposing posterior hiatus for dissection.
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Hiatal repair. Sutures should be placed from posterior to anterior.
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Hiatal repair.
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Anterior wall of gastric fundus is passed behind esophagus with atraumatic Babcock forceps.
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Rossetti-Nissen fundoplication.
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Anatomy of lower esophageal sphincter.
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Original Nissen fundoplication, as described by Dr Rudolf Nissen.
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Severe distal reflux esophagitis, as seen via esophagogastroduodenoscopy. Video courtesy of Dawn Sears, MD, and Dan C Cohen, MD, Division of Gastroenterology, Scott & White Healthcare.
