II. Epidemiology
- Second most common U.S. elective surgery
- Gallbladder surgery is first
III. Indications
- Refractory Gastroesophageal Reflux disease
- Failed medical therapy
- Persistent symptomatic Esophagitis
- Anticipated Long-term medical therapy in young patient
- Esophageal bleeding
- Barrett's Esophagus
- Linear erosions secondary to Hiatal Hernia
- Persistent secondary complications of regurgitation
IV. Contraindications (Relative)
- Elderly patients with significant comorbidities
- Significant Esophageal Dysmotility
- Functional symptoms at risk of worsening with surgery
- No available experienced anti-reflux surgeon
V. Advantages compared with GERD Medical Therapy
- GERD relapses in 80% of medical treatment in 3 years
- Surgery in less expensive than 10 years of PPI Therapy
- Very safe, laparoscopic procedure
VI. Disadvantages
- No long-term studies confirm Nissen efficacy
- Laparoscopic Nissen has a steep learning curve
- Studies recommend first 20 procedures supervised
- Surgical residents before and after 25-50 procedures
- Comfort with procedure after 10-15 operations
- Complications reduced after experience
- Initial intra-operative complications: 20%
- Later intra-operative complications: 2-4%
- Converting laparoscopic to open procedure reduced
- Initial conversion to open procedure: 56%
- Later conversion to open procedure: 16%
VII. Complications
- Overall complication rate: 1-2%
- Conversion from laparoscopic to open procedure: <1-2%
- Pneumothorax: <1%
- Esophageal Perforation or gastric perforation: <1-2%
- Peri-operative mortality: <0.5%
- Splenic Injury or Hepatic Injury: Rare
VIII. Adverse Effects
- New onset of gastrointestinal symptoms (67%)
- Dysphagia
- Gas
- Bloating
- Required continued antireflux drugs post-surgery (27%)
- Follow-up found 52% taking Antacids 3-5 years post-op
- Lundell (2001) J Am Coll Surg 192:172-9 [PubMed]
- Solid food Dysphagia (10%)
- Required esophageal dilatation after surgery (8%)
- Repeat surgery required (7%)
- References
IX. Preparatory Studies
- Upper Endoscopy (evaluate for Barrett's Esophagus)
- Upper Gastrointestinal Series (defines anatomy)
- Manometry
- 24-Hour pH Monitoring
X. Prognosis: Best surgical candidates for best outcomes
- Age under 50 years
- Typical Gastroesophageal Reflux disease symptoms
- Erosive Esophagitis on endoscopy
- Good response to Proton Pump Inhibitor
- Positive 24 hour pH study
- References
- Frick (2003) New Therepeutics, Cable, WI
XI. Alternative endoscopic procedures (new)
- Endoscopic suturing (Endo-Cinch)
- Stretta Procedure (Radiofrequency ablation)
- Experimental endoscopic procedures
- LES Augmentation (Microcapsule injection)
- Enteryx Ethylene Vinyl Alcohol Injection
XII. References
- Bowrey (2000) Surg Clin North Am 80(4):1213-42 [PubMed]
- Cattey (1996) Surg Laparosc Endosc 6(6):430-3 [PubMed]
- Feldman (1998) Sleisenger and Fordtran's, p. 509-17
- Frantzides (1998) 124(4):651-4 [PubMed]
- Hinder (1997) Am J Med 103(5A):144S-148S [PubMed]
- Horgan (1997) Surg Clin North Am 77(5):1063-82 [PubMed]
- Laine (1997) Surg Endosc 11(5):441-4 [PubMed]
- Lundell (2001) J Am Coll Surg 192:172-81 [PubMed]
- Nessen (1999) JSLS 3(2):103-6 [PubMed]
- Peters (1998) Ann Surg 228(1):40-50 [PubMed]
- Rantanen (1999) Br J Surg 86(12):1573-7 [PubMed]
- Soot (1999) Arch Surg 134(3):278-81 [PubMed]
- Townsend (2001) Sabiston Surgery, Saunders, p. 755-66
- Watson (1996) Ann Surg 224(2):198-203 [PubMed]