What is GERD?
- Development & Prevention
- Diagnosis & Management
- Barrett's Esophagus
- Esophageal Function Tests
- Antireflux Surgery
Anti Reflux Surgery
Reflux occurs because of the impaired function of the anti-reflux mechanism located in the most distal part of the gullet (lower esophageal sphincter). Anti-reflux surgery aims to repair the anti-reflux barrier. Anti-reflux surgery is performed laparoscopically or endoscopically. Esophageal function tests (manometry, pH monitoring) should be done prior to surgery.
Laparoscopic fundoplication is conducted under general anesthesia. During the operation the proximal stomach (fundus) is wrapped around the reflux-damaged distal part of the esophagus, i.e. the dilated gullet (Figure 1).
Figure 1: Principle of fundoplication
The proximal part of the stomach can be wrapped around the total circumference of the distal gullet (360° Nissen fundoplication) or include the partial circumference of the distal esophagus (270° Toupet fundoplication) (Figure 1). During the fundoplication the so called hiatal hernia is also repaired.
Figure 2: Total or partial fundoplication and repair of the hiatal hernia
Hiatal Hernia Repair: During its course from the neck to the stomach the gullet passes through a small hole within the diaphragm. During reflux disease the gullet gets dilated and by that enlarges the esophageal hole within the diaphragm and contributes to the disarrangement of the geometry of the antireflux mechanism.
During fundoplication the enlarged hole in the diaphragm in reduced to the diameter required for the passage of the gullet (Figure 3). The repair should not be too dense, otherwise difficulties in swallowing may occur. Following closure of diaphragmatic hole, the fundoplication is conducted (Figure 1,2).
Figure 3: Hiatal hernia repair
Endoscopic fundoplication is conducted under general anesthesia or sedoanalgesia. During the procedure the fundic wrap is created using an endoscopic suture device (Figure 4). Repair of the hiatal hernia can not be conducted using this approach. Therefore the endoscopic fundoplication may be considered for the early stage of the disease without the presence of an hiatal hernia.
Figure 4: Endoscopic fundoplication
Magnetic sphincter (Bonavina Ring): A novel method uses a magnetic ring (Luigi Bonavina ring, named after an Italian surgeon from Milano) to enwrap the esophagus for creation of an antireflux barrier valve). The ring is applied laparoscopically (with or without hiatal hernia repair). The magnetic ring (sphincter) withstands reflux, but allows normal passage of food. Short term data are promising. The magnetic sphincter seems to be a good method for repair of the early stages of the disease.
Figure 5: Magnetic sphincter for creation of an antireflux barrier
The disadvantage of the method is due to the fact that the magnetic ring does not allow magnetic resonance tomography, which is used in the radiological work up of diseases of the connective tissue, joints (spine, legs, arms) and muscles. Currently the method is available in few centers around the world (Milano, Los Angeles, Nürnberg).