What is the optimal surgical procedure for long-term control of gastroesophageal reflux disease, with regard to the antireflux barrier and postoperative complaints?
L. Olbe (Gothenburg)
The alternative to surgical treatment
Modern medical treatment of gastroesophageal reflux disease (GERD) with potent antisecretory drugs can heal the esophagitis and relieve the reflux symptoms in most patients. Proton pump inhibitors (PPIs) are the most effective antisecretory drugs. Some patients, often with a severe reflux disease, need a high dose of the proton pump inhibitor and a treatment period of 3-4 months before healing and complete relief of symptoms. In patients with predominantly volume reflux or respiratory symptoms and in the few patients with alkaline reflux disease, medical treatment is fair less effective and surgical treatment should be considered at an early stage.
It is well established, that the PPI omeprazole can keep the GERD patients in clinical remission during long-term maintenance treatment. Even daily, full dose omeprazole treatment over 4-12 years has resulted in only very few side effects. A preliminary report  has suggested that long-term acid suppressive therapy will facilitate the development of atrophic gastritis and ECL hyperplasia, that is induced by Helicobacter pylori infection. If this finding is confirmed, it might be reasonable to recommend eradication of Helicobacter pylori infection in GERD patients selected for long-term antisecretory maintenance therapy.
Indications for surgical treatment
Surgical treatment of GERD is indicated in relatively young and otherwise fit patients as an alternative to life-long antisecretory maintenance treatment. The patient should be well informed about the advantages and disadvantages of the two alternatives. The diagnosis should be established by endoscopy and 24-hour pH-metry. Preoperative manometry should be performed to explode primary motor disorders and to register any reflux associated motility disturbances. The history should be penetrated and the patient should be informed that symptoms from any other disease or disorder that might occur concomitantly, like e.g. the irritable bowel syndrome (IBS), will not be improved by the operation.
The aim of the surgical treatment is of course to prevent gastroesophageal reflux (GER), but also to minimize mortality and morbidity. The most common side-effects are dysphagia and the gas-bloat syndrome, which includes postprandial epigastric fullness, oppression and sometimes pain as well as general meteorism with increased flatulence. The gas-bloat syndrome is facilitated by an impaired gastric emptying and is particularly prone to develop, if the operation results in an inability to belch. The gas-bloat syndrome and the IBS have many symptoms in common.
Surgical procedures and postoperative short-term results
The classical operation is a total fundic wrap according to Nissen. This operation has been modified by Rossetti , who used only the front wall of the gastric fundus for the construction of the wrap in order to prevent slipping of the wrap. Partial 180° - 270° fundoplication has produced similar clinical results as the total Nissen-Rossetti wrap, although few prospective, randomized comparisons have been performed .
Surgeons with well established experience in GERD usually present a postoperative success rate of > 80% with failure in 5-10% and significant side-effects in 5-10% [3-5]. Postoperative mortality is well below 0.5%. There are a number of technical details, that have to be handled in an adequate way.
Disruption of the antireflux barrier and hiatal hernia is very often present and predisposes to GERD. The hernia must be dissected free and taken down into the abdominal cavity to allow the fundoplication to be placed around the distal esophagus. A total fundoplication can preferably be constructed according to Rossetti in order to minimize slipping of the wrap and can furthermore be hooked up on the hepatic branches of the vagal nerve for the same reason. The diaphragmatic crura should be narrowed in order to prevent herniation of the wrap into the thoracic cavity with obstructive symptoms. Whether the narrowing of the crura will restore the contribution of this structure to the gastroesophageal high pressure zone  is unknown. The fundoplication should be short,
2-3 cm, and floppy in order to minimize postoperative dysphagia, allow belching [5, 7, 8], and thereby reducing the risk of gas-bloat syndrome. A floppy fundoplication does not impair the antireflux barrier of the wrap. The mechanism of the antireflux barrier of the fundoplication is complex. A mucosal flap is created that will act as a one-way mechanical valve, easily demonstrated at endoscopy. The resting tone in the lower esophageal sphincter (LES) area is increased by both total and partial fundoplication, but to a higher degree after a total wrap . This difference may explain a higher rate of early postoperative dysphagia after total wrap than after partial fundoplication . Furthermore, the antireflux effect of total fundoplication was associated with a substantial reduction of the rate of transient lower esophageal sphincter relaxations as well as the proportion of these relaxations accompanied by reflux .
Many surgeons recommend partial fundoplication in GERD patients with reflux associated motor disturbances. This is, however, a controversial strategy. In fact the frequency of dysphagia after the first three months was the same irrespective of total or partial fundoplication despite that the outcome of the preoperative manometry had not been a selection factor . The partial fundoplication according to Toupet had the same antireflux effect as the total fundoplication according to Rossetti in a prospective, randomized study followed over several years . The ability to belch was the same after the Toupet procedure and the floppy Rossetti procedure as was the main symptoms of the gas-bloat syndrome, i.e. epigastric fullness, oppression and pain. The only long-term difference between the two procedures was significantly more complaints of flatulence after the total fundoplication.
Laparoscopic total and partial fundoplication can now be performed [11, 12] with equally good short term results as after traditional surgery, and with no difference in the outcome of the two procedures .
The long-term clinical outcome of total and partial fundoplication in GERD is very similar. The only difference is less flatulence after partial fundoplication.
More important are strict selection of patients and meticulous surgical technique to optimize the construction of an antireflux barrier and minimize the risk of recurrence as well as dysphagia and gas-bloat syndrome. There is reason to believe, that the laparoscopic approach will be the most common procedure.
1. Kuipers EJ, Klinkenberg-Knol EC, Havu N, Festen HPM, Lamers CBHW, Jansen JBMJ, et al. Helicobacter pylori and development of atrophic gastritis during omeprazole maintenance therapy. Gastroenterology 1995;108: A137.
9. Lundell L, Abrahamsson H, Ruth M, Rydberg L, Lönroth H, Olbe L. Long-term results of a prospective randomized comparison of total fundic wrap (Nissen-Rossetti) or semifundoplication (Toupet) for gastro-oesophageal reflux. Br J Surg 1996;83:830-835
11. Lund RJ, Wetscher GJ, Raiser F, Glaser K, Perdikis G, Gadenstätter M, Katada N, Hinder RA. Laparoscopic Toupet fundoplication for gastroesophageal reflux disease with poor esophageal body motility. Gastroenterology 1996;110: A1401.
12. Patti MG, De Pinto M, de Bellis M, Arcerito M, Tong J, Wang A, Mulvihill SJ, Way LW. Comparison of laparoscopic total and partial fundoplication for gastroesophageal reflux disease. Gastroenterology 1996;110: A1409.