Χειρουργείο Γαστροοισοφαγικής Παλινδρόμησης – Επιλογή Ασθενών & Τεχνική Ενισχύουν την Επιτυχία
Laparoscopic antireflux surgery remains a highly effective treatment in 80%-90% of patients with gastroesophageal reflux disease (GERD). Despite this, 10%-20% of patients continue to have symptoms postoperatively. Of these, some 3%-6% require a second surgery. A literature review by Marco G. Patti, MD, of the Department of Surgery at the University of Chicago Pritzker School of Medicine, and colleagues has revealed that redo operations, which are more difficult to perform than primary surgery and are often associated with higher morbidity, can be avoided by selecting the right patients and using meticulous surgical technique.
“Laparoscopic antireflux surgery is a very effective and long-lasting treatment for GERD,” said Patti in JAMA Surgery published online April 8, 2015. “Its success is based on careful patient selection that takes into account a thorough preoperative evaluation, and on the performance of a fundoplication that respects the key technical elements.”
In patients who remain symptomatic after surgery, a thorough evaluation to identify the cause of failure and to individualize treatment must be carried out, he added.
The qualitative and selective review included the following search terms: heartburn, regurgitation, dysphagia, gastroesophageal reflux disease, cough, aspiration, laryngitis, GERD/GORD, endoscopy, manometry, pH monitoring, proton pump inhibitors, and Nissen fundoplication.
The goal, said Patti, “…was to provide an evidence- and experience-based analysis of the causes of failure and to underscore the principles of treatment.”
The review showed that fundoplication is indicated when the patient’s main symptoms include heartburn and regurgitation and when extraesophageal symptoms such as cough and hoarseness are present due to high reflux and aspiration.
Antireflux surgery is also recommended in patients who have complications secondary to proton pump inhibitors (PPIs), such as osteoporosis, Clostridium difficile infections, pneumonia, or hypomagnesemia with cardiac arrhythmias. In addition, the review indicated that surgery would be appropriate in young patients who don’t want to take medical therapy for the rest of their lives.
Patti emphasized that “… in the United States today, a total fundoplication is the procedure of choice, while a Toupet or a Dor fundoplication are chosen mostly for patients with absent peristalsis such as in achalasia or scleroderma.”
He pointed out that guidelines published in 2013 by a panel of expert gastroenterologists and surgeons recommended that a proper preoperative workup should include:
- Symptomatic evaluation
- Barium swallow
- Esophageal manometry
- 24-hour ambulatory pH monitoring.
The same panel recommended that only selected patients should undergo a gastric emptying study and combined multichannel impedance pH.
The review also showed that clinical history and an upper endoscopy are not sufficient to diagnose GERD. “Many believe that GERD can be securely diagnosed by the clinical history and an upper endoscopy and that additional tests are not necessary,” said Patti. “However, many studies have shown that even typical symptoms, such as heartburn and regurgitation, have low accuracy leading to a wrong diagnosis of GERD in 30% to 50% of patients.” In his own study of 822 consecutive patients referred for esophageal function tests because of a clinical diagnosis of GERD, abnormal reflux by pH monitoring was present in 70% of patients, he noted.
A wrong diagnosis of GERD can lead to drug therapy that masks other diseases such as irritable bowel syndrome, gallstone disease, and coronary artery disease. In addition, said Patti, some patients referred for surgery because they didn’t respond to PPI therapy were later found to have achalasia.
Studies also showed that the three most important predictors of successful antireflux surgery are:
- Presence of typical symptoms (heartburn and regurgitation)
- Good relief of symptoms with PPI therapy
- Presence of a pathologic amount of reflux as determined by pH monitoring
Managing patients who fail antireflux surgery is not easy, Patti acknowledged. He noted that it is generally agreed fundoplication fails for one of the following reasons:
- Wrong indications for the operation
- Wrong preoperative workup
- Failure to execute the proper technical steps
In more than 60% of studies, said Patti, the causes of antireflux surgery failure were identified as the presence of atypical symptoms and poor response to medical therapy. In 33% of studies, a body mass index greater than 30 or 35 correlated with poor outcomes.
“We anticipate that patients who have symptoms not responsive to proper medical therapy, patients with bloating or epigastric pain, and patients with normal preoperative ambulatory pH monitoring will likely be dissatisfied with their operation,” said Patti.
“Conversely,” he added, “in patients with new GERD symptoms that coincide with weight gain, who do not meet the criteria for morbid obesity, and who have failed lifestyle modifications, a fundoplication is appropriate with specific body mass index cutoff below the threshold of morbid obesity.”
Success of antireflux surgery depends on the use of key technical elements of a laparoscopic fundoplication, said Patti. These elements include:
- Dissection in the posterior mediastinum. (It is essential to have 3-5 cm of esophagus without tension below the diaphragm)
- Identification and preservation of both vagi nerves during the hiatal dissection
- Transection of the short gastric vessels
- Approximation of the right and left pillars of the esophageal crus
- Creation of the wrap over a bougie (56F-60F)
- Choice of the correct wrap
- Choice of the correct part of the stomach to bring around the esophagus and the gastroesophageal junction
The anatomic causes of failure of a fundoplication, first categorized in 1999, include technical shortcomings, large hiatal hernias, and early postoperative vomiting, noted Patti. An anatomic classification of failures based on the different types of hernias now includes Type 1A hernia, Type 1B hernia, Type II hernia, and Type III hernia.
Patients with persistent or recurrent symptoms must undergo a thorough examination to pinpoint the cause and maximize treatment. This examination should include symptomatic evaluation, barium swallow and upper endoscopy, esophageal manometry, and ambulatory pH monitoring.
Patti pointed out that in a literature review of 4,584 reoperations in 4,509 patients reported:
- Mortality rate of 0.9%
- Intraoperative complication rate of 21.4%
- Postoperative complication rate of 15.6%
- Success rate of 65%-70% (versus 85%-90% for a primary operation)
“Objective and subjective evaluation showed a failure rate of 41% [for redo laparoscopic fundoplication], confirming that laparoscopic repair of a failed fundoplication has a high failure rate that increases over time,” he said.
April 9th, 2015