Antireflux Surgery

15 Pages·2014·0.15 MB·English

Antirefl ux Surgery

Lee L. Swanstrom • Christy M. Dunst

Editors
Antirefl ux Surgery
Editors
Lee L. Swanstrom Christy M. Dunst
GI and MIS Surgery GI and MIS Surgery
The Oregon Clinic The Oregon Clinic
Providence Portland Medical Center Providence Portland Medical Center
Portland, OR , USA Portland, OR , USA
ISBN 978-1-4939-1748-8 ISBN 978-1-4939-1749-5 (eBook)
DOI 10.1007/978-1-4939-1749-5
Springer New York Heidelberg Dordrecht London
Library of Congress Control Number: 2014953965
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I would like to dedicate this book to surgery of the esophagus:
This surgical specialty has rewarded me with a fabulous career, fascinating
research and peers around the world who are some of my best friends.
It has also helped thousands of my patients have a better quality of life—the
greatest reward I can imagine. Esophageal surgery has also given me two
of the best practice partners one could hope for: Christy Dunst and Kevin
Reavis, whose uncomplaining support makes my surgical practice
possible—thanks guys….
—Lee L. Swanstrom, MD
This book is dedicated to all those surgeons committed to excellence
in esophageal surgery. My sincerest thank you to my lovely husband Mark,
to my beautiful children Tyler and Hailey and to my cool partners who
supported me endlessly allowing this book to happen.
—Christy M. Dunst, MD, FACS

Foreword
Gastroesophageal refl ux disease (GERD) is the most common foregut disease in the world and
accounts for approximately 75 % of all esophageal pathology. The majority of affl icted patients
have mild disease and are successfully managed with lifestyle modifi cations and acid suppres-
sion medication. However, the disease progresses in at least 10 % of patients leading them to
seek surgical alternatives. For nearly 50 years, I have dedicated my career to the complex
pathophysiology of this disease and its sequelae, which at its worst includes the progression to
esophageal adenocarcinoma. Precise understanding of the functional and anatomical aspects
of the refl ux barrier is absolutely critical to successful surgical treatment.
T he discovery of the lower esophageal high pressure zone, or LES as it was later named,
leads to the realization that almost half of the patients with confi rmed GERD have a normal
LES on a motility study performed at rest, in the recumbent position, and after an overnight
fast. The etiology of refl ux in patients with a normal LES is transient openings of the LES
when challenged by gastric distention or dilation. These events are called transient LES relax-
ations (TLESRs) and were fi rst described by Dodds in 1982. Gastric distension occurs with
overeating or excessive dry swallowing. Each dry swallow carries with it saliva and the 15 cc
of air contained within the pharyngeal space. The swallowed food and air collect in the stom-
ach and if excessive cause pressure generated gastric distension. Gastric dilation, on the other
hand, is due to normal physiologic relaxation of gastric muscle with the ingestion of a meal
and is termed adaptive relaxation. It should be noted that gastric dilation is not associated with
an elevation of intragastric pressure.
T here are two proposed explanations for the occurrence of TLESRs. One, favored mainly
by gastroenterologists, proposes that TLESRs are due to a neuro-mediated refl ex initiated by a
pressurized gastric distension or gastric dilation from a meal induced adaptive relaxation.
These conditions stimulate stretch receptors in the gastric fundus that in turn stimulate vagal
afferents that relay the input from the receptors to the medulla. Medullary nuclei then orches-
trate the efferent limb of the refl ex via the vagal and phrenic nerves to elicit prolonged LES
relaxation, crural diaphragm inhibition, and distal esophageal shortening. The second explana-
tion, favored mainly by surgeons, proposes that TLESRs are due to transient shortening of the
LES length with the effacement of the LES by pressurized gastric distension or dilation due to
meal induced adaptive relaxation. Normally in the fasting state and resting recumbent position
the median overall LES length is 3.6 cm and the intra-abdominal length is 2.2 cm. With gastric
distension or dilation, the length of the LES shortens as the LES is effaced and taken up by the
gastric fundus. When gastric distention or dilation is excessive, the length of the LES shortens
to the point where the corresponding pressure of the LES can no longer maintain closure, the
LES opens and gastroesophageal refl ux occurs. This occurs predominately during the post-
prandial period. During shortening, the distal end of the LES is taken up by the fundus and
exposed to gastric juice causing infl ammation and ulceration of the distal LES. If the infl am-
mation continues, it can permanently reduce the abdominal length to <1 cm and limit the abil-
ity of the LES to respond to intra-abdominal pressure challenges. Persistence of the
infl ammation can reduce the overall length of the LES to <2 cm and limits its ability to resist
gastric distension or dilation. In both situations, a transient failure of the LES due to gastric
distension or dilation has advanced to a permanent failure of the LES due to the loss of
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viii Foreword
functional sphincter length and the development of axial hiatal hernias from chronic infl amma-
tory injury. At this point, patients develop more severe volume refl ux and atypical symptoms
such as aspiration and cough. With a completely destroyed barrier, medication will no longer
be able to mitigate the symptoms and surgical reconstruction is advised.
T he impetus to identify and counsel patients with progressive disease regarding the need for
surgical therapy is critical. This goes largely unheeded by the gastroenterologists due to their
lack of confi dence in the durability of a fundoplication and concern over the side effects of the
operation. Consequently, the early referral of a patient with symptoms and signs of progressive
disease for surgical therapy is resisted. Further, there is widespread concern that not all sur-
geons are suffi ciently experienced in evaluating esophageal patients, many are not knowledge-
able enough to select the proper anti-refl ux procedure and some are not suffi ciently trained to
properly perform the procedures.
While these concerns are valid, I would argue that they are somewhat outdated, as major
advances to individualize surgical treatments to the individual patient pathophysiology have
evolved over the decades to improve outcomes. For example, we now know that performance
of a complete fundoplication on a patient with a normal LES that transiently fails leads to
excessive post-prandial symptoms. This occurs because the fundoplication prevents the short-
ening and opening of the sphincter to relieve post-prandial distension or excessive dilation. As
would be expected, these patients complain of bloating, the inability to belch, and social prob-
lems associated with increased fl atus. These side effects are less frequent and severe when a
fundoplication is placed over a LES that has been partially or completely destroyed.
Furthermore, it is generally accepted that a modifi ed or partial fundoplication may be a better
choice for patients with underlying esophageal body dysmotility or troublesome gas bloat
symptoms. The recognition of the differences in side effects between a permanently failed LES
and a LES that transiently fails has led to the development of surgical procedures specifi cally
designed to prevent transient LES failure and block the progression to permanent LES failure
with minimal surgical dissection and minimal to no side effects. It is hoped that the effective-
ness and gentleness of these newer procedures will encourage their use earlier in the course of
GERD, when the symptoms and signs of progressive disease fi rst appear.
O verall, advancements in surgical techniques such as modifi ed fundoplication and isolated
sphincter augmentation have been made only through dedicated research efforts aimed at
unveiling the intricate interaction between anatomy, physiology, function and symptoms of
GERD. It is expected that these procedures will interrupt the progression of disease, avoid the
complications of end stage GERD, and eliminate the risk of Barrett’s esophagus. Armed with a
genuine curiosity and fascination of the esophagus and the gastroesophageal refl ux barrier simi-
lar to my own, editors Lee Swanstrom and Christy Dunst have structured this textbook as a
comprehensive resource fi lled with contributions from the world’s most recognized esophageal
surgeons. “Antirefl ux Surgery” is a must-read for anyone performing antirefl ux surgery today.
Tom R. DeMeester, MD
Pref ace
Gastroesophageal refl ux disease (GERD) is one of the most common medical disorders in the
USA, and increasing worldwide, affecting approximately 40 % of the population. GERD may
lead to Barrett’s esophagus, which is a direct risk factor for esophageal adenocarcinoma of the
esophagus. With the incidence of esophageal adenocarcinoma worldwide there is a growing
interest in treatment options for gastroesophageal refl ux disease. Over $40 billion is spent
annually for the treatment of GERD.
The mainstays of GERD treatment include medications and surgery. Antirefl ux surgery has
been an important part of GERD therapy since the 1950s but lost its popularity with the advent
of potent antacid medications, specifi cally proton pump inhibitors. However, in the 1990s
laparoscopy introduced a renaissance in the interest in surgical treatment leading to an increase
in antirefl ux procedures. Nevertheless, antirefl ux surgery is not a “one size fi ts all” procedure.
The various degrees of anatomic derangement of the antirefl ux barrier, the pathophysiology of
refl ux, and the complex patient population seeking treatment are complicated and often not
understood well enough by the consulting surgeon. Furthermore, the technical diffi culty of the
operations has led to a lack of consistency in outcomes bringing criticism to the fi eld. Still,
with up to 40 % of patients reporting dissatisfaction with current medical therapy, it is impera-
tive that quality surgical options are available.
“Antirefl ux Surgery” represents the only resource of its kind designed to provide a compre-
hensive and state-of-the-art overview of the major issues specifi c to the fi eld compiled as one
reliable resource. The book provides exceptional instructional detail as well as comprehensive
discussions of relevant pathophysiology. The book includes a comprehensive list of topics
important to anyone involved in the care of patients with GERD but is tailored purposefully to
meet the needs of the antirefl ux surgeon with chapters written by recognized esophageal
experts from around the world.
Portland, Oregon, USA Lee L. Swanstrom, MD
Christy M. Dunst, MD
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