Surgical Treatment

Surgical Treatment

Antireflux operations such as the Nissen fundoplication and its modifications e.g. Toupet, Rosetti and Dor fundoplication, the Hill operation, the Belsey Mark IV and the Collis operations to cure reflux and have been practiced by open surgery with incisions through the abdomen (Nissen and its modifications) or through the Chest (Belsey) since the 1950’s. Since 1987 when Phillip Mouret performed the first cholecystectomy laparoscopically, i.e. with small incisions rather than one large incision. Many operations have been perfected by the laparoscopic approach. Among the most popular are the Nissen fundoplication and its modifications. Nissen, a Swiss surgeon, did his first fundoplication for reflux disease in the fifties. Nineteen years earlier, he had performed the same operation for cancer of the esophagus in Turkey before World War II. He was not satisfied with the anastomosis between the esophagus and the stomach so he wrapped the suture line with the stomach. He lost track of the patient and moved back to Switzerland at the outbreak of the war. Nineteen years later, the nephew of the patient went to him in Switzerland. Nissen asked the nephew if his aunt was suffering from severe heartburn and reflux since he had removed the valve or LES with the cancer. When he found out that she had no reflux he started using that method (wrapping the stomach around the lower esophagus) for reflux disease or GERDS and hiatal hernia. This operation proved to be very successful giving over 90% relief ten years after the surgery. Laparoscopic or Minimally Invasive fundoplications are essentially identical to the open operations and have yielded comparable results to the open cases approaching the 10 years. There is no reason to believe that the two approaches should not have similar long-term results. The major advantage laparoscopic surgery has over the open surgery is that now we can address the less than satisfactory results earlier since the pain and morbidity is much less than with the open approach. We are now accumulating a lot of experience reoperating patients who have previously had open or laparoscopic surgery. To redo a laparoscopic surgery is somewhat easier because fewer adhesions exist than after open surgery. In the Nissen fundoplication the stomach is wrapped around the lower esophagus similar to the way a mother hugs her child.
FIGURE 1 Shows a hiatal hernia with part of the stomach pushed up or herniated into the chest, this may be of varying degree and in extreme cases most of the stomach may be in the chest. In these extreme cases the chance of a recurrence of the hernia is greater than in smaller sized hernias. If a partial recurrence occurs it is quite amenable to reoperation with the smaller sized recurrence and the scar tissue allowing better fixation the second time around. This will be discussed later under recurrence and postoperative weight restrictions. The insert in shows the view an endoscopist would see if he placed a gastroscope into the stomach and looked back upwards by retroflexing the gastroscope. The upper part of the stomach looks like a golf hole and acts like a funnel sucking gastric contents into the esophagus when a patient lies down. The negative chest pressure produced by breathing and the loss of gravity on lying down, further increases the aspiration of gastric juices into the esophagus.
FIGURE 2 Shows the lower most of the two sutures placed in the opening or hiatus being cinched or tightened down with the GAZAYERLI KNOT PUSHER. The posterior wall of the stomach is also shown pulled to the right of the esophagus with three sutures joining it to the anterior wall of the stomach. Two of these sutures are also shown picking up a partial thickness of the wall of the esophagus. The number of sutures placed here varies, but at least one attaches the wrap to the esophagus anchoring it to the stomach.
FIGURE 3 Shows the completed Nissen fundoplication and the closed hiatus. The insert now shows that there is a flap of tissue around the opening of the esophagus into the stomach. This effectively changes what looked like a funnel into a spout. This flap, as well as an increase of the pressure of the LES, prevents the reflux of gastric juice and contents into the esophagus, allowing the inflammation and ulcers to heal. Evidence is mounting that in a fair percentage of cases the precancerous Barrett esophagus becomes less inflamed and can actually disappear after surgery, thereby reducing the risk of cancer.
FIGURE 4 Shows the same points mentioned in figure 2 but is a photograph taken during an actual Nissen fundoplication.
FIGURE 5 Shows the same points mentioned in figure 3 and is also a photograph taken during an actual Nissen fundoplication.

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