Laparoscopic Total Fundoplication for Refractory GERD: How to Achieve Optimal Long-Term Outcomes by Preoperative Instrumental Assessment and a Standardized Technique

Abstract

Gastroesophageal reflux disease (GERD) is one of the most common gastrointestinal disease among adults in Europe and USA. A recent consensus conference (the Montreal Consensus) defined GERD as condition which develops when the reflux of stomach contents causes symptoms and/or complications. Symptoms were considered to be troublesome if they adversely affected an individual's well-being. GERD can lead to both esophageal and non-esophageal symptoms. The most common typical symptoms of GERD are heartburn and regurgitation. Non-esophageal GERD symptoms include chronic aspiration with cough and laryngitis (Shaheen & Ransohoff, 2002). At its core, GERD is the failure of the antireflux barrier, allowing abnormal amounts of reflux of gastric contents into the esophagus (Dodds et al., 1982). The primary treatment modality for GERD is acid suppression therapy, in particular by use of PPI (Castell et al., 2002). However, consideration should be given for surgery if the following indications exist: complications of GERD (such as peptic stricture or Barrett's esophagus), extraesophageal manifestations (chest pain, pulmonary symptoms), failed medical management, or desire to discontinue medical treatment despite adequate symptomatic control. Minimal invasive anti-reflux surgery can be considered an effective GERD therapy, with its mechanical function both in the short and long term period. Several different ways of fashioning a total fundoplication lead to different outcomes. This chapter addresses the technical details of the antireflux technique we adopted without modifications for all patients with GERD. In particular it