Surgical treatment of gastroesophageal reflux and its complications.

Abstract

AbstractAlthough most patients with reflux peptic esophagitis have the sliding type of hiatal hernia, correction of the hernia is incidental and the objective of the surgeon is to reestablish continence of the lower esophageal sphincter (LES). The presence of this crucial closure mechanism between the stomach and esophagus was demonstrated just over 2 decades ago by manometric and cineradiographic studies of the esophagogastric junction. Although the abdominal location of the LES exerts a favorable influence, it is possible to have normal LES function in the supradiaphragmatic position, and the relationship between the sliding hiatal hernia and reflux peptic esophagitis remains unclear. Some patients develop esophagitis in the absence of a hernia.Three surgical methods are in common use today for correcting gastroesophageal reflux: the Belsey cardioplasty, the Nissen fundoplication, and the Hill posterior gastropexy. Results have been analyzed on the basis of clinical, anatomic, and physiologic success. The Nissen fundoplication is the most certain to correct reflux and, as an added advantage, can be performed by either the thoracic or abdominal approach. However, it is associated with the highest incidence of chronic side effects, particularly the “postfundoplication” or “gas‐bloat syndrome.” The Hill procedure can be accomplished only through the abdomen and is associated with a somewhat higher incidence of recurrent esophagitis and recurrent hernia. However, side effects are minimal. The Belsey cardioplasty has the advantage of requiring a minimum of available tissue for its successful accomplishment. However, it can be performed with ease only by the thoracic approach and also has a relatively high incidence of recurrent or persistent esophagitis.For these reasons, we prefer the Hill posterior gastropexy in the medically intractable, but otherwise uncomplicated, patient with reflux peptic esophagitis. The Nissen fundoplication is preferred for cases complicated by prior unsuccessful surgery, stenosis with short esophagus, and marked obesity. The Belsey cardioplasty is most useful in patients who have had extensive prior gastric surgery with loss of available tissue for repair. The combined Thal patch‐Nissen fundoplication is considered the primary treatment of choice in patients with transmural strictures of the esophagus, particularly because it is associated with a low morbidity and mortality.