The surgery of complicated gastro-oesophageal reflux.

Abstract

A properly performed anti-reflux operation is the most effective and durable method of control l ing gastrooesophageal reflux and its complications but is only required in a minority of affected patients TM. Because of recent advances in the medical management of reflux disease, maintenance medical therapy is a legitimate alternative to surgery and the frequency of anti-reflux operations has been reduced. In consequence, only those patients with the most severe form of disease or complex symptomatology are referred for surgical correction. Thus the surgical challenge is now greater and the avoidance of failure requires strict selection of the right patient with the right disease (reflux) for the right operation. Upper gastro-intestinal contrast studies, endoscopy, oesophageal manometry and 24 hour oesophageal pH monitoring are mandatory preoperative base-line investigations. Prior to selecting patients for surgery, the following cri teria should be satisfied: (a) pathological gastrooesophageal reflux should he demonstrated to he the cause of the symptoms. (b) complications of reflux should be sought these include oesophagitis, stricture, Barrett 's oesophagus, motor dysfunction, pulmonary aspiratio n and failure to thrive in children. (c) an oesophageal motility disorder such as achalasia, diffuse spasm or scleroderma should be excluded. (d) co-existing diseases with similar or overlapping symptoms such as angina pectoris, peptic ulceration and gallstones should be excluded. (e) the patient should have had an adequate trial of modern medical therapy. This should include a programme of weight reduction, withdrawal of alcohol or nicotine, and drug therapy with optimal doses of either an Histamine H2 receptor blocker or proton pump inhibitoi" together with antacids and/or prokinetic agent. Modern drugs are safe in the long term and economic reasons are a weak and rare justification for surgery. (f) The patient should be evaluated for a contraindicat ion to surgery such as intercurrent cardiac or pulmonary disease or a general medical problem. Patients undergoing definitive surgery for gastrooesophageal reflux fall into two general categories, the complex and the straight-forward case. The presence of an oesophageal stricture, oesophageal foreshortening, deep ulceration, irreducibility of an associated hiatal hernia, suspected carcinoma, scleroderma and previous surgery define the complex case and should b e approached