MANAGING FAILED ANTIREFLUX THERAPYpH monitoring while the patient is taking medicationsmay help identify which patients aremore likely to respond to surgeryPatients with Airway Manifestations of G ID: 958611
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Principles of Successful Surgical Federico Cuenca-Abente,Brant K.Oelschlager,and Carlos A.Pellegrini MANAGING FAILED ANTI-REFLUX THERAPYpH monitoring while the patient is taking med-ications,may help identify which patients aremore likely to respond to surgery.Patients with Airway Manifestations of GERDPatients with GERD and related airway symp-toms represent a signicant management challenge.When compared with patients withtypical symptoms,medical therapy is moreoften ineffective,making surgery a more attrac-tive alternative for these patients.The greaterproblem is that there is no current diagnostictest to conclusively link GERD and airwaysymptoms.The gold standard,24-hour pH mon-itoring,is helpful,but reux,although present,may not be the cause ofthe symptoms.Fur-thermore,abnormal reux may be causedbypulmonary diseases such as asthma.Patients with Barretts EsophagusPatients with Barretts esophagus generally havemore severe GERD,and thus often seek surgeryto relieve symptoms.Surgical therapy is veryeffective,in our experience,at relieving reuxsymptoms,although others have shown slightlyless favorable results.We believe that ifa tech-nically good operation is performed,excellentresults can be obtained in this population.Moreover,recent data support the fact thatBarretts esophagus regresses after an anti-reux procedure.Indeed,we reported regres-sion in 50% ofpatients with short segment (cm) Barretts esophagus.Hofstetter et al.alsoreported regression from low-grade dysplasia tonondysplastic Barretts esophagus in 44% oftheir patients,and regression ofintestinal meta-plasia to cardiac mucosa in 14% ofcases.Finally,Bowers et al.reported a regression rate of59%ofpatients with short segment Barretts esoph-agus.For these reasons,surgical therapy shouldbe strongly considered for Barretts esophagus,especially for young patients with symptomaticreux.ContraindicationsThere is evidence that morbid obesity (body40) is associated with a higherfailure rate,and thus,the presence ofmarkedobesity represents a relative contraindication.Furthermore,there is evidence that a Roux-en-Y gastric bypass provides excellent reliefofas well as the health benets ofweightloss.We therefore recommend this approach tomorbidly obese patients with severe GERD.Severe ComorbiditiesAnesthetic and perioperative risk due to othermedical comorbidities is another relative con-traindication.Patient age,in a population-basedcohort study,has been shown to be an inde-pendent predictor ofmortality.The
severity ofGERD and GERD-related complications shouldbe considered in light ofthe patients age andoverall risk factors when deciding about the ap-propriateness ofsurgical therapy.Preoperative EvaluationFor a practical description ofthe preoperativeevaluation,we can divide patients into thosewith typical symptoms (heartburn and regurgi-tation) and those with atypical ones (airwaysymptoms,chest pain,etc.).For both groups,webelieve an adequate work-up should includeupper endoscopy (EGD),manometry,24-houresophageal pH monitoring,and upper gastroin-testinal series.For those with atypical or airwaysymptoms,esophageal/pharyngeal pH monitor-ing and laryngoscopy appear as useful adjunc-tive tools that help link these manifestationswith GERD.Esophageal impedance is becomingrecognized as a useful tool to evaluate thesepatients.Flexible Endoscopy (EGD)This test gives the best information regardingthe internal anatomy ofthe foregut.The contourofthe cardia has good correlation with its com-petency as an anti-reux valve,and is especiallyimportant in evaluating the competency in thepostoperative setting.Complications ofreux,such as esophagitis and intestinal metaplasia,are diagnosed with endoscopy and can be biop-sied appropriately.Endoscopy may identifyunexpected ndings that may change the surgi-cal strategy,such as unsuspected pathology inthe esophagus,stomach,and duodenum.The PRINCIPLES OF SUCCESSFUL SURGICAL ANTI-REFLUX PROCEDURESendoscopic view can also detect the presence ofa hiatal or paraesophageal hernia and evaluatethe patency ofthe gastroesophageal valve.Thus,in many instances,it helps to dene the severityofthe disease as well as the anatomy,both ofwhich have an important role in planning theoperation.ManometryEsophageal manometry evaluates the peristalticmechanism ofthe esophageal body (amplitudeand character ofperistaltic waves) and the pressure,location,and relaxation ofthe loweresophageal sphincter (LES).In the past,theresults ofmanometry were used by many sur-geons to tailorthe subsequent fundoplication.Specically,patients with impaired peristalsisunderwent a partial fundoplication,such as aToupet procedure.We have shown that mostpatients with defective esophageal peristalsisrespond well to a Nissen fundoplication and donot develop postoperative dysphagia.There-fore,we recommend this as the treatment ofchoice except for those with essentially an aperi-staltic esophagus.Others have conrmed ourresults and these recommendations are becom-ing accepted by more grou
ps.Likewise,the nding ofother motility disor-ders such as hypercontractile esophagus (distalesophageal amplitudes 180mmHg) and hyper-tensive LES (45mmHg) in the setting ofGERDshould not dissuade the surgeon from perform-ing an anti-reux procedure ifthe patients clinical presentation is ofGERD (heartburn orregurgitation) and not ofa primary motilitydisorder (dysphagia or chest pain).Twenty-four-hour pH Esophageal MonitoringThis is the gold standard for the detection andquantication ofGERD.At the University ofWashington,we,as a matter ofroutine,simulta-neously evaluate both the proximal and distalesophageal acid exposure.Normal pH monitor-ing should prompt a thorough work-up to ruleout other etiologies,because these patients havean inferior result with surgical therapy.This testcan also be used to correlate reux episodeswith symptom events,often serving as a con-rmation ofthe clinical association.Finally,preoperative pH monitoring serves as a baselineby which to compare studies should the patienthave recurrent or persistent symptoms after ananti-reux procedure.Upper Gastrointestinal SeriesThis test gives information regarding theanatomy ofthe esophagus and stomach,as wellas the relation between these structures and thehiatus.It may detect a short esophagus,stric-tures,or a hiatal or paraesophageal hernia,eachofwhich may affect the surgical strategy.Thedetection ofspontaneous reux during this test usually correlates with abnormal reux.Ingeneral,this test is reserved for those patients inwhom an operation is being planned.Twenty-four-hour Esophageal and Pharyngeal pH MonitoringWe have used pharyngeal pH monitoring todetect acid in the pharynx as an effective proxyfor microaspiration.The detection ofabnor-mal amounts ofpharyngeal reux (more thanone pharyngeal reux event in 24 hours) is abetter predictor ofsuccessful medical and sur-gical therapy than is esophageal pH monitor-ing.Although the positive predictive value ofthe test is quite good,many patients with reux-associated respiratory symptoms will have anormal pharyngeal environment during thestudy period.LaryngoscopySimilar to endoscopy ofthe esophagus,laryn-goscopy can identify injury to the larynx causedby acid.Typical ndings include erythema,ulcers,swelling,nodules,etc.Unfortunately,these seem to be general markers ofinjury,andnone ofthese lesions are specic for reux.Nevertheless,it remains an important test in the evaluation ofpatients with possible reuxlaryngitis.This technology has recently garner
ed interestin the work-up ofpatients with GERD.Imped-ance is the measure ofelectrical resistancebetween two electrodes.When multiple pairs of PRINCIPLES OF SUCCESSFUL SURGICAL ANTI-REFLUX PROCEDURESimpaired esophageal motility.Because it is lessthan a 360° fundoplication,it does not augmentthe LES to the degree that a Nissen does,and asa result it generally has less control ofreuxthan a Nissen.We have abandoned this proce-dure for most patients,because we found inpatients with impaired peristalsis,a Nissen pro-vided better control ofGERD without increas-ing the incidence ofdysphagia.Dor fundoplication.This is an anterior 180°fundoplication.It does not require as muchesophageal length,nor does it augment the LESor accentuate the angle ofHis as much the otherfundoplications described.As such,it is rarelyused as a primary anti-reux procedure,and ismost often used after a myotomy for achalasia.Hill fundoplication.This operation is usuallyreferred to as a cardioplasty,rather than a fundoplication.The operation secures the gastroesophageal junction intraabdominallyand tightens the collar sling mechanism.It is adifcult operation to reproduce consistently,thus has few proponents apart from thosetrained by Lucius Hill,its developer.We believe that the Nissen fundoplication isthe most reproducible fundoplication proce-dure,has a long track record with exceptionalresults,and,as we have discussed,can be usedfor almost all patients.Therefore,we willdescribe our technique ofperforming a Nissenfundoplication as an example ofhow a fundo-plication operation adheres to the principlesoutlined earlier.Perioperative ConsiderationsGeneral anesthesia is necessary for this opera-tion.Each patient receives a single dose ofbroad-spectrum antibiotic.Sequential compres-sion devices are placed to decrease the risk ofdeep venous thrombosis.A Foley catheter isused to decompress the bladder and monitorurine output during the operation.We place the patient in low lithotomy posi-tion,which allows the surgeon to stand betweenthe patients legs during the procedure.Tosecure the patient in steep reverse Trendelen-burg position,a seat is fashioned using abeanbag.The monitor is placed over thepatients head so it can be viewed by the wholeoperating team.An additional monitor is usedto show the anesthesiologist the operative eldas he or she is manipulating the esophagealbougie during the operation.The assistantstands on the patients left side.A self-retainingretractor is secured to the right side ofth
e bedto hold the liver retractor,minimizing the needfor a second assistant.Creation of Pneumoperitoneum and Port PlacementPneumoperitoneum is established with a Veressneedle using the site through which the cameraport or left upper quadrant port will be placed(Figure 5.1).An open technique may be usedespecially ifthe patient has had a prior opera-tion and adhesions are suspected.We use anoptical access port (Visiport;US Surgical,Norwalk,CT) for the rst port because it showsthe different layers as one is going through,thusdecreasing the chance ofbowel or vascularinjury and signicantly increasing the chance ofan immediate diagnosis ifthey occur.Thecamera port is placed 2cm to the left ofmidlineand 10cm below the costal margin.Diagnosticlaparoscopy is performed to exclude injuryfrom entry or other pathology.The upper twoports are used by the surgeon and should forman equilateral triangle with the camera port.This allows the surgeons instruments to be usedat an angle,enabling correct visualization ofthetips.The liver retractor and rst assistant portsare placed at the level ofthe camera port in theanterior axillary line. Figure 5.1.Port placement.(Reprinted from Hiatal Hernia andGastroesophageal Reux Disease.In: Townsend CM,BeauchampDR,Evers MB,Mattox KL,eds.Sabiston Textbook of Surgery.16thed.2004:1158,Copyright 2004,with permission from Elsevier.) MANAGING FAILED ANTI-REFLUX THERAPYDissection of the Cardia (Left Crus Approach)We begin the operation on the left side by divid-ing the phrenogastric ligament to expose the leftcrus.This approach minimizes the risk ofinjuryto structures around the gastrohepatic ligamentsuch as the nerve ofLatarjet and vena cava inobese patients.This approach also allows forsafer division ofthe short gastric vessels,espe-cially at the superior pole ofthe spleen.Division of the Short Gastric VesselsThe fundus is mobilized by dividing the shortgastric vessels as this has been shown to resultin less dysphagia.A general landmark for thecaudal extent ofthe mobilization is the inferiorpole ofa normal-sized spleen.Short gastricvessels are subsequently identied and tran-sected with the Autosonic scalpel (Tyco Health-care,Norwalk,CT),although this can becompleted with clips or other energy sources(Figure 5.2).These vessels are divided upwarduntil one reaches the previously dissected leftcrus.The vessels to the upper pole ofthe spleenmay be very short and deep,making divisionvery difcult without prior division ofthephrenogastric ligament (left cr
us approach).These last vessels are best exposed by having theassistant retract the posterior wall ofthe bodyofthe stomach toward the patients right as thesurgeon pulls the posterior wall ofthe fundus ofthe stomach anteriorly.A space at the base oftheleft crus between the lesser sac and our initialdissection along the left crus is created,allow-ing the more cephalad short gastric vessels to beexposed and divided.Esophageal MobilizationAfter the fundus is free and the left crus com-pletely exposed,the left phrenoesophagealmembrane is incised,safely entering the medi-astinum between the left crus and esophagus.The dissection is continued anteriorly and supe-riorly,dividing the peritoneum overlying theanterior aspect ofthe crus.This line ofdivisionis extended down to the base ofthe right crus.Only now do we divide the gastrohepatic ligament.Most ofthe hepatic branches ofthe vagus andoccasional hepatic branch ofthe left gastricartery can be preserved with this approach.Theright phrenoesophageal membrane is divided,exposing the inner edge ofthe right crus.Another advantage ofthis technique is thatbecause the decussation ofthe right and leftcrus is identied,a posterior esophagealwindow is created without dissection toward thesplenic hilum.A 0.5-in.Penrose drain is placedin this posterior window and secured aroundthe esophagus and two vagi with a clip orsuture.With the assistant tractioning from thePenrose drain,dissection ofthe intrathoracicesophagus is started.This is done until weachieve an intraabdominal esophageal length ofat least 3cm.Mobilization ofthe esophagus canusually easily be carried to the carina,and as aresult we rarely lack enough intraabdominalesophagus to perform a tension-free repair.Careful attention should be paid to avoidinginjury to the anterior and posterior vagalnerves,both pleural surfaces,and the aorta. Figure 5.2.Transecting the short gastric vessels.(Reprintedfrom Hiatal Hernia and Gastroesophageal Reux Disease.In:Townsend CM,Beauchamp DR,Evers MB,Mattox KL,eds.Sabiston Textbook of Surgery.16th ed.2004:755 768,Copyright2004,with permission from Elsevier.) PRINCIPLES OF SUCCESSFUL SURGICAL ANTI-REFLUX PROCEDURESHiatal ClosureThe hiatus is closed posteriorly with simple 2-0silk stitches placed no more than 5mm apart(Figure 5.3).The hiatal closure is calibrated suchthat a 52-French bougie ts through the hiatuseasily.For large hiatal hernias (type II IV),webuttress the tenuous closure with a bioprosthe-sis (Surgisis;Cook Surgical,Bloomington,Cons
truction of the WrapIt is critical to the proper function ofthe fun-doplication that the two aps ofgastric fundusthat will wrap the lower end ofthe esophagusbe symmetrical.In other words,it is importantthat the amount ofdisplacement ofthe poste-rior and anterior gastric aps be the same sothat there is no tendency to produce a torque inthe esophagus.To achieve this,we rst identifya point on the posterior wall ofthe stomach thatis 3cm below the gastroesophageal junction and2cm away from the greater curvature.We thenplace a loose stitch to identify this area.Thisassures that we do not mistakenly grasp theanterior portion or body ofthe stomach,whichis a common error seen in failed fundoplica-tions.The portion ofposterior stomach withthe suture is then brought posterior to theesophagus.A mirror-image portion ofthe anteriorstomach wall (3cm below the gastroesophagealjunction and 2cm away from the greater cur-vature) is grasped with the right hand (the posterior stomach is in the left).This creates asymmetrical fundoplication.Once this isachieved,we check the entire wrap by momen-tarily undoing it.This is accomplished bypassing (and holding) the posterior aspect ofthe gastric fundus (being held by the left hand)behind the esophagus,back toward the leftupper quadrant while the right hand holds theanterior gastric ap.Now the entire wrap can beseen just to the left ofthe esophagogastric junc-tion,in front ofthe upper portion ofthe spleen,and the distance from each point (the left hand grasp and the right hand grasp) to thegreater curvature observed and measured once again.The wrap is then restored to its original position around the esophagus andsutured.The fundoplication is created by suturingthese two aps ofgastric fundus with four inter-rupted stitches of2-0 silk suture 1cm apart.Care is taken to avoid entrapping the anteriorvagal nerve,which is why we do not incorporatea bite ofesophagus with these sutures.The fun-doplication is created while a 52-French bougieis in place through the gastroesophageal junc-tion and ends up being approximately 3cmlong.Anchoring the FundoplicationTo decrease the likelihood ofherniation ofthewrap,we anchor it to the diaphragm and esoph-agus.Two coronalsutures are placed,the rstfrom the top ofthe posterior fundus to the rightlateral esophagus and the right crus.A similarsuture is placed from the left crus,esophagusand greater curvature.Two additional stitchesare placed:the posterior one,xing the poste-rior valve to a place in the diaphra
gm thatavoids excessive traction ofthe stomach,and ananterior one xing the top ofthe anterior valveofthe fundoplication to the anterior aspect ofthe hiatus (Figure 5.4). Figure 5.3.Diaphragmatic closure.(Reprinted from HiatalHernia and Gastroesophageal Reux Disease.In: Townsend CM,Beauchamp DR,Evers MB,Mattox KL,eds.Sabiston Textbook ofSurgery.16th ed.2004:755 768,Copyright 2004,with permis-sion from Elsevier.) MANAGING FAILED ANTI-REFLUX THERAPYConclusionLaparoscopic anti-reux surgery,and even openfundoplication operations,are viable alterna-tives to medical management in the treatmentofsevere GERD.The key to successful outcomeswith this procedure include proper patientselection thorough preoperative evaluation andcareful operative technique.The chapter out-lines our approach which has resulted in excel-lent outcomes at the University ofWashington.References1.Oelschlager BK,Pellegrini CA.Minimally invasivesurgery for gastroesophageal reux disease.J Laparoen-dosc Adv Surg Tech A 2001;11:341 349.2.Guilherme MR,Campos MD,Peters JH,et al.Multi-variate analysis offactors predicting outcome afterlaparoscopic Nissen fundoplication.J Gastrointest Surg3.Westscher G,Schwab G,Klinger A,et al.Respiratorysymptoms in patients with gastroesophageal reux fol-lowing medical therapy and following anti-reuxsurgery.Am J Surg 1997;174:639 643.4.Tobin RW,Pope CE II,Pellegrini CA,Emond MJ,SilleryJ,Raghu G.Increased prevalence ofgastroesophagealreux in patients with idiopathic pulmonary brosis.Am J Respir Crit Care Med 1998;158:1804 1808.5.Oelschlager BK,Barreca M,Chang L,et al.Clinical andpathologic response ofBarretts esophagus to laparo-scopic anti reux surgery.Ann Surg 2003;238(4):6.Csendes A,Braghetto I,Burdiles P,et al.Long-termresults ofclassic anti-reux surgery in 152 patients withBarretts esophagus:clinical,radiologic,endoscopic,manometric,and acid reux test analysis before and lateafter operation.Surgery 1998;123:645 657.7.Hofstetter W,Peters J,DeMeester T,et al.Long-termoutcome ofanti-reux surgery in patients with Barrettsesophagus.Ann Surg 2001;234:532 539.8.Bowers SP,Mattar SG,Smith CD,et al.Clinical and his-tologic follow-up after anti-reux surgery for Barrettsesophagus.J Gastrointest Surg 2002;6(4):532 538.9.Perry Y,Courcoulas AP,Fernando HC,Buenaventura PO,McCaughan JS,Luketich JD.Laparoscopic Roux-en-Ygastric bypass for recalcitrant gastroesophageal reuxdisease in morbidly obese patients.JSLS 2004;8:19 23.10.Perez AR,Moncure AC,Rattner DW.Obesity adverselya
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