Page 24 - Jourmal of World Association of Laparoscopic Surgeon

Mohamed Solih

it failed to normalize the acid reflux and had some serious Clinical outcome of laparoscopic fundoplication is
complications. excellent, but still need for redosurgery is relatively high
Plicator device mimics the effects of conventional and ranges from 4 to 13%. Some long-term follow-up of
antireflux surgery by recreating the antireflux barrier, laparoscopic fundoplication patients has shown 90%
restoring the angle of his and by forming a one-way symptom control 10 years after the surgery while only
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gastroesopheageal valve. This procedure is free from 10% had to resume medications. Patients with dysphagia
serious complications and is reasonably tolerated. after Nissen fundoplication sometimes require revision of
Another novel endoluminal technique is the endoluminal surgery and convert to a Toupet procedure or dilatation.
fundoplication technique. This is an improvement over Persistant dysphagia, wrap disruption, incorrect wrap
plicator technique and in this technique the gastroesophageal placement and slippage are other causes which require
valve is recreated from within the stomach through oral revision of surgery. Revision of surgery after initial
route. It is claimed that this technique creates a robust and fundoplication is technically demanding but experienced
durable gastroesophageal valve that helps in reconstructing surgeons are able to reproduce results comparable to initial
the altered antireflux barrier in patients with GERD. There correct surgery. 33,34
is an ongoing multicenter study in Europe to assess the long- Studies comparing laparoscopic fundoplication with
term efficacy of the endoluminal fundoplication technique. 19 open surgery have demonstrated that laparoscopic
fundoplication is as effective as open surgery in controlling
ADVANTAGES AND DISADVANTAGES OF symptoms of GERD. With the advantages of minimally
ANTIREFLUX SURGERY invasive surgery and the procedures ability to effectively
Conventional Nissen fundoplication involves a complete control GERD symptoms and improve quality of life even
fundal wrap and is associated with acceptable morbidity in patients with intractable GERD, laparoscopic
and mortality and has a success rate of 90% in the control fundoplication has replaced the open surgery in most of the
of reflux in GERD patients who had undergone this centers world over. 19
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surgery. However, it is associated persistent dysphagia,
inability to belch and vomit. Other problems like epigastric DISCUSSION
fullness, postprandial pain and bloating, temporary Open antireflux surgery is effective management option for
swallowing discomfort and intense flatus also has been patients with GERD affecting quality of life, but this option
reported. On the other hand Toupet fundoplication is a used to be offered to patients with chronic complicated
partial wrap and, hence, basal lower esophageal sphincter reflux who fail to respond to medication and lifestyle
tone is significantly lower than in Nissen fundoplication modification. This is because open reflux surgery is a major
following this procedure. This procedure is reported to invasive procedure and is associated with peroperative and
normalize lower esophageal sphincter tone, without postoperative major complications. However, with the
impairing the ability of the lower esophageal sphincter to introduction of laparoscopic fundoplication there is a
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relax on proper stimulation. Toupet procedure used to be tendency to offer surgery for less complicated GERD. There
recommended for the patients with poor esophageal motility are several reasons for this trend. One of the main reasons
but randomized clinical trials fail to support this for this is that now the surgeons performing this surgery
recommendation and certain modifications on Nissen are more experienced in this procedure and techniques of
procedure has minimized the side effects which used to the procedure are more refined and they are able to
follow Nissen fundoplication. Floppy Nissen with a short reproduce constant and reliable results. Since, laparoscopic
wrap is the preferred modification and it is reported to have fundoplication is less invasive and postoperative morbidity
a success rate of 90% with minimal morbidity and is much less, it has become more acceptable to patients
mortality. 31 as well.
Patients with Barrets esophagus usually have severe On the other hand, modern medical treatments like PPIs
reflux and antireflux surgery, have the potential to restore are equally effective in the long-term management of GERD,
lower esophageal sphincter pressure and prevent but there are concerns over their safety in prolonged
gastroesophageal reflux. However, complete regression of use. Some of these concerns include; interference with
intestinal metaplasia does not occur but some regression of vitamin B absorption, iron absorption and calcium.
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Barret’s epithelium is observed following antireflux surgery. However, these concerns have not been proved in large scale
It is also observed that progression to severe dysplasia or randomized control trials. More serious issues raised against
adenocarcinoma is also less compared to medical therapy prolonged use of PPIs include the theoretical risk of
in patients who had undergone antireflux surgery. 32 developing gastric carcinoid and colonic malignancies.
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