Upper Gastrointestinal Surgery Unit

GASTRO-ESOPHAGEAL REFLUX DISEASE

Gastro-Esophageal Reflux Disease (GERD) is a motility disorder of the upper gastro-intestinal tract that results in an excessive exposure of the esophageal mucosa to gastric juice.

Patients with documented chronic esophageal symptoms and inflammation can be treated in two main different ways:

  • The first option is life-long antacid therapy using either H2-blokers or proton pump inhibitors. These medications modify the composition of the gastric juice without preventing it from refluxing into the esophagus, so that reflux symptoms are alleviated and esophageal inflammation is reduced. These drugs are well tolerated by most patients but reflux symptoms and inflammation usually reappear after drug discontinuation. Maintenance therapy does not prevent mucosal transformation into intestinal metaplasia.
  • The second option is the restoration of a permanent barrier against reflux at the gastro-esophageal junction.
    Although endoscopic methods are currently on trial, the most reliable technique for the restoration of an effective lower esophageal sphincter against reflux consists of performing a gastric wrap around the lower esophagus with the fundus of the stomach. Effective fundoplication suppresses gastro-esophageal reflux symptoms and lesions and prevents the transformation of the esophageal mucosa into intestinal metaplasia. Good candidates for a fundoplication are patients having a good general condition whose documented symptomatology is poorly alleviated by optimal medical therapy and those who experience recurrence of typical reflux symptoms and lesions after drug discontinuation. Patients whose gastric contents is contaminated by an excessive amount of duodenal juice, because they at risk for the development of intestinal metaplasia in the lower esophagus, also are eligible for a fundoplication.

SURGICAL PROCEDURES:

The choice of the most relevant procedure depends on the existence of a short esophagus or not, the presence of severe motor abnormalities in the esophageal body or not, and the past surgical history in the abdomen.

  • Patients with a normal-length esophagus, a normal esophageal body motility, and no history of previous major abdominal surgery are treated by complete laparoscopic fundoplication according to Nissen-Demeester technique.
  • Patients with esophageal body dyscontractility are best treated by laparoscopic posterior fundoplication
  • Patients with a normal-length esophagus but with a history of previous major surgery in the abdomen are operated on through a conventional upper abdominal incision.
  • Patients with a short esophagus require a thoracotomy for the construction of a complete fundoplication around the intrathoracic lower esophagus (Intrathoracic Nissen Fundoplication).