Benjamin K. Poulose and Michael D. Holzman

Introduction

Gastroesophageal reflux disease (GERD) remains one of the most common diseases for which patients seek medical attention. Identifying suitable candidates for surgical management of GERD is a complex process involving documentation of pathologic reflux, assessment of esophageal motility, and discussion of postoperative expectations with patients. The surgical approach to GERD serves to reestablish the original anatomic barriers to reflux, supplemented by fundoplication. The 360-degree fundoplication originally proposed by Rudolph Nissen in the mid-20th century remains the standard by which interventional approaches to GERD are measured.

Surgical Principles

The goals of successful surgical management of GERD are to restore the intraabdominal esophagus, repair the diaphragmatic crura, and reestablish a competent lower esophageal sphincter. A thorough understanding of hiatal anatomy, upper abdominal organ relationships, and mediastinal structures is critical to safe and effective operations for GERD (Figs. 6-1 to 6-3). Restoration of the lower esophageal sphincter is usually accomplished with a “floppy” 360-degree (Nissen) fundoplication formed around the distal esophagus.

Preoperative Studies

Preoperative studies include upper endoscopy, upper gastrointestinal (GI) series, esophageal manometry, and pH testing. Esophageal impedance may help identify patients with pathologic nonacid reflux. Patients with chronic nausea and emesis may benefit from a gastric emptying study to ascertain whether gastroparesis contributes to their symptomatology.

Upper endoscopy can reveal intraluminal pathology that can alter surgical decision making and can help ascertain anatomic changes that would impact the operation for GERD. The most common anatomic abnormality seen in this setting is the sliding, type I hiatal hernia (Fig. 6-4). Upper endoscopy can also reveal a shortened esophagus. The upper GI series also helps define anatomic abnormalities and is useful when more complex hiatal hernias are noted (types II-IV). Testing for acid exposure, nonacid reflux, and assessment of esophageal motility are also important nonimaging modalities that help in preoperative decision making.

Anatomy for Esophageal Mobilization