c l i n i c a l f o l i o s : d i s c u s s i o n

Gastroesophageal Reflux Disease (GERD)



Related narratives: Laparoscopic Nissen Fundoplication, Laparoscopic Nissen Fundoplication (Video), Open Nissen Fundoplication

Reflux of gastric contents exceeding the physiological ability of the esophagus to efficiently clear, over time can lead to esophagitis, ulceration, bleeding, stricture, and Barrett's metaplasia above the squamo-columnar junction. Exposure of the esophagus to acid reflux is mediated by competence of the lower esophageal sphincter (LES), esophageal peristalsis and normal gastric acid production and emptying. Reflux may or may not be associated with hiatus hernia. The LES function depends on normal resting tone, the valve created by the esophagogastric angle, and exposure of the terminal esophagus to intraabdominal pressure. Over half of patients with GERD have a defective lower esophageal sphincter mechanism. About a third of patients have delayed gastric emptying or aerophagia forcing acid up into the stomach past a normal LES.

Mild gastroesophageal reflux disease is managed medically (H2 blockers, proton pump inhibitors, small meals, no late meals, elevation of the head of the bed, weight loss, elimination of drugs that decrease lower esophageal sphincter pressure). Patients who do not respond to an adequate (8-12 week) course of intense acid suppression, who have severe (above the 95th percentile) increased esophageal acid exposure on 24hr esophageal pH monitoring (pH <4 for more than 4 1/2 hrs, episodes longer than 19.8 min. at a time), who have a defective LES (<6mm Hg) by manometry and have adequate esophageal motor function are candidates for antireflux surgery. Medication dependence because of relapsing symptoms, severe dietary and lifestyle restrictions, and primary respiratory complications (asthma, aspiration pneumonia) are additional indications. Young patients with significant reflux are more prone to develop complications and surgery should be considered earlier. The extension of laparoscopic abdominal surgery in the 1990's has led to a rejuvenation of interest in antireflux surgery, primarily fundoplication.

When decreased esophageal motility is the primary problem, fundoplication superimposed on a normal LES can lead to esophageal obstruction. A partial wrap may be indicated in these cases. Patients whose primary problem is delayed gastric emptying or pyloric outlet obstruction from chronic peptic ulcer disease may develop gas bloat syndrome after fundoplication and need to be treated for the primary pathology. A small subset of patients (5%) with both hyperacidity and LES incompetence are candidates for fundoplication combined with highly selective vagotomy.

Patients with a shortened esophagus may pose problems for an abdominal laparoscopic approach. Failure of a hiatus hernia to reduce in the upright position in the upright position may indicate a shortened esophagus. In clinical practice, an adequate length of esophagus can usually be mobilized for fundoplication. With a true short esophagus, the wrap can be left in the chest and the hiatus sutured around it with good functional results. The reason for this is that the wrap acts like the nipple valve in a basketball, closing the valve as the stomach distends. Those with advanced laparoscopic skills can increase esophageal length with a gastroplasty.

Paraesophageal hernia requires surgical treatment because of the risk of strangulation. The dissection in such cases is more difficult and there is an increased risk of esophageal perforation. A fundoplication should be performed, and a gastropexy may be added to help keep the stomach down in the abdomen.

A short (2cm), loose wrap helps prevent postoperative dysphagia. Many patients will experience some initial post op dysphasia until the edema from the surgical manipulation subsides, and the diet is modified accordingly. In properly selected, uncomplicated patients, fundoplication is 80-90% effective with minimal morbidity.


Hinder, RA, Filipi CJ. The laparoscopic management of gastroesophageal reflux disease. In: Cameron JL, (ed), Adv Surg, St. Louis: Mosby, 1995:41-58.

Patterson-Brown S, Garden J (eds.). Principles and practice of surgical laparoscopy. London: WB Saunders Co. Ltd, 1994: 246-261.

Peters JH, Demeester TR, Minimally invasive surgery of the foregut, St. Louis: Quality Medical Publishers, 1994: 38-70, 119-176, 188-196.

Wind GG, Applied laparoscopic anatomy: abdomen and pelvis, Baltimore: Williams & Wilkins, 1997: 143-184.

This page was last modified on 20-Jul-2002.