Complications of Operations for Hiatal Hernias and Reflux Disease
There has been a huge increase in antireflux operations over the last two decades. The emergence of minimally invasive surgery has led to a widening of surgical indications for the operation. Reflux disease remains a functional disorder and it must still be assessed with objectivity if unequivocal evidence of mucosal damage within the esophagus is to be documented before indicating a medical treatment or a surgical approach. As hiatal hernias and reflux esophagitis have been closely associated over the last half century, complications in their surgical management will be treated together.
Gastroesophageal reflux disease (GERD) is a pathologic reflux disorder that causes mucosal damage. The presence of symptoms suggestive of reflux without any mucosal alteration is considered a functional reflux disorder.1 As all humans have physiologic episodes of reflux, the diagnosis, to be clear, must be based on objective criteria if a wrong diagnosis with its unhappy results is to be avoided. Operations should not be planned on the basis of symptoms, alone, as they bear little relationship to the degree of damage present in the esophagus. At a minimum, radiologic and endoscopic documentation of the disease must be obtained. Classification of damage using the MUSE (Metaplasia, Ulcerations, Stricturing, and Erosions) classification or the Los Angeles classification are considered objective as they only consider mucosal breaks in the esophagus to be evidence of damage (Table 32-1).
Table 32-1The Muse (Metaplasia, Ulceration, stricture, Erosion) Classification |Favorite Table|Download (.pdf) Table 32-1The Muse (Metaplasia, Ulceration, stricture, Erosion) Classification
| ||METAPLASIA ||ULCERATION ||STRICTURE ||EROSION |
|Grade 0 ||M0 absent ||U0 absent ||S0 absent ||E0 absent |
|Grade 1 ||M1 one ||U1 one ||S1 >9 mm ||E1 one |
|Grade 2 ||M2 circumferential ||U2 ≥ 2 ||S2 ≤9 ||E2 circumferential |
|The Los Angeles Classification |
|Grade A ||≥1 Mucosal break <5 mm long that dose not extend between the tops of 2 mucosal folds |
|Grade B ||≥1 Mucosal break >5 mm long that dose not extend between the tops of 2 mucosal folds |
|Grade C ||≥1 Mucosal break that extends between the tops of ≥2 mucosal folds involving <75% of the esophageal circumference |
|Grade D ||≥1 Mucosal break that involves ≥75% of the esophageal circumference |
Complications during the Operation
Most of the antireflux operations completed today are by laparoscopic approach. The reported morbidity varies from 4% to 7% with a 0.1% mortality.2 Morbidity, however, even if these new approaches have modified its prevalence, must be looked at independently of open abdominal, thoracic, or minimally invasive incisions. Open repairs, especially those utilizing laparotomy, are thought to produce more splenic trauma, primarily during mobilization of the gastric fundus for fundoplication or by simple traction on the omentum causing avulsion of adhesions on the splenic capsule. The open approach is also associated with a greater number of incisional hernias. However, the transition ...