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INDICATIONS

Laparoscopic total or Nissen fundoplication is indicated for individuals with gastroesophageal reflux disease (GERD) that meets one of the following criteria: (1) GERD that is refractory to proton pump inhibition, (2) GERD that is incompletely responsive to proton pump inhibition, (3) GERD that is entirely responsive to proton pump inhibition, but patient choice or side effect profile merits consideration of antireflux surgery, (4) extraesophageal manifestations of GERD, and (5) complications of GERD (stricture, bleeding, aspiration, Barrett esophagus). Of these criteria, the patients who are most likely to achieve complete symptom relief are those who are responsive to medical therapy, who have esophageal symptoms of reflux (heartburn, regurgitation, chest pain), and those with a strongly positive pH study (see later discussion).

Contraindications are few, but the morbidly obese patient with gastroesophageal reflux may be better served with gastric bypass than with Nissen fundoplication. Although observational data demonstrate good outcomes in laparoscopic Nissen patients with a BMI up to 40, individuals who meet the indications for bariatric procedures (see Chapter 29) and who also have gastroesophageal reflux should be referred for a bariatric procedure rather than undergoing Nissen fundoplication.

PREOPERATIVE PREPARATION

Before performing laparoscopic Nissen fundoplication, the patient must undergo anatomic and physiologic esophageal evaluation. This entails the performance of esophagogastroduodenoscopy (EGD), barium swallow, and esophageal motility study at a minimum. Although it is generally advisable to obtain an ambulatory 24-hour pH study in all patients before operation, this test may be omitted in individuals with esophageal symptoms of GERD, a response to proton pump inhibitors, and endoscopic evidence of esophageal injury. Multichannel intraluminal impedance (MII) measurement, especially when combined with pH measurement (MII-pH), may be the best tool to measure acid and non-acid reflux. Because of the nonspecific nature of esophageal symptoms, it is best not to perform laparoscopic Nissen fundoplication on patients with an anatomically normal esophagus, without confirming reflux using pH or impedance testing. Radionucleotide gastric emptying studies are indicated before laparoscopic antireflux surgery in patients with diabetes, previous gastric surgery, bezoars, or prominent nausea and vomiting symptoms.

Generally, the patient is continued on all preoperative medications until the morning of surgery. If possible, anticoagulants, antiplatelet agents, and nonsteroidal anti-inflammatory agents are discontinued. Glucose control should be optimized, and cardiopulmonary disease should be thoroughly evaluated with appropriate consultation and testing preoperatively. It is unnecessary to prep the colon for laparoscopic Nissen fundoplication.

ANESTHESIA

General anesthesia with endotracheal intubation is necessary for this operation. Complete neuromuscular blockade is required. Intravenous antibiotics are not generally indicated. Before emergence from anesthesia, it is important that the patient be aggressively treated for postoperative nausea with ondansetron and phenergan or its equivalent. Some anesthesiologists also add low doses of steroids for their antiemetic effects. Last, if there has been little bleeding during the dissection, we also administer ketorolac at the end of the procedure to ...

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