Gastroesophageal reflux disease (GERD) is caused by the chronic reflux of gastric acid from the stomach to the esophagus. This may be the result of an incompetent lower esophageal sphincter (LES) or poor gastric emptying. GERD is an anatomic and physiologic problem that may lead to surgical consultation for treatment of either the symptoms or sequelae of reflux. It was first recognized as a clinical entity in the 1930s. Today, it is the most prevalent upper gastrointestinal disorder in the Western world.1
GERD gives rise to a spectrum of symptoms that range in intensity from mild to severe. Up to 80% of patients present with so-called typical symptoms of GERD. These include heartburn, regurgitation, sour taste, and intermittent dysphagia but no evidence of esophageal inflammation or injury. Approximately 20% of patients present with atypical symptoms, namely, chest pain, hoarseness, nocturnal choking, chronic cough, asthma, shortness of breath, and pneumonia. For some, GERD causes severe medical disabilities, such as recurrent aspiration, ulceration, end-stage lung disease, or recurrent esophageal stricture. Left untreated, these complications may lead to disability and rarely mortality. For most, however, GERD is a non-life-threatening condition, and patients suffering from this disease seek treatment mainly to improve their quality of life.
The treatment options for GERD range from lifestyle change and medical therapy to antireflux surgery based on the severity of the patient’s symptoms or presence of complications. Long-term treatment with proton pump inhibitor (PPI) therapy is highly effective in terms of symptoms but may require indefinite duration because 82% of patients have recurrent symptoms within 6 months of discontinuation. When conservative treatment fails, several interventions are possible. Herein, we describe both the open Nissen fundoplication and the laparoscopic adaptation, the current surgical standard for the treatment of GERD. These operations were designed to fix the anatomic and physiologic problems that give rise to GERD.
GENERAL PRINCIPLES AND PATIENT SELECTION
The Nissen fundoplication consists of hiatal closure and a 360-degree wrap of stomach posteriorly around the distal esophagus to augment and restore the function of the LES. The laparoscopic adaptation is associated with reduced morbidity compared with the open approach; however, a history of previous abdominal operation with dense scar and adhesion still poses a significant challenge. Since its conception,2 the Nissen fundoplication has been a successful operation with excellent long-term outcomes. The morbidity associated with the upper midline incision of the open approach, however, limited its application to patients with symptoms refractory to medical therapy and severe complications of GERD.
The laparoscopic adaptation, first reported in 1991,3 revitalized interest in the surgical treatment of GERD. Factors underlying this increased interest included the rising incidence of GERD in Western countries, the decreased morbidity and mortality of the minimally invasive approach, poor compliance or dissatisfaction with long-term medical treatment, recognition of an association between GERD and esophageal cancer, and curative potential of the ...