1. Laparoscopic Nissen Fundoplication with minimal mobilization and without crural repair in patients without hiatus hernia.
HA Khokhar, W Fahmy, AA Toor, M Kazanowski, B Meskat, TN Walsh
Department of Upper GI Surgery, James Connolly Hospital, Dublin, Ireland.
INTRODUCTION
Nissen fundoplication has traditionally involved extensive dissection of the phreno-esophageal ligament to create a 2 to 3 cm segment of intra-abdominal oesophagus followed by crural repair. .
The upper internal component is aligned with the crura and moves during respiration, implicating the importance of the phrenoesophageal membrane(3).
The lower internal component lies at the junction of the gastric cardia and oesophagus (gastric sling muscle)3.
Adult patients with reflux have been shown to have an abnormality in the lower intrinsic component only (4).
Pharmacologic manipulation in patients who have undergone Nissen fundoplication has demonstrated that tonic contraction of the gastric smooth muscle in the wrap augments the lower intrinsic component (5).
Therefore, it would argue against disrupting the anatomical association between the upper internal component and the crural sling in patients without a hiatal hernia.
AIMS
We present a technique of fundoplication with minimal mobilization of the phreno- esophageal ligament and without crural repair in patients without a hiatus hernia.
The posterior 360 degree wrap completed.
RESULTS
From 2008 to 2013, seventy six patients underwent anti-reflux surgery.
Thirty four patients did not have a hiatus hernia and were included in the study.
The average age was ± years
The male to female ratio was 2.09: 1
The average DeMeester score
The average hospital stay was1.97 ± 1.56 days .
Twenty four (71%) patients had complete resolution of their symptoms.
Three (9%) had mild symptoms of reflux requiring PPIs.
Four (12%) had dysphagia out of which 2 patients required dilations.
One(3%) patient complained of bloating and 2 were lost to follow up
METHODS
Patients are selected for fundoplication after careful history (to exclude functional bowel disorder), endoscopy to establish hiatal status, pH monitoring and manometery and barium studies when required.
A window is created above the hepatic branch of vagus nerve and a narrow tunnel is developed behind the oesophagus.
The proximal short gastric vessels are taken down, a nylon tape is secured to a point on the posterior gastric wall 5cm from the OG junction and is delivered through the tunnel and secured over a F bougie to its anterior wall counterpart.
A regular diet is allowed from the next day and the patient discharged.
CONCLUSION
Augmenting the lower intrinsic component with a fundal wrap around the distal oesophagus in its native anatomical position, should overcome the physiologic deficit while preserving the function and relationship of the upper smooth muscle and the skeletal muscle crural sling.
Thus making any crural repair unnecessary.
DISCUSSION
The use of high-frequency ultrasound transducers combined with manometry has demonstrated that the normal high pressure zone of the lower oesophagus is composed of three components;
An upper Internal LES (Smooth Muscle).
A lower Internal LES (the gastric sling fiber).
External LES or the diaphragmatic crura(1,2)
REFERENCES
Brasseur JG, Ulerich R, Dai Q, et al. Pharmacological dissection of the human gastro-oesophageal segment into three sphincteric components.J Physiol 2007;580:
Miller L, Vegesna A, Kalra A, et al. New observations on the gastroesophageal antireflux barrier. Gastroenterol Clin North Am 2007;36:
McCray Jr WH, Chung C, Parkman HP, et al. Use of simultaneous high-resolution endoluminal sonography (HRES) and manometry to characterize high pressure zone of distal esophagus. Dig Dis Sci 2000;45:
Stannard Miller LS, Ulerich R, Thomas BJ, et al. A new theory to explain the pathophysiology of GERD. Pharmacological separation of the gastroesophageal junction high pressure zone demonstrates an absent gastric sling fiber pressure profile in patients with GERD. Gastroenterology 2004;A-126(4 Suppl 2).