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Neto et al. Laparoscopic Nissen fundoplication

rate of false-negativity. the symptoms to the disease increase the likelihood
of excellent outcomes. Thus, a pathologic pH
Many studies have shown that even typical symptoms monitoring increases the chance of success by 5 times
such as heartburn and regurgitation have low accuracy compared to a normal test, [20] and clinical response to
leading to an incorrect diagnosis of GERD in 30-50% of acid suppression therapy has been associated with
patients. [11,12] Likewise, the presence of reflux or hiatal a 3 times better response to surgical treatment. [20]
hernia on esophagogram does not correlate well with Esophageal symptoms are more prone to be caused
reflux on pH monitoring, or esophagitis on endoscopy. by GERD, and also have a better prognosis compared
[10]
to extra-esophageal symptoms. [18,20]
Extra esophageal symptoms may bring additional
difficulty for the diagnosis. Other tests, such as “Illness behavior” may influence [19-21] expectations,
laryngoscopy may be added to the armamentarium; satisfaction and tolerance to post-operative side
however, a low positive predictive value for the effects.
diagnosis of GERD is anticipated. [13] Other diseases
may coexist with GERD. and symptoms may have This fact may explain worse outcomes in females,
other causes or may be multifactorial with GERD as patients with psychiatric disorders, and individuals of
only an adjuvant. The response to specific GERD lower socioeconomic status.
treatment as a trial, and the association of the symptom
with reflux episodes at the time of pH monitoring may Although not unanimously, some series show poorer
help to determine the cause of the symptom. outcomes for obese patients [18,22] that undergo a
fundoplication likely due to a more demanding
Ambulatory 24-h pH monitoring should be routinely operation with longer operative times [23] and more
performed in the preoperative workup of patients complications. [24]
suspect of having GERD. [10] Either alone or in
combination with multichannel intraluminal impedance One must consider the operation contraindicated in
(MII-pH) pH monitoring. This testing provides the best the presence of various predictors for unsuccessful
objective information on esophageal acid exposure, outcomes, while older age and esophageal dysmotility
[25,26]
allowing diagnosing and quantifying GERD, and (excluding achalasia) do not influence outcomes.
temporal correlation between symptoms and episodes
of reflux. [14] TECHNIQUE
Some technical points must be followed to ensure an
Lastly, an adequate preoperative workup should bring adequate fundoplication.
several pieces of information in order to allow a clinical
judgement for a better diagnosis since diagnostic tests An extensive esophageal dissection in the abdominal
individually (laryngoscopy, endoscopy, and even pH- and lower thoracic segments to achieve a 2-4 cm
or pH-impedance monitoring) may not be sufficient to segment of abdominal esophagus is helpful to prevent
make the definitive diagnosis of GERD. [15] hernia recurrence. The presence of a long abdominal
esophagus is per se an efficient antireflux mechanism
PATIENT SELECTION [Figure 1], [27] and careful attention should be taken to
avoid damage to the vagal branches that are close to
Following the example of any other elective surgical this portion of the esophagus. [16,28]
procedure, patients planned to undergo an antireflux
operation should be carefully clinically evaluated. Hiatal closure is an important part of this operation since
Patients under high anesthetic risk or those with the integrity of this muscle barrier exerts synergistic
uncontrolled co-morbidities should not be offered this
kind of therapy.
Table 1: Predictors for bad outcomes after laparoscopic
Nissen fundoplication
Some predictors of worse outcomes after a
fundoplication have been identified [Table 1]. Some Patient Disease More difficult operation
are inherent to the patient, others to the disease, and Female gender Extra-esophageal Obesity
some to technical difficulty during the operation. [16-19] symptoms
Lack of response
With the exception of obesity, these predictors cannot Psychiatric to acid suppression Reoperation
disorders
be changed in the majority of patients. therapy
Low socioeconomic Absence of hiatal
The certainty of the GERD diagnosis and attribution of status hernia
Mini-invasive Surgery ¦ Volume 1 ¦ March 31, 2017 7