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Langenbecks Arch SurgDOI 10.1007/s00423-005-0002-8 disease (GERD) by anti-reflux surgeryrespecting the functional–morphologicalrestoration of the esophagus also dealt with during the operation.
restoration of functional morphology.
R. Horstmann (*) . C. Classen .
S. RöttgermannDepartment of Surgery, Herz 125.2±12.7 points in the follow-up.
operatively, all patients underwentendoscopy, pH metry and manometry.
Department of General Surgery,Muenster University Hospital, investigated, or have even been ignored. In 1968 and 1978,Stelzner and Lierse [, ] demonstrated that the muscle Numerous mechanisms and various factors have been fibres of muscularis propria of the esophagus run in a spiral proposed as possible causes of heartburn. The sensation of and are arranged horizontally with respect to the stomach. An heartburn is directly provoked by stimulation of esophageal increase in the longitudinal tension of the esophagus pro- chemoreceptors by an abnormal gastroesophageal acid re- duces the so-called “stretch closure”. This can open only if, at flux, dependent on the pH of the acid from the stomach and a given basic tone, the closure segment can further contract the duration of its action [. Local irritation of the esoph- and the fibres can shorten still further. The opening of the ageal mucosa by foodstuffs, stretching of the esophagus by closure segment is therefore an active process, but can also large volumes of reflux, a hypersensitive esophagus and occur passively. This happens as the result of a decrease in functional complaints are of subordinate importance ].
basic tone caused by shortening of the entire esophagus, for According to most investigators the functioning of the example, in a case of axial hiatus hernia. In this case, the lower esophageal sphincter (LES) plays a crucial part in the “stretch closure” becomes incompetent. Furthermore, there is pathogenesis of gastroesophageal reflux disease (GERD) a physiological reflux of gastric juice into the esophagus even (Fig. ). In present-day diagnostic investigations it is demon- in healthy people ]. The postprandial distension of the strated by intra-esophageal measurements of pressure and pH stomach triggers a transient relaxation of the reflux barrier, ]. However, the morphological principles of the closure which allows the physiological expulsion of swallowed air mechanism are, for the most part, unknown, have not been These morphological investigations of Stelzner have dem- onstrated that operative therapy for gastroesophageal refluxdisease (GERD) must fulfil the following requirements: . Retensioning (or restretching) of the esophagus . Lasting maintenance of esophageal tension In the present study, Stelzner’s concept of anti-reflux surgery in terms of the morphological requirements men-tioned above was proven for symptomatic patients. Thetherapeutic goal, namely freedom from long-term symp-toms of GERD, especially heartburn, was determinedduring follow-up by measuring the gastrointestinal qualityof life index (GQLI) proposed by Eypasch et al. in amean follow-up of 4 years.
Between January 1999 and December 2000, 221 patientswith symptoms of GERD were treated via surgery. Beforethe operation, all patients underwent esophagogastroscopytogether with diagnostic testing (pH measurement and Fig. 1 Suggested pathogenesis of GERD (according to Stelzner [ manometry). All patients had been treated preoperatively ]). The muscle fibres of the tunica muscularis propria of the with proton pump inhibitors (PPIs) for at least 6 months.
esophagus run spirally and are arranged horizontally with respect to After excluding those patients who declined to participate the stomach. When the longitudinal tensioning of the esophagus is (n=7) and those with serious pathological changes in the area present (existing), the so-called “stretch closure” results (a). The esoph- agus can open only if, at a given basic tone, the occluded segment can of the gastroesophageal junction (peptic stricture, n=3; further contract and the fibres can shorten still more. Any shortening Barrett n=26), there remained 185 patients who were in- of the esophagus, as may occur in a case of axial hiatus hernia, will cluded in the study. Their mean age was 52.7 years (16–79 lead to diminution of basic tone and with it the active contractile force years). There were 102 women and 83 men. The duration of with consequent incompetence of stretch closure (b). The functional– morphological concept of anti-reflux surgery includes the restoration the patients’ symptoms was on average 10.5 years (0.5–50 of this “stretch closure” by retensioning the entire esophagus using years), while the mean duration of medical treatment was 4.1 three layers (c): the hiatoplasty which is strengthened by a polypro- years (0.5–40 years). Postoperative questioning was carried pylene mesh (arrow), coaption of diaphragmatic crura and the fundus out with a standardised questionnaire in the fall of 2003, a cuff which acts as a “spacer” between the diaphragm and the cardia median of 45 months after the operation (30 and fixes the gastroesophageal junction within the abdomen Fig. 2 Essential steps of anti-reflux surgery. Because the esophagus(*) is mobilised over a long distance within the mediastinum (7– 10 cm), the gastroesophageal junction can be safely displaced intothe abdomen with the aid of a silicone tape, and the esophagus can Sixty-seven (36%) patients with a history of non-erosive thereby be retensioned (a). Reconstruction of the gap in the dia- reflux disease (NERD) had no demonstrable mucosal phragm dorsal to the esophagus with non-absorbable single knotsutures (b), reinforced by an alloplastic mesh (c) and by the lesions in the esophagus at any time, while 118 patients posterior wall of the fundus (d), provides a stable, three-layered (64%) had signs of esophagitis of differing severity. At cushion (counterfort) for the cuff, which then, acting as a spacer, endoscopy performed immediately before the operation, covers the posterior circumference of the esophagus to an extent of inflammatory changes were still seen in 23 patients, 180° only, and is then fixed on both sides with a short continuoussuture to the esophagus (‘short floppy Toupet’). In this way, any although this was due to the influence of PPI medication.
narrowing of the esophagus by the crura of the diaphragm and by After stopping PPI intake for 5 days, pH measurement was the cuff can be avoided and physiological reflux can be guaranteed performed in all patients, with the mean duration of datarecording amounting to 21.4 h (16.5–25 h). The percentagetime with pH of below 4 was 17.7% (1.5% to 96.3%). Inview of the physiological reflux phases, a value of less than 4.5% is regarded as normal, while values exceeding 4.5%are considered abnormal. The median DeMeester score was After dividing the lesser omentum in the area of its pars 81.4 (6.5–298.9). A value greater than 14.72 was regarded flaccida, the right crus of the diaphragm was exposed. The as abnormal. This method failed to demonstrate abnormal next step was to reposition the contents of the hernia in front reflux in 27 patients. The median resting pressure in the of the aorta, so as to expose the left crus of the diaphragm lower esophageal sphincter (LES) was 19.7 mmHg (4– dorsal to the esophagus, and to follow it ventrally. After 30.2 mmHg), and in these cases pressures of below 20 ventral dissection of the hernial sac, a silicone tape was or over 50 mmHg [were defined as abnormal. No case passed round the esophagus and the gastroesophageal junc- of achalasia, diffuse esophageal spasm or supersqueezer- tion was drawn caudally. In this way, the esophagus could be esophagus was observed, but in a total of 68 patients there mobilised under direct vision far into the mediastinum, care was decreased LES pressure and in some cases additionally being taken to protect the branches of the vagus nerve. The a non-specific motility disorder-like decrease in esophageal esophagus was dissected free from its mediastinal adhesions amplitude of less than 30 mmHg or a propagation speed around its circumference for a distance of 7–12 cm, so that exceeding 20 cm/s. No abnormal parameters of any kind the gastroesophageal junction was located in the abdomen were found in manometry in 117 patients (63%).
and the esophagus was kept under tension by traction on thesilicone tape.
Permanent maintenance of esophageal tension All operations were conducted by a standardised proceduredivided into three steps according to the above-named To avoid any tendency of the gastroesophageal junction to slide back into the mediastinum and to create an adequate place for its fixation, a stable dorsal hiatoplasty was per- Table 2 Questionnaire for appraisal of quality of life (modified formed. This was the essential component of the reconstruc- from []), showing mean values for the normal population tion and consists of three layers. First, the two more or less gaping diaphragmatic crura were coapted with non-absorb-able single knot sutures (Ethibond®, Gauge 0, Ethicon). We took care that the esophagus would not be narrowed by the diaphragmatic crura if traction on the silicone tape was relaxed. The hiatoplasty was then strengthened by a poly- propylene mesh (Prolene®, Ethicon) measuring about 3×6 cm, and cut so as to have its cranial margin concave (this prevents any irritation of the esophagus by the mesh).
When fixing the net with the hernia stapler (CMS®, Ethicon), care had to be taken that the upper margin of the mesh came to lie below the cranial coaptation suture of the diaphragmatic crura. The third layer consisted of the fundus itself. In order to place it without tension, it was mobilised in the usual fashion by dividing the short gastric vessels. In this way, it could then be placed dorsal to the esophagus onto the hiatoplasty, and is completely covering the polypropylene mesh. To secure it to the left and right of the esophagus in the form of a bilateral fundophrenicopexy, it was fixed to the diaphragm by two single knot sutures. The main purpose of this fixation was to ‘cranialise’ the cuff and thus to prevent any contact between the esophagus and the polypropylene Bodily appearanceStrength, stamina, fitness The distal part of the esophagus and the gastroesophageal junction rested upon the fundus ‘as if on a cushion’. Finally, the distal esophagus was fixed in this site by two shortcontinuous sutures, so that a posterior 180° hemifundopli- cation is formed and physiological reflux is possible.
Gastrointestinal quality of life was determined by standard-ised questionnaires according to Eypasch [This GQLIconsisted of 36 questions regarding symptoms, bodily, plications. Intra-abdominal adhesions merely led to some mental and emotional well-being, and social relationships, prolongation of operating time, and in two cases an injury to and leads to a score of between 0 and 144 points (Table the spleen capsule had to be treated with fibrin glue. In one In all patients the preoperative score was compared with case an injury to the esophagus was noted during the oper- the postoperative score and with the score of the normal ation and was oversewn. The median operating time was population without heartburn (reference group, n=50).
74 min (55–157 min). Postoperatively, small pleural ef- Differences in quality of life were tested for significance by fusions were noted in 15 patients, but puncture was nec- the Kruskal–Wallis test (p< 0.05).
essary in one case only. Six patients developed pneumonia,atelectasis was observed in seven patients, and postopera-tive lung oedema occurred in two. All these complications were treated conservatively with success.
In the long-term course, 93% were followed up for a median of 45 months. It was necessary to perform anesophago-gastro-duodenoscopy in 12 patients. Three pa- The surgical procedures, 185 in total, were completed tients had problems due to a diet mistake; in these patients, without any serious intraoperative or postoperative com- a food bolus was removed during esophagoscopy. Nine patients were suspected to have a recurrence of reflux esophagitis and hiatus hernia. In these patients an esoph- agoscopy and gastrographin swallow was performed with the result of a recurrence in four patients (recurrence rate of2.3%).
Preoperatively, all the patients with GERD had a signifi- cantly poorer quality of life (81.6±12.4 points) than the normal population (132.9±10.5 points). In particular, the patients had more symptoms in the form of heartburn, sensations of epigastric fullness and abdominal pain (45.3±7 points), and displayed significantly higher emotional labilityin the form of sadness, frustration and anxiousness (9.9±2.7points) than the normal population. The patients also report-ed significant limitation in their physical activities, affecting, difference between the patients and the normal population for example, strength, vitality and fitness (14.5±4.5 points), and social activities (10.6±2.7 points) as compared with thenormal population (26.3±1.2 points) together with morefrequent intake of drugs (Table At the time of follow-up, the cardinal symptoms of heartburn and acid regurgitation were still reported by 10 By means of anatomical investigations, Stelzner and Lierse patients (Table ). In four or these patients pH measurements demonstrated that the reflux barrier is not represented by a showed objective evidence of renewed abnormal acid reflux well-defined sphincter as known for anorectal continence and on gastroscopy a gaping cardia, so that laparoscopic re- , , It is rather dependent on the longitudinal intervention was indicated (2.3%). The rate of reoccurrence tension of the muscle fibres, the so-called “angio-muscular of severe symptoms was 5.8%. Six of these symptomatic stretch-closure”, to such an extent that, at a given basic tone patients causally showed a fresh mucosal tear (1), gastritis throughout the entire esophagus, it is opened by shortening, (3), or a reactive depressive illness with a tendency to soma- e.g. by swallowing and closed in a tensioned condition. The tisation (2). They were treated with proton pump inhibitors, more relaxed the distal esophagus (for example, in a case of and in some cases a tranquilizer in low doses. A further 21 axial hiatus hernia), the more incompetent is the muscle patients (12.2%) reported that they occasionally took PPIs, spiral, which does indeed possess its own intrinsic tone, but usually after dietary indiscretions. Swallowing problems of its active contractile power has been largely lost by passive the nature of dysphagia were a common problem in the early postoperative phase. Many patients also complained of Based on these pathophysiological considerations, the undue flatulence and sensations of fullness in the mid-term.
functional–morphological concept of anti-reflux surgery Symptoms were treated by medication. At follow-up more must include the restoration of this “stretch closure” by than 3 years postoperatively, these side effects had receded retensioning the entire esophagus. All previously described into the background. The operation was successful in sig- modifications of the fundus cuff have achieved just such a nificantly improving quality of life (125.2±12.7 points), retensioning of the esophagus. Irrespective of its config- symptoms (69.1±5.7 points), emotional lability (16.7±3.7 uration (180° or 360° cuff), the cuff itself acts as a “spacer” points) and physical (22.8±4.4 points) and social impairment between the diaphragm and the cardia and fixes the (13.3±2.1 points), where results no longer showed any gastroesophageal junction within the abdomen (“junction- pexy”), thus representing the precondition for a relaxation is responsible for the occurrence of GERD, our results of the muscle fibres. Improvement of the reflux barrier is showed that reduced LES pressure was present in only one therefore explained by the stretching of the muscle fibres in third of symptomatic patients. Moreover, as has been shown the entire organ rather than by direct conduction of pressure in this and other studies, even patients with normal LES through the fundus cuff or by the influence of the abdom- pressure benefit from the improvement in their symptoms after laparoscopic fundoplication [the operation corrects Traditional measures used to diagnose GERD include pH reflux irrespective of the resting LES pressure []. We metry, manometry and endoscopy of the esophagus. In recent therefore do not use manometry of the esophagus for routine years, however, there has been a growing interest in diagnosis of GERD. However, a manometry should be measuring the quality of life for diagnosis and evaluation routinely performed in patients who are suspected to have of the success of either medical or surgical treatment of motility disorder of the esophagus, e.g. achalasia, diffuse GERD ]. In our clinic, pH metry, endoscopy of the spasmus of the esophagus or nutcracker esophagus.
esophagus and measurement of quality of life are used for Currently, proton pump inhibitors (PPIs) represent the diagnosis and assessment of the outcome of surgical gold standard for treatment of GERD, but as PPIs do not treatment of GERD, whereas manometry is not routinely restore the anti-reflux barrier, lifelong medication is required used. pH metry correlated well with the symptoms of GERD in most cases. Newly developed endoscopic anti-reflux tech- in this study. Preoperatively, 85.4% of all patients showed an niques (EAT) have demonstrated potential treatment advan- increased DeMeester score. In particular, pH metry is a tages (e.g. less invasiveness, shorter hospital stay) but failed powerful diagnostic tool for patients who are suspected to to show long-term effectiveness, durability, and safety in the have functional disorders []. However, it should be kept in treatment of GERD since they do not restore the function and mind that the sensitivity of pH metry can be restricted in morphology of the esophageal reflux barrier , ]. There- cases of non-compliant patients who have not interrupted fore, laparoscopic fundoplication can be considered as an their acid-suppressing treatment for at least 1 week before pH attractive alternative to PPIs and EATs, especially in young metry or in patients with a hypersensitive esophagus ].
and fit patients [, ]. Nissen fundoplication using a Endoscopy of the esophagus together with a histological “floppy” 360° wrap is favored by most surgeons around the examination should be routinely performed in order to world, probably because it is easy to perform. The Toupet exclude patho-morphological findings, e.g. stenosis, bleed- procedure, a partial posterior 270° wrap, was more recently ing, metaplasia and dysplasia of the esophagus. Patients with reported to be as effective as the 360° Nissen procedure but these findings were excluded in this study because of the associated with fewer postoperative problems ]. The difference in treatment and screening. Among all patients anatomical investigations of Stelzner and Lierse demonstrat- with heartburn as symptom for GERD in this study, only ed why it is possible to control the gastroesophageal reflux by 63.8% showed esophagitis. This poor correlation can be a fundoplication when the following requirements are explained by the non-erosive reflux disease (NERD) [].
fulfilled. The esophagus should be adequately retensioned Since GERD significantly affects the quality of life of by mobilizing it in the lower mediastinum and displacing the patients, quality of life scales are emerging as an additional gastroesophageal junction safely into the abdomen with the important factor in determining the role of surgery in the aid of a silicone sling. By locating the gastroesophageal treatment of GERD and in selecting a treatment option junction into the abdomen and performing a fundophrenico- between medical and surgical therapy for these patients.
pexy, a restoration of the angle of His is also possible. In this Comparison of generic (e.g. SF-36) and disease-specific context, a Collis gastroplasty is not necessary, and any such quality of life scales (e.g. GERD-HRQL) for GERD suggests measure would not be in accordance with the principle of the that generic instruments are less sensitive in measuring the operation Reconstruction of the hiatus in the diaphragm effects of treatment of GERD ]. We therefore developed a dorsal to the esophagus, strengthened by alloplastic material disease-specific quality of life questionnaire based on the and the posterior wall of the fundus, produces a stable, three- gastrointestinal quality of life score according to Eypasch layered bed—a “counterfort” for the cuff, which then func- This questionnaire could be easily managed in the clinic tions as a “spacer”, covering only 180° of the posterior since it takes less than 10 min to fill out. In this study, all circumference of the esophagus (“short floppy Toupet”).
quality of life scales were significantly improved after Through this technique, any narrowing caused by the crura of surgical treatment of GERD, showing no difference when the diaphragm and by the cuff can be avoided, so that phys- compared with those of the normal population, which iological reflux can be guaranteed after a short adaptation indicates that quality of life represents an important endpoint phase. The concept of strengthening the hiatoplasty by a PP for clinical trials concerning GERD. The importance of lower mesh originated from our excellent experience with PP esophagus sphincter (LES) pressure in the pathogenesis of meshes in laparoscopic inguinal hernia surgery. In this study GERD is at present the subject of controversy ].
no mesh-associated complications, e.g. migration, esophagus Contrary to the general perception that reduced LES pressure In summary, based on anatomical investigations of the the excellent long-term results comprising a significant pathogenesis of GERD, a causal treatment can only be improvement in quality of life and low recurrence rates, the achieved by anti-reflux surgery that considers the functional functional–morphological concept of anti-reflux surgery morphology of the tension-dependent “stretch-closure” of should be considered as an attractive alternative option, the esophagus, whereas PPIs and the newly developed EATs especially in young and fit patients.
represent only symptomatic therapeutic approaches. Due to tion closing of the terminal esophagus.
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