Figure 42-37. Computer-generated graphic representation of esophageal body contraction amplitudes, duration of contraction, and

wave progression.

Figure 42-38. High-resolution manometry (HRM) display. Note the color-coded graphic description of esophageal body wave

amplitudes and lower esophageal sphincter function.

Poor gastric emptying or transit can provide for reflux of gastric contents into the distal esophagus.

Standard gastric emptying studies are performed with radionuclide-labeled meals. They are often poorly

standardized and difficult to interpret. Emptying of solids and liquids can be assessed simultaneously

when both phases are marked with different tracers. After ingestion of a labeled standard meal, gamma

camera images of the stomach are obtained at 5- to 15-minute intervals for 1.5 to 2 hours. After

correction for decay, the counts in the gastric area are plotted as percentage of total counts at the start

of the imaging. The resulting emptying curve can be compared with data obtained in normal volunteers.

In general, normal subjects will empty 59% of a meal within 90 minutes.

Evolving Technologies for Assessment of Extraesophageal Manifestations of GERD. Given the

difficulty inherent in proving that GERD is etiologic to extraesophageal symptoms, such as cough, sore

throat, or hoarseness, or to more chronic and insidious conditions, such as repetitive aspiration or

pulmonary fibrosis, a great interest exists to develop testing modalities that are both more sensitive and

more specific than the technologies widely utilized at present. Several recent testing paradigms have

emerged that appear promising, despite lacking extensive data.

Simultaneous 24-hour MII-pH and continuous pulse oximetry recently was evaluated in 20 subjects

with primary RSs and 10 with primary ESs.179 Oxygen saturation monitoring was performed using a

finger clip probe (Pulsox-300i, Konica Minolta Sensing, Inc., Ramsey, NJ) that measures the arterial

oxygen saturation (SpO2

) and pulse rate every second via standard photometrics (Fig. 42-39). An

oxygen desaturation event was defined by either (a) SpO2

less than 90% or (b) SpO2 drop of 6% or

greater (Fig. 42-40). Reflux events, both acid and nonacid, were temporally correlated to desaturation

events. Markedly more reflux events were associated with desaturation in patients with RSs (74.5%,

832/1,117 reflux events) than in patients with ESs (30.4%, 223/734 reflux events, p < 0.0001) (Fig.

42-41). In addition, the difference in reflux desaturation association was more pronounced with

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proximal reflux (80.3% with RSs vs. 20.4% with ESs, p < 0.0001). While a number of issues still need

to be resolved with this technique for it to be considered reliable and useful, the observation of oxygen

desaturations in temporal proximity to reflux events, particularly in patients with RSs, is intriguing and

may prove meaningful.

A pharyngeal pH catheter (Restech, San Diego, CA) also was recently developed and consists of a thin

(1.5-mm diameter) nasally passed catheter that can be positioned in the pharynx with the assistance of a

light-emitting diode (LED) mounted on the tip. The catheter, being small, is well tolerated and measures

both liquid and aerosolized reflux events. Optimal pH thresholds are currently being evaluated to

predict the responsiveness of extraesophageal symptoms to antireflux therapy, either medical or

surgical.

Finally, several centers have investigated the utility of salivary/sputum or laryngoscopic biopsy

specimen assays for pepsin as a marker for underlying GERD.180–182 As pepsin is produced only in the

gastric mucosa, its presence in the sputum or larynx reflects gastric reflux. Pepsin assays, when

compared to ambulatory pH monitoring, showed a high correlation to proximal reflux events. Positive

assays were also highly correlated with the presence of LPR symptoms. Still lacking are data showing

that a positive sputum or laryngeal pepsin assay predicts a successful symptomatic response to

antireflux therapy. With additional study, the utility and reliability of each of these modalities will be

determined in the clinical marketplace.

Partial Versus Complete Fundoplication. The decision between partial and complete fundoplication

and an open or laparoscopic approach requires considerable judgment. Two randomized studies of

unselected patients undergoing laparoscopic fundoplication have shown equivalence of complete and

partial fundoplications, anterior in one study183 and posterior in the other,83 in terms of operative time,

perioperative morbidity, and hospital stay. Watson et al.183 noted that resting and residual LES

pressures were greater after complete fundoplication and that esophageal clearance of liquid

radioisotope was prolonged in these patients compared with after partial fundoplication. Six months

after operation, partial fundoplication was linked to a greater overall level of patient satisfaction

manifested by a lower incidence of the symptoms of dysphagia, inability to belch, and excessive flatus.

Laws et al.184 did not identify any difference in symptomatic outcome between patients treated by

complete and those treated by posterior partial fundoplication at a mean follow-up time of 27 months.

Figure 42-39. Pulsox-300i with finger probe used to assess ambulatory oxygen saturation (Konica Minolta Sensing, Inc.).

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Figure 42-40. Example of the association between a reflux episode detected by multichannel intraluminal impedance–pH study

and oxygen desaturation detected by pulse oximetry. (Reproduced with permission from Salvador R, Watson TJ, Herbella F, et al.

Association of gastroesophageal reflux and O2 desaturation: a novel study of simultaneous 24-h MII-pH and continuous pulse

oximetry. J Gastrointest Surg 2009;13:854–861.)

Hagedorn et al.185 reported on the results of a randomized, controlled trial comparing total (NissenRossetti) and posterior partial (Toupet) fundoplication in which long-term efficacy was assessed. A total

of 110 patients (54 undergoing a total wrap, 56 a partial wrap) completed a median follow-up of 11.5

years. No significant differences were observed between the groups in terms of heartburn,

regurgitation, or dysphagia scores. A significant difference, however, was noted in the prevalence of

rectal flatus and postprandial fullness, which were reported more often by those having undergone a

total fundoplication.

Figure 42-41. Scatterplot of association between reflux episodes and desaturation events by patient group. The prevalence of

reflux-associated desaturations was remarkably different between the two groups (p < 0.0001). (Reproduced with permission from

Salvador R, Watson TJ, Herbella F, et al. Association of gastroesophageal reflux and O2 desaturation: a novel study of

simultaneous 24-h MII-pH and continuous pulse oximetry. J Gastrointest Surg 2009;13:854–861.)

A recent prospective, randomized trial from Australia comparing laparoscopic Nissen fundoplication

to an anterior 180-degree partial fundoplication similarly revealed no significant differences between

the two groups with regard to reflux symptoms, dysphagia, abdominal bloating, ability to belch, and

overall satisfaction at 10 years’ follow-up.186

These observations, however, must be tempered by reports questioning the durability of partial

fundoplications. Jobe et al.187 found that 51% of patients studied by 24-hour esophageal pH monitoring

after Toupet fundoplication still had pathologic acid exposure. Disturbingly, only 40% of the refluxers

were symptomatic. Two studies have identified the presence of a defective LES function, an aperistaltic

distal esophagus, and higher grades of esophagitis (Savary-Miller grades 2 to 4) as risk factors for

partial fundoplication failure.185,187 Bell et al.188 reported recurrent reflux in 14% after Toupet

fundoplication. The presence of mild esophagitis and a normal LES were associated with a 3-year

success rate of 96%, whereas the presence of complicated esophagitis or a defective LES lowered this

value to 50% (Fig. 42-35).

These findings highlight an apparent paradox, in that partial fundoplications afford suboptimal reflux

protection in those most at risk from the effects of unabated GERD. The question arises, therefore,

whether total fundoplication should be applied more liberally to patients with severe reflux disease and

associated esophageal dysmotility. Patti et al. recently reported on 357 patients undergoing antireflux

surgery, 235 undergoing a “tailored approach” with either a partial or total fundoplication depending on

the results of preoperative manometry, and 122 more recent patients undergoing a total fundoplication

regardless of the quality of esophageal peristalsis.189 In the first group, heartburn from pathologic

reflux, confirmed by postoperative ambulatory esophageal pH monitoring, recurred in 19% after partial

fundoplication and in 4% after total fundoplication. In the latter group, heartburn recurred in 4% after

total fundoplication. Importantly, the incidence of postoperative dysphagia was similar in the two

groups. This recent evidence, as well as our own experience, has led us to utilize the complete

fundoplication more readily, particularly in patients with Barrett esophagus. Currently, partial

fundoplication is best reserved for patients with severe esophageal dysmotility approaching aperistalsis,

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such as occurs in scleroderma, or in combination with a distal esophageal myotomy for achalasia.190

Laparoscopic Nissen Fundoplication. The performance of laparoscopic fundoplication should include

the steps identified in Table 42-8.

MANAGEMENT

Table 42-8 Elements of Laparoscopic Fundoplication

Port Placement. Five ports are used. The camera is placed above and to the left of the umbilicus,

roughly one-third of the distance to the xiphoid process. In most patients, placement of the camera in

the umbilicus is too low to allow adequate visualization of the hiatal structures once dissected. A

transrectus location is preferable to midline to minimize the prevalence of port site hernia formation.

The liver is retracted with a Nathensen retractor placed through a 5-mm incision on the right side of the

xiphoid. A retraction port is placed slightly above the level of the umbilicus, in the left anterior axillary

line. Placement of these ports too far lateral or too low on the abdomen will compromise the excursion

of the instruments and thus the ability to retract. The left-sided operating port (surgeon’s right hand) is

placed 1 to 2 cm below the costal margin approximately at the lateral rectus border. Such placement

allows triangulation between the camera and the two instruments and avoids the difficulty associated

with the instruments being in direct line with the camera. The right-sided operating port (surgeon’s left

hand) is placed last, after the left lateral segment of the liver has been retracted. This placement

prevents “sword fighting” between the liver retractor and the left-handed instrument. The falciform

ligament hangs low in many patients and provides a barrier around which the left-handed instrument

must be manipulated.

Hiatal Dissection. In patients without a large or PEH dissection begins with division of the

gastrohepatic omentum and identification of the right crus of the diaphragm. Alternatively, when a PEH

is present sac excision is started at the 2 o’clock position at the hiatus to avoid injuring the left gastric

vessels which are routinely up in the chest on the right side of the hiatus.

Crural Dissection. A large left hepatic artery arising from the left gastric artery is present in up to 25%

of patients (Fig. 42-42); it should be identified and can typically be divided without consequence but a

pulse in the hepatoduodenal ligament should be confirmed. After incising the gastrohepatic omentum,

the outside of the right crus will become evident. The peritoneum overlying the anterior aspect of the

right crus is incised and the plane between the esophagus and right crus developed.

Following dissection of the right crus, attention is turned toward the phrenoesophageal ligament

anteriorly. These tissues are held upward by the left-handed grasper and the esophagus and anterior

vagus nerve are swept downward away from the phrenoesophageal ligament. The anterior crural tissues

are then divided and the left crus identified. The anterior vagus nerve often “hugs” the left crus and can

be injured in this portion of the dissection if not carefully searched for and protected. The left crus is

dissected as completely as possible, including taking down the angle of His and the attachments of the

fundus to the left diaphragm (Fig. 42-43). The short gastric vessels are divided along with the posterior

pancreatic vessels to completely mobilize the gastric fundus. Failure to do so will result in difficulty

encircling the esophagus, and increase the risk of a perforation of the posterior esophagus when

developing the retroesophageal window. A window behind the GE junction can generally now be easily

created and a Penrose drain passed for esophageal retraction.

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Figure 42-42. Illustration of the initial dissection of the esophageal hiatus. The right crus is identified and dissected toward its

posterior confluence with the left crus.

Esophageal Mobilization and Crural Closure. The esophagus is mobilized into the posterior

mediastinum for several centimeters to provide maximal intra-abdominal esophageal length. Posterior

and right lateral mobilization is readily accomplished. In performing the anterior and left lateral

mobilization, the surgeon must take care not to injure the anterior vagus nerve. Gentle traction on the

Penrose drain around the GE junction facilitates exposure. The right and left pleural reflection often

come into view and should be avoided, although if a pleural opening is created it is well tolerated

provided the hole is made large enough to prevent a ball-valve tension pneumothorax from developing.

Continue the crural dissection to enlarge the space behind the GE junction as much as possible.

Following mobilization and an assessment of intra-abdominal esophageal length, the hiatus is closed in

all patients. The esophagus is held anterior and to the left and the crura approximated with two to four

interrupted figure-of-eight 0-Ethibond sutures, starting just above the aortic decussation and working

anterior. The authors prefer a large needle (CT1) passed down the left upper 10-mm port to facilitate a

durable crural closure using absorbable pledgets in a horizontal mattress fashion. The aorta may be

punctured while suturing the left crus. Identification of the anterior aortic surface and retracting the left

crus via the left-handed grasper will help avoid inadvertent aortic puncture. The authors prefer

extracorporeal knot tying using a “tie knot” device (LSI Solutions, Victor, New York). More recently, we

have inspected the crural closure at the completion of the procedure following creation of the

fundoplication and removal of the bougie. Doing so will often reveal that the bougie has dilated the

hiatal opening such that a final stitch should be placed to further approximate it. Although there have

been no randomized studies evaluating the role of routine crural closure, there is compelling evidence

to indicate that closure should be standard. Watson et al.191 identified paraesophageal herniation in 17

of 253 patients (7%), the frequency being 3% in those who had undergone crural repair and 11% in

those who had not.

Figure 42-43. Left-sided crural dissection. The left crus is dissected as completely as possible and the attachments of the fundus of

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