Typical symptoms

• Stomach acidity (heartburn) 80%
• Regurgitation (food that returns to the mouth) 55%.
• Dysphagia (difficulty in swallowing) 25%.
• Sour taste
• Chest pain
• Abdominal pain

Atypical symptoms (mainly related to respiratory response to gastric contents in the airway)

• Chronic nausea
• Asthma
• Cough
• Hoarseness or voice changes
• Dental erosions
• Wheezing

DIAGNOSIS

The primary factor related to GERD is a defective LES (Lower Esophageal Sphincter), however, there are many other factors that can lead to GERD unrelated to the proper function of this «valve» and therefore tests to evaluate the function of the LES, esophageal body and stomach may be necessary in most patients with GERD symptoms.

Since physical examination of patients with GERD symptoms rarely contributes to the confirmation of the diagnosis, some of these tests are required.

PREOPERATIVE PHYSIOLOGICAL AND/OR IMAGING TESTS

• EGD (esophagogastroduodenoscopy or upper endoscopy) **
• pH monitoring (considered the «gold standard» for the diagnosis of GERD) ** pH monitoring (considered the «gold standard» for the diagnosis of GERD) ** pH monitoring (considered the «gold standard» for the diagnosis of GERD)
• Esophageal manometry **.
• Contrast radiographs (barium swallow, gastrointestinal series)
• Acid infusion test
• Computed Tomography

** These tests are mandatory in almost all patients, the rest are reserved for atypical symptoms or atypical response to medication.

TREATMENT

As mentioned above, the best, longest-lasting and most effective treatment for GERD is surgery, which involves creating a «new valve» or sphincter at the end of the esophagus using the upper part of the stomach (a stomach wrap known as a Nissen fundoplication).

INDICATIONS FOR SURGERY:

• Objective evidence of GERD plus:
• Complications of GERD that do not respond to medical treatment (e.g., esophagitis, stricture, recurrent aspiration or pneumonia, Barrett’s esophagus). Barrett’s esophagus is one of the most serious complications of GERD, as it can progress to cancer!
• • GERD symptoms interfering with lifestyle, despite medical therapy
  • Hiatal hernia with GERD
  • Need for continued drug treatment in a patient who no longer wishes to take medications (e.g., financial burden, noncompliance, lifestyle choice, young age, etc.).
  • The presence of extraesophageal manifestations of GERD may indicate the need for surgery (e.g., coughing, wheezing, aspiration, hoarseness, sore throat, otitis media, etc.).

CONTRAINDICATIONS

• Absolutes
  • Inability to tolerate general anesthesia.
  • High risk of bleeding

• Relative
  • Previous abdominal surgery near the hiatal region.
  • Severe obesity
• Esophageal shortening

ADVANTAGES OF LAPAROSCOPIC ANTIREFLUX SURGERY VS. OPEN SURGERY

• Very small incisions (5)
• Rapid recovery time (one or two night hospital stay, depending on the case)
• Minimal postoperative pain.
• Lower morbidity rate
• Shorter hospital stay
• Return to normal activity and return to work in a shorter period of time (full recovery in 5 to 7 days).
• Decreased risk of wound infection and hernia formation.
• Very small scars

RESULTS / COMPLICATIONS

The results of laparoscopic antireflux surgery are encouraging with low perioperative morbidity and mortality rates. The conversion rate from laparoscopic to open procedure is higher in inexperienced hands; the conversion rate in Dr. Rosales’ experience is less than 3%. Perioperative complications requiring reoperation, such as stomach migration (wrap) or esophageal perforation, occur in less than 1%.

Overall symptom satisfaction rates after the procedure range from 90 to 100% and a significant improvement in quality of life a few weeks after the procedure.

SUGICAL TECHNIQUE (SIPLIFIED) 

Under general anesthesia, a 5 mm abdominal incision is made in the left subcostal region (below the rib cage), CO2 is introduced into the cavity, subsequently 4 more incisions are made in the abdomen (one of 10 mm and the rest of 5 mm) to introduce the instruments; The junction between the esophagus and the stomach is dissected along its entire circumference. some vessels that hold the upper part of the stomach are ligated, we look for a hiatal hernia, if present, the hernia is repaired (see Laparoscopic repair of hiatal hernia). We proceed to make the 360° stomach wrap around the esophagus fixing it with suture material, the incisions are closed with suture and the procedure is completed.

NISSEN FUNDOPLICATION

Incisions for Laparoscopic Antireflux Surgery