Adult Chest Surgery

Chapter 32. Other Reflux Procedures (Toupet, Dor, and Hill) 

 

The ideal therapy for gastroesophageal reflux disease (GERD), viewed conceptually along a continuum, is a tailored approach with a short, floppy Nissen total fundoplication as the current "gold standard" for patients with GERD and normal esophageal motility. However, because total fundoplication often results in unacceptable rates of postoperative dysphagia in the subset of patients with GERD and disordered motility with delayed esophageal clearance, most surgeons prefer a Toupet 270-degree partial posterior fundoplication for this group.1 Some surgeons advocate partial fundoplication for all patients to minimize the undesirable side effects of a 360-degree wrap.2

Laparoscopic Technique

The operation is performed with the standard laparoscopic equipment using a 5- or 10-mm, 0- or 30-degree laparoscope. With the patient in the lithotomy reverse Trendelenburg position, the surgeon stands between the patient's legs, and the two assistants are on the patient's left and right sides. Five trocars for proper port placement are required (Fig. 32-1).

Figure 32-1.

 

Trocar placement.

 

After the left lobe of the liver has been retracted and the hiatal hernia reduced by pulling at the anterior part of the stomach, the surgeon gains access to the hiatal region and the right crus by opening the lesser omentum. Attention is paid to an accessory left hepatic artery, which is spared if present. The hepatic branches of the anterior vagus are preserved to avoid impaired gallbladder motility and to reduce the risk of wrapping the gastric fundus around stomach instead of esophagus (Fig. 32-2).

Figure 32-2.

 

Exposure for performing the Toupet fundoplication.

 

The phrenoesophageal membrane is detached from both pillars of the right crus circumferentially. Care should be taken to avoid stripping the peritoneal covering of the pillars because this will compromise subsequent suture repair. The gastrophrenic ligament is incised. Working from the right side, a retroesophageal window is created, and the esophagus is encircled with a Penrose drain. The mediastinal esophagus is freed circumferentially over about 10 cm with blunt and sharp dissection to obtain 3–4 cm of tension-free intraabdominal distal esophageal length.

The anterior and posterior vagal nerves are localized but not isolated to avoid the risk of delayed gastric emptying with a gas bloat syndrome. Although not described in the original Toupet fundoplication, the upper short gastric vessels are divided to create a fundoplication without undue tension. Temporarily, a 30-degree scope is used, and this also permits direct access to the retrogastric attachments, which are divided.

Upward traction on the sling provides good access to the V-shape junction of the pillars (see Fig. 32-2). A loose, nonobstructing hiatal closure leaving a 2-cm retroesphageal space is performed. Unlike the originally described Toupet repair, in which the posterior wrap is sutured to the right and left pillars, the approximation of the pillars is performed with one- to three-big-bite 0 nonabsorbable sutures tied snugly with an extracorporeal knot. Some surgeons advocate using a bougie to calibrate the degree of closure. We do not recommend the 54F–58F Maloney bougie because of the risk of perforation.

The gastric fundus is passed behind the esophagus. Three to four interrupted 0 nonabsorbable sutures are placed from the esophagus to the left and right anterior edges of the fundus at the 2- and 10-o'clock positions to create a 3- to 4-cm posterior wrap. Two or three additional sutures are placed from the right side of the wrap to the corresponding pillar. The final result should be a tension-free 270-degree posterior fundoplication securely fixed to the diaphragm (Fig. 32-3). The abdomen is deinsuflated, and all 10-mm fascial defects are closed.

Figure 32-3.

 

Toupet fundoplication. A. Right-side wrap fixation. B. Left wrap fixation.

Results

Laparoscopic Toupet fundoplication shows good results in 80–90% of patients at 2 years of follow-up.3 Temporary dysphagia, abdominal discomfort, and gas bloat syndrome are infrequent. Despite documentation of adequate fundoplication in most patients, the weakness of the Toupet repair is over the long term. At least in patients with normal esophageal motility, the repair seems to afford a generally less competent antireflux mechanism, with a failure rate of up to 50% by 24-hour pH testing, although half such patients are asymptomatic.3,4 Results are not documented separately for the group of patients with GERD and disordered esophageal motility, but it is suggested that a 360-degree total fundoplication would result in an unacceptable rate of postoperative dysphagia. Although there is still a lot of controversy, many groups prefer the Toupet fundoplication for these patients and accept the higher postoperative reflux rate.5,6

DOR FUNDOPLICATION

The Dor fundoplication procedure consists of a 180-degree anterior fundoplication. This type of fundoplication is particularly indicated in patients with severe impairment of esophageal body motility. The principle of this operation consists of restoration of an intraabdominal segment of distal esophagus, accentuation of the angle of His, and as a result, creation of a long anterior mucosal valve at the gastroesophageal junction (GEJ).

Laparoscopic Technique

Surgical equipment, patient positioning, and placement of trocars are the same as for all other laparoscopic antireflux procedures. The anterior and lateral dissections of the hiatus, the crura, and the esophagus are performed as described previously under the Toupet procedure.

The posterior phrenoesophageal attachments are preserved, no retroesophageal window is created, nor is a sling used. This operation cannot be performed in patients with foreshortened esophagus or large hiatal hernia. Although division of the upper short gastric vessels may reduce the effectiveness of the fundoplication, it is still preferable in patients with tension expected on the repair.

Fundamental features are the restoration of at least 5 cm of esophagus in the abdomen and fixation of the gastric fundus (gastropexy) to the diaphragmatic crura. The right margin of the fundus is sutured to the left margin of the esophagus with four interrupted 0 nonabsorbable sutures extending upward from the angle of His. A fifth suture is fixed to the left margin of the hiatus (Fig. 32-4A).

Figure 32-4.

 

Dor fundoplication. A. Left wrap fixation. B. Completed procedure.

The gastric fundus is folded over the anterior aspect of the esophagus and fixed with one suture from the anterior aspect of the esophagus to the superior margin of the hiatus. The folded fundus then is secured with four stitches to the right margin of the esophagus from immediately below the esophagogastric junction up to the superior diaphragmatic rim. These sutures are secured to the right crus (see Fig. 32-4B). The 5-cm-long partial fundoplication additionally is fixed to the diaphragm, resulting in closure of the anterior part of the hiatus. The final result is a 180-degree partial anterior fundoplication securely fixed to the diaphragm.7

Results

Early and intermediate-term results are satisfactory in 90–94% of patients, with a very low frequency of 0–2% postoperative dysphagia.8,9 Because the Dor repair at long-term follow-up appears to have a higher incidence of recurrence of reflux compared with 270- and 360-degree fundoplication, it is used less frequently today as the procedure of choice in the surgical treatment of primary GERD. It is used mostly in combination with the laparoscopic Heller myotomy for the surgical treatment of achalasia with very good results.10

HILL REPAIR

This technique is based on the principles of accentuation of the angle of His, restoration of the gastroesophageal valve, and augmentation of the lower esophageal sphincter pressure. Moreover, the GEJ with the restored 180-degree gastroesophageal valve is anchored to the preaortic fascia, which is important for restoration of esophageal clearance. The use of intraoperative manometry to evaluate the antireflux pressure barrier is recommended.11

Laparoscopic Technique

Laparoscopic equipment, patient positioning, and the pneumoperitoneum are identical to the previously described Toupet and Dor fundoplications. The left lobe of the liver is retracted cephalad.

With incision of the gastrohepatic ligament but preservation of the hepatic vagal branches, the right crus is exposed. Gentle downward traction on the stomach reduces the hernia when present. Incision of the phrenoesophageal ligament at its diaphragmatic origin exposes the anterior part of the esophagus (Fig. 32-5A). This maneuver preserves the substantial phrenoesophageal bundles, which are of major importance for the subsequent repair. The phrenogastric attachments are divided, and one or two superior short gastric vessels are secured. With blunt dissection of the junction of the pillars of the right crus and the posterior part of the left pillar, a retroesophageal window is created. Any adhesions are divided, giving access to the most caudal portion of the preaortic fascia, the median arcuate ligament, and the celiac axis at its aortic origin (see Fig. 32-5B).

Figure 32-5.

 

Hill repair. A. Incision of the phrenoesophageal ligament. B. Preaortic fascia and celiac axis. C. Sutures in place. The inset shows the posterior phrenoesophageal bundle and right pillar on the left and the anterior phreno-esophageal bundle on the right.

With circumferential dissection of the esophagus in the posterior mediastinum, a tension-free 3- to 4-cm length of intraabdominal esophagus is obtained. The vagal nerves are identified but not isolated. The pillar of the hiatus are loosely approximated with at least two size 0 nonabsorbable sutures (with or without Teflon pledgets) including peritoneum, muscle, and fascia.

The previously described anterior and posterior phrenoesophageal bundles are exposed. From the cephaled part of the angle of His, three deep-bite sutures with Teflon pledgets are placed in caudal direction through the anterior bundle, the seromuscular layer of the stomach, the posterior bundle, and the preaortic fascia; two other sutures without pledgets are placed through the median arcuate ligament (see Fig. 32-5C). To prevent tearing the aorta, anterior elevation with a grasper separates the fascia, the ligament, and the aorta. To provide a barrier to reflux that is adequate, but not excessive, sutures are tightened gradually until a pressure range of 25–35 mm Hg is obtained at intraoperative manometry. Three to five additional sutures from the fundus to the hiatus prevent a recurrent hernia and further augment the valve.

Results

With the use of intraoperative manometry, long-term results in open surgery were categorized as good to excellent in 96% of patients over 5 years and 90% of patients followed for an average of 18 years.12 Comparable early results were achieved with the laparoscopic approach, with 97% good to excellent clinical control at 1-year follow-up.13 The occurrence of dysphagia and gas bloat is uncommon with this 180-degree valve. Major disadvantages are the potential injury of the aorta and celiac trunk, the availability of intraoperative manometry, and the learning curve.

EDITOR'S COMMENT

This chapter reviews the standard approaches for non-standard operations for reflux. Additional modifications may be made for redo surgery or for surgery in conjunction with other procedures. For example, while converting a Nissen fundoplication to a Toupet, the wrap is already attached to the posterior esophageal window; so all that needs to be done is to connect the gastric edge to the right crus. In the case of a Dor fundoplication associated with a Heller myotomy, the esophageal muscle should be included in the bites, and fewer stitches are required.

–RB

REFERENCES

1. Swanstrom LL: Partial fundoplications for gastroesophageal reflux disease: Indications and current status. J Clin Gastroenterol 29:127–32, 1999.[PubMed: 10478871]

2. Holzinger F, Banz M, Tscharner GG, et al: Laparoscopic Toupet partial fundoplication as general surgical therapy of gastroesophageal reflux: 1-year results of a 5-year prospective long-term study. Chirurgie 72:6–13, 2001.[PubMed: 11225458]

3. Swanstrom LL: Partial fundoplication. In Shackelford's Surgery of the Alimentary Tract, 6th ed. Philadelphia, Saunders Elsevier, 2007:276–284.

4. Jobe BA, Wallace J, Hansen PD, Swanstrom LL: Evaluation of laparoscopic Toupet fundoplication as a primary repair for all patients with medically resistant gastroesophageal reflux. Surg Endosc 11:1080–3, 1997.[PubMed: 9348378]

5. Jobe BA, Kahrilas PJ, Vernon AH, et al: Endoscopic appraisal of the gastroesophageal valve after antireflux surgery. Am J Gastroenterol 99:233–43, 2004.[PubMed: 15046210]

6. Patti MG, Robinson T, Galvani C, et al: Total fundoplication is superior to partial fundoplication even when esophageal peristalsis is weak. J Am Coll Surg 198:863–9; discussion 869–70, 2004. 

7. Kneist W, Heintz A, Trink T: Anterior partial fundoplication for gastroesophageal reflux disease. Langenbecks Arch Surg 388:174–80, 2003.[PubMed: 12845536]

8. Kleimann E, Halbfass H: Laparoscopic anti-reflux surgery in gastroesophageal reflux. Langenbecks Arch Surg 115:1520–2, 1998.[PubMed: 9931930]

9. Watson DI, Jamieson GG, Pike GK, et al: Prospective randomized double-blind trial between laparoscopic Nissen fundoplication and anterior partial fundoplication. Br J Surg 86:123–30, 1999.[PubMed: 10027375]

10. Zaninotto G, Costantini M, Molena D, et al: Treatment of esophageal achalasia with laparoscopic Heller myotomy and Dor partial anterior fundoplication: Prospective evaluation of 100 consecutive patients. J Gastrointest Surg 4:282–9, 2000.[PubMed: 10769091]

11. Hill LD: Progress in the surgical management of hiatal hernia. World J Surg 1:425–36, 1977.[PubMed: 333784]

12. Low DE, Anderson RP, Ilves R, et al: Fifteen- to twenty-year results after the Hill antireflux operation. J Thorac Cardiovasc Surg 98:444–9; discussion 449–50, 1989. 

13. Aye RW, Hill LD, Kraemer SJ, Snopkowski P: Early results with the laparoscopic Hill repair. Am J Surg 167:542–6, 1994.[PubMed: 8185045]



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