Prevalence. GER is a normal event after a meal and during belching. Symptoms of heartburn and excessive regurgitation are relatively common in the United States, occurring in approximately 7% of the population on a daily basis and in 33% at least once a month. Often, these individuals have x-ray evidence of a hiatal hernia. Reflux and hiatal hernia are not necessarily related, and each can occur independently.
Pathophysiology in GER relates to abnormal exposure of the distal esophagus to refluxed stomach contents. In 60% of patients, a mechanically defective lower-esophageal sphincter (LES) is responsible for the GER. The sphincter function of the LES depends on the integrated mechanical effect of the sphincter’s intramural pressure and the length of esophagus exposed to intra-abdominal positive pressure. Other etiologies of GER are inefficient esophageal clearance of refluxed material, fixed gastric outlet obstruction, functional delayed gastric emptying, increased gastric acid secretion, and inappropriate relaxation of the LES.
The classic symptom of GER is posturally aggravated substernal or epigastric burning pain that is readily relieved by antacids. Additional common symptoms include regurgitation or effortless emesis, dysphagia, and excessive flatulence. Atypical symptoms may mimic laryngeal, respiratory, cardiac, biliary, pancreatic, gastric, or duodenal disease.
Diagnosis and evaluation
Contrast radiography (upper GI) demonstrates spontaneous reflux in only approximately 40% of patients with GER. However, it documents the presence or absence of hiatal hernia; can demonstrate some complications of reflux, such as esophageal stricture and ulcers; and is an appropriate initial study. The study should include a full view of the esophagus as well as a complete evaluation of the stomach, pylorus, and duodenum.
EGD is indicated in patients with symptoms of GER to evaluate for esophagitis and the presence of Barrett changes. Esophagitis is a pathologic diagnosis, but an experienced endoscopist can readily distinguish the more advanced stages. Four general grades of esophagitis occur.
Grade I: normal or reddened mucosa
Grade II: superficial mucosal erosions and some ulcerations
Grade III: extensive ulceration with multiple, circumferential erosions with luminal narrowing; possible edematous islands of squamous mucosa present, producing the so-called cobblestone esophagitis
Esophageal manometric testing is appropriate in the patient with reflux symptoms once surgery is being considered. Manometry defines the location and function of the LES and helps to exclude achalasia, scleroderma, and diffuse esophageal spasm from the differential diagnosis. Characteristics of a manometrically abnormal LES are (1) a pressure of less than 6 mm Hg, (2) an overall length of less than 2 cm, and (3) an abdominal length of less than 1 cm. These values are abnormal, and a patient with one or more of these abnormal values has a 90% probability of having reflux. Manometry also assesses the adequacy of esophageal contractility and peristaltic wave progression as a guide to the best antireflux procedure for the patient.
Esophageal pH testing over a 24-hour period is regarded as the gold standard in the diagnosis of GER. It is now used mainly when the data from the remainder of the evaluation are equivocal and diagnosis of reflux is in doubt. Twenty-four-hour pH testing can be performed on an outpatient or ambulatory basis: The patient has an event button to record symptoms and keeps a diary of body position, timing of meals, and other activities. This allows correlation of symptoms with simultaneous esophageal pH alterations. A Demeester score is derived based on the frequency of reflux episodes and the time required for the esophagus to clear the acid. Score values that fall outside of two standard deviations from the mean of values obtained from normal volunteers are considered abnormal. This test has a 90% sensitivity and a 90% specificity for diagnosing or excluding reflux (J Thorac Cardiovasc Surg 1980;79:656).
A gastric emptying study can be useful in evaluating patients with reflux and symptoms of gastroparesis. It may be especially pertinent in patients considered for redo surgery when there is suspicion of vagus nerve injury.
Complications. Approximately 20% of patients with GER have complications, including esophagitis, stricture, or Barrett esophagus. Other, less common complications include acute or chronic bleeding and aspiration.
Medical treatment aims to reduce the duration and amount of esophageal exposure to gastric contents and to minimize the effects on the esophageal mucosa.
Patients are instructed to remain upright after meals, avoid postural maneuvers (bending, straining) that aggravate reflux, and sleep with the head of the bed elevated 6 to 8 inches.
Dietary alterations are aimed at maximizing LES pressure, minimizing intragastric pressure, and decreasing stomach acidity. Patients are instructed to avoid fatty foods, alcohol, caffeine, chocolate, peppermint, and smoking and to eat smaller, more frequent meals. Obese patients are instructed to lose weight, avoid tight-fitting garments, and begin a regular exercise program. In addition, anticholinergics, calcium channel blockers, nitrates, beta-blockers, theophylline, alpha-blockers, and nonsteroidal anti-inflammatory medications may exacerbate reflux and should be replaced with other preparations or reduced in dose if possible.
Pharmacologic therapy is indicated in patients who do not improve with postural or dietary measures. The goal is to lower gastric acidity or enhance esophageal and gastric clearing while increasing the LES resting pressure.
Antacids neutralize stomach acidity and thus raise intragastric pH.
H2-receptor antagonists lower gastric acidity by decreasing the amount of acid that the stomach produces.
Proton-pump inhibitors act by selective noncompetitive inhibition of the H+/K+ pump on the parietal cell and are more effective than H2 antagonists in healing esophagitis (Aliment Pharmacol Ther 1990;4:145).
Prokinetic agents, such as metoclopramide (dopaminergic antagonist), can decrease GER by increasing the LES tone and accelerating esophageal and gastric clearance.
Transoral endoscopic suturing to plicate the gastroesophageal junction and endoscopic application of radiofrequency energy (Stretta procedure) to the lower esophagus are two novel endoluminal therapies that can be performed on an ambulatory basis and generally with the patient under light sedation. These therapies, approved by the Food and Drug Administration, have been evaluated in several small, non–placebo-controlled trials with limited posttreatment evaluation. Evidence of dysphagia, stricture, large hiatal hernia, and moderate to severe esophagitis generally has excluded patients from eligibility for inclusion in these two endoluminal trials. Other treatments being developed include injection of biocompatible prostheses into the LES to alter compliance. These options remain experimental and controversial.
Surgical treatment should be considered in patients who have symptomatic reflux, have manometric evidence of a defective LES, and fail to achieve relief with maximal medical management. Alternatively, surgical therapy should be considered in symptomatic patients who have achieved relief with medical therapy but to whom the prospect of a lifetime of medicine is undesirable (i.e., because of cost, side effects, inconvenience, or compliance). Surgical treatment consists of either a transabdominal or a transthoracic antireflux operation to reconstruct a competent LES and a crural repair to maintain the reconstruction in the abdomen.
A laparoscopic, transabdominal approach is preferred in most patients, except when a shortened esophagus is present. A shortened esophagus should be suspected when a stricture is present and in patients who have had a failed antireflux procedure. The transabdominal approach is recommended for patients with a coexisting abdominal disorder, a prior thoracotomy, or severe respiratory disorder.
Nissen fundoplication is the most commonly performed procedure for GER. It consists of a 360-degree fundic wrap via open or laparoscopic technique. Long-term results in several series of open procedures are excellent, with 10-year freedom from recurrence of greater than 90%. Short-term results of the laparoscopic approach are as good as the open-repair results for relief of GER symptoms, with concomitant shorter hospital stay, better respiratory function, and decreased pain postoperatively (Br J Surg 2000;87:873). The complete fundoplication in this repair is very effective at preventing reflux but is associated with a slightly higher incidence of inability to vomit, gas bloating of the stomach, and dysphagia. During surgery, care must be taken to ensure that the wrap is short, loose, and placed appropriately around the distal esophagus to minimize the incidence of these complications.
The Hill posterior gastropexy aims to anchor the GE junction posteriorly to the median arcuate ligament and creates a partial or 180-degree imbrication of the stomach around the right side of the intra-abdominal esophagus. In the original description, Hill recommended using intraesophageal manometry during placement of the sutures to achieve a pressure of 50 mm Hg in the distal esophagus.
The Toupet fundoplication is a partial 270-degree posterior wrap, with the wrapped segment sutured to the crural margins and to the anterolateral esophageal wall. For patients in whom esophageal peristalsis is documented to be markedly abnormal or absent preoperatively, a partial wrap has often been used to lessen the potential for postoperative dysphagia.
A transthoracic approach is recommended in patients with esophageal shortening or stricture, coexistent motor disorder, obesity, coexistent pulmonary lesion, or prior antireflux repair.
Nissen fundoplication can be done via a transthoracic approach, with results similar to those obtained with a transabdominal approach.
The Belsey Mark IV repair consists of a 240-degree fundic wrap around 4 cm of distal esophagus. In cases of esophageal neuromotor dysfunction, it produces less dysphagia than may accompany a 360-degree (Nissen) wrap. Furthermore, the ability to belch is preserved, thereby avoiding the gas-bloat syndrome that may occur after a complete wrap. Careful 10-year follow-up demonstrates a good long-term result in 85% of patients (J Thorac Cardiovasc Surg 1967;53:33).
Collis gastroplasty is a technique used to lengthen a shortened esophagus. To minimize tension on the antireflux repair, a gastric tube is formed from the upper lesser curvature of the stomach in continuity with the distal esophagus. The antireflux repair then is constructed around the gastroplasty tube. A gastroplasty should be considered preoperatively in patients with esophageal shortening, such as those with gross ulcerative esophagitis or stricture, failed prior antireflux procedure, or total intrathoracic stomach (Ann Surg 1987;206:473). However, in many of these patients, the esophagus can be adequately mobilized to allow more than 3 cm of intra-abdominal esophagus and thereby avoid the need to lengthen the esophagus. Development of an angled endoscopic stapler has made laparoscopic Collis gastroplasty technically feasible.