World J. Surg. 16, 347-348, 1992
World Journal of Surgery O 199"2by tile S¢¢i~t6 Internationale de C h i r ~
Minimally Invasive Antireflux Procedures H.J. Stein, M . D . , H. F e u s s n e r , M . D . , and J.R. Siewert, M.D, Department of Surgery, Technical University of Munich, Munich, Federal Republic of Germany The advance of endoscopic and laparoseopic techniques in recent years has prompted several groups throughout the world to investigate the possibilities for a minimally invasive approach to reconstruct a defective antireflux mechanism in patients with intractable gastra-esophgeai reflux disease. Prospective trials are needed to evaluate the long-term durability and efficiency of these procedures.
A surgical antireflux procedure is currently the most effective way to reconstruct a defective antireflux mechanism at the gastro-esophageal junction and effectively abolish gastroesophageal reflux [1]. To be competitive with medical treatment, it is necessary that antireflux procedures achieve this goal without undue side effects or complications. Modifications in the original technique have reduced the side effects of a fundoplication, i.e., dysphagia, gaseous distension, and inability to belch or vomit, to a minimum without compromising the efficiency of the procedure [2, 3]. So far, surgical reconstruction of the antireflux mechanism has, however, only been possible through a relatively large abdominal or thoracic incision with extensive dissection at the cardia with the inherent disadvantages of a prolonged hospital stay and recovery time and the associated risk of pulmonary, thromboembolic, and wound complications. The advance of endoscopic and laparoscopic techniques in recent years has prompted several groups throughout the world to investigate the possibilities for a minimally invasive approach to reconstruct a defective antireflux mechanism in patients with intractable gastro-esophageal reflux disease. As we have learned from the experience with laparoscopic cholecystectomy, minimally invasive procedures will markedly shorten the hospital stay and recovery period and may even be performed on an outpatient basis. The positive impact of these factors on health care costs and productivity of the individual with gastroesophageal reflux disease are evident. Endoscopic or laparoscopic procedures also have the theoretical potential to reduce the frequency and severity of postoperative incisional pa!n, wound infections, incisional hernia, adhesion formation, pneuReprint requests: J.R. Siewert, M.D., Chirurgische Klinik und Poliklinik, Klinikum rechts der lsar der TU M~inchen, Ismaninger Str 22, D-8000 M0nchen 80, Federal Republic of Germany.
mania, and thromboembolic complications associated with a laparotomy or thoracotomy, Laparoscopic or endoscopic procedures undoubtedly also provide a cosmetically more satisfying result for the patient [4]. Endoscopic injection of the gastro-esophageal junction with scar inducing agents has already been extensively tested and has been shown to enhance the gastro-esophageal barrier function for at least a period of time [5, 6]. Endoscopic invagination of the distal esophagus into the gastric fundus and stapling of the invaginated esophagus to the lesser curvature of the stomach is currently under investigation at two centers in the United States of America [7]. The development of dedicated instruments has also made laparoscopic dissection and functional procedures at the gastro-esophageal junction possible. We have performed laparoscopic myotomies with a fundic patch as antireflux protection in patients with achalasia (unpublished data). Laparoscopic gastropexy with a ligament teres plastic in patients with intractable gastro-esophageal reflux disease has been reported from Dundee, Scotland [8]. Laparoscopic placement of a vicryl band around the distal esophagus, or a hemifundoplication, are also feasible and have been performed in experimental models and in the clinical situation (unpublished data). Certainly, laparoscopic construction of a short, floppy 360 ° fundic wrap around the distal esophagus, which has proven its superiority over all other antireflux procedures in the past [2, 3], through the laparoscope is the ultimate goal of minimally invasive antireflux surgery. The technical aspects of this procedure are currently being evaluated in our laboratory and various other centers [9, 10]. Clinical tests are scheduled. The long term durability and efficiency of endoscopic and laparoscopic antireflux procedures is not known at the present time. Whether minimally invasive antireflux procedures compromise the goal of antireflux surgery, i.e., efficient long-term reflux control, will have to be shown in prospective trials. Should endoscopic or laparoscopic antireflux procedures achieve this goal with less side effects than the classic antireflux operations, indications for antireflux procedures will increase. Mechanical reconstruction of the antireflux mechanism in gastro-esophageal reflux disease will then win back ground which has been lost to medical treatment since the introduction of H2 blockers and proton pump inhibitors.
348
World J. Surg. Vol. 16, No. 2, Mar./Apr. 1992
R~sum~
References
Ces derni~res ann6es, les progr~s dans les techniques endoscopiques et laparoscopiques ont incit6 plusieurs groupes de par le monde ~ rechercher les possibilit6s d ' u n e voie d'abord peu invasive pour reconstruire un m6canisme antireflux d6fectueux chez des patients souffrant de reflux gastro-oesophagien r6sistant au traitement. Des essais prospectifs sont n6cessaires pour 6valuer I'efficaciet6 et la durabilit6 ~ long terme de telles proc6dures.
I. Stein H.J., DeMeester, T.R.: Who benefits from antireflux surgery? World J. Surg. 16:312, 1992 2. Siewert, J.R., Feussner, H., Walker, S.: Fundoplication--How to do it? Periesophageal wrapping as the therapeutic principle in gastroesophageal reflux prevention World J. Surg. •6:325, 1992 3. DeMeester, T.R., Stein, H.J.: Minimizing the side effects of Nissen fundoplication. World J. Surg. •6:334, 1992 4. Wickham, J., Fitzpatrick, J.M.; Minimally invasive surgery. Br. J. Surg. 77:721, 1990 5. Donahue, P.E., Cavallo, J.P.C., Denis, P.E.: Endoscopic sclerosis of the gastric cardia for prevention of experimental gastroesophageal reflux. Gastrointest. End 36:253, 1990 6. McGouran R.C.M., Galloway, J.M.: A laser induced scar increases the yield pressure of the lower esophageal sphincter. Gastrointest. End. 36:439, 1990 7. DeMeester, T.R.: Personal communication. 8. Nathanson, L.K., Cushieri, A.: Laparoscopic ligamentum teres cardiopexy. Br. J. Surg. 78:947, 1991 9. Dellamagne, B,, Weents, J.M., Jehees, S.: Laparoscopic Nissen fundoplication: Preliminary report, Surg. Lap. End. 1:138, 1991. 10. Minder, R.A.: Personal communication.
Resumen
Las t6cnicas de endoscopia y laparoscopia de avanzada en los tiltimos afios han llevado a Varios grupos de diversas partes del mundo a investigar las posiblidades de emplear procedimientos mfnimamente invasivos para reconstruir defectos en el mecanismo antirreflujo de pacientes con reflujo gastroesof~igico intratable. Aparece necesario realizar estudios prospectivos para evaluar la duraci6n y la eficiencia a largo plazo de estos procedimientos.
World Journal of Surgery O 199"2by tile S¢¢i~t6 Internationale de C h i r ~
Minimally Invasive Antireflux Procedures H.J. Stein, M . D . , H. F e u s s n e r , M . D . , and J.R. Siewert, M.D, Department of Surgery, Technical University of Munich, Munich, Federal Republic of Germany The advance of endoscopic and laparoseopic techniques in recent years has prompted several groups throughout the world to investigate the possibilities for a minimally invasive approach to reconstruct a defective antireflux mechanism in patients with intractable gastra-esophgeai reflux disease. Prospective trials are needed to evaluate the long-term durability and efficiency of these procedures.
A surgical antireflux procedure is currently the most effective way to reconstruct a defective antireflux mechanism at the gastro-esophageal junction and effectively abolish gastroesophageal reflux [1]. To be competitive with medical treatment, it is necessary that antireflux procedures achieve this goal without undue side effects or complications. Modifications in the original technique have reduced the side effects of a fundoplication, i.e., dysphagia, gaseous distension, and inability to belch or vomit, to a minimum without compromising the efficiency of the procedure [2, 3]. So far, surgical reconstruction of the antireflux mechanism has, however, only been possible through a relatively large abdominal or thoracic incision with extensive dissection at the cardia with the inherent disadvantages of a prolonged hospital stay and recovery time and the associated risk of pulmonary, thromboembolic, and wound complications. The advance of endoscopic and laparoscopic techniques in recent years has prompted several groups throughout the world to investigate the possibilities for a minimally invasive approach to reconstruct a defective antireflux mechanism in patients with intractable gastro-esophageal reflux disease. As we have learned from the experience with laparoscopic cholecystectomy, minimally invasive procedures will markedly shorten the hospital stay and recovery period and may even be performed on an outpatient basis. The positive impact of these factors on health care costs and productivity of the individual with gastroesophageal reflux disease are evident. Endoscopic or laparoscopic procedures also have the theoretical potential to reduce the frequency and severity of postoperative incisional pa!n, wound infections, incisional hernia, adhesion formation, pneuReprint requests: J.R. Siewert, M.D., Chirurgische Klinik und Poliklinik, Klinikum rechts der lsar der TU M~inchen, Ismaninger Str 22, D-8000 M0nchen 80, Federal Republic of Germany.
mania, and thromboembolic complications associated with a laparotomy or thoracotomy, Laparoscopic or endoscopic procedures undoubtedly also provide a cosmetically more satisfying result for the patient [4]. Endoscopic injection of the gastro-esophageal junction with scar inducing agents has already been extensively tested and has been shown to enhance the gastro-esophageal barrier function for at least a period of time [5, 6]. Endoscopic invagination of the distal esophagus into the gastric fundus and stapling of the invaginated esophagus to the lesser curvature of the stomach is currently under investigation at two centers in the United States of America [7]. The development of dedicated instruments has also made laparoscopic dissection and functional procedures at the gastro-esophageal junction possible. We have performed laparoscopic myotomies with a fundic patch as antireflux protection in patients with achalasia (unpublished data). Laparoscopic gastropexy with a ligament teres plastic in patients with intractable gastro-esophageal reflux disease has been reported from Dundee, Scotland [8]. Laparoscopic placement of a vicryl band around the distal esophagus, or a hemifundoplication, are also feasible and have been performed in experimental models and in the clinical situation (unpublished data). Certainly, laparoscopic construction of a short, floppy 360 ° fundic wrap around the distal esophagus, which has proven its superiority over all other antireflux procedures in the past [2, 3], through the laparoscope is the ultimate goal of minimally invasive antireflux surgery. The technical aspects of this procedure are currently being evaluated in our laboratory and various other centers [9, 10]. Clinical tests are scheduled. The long term durability and efficiency of endoscopic and laparoscopic antireflux procedures is not known at the present time. Whether minimally invasive antireflux procedures compromise the goal of antireflux surgery, i.e., efficient long-term reflux control, will have to be shown in prospective trials. Should endoscopic or laparoscopic antireflux procedures achieve this goal with less side effects than the classic antireflux operations, indications for antireflux procedures will increase. Mechanical reconstruction of the antireflux mechanism in gastro-esophageal reflux disease will then win back ground which has been lost to medical treatment since the introduction of H2 blockers and proton pump inhibitors.
348
World J. Surg. Vol. 16, No. 2, Mar./Apr. 1992
R~sum~
References
Ces derni~res ann6es, les progr~s dans les techniques endoscopiques et laparoscopiques ont incit6 plusieurs groupes de par le monde ~ rechercher les possibilit6s d ' u n e voie d'abord peu invasive pour reconstruire un m6canisme antireflux d6fectueux chez des patients souffrant de reflux gastro-oesophagien r6sistant au traitement. Des essais prospectifs sont n6cessaires pour 6valuer I'efficaciet6 et la durabilit6 ~ long terme de telles proc6dures.
I. Stein H.J., DeMeester, T.R.: Who benefits from antireflux surgery? World J. Surg. 16:312, 1992 2. Siewert, J.R., Feussner, H., Walker, S.: Fundoplication--How to do it? Periesophageal wrapping as the therapeutic principle in gastroesophageal reflux prevention World J. Surg. •6:325, 1992 3. DeMeester, T.R., Stein, H.J.: Minimizing the side effects of Nissen fundoplication. World J. Surg. •6:334, 1992 4. Wickham, J., Fitzpatrick, J.M.; Minimally invasive surgery. Br. J. Surg. 77:721, 1990 5. Donahue, P.E., Cavallo, J.P.C., Denis, P.E.: Endoscopic sclerosis of the gastric cardia for prevention of experimental gastroesophageal reflux. Gastrointest. End 36:253, 1990 6. McGouran R.C.M., Galloway, J.M.: A laser induced scar increases the yield pressure of the lower esophageal sphincter. Gastrointest. End. 36:439, 1990 7. DeMeester, T.R.: Personal communication. 8. Nathanson, L.K., Cushieri, A.: Laparoscopic ligamentum teres cardiopexy. Br. J. Surg. 78:947, 1991 9. Dellamagne, B,, Weents, J.M., Jehees, S.: Laparoscopic Nissen fundoplication: Preliminary report, Surg. Lap. End. 1:138, 1991. 10. Minder, R.A.: Personal communication.
Resumen
Las t6cnicas de endoscopia y laparoscopia de avanzada en los tiltimos afios han llevado a Varios grupos de diversas partes del mundo a investigar las posiblidades de emplear procedimientos mfnimamente invasivos para reconstruir defectos en el mecanismo antirreflujo de pacientes con reflujo gastroesof~igico intratable. Aparece necesario realizar estudios prospectivos para evaluar la duraci6n y la eficiencia a largo plazo de estos procedimientos.
