Procedure for refractory GERD

Alaa eldin Badawy, MD, Mohamed Gad, PhD

Alexandria university hospital, Alexandria faculty of medicine

OBJECTIVE: To evaluate a procedure that involves crural repair, 1800 partial posterior fundoplication and adding anterior truncal vagotomy for patients with refractory GERD after failure of medical treatment.

METHODS: Fifty patients of failed or poor response to medical treatment for GERD in at least the last six months were surgically treated after doing upper GIT endoscopy and esophageal manometry to exclude other pathology and cases of hiatal hernia. Patients were divided into two equal groups : Group( A) were subjected to standard Toupet procedure, the other group (B) for crural repair, 1800 partial posterior fundoplication and adding anterior truncal vagotomy without division of the gastro-splenic ligament. Laparoscopic approach was done through: 1. optic trocar midway between the linea alba and left midclavicular line (midway between umbilical plane and xiphisternum), 2. working port at the left midclavicular line below rib cage, opposite to 3. working port right paramedian, below it on the same line is the 4.assistant port then 5. at the right midclavicular line is the liver retractor port. This layout on working from the left side of the patient after crural dissection gives good access to dissect the gastric fundus freeing all of the diaphragmatic and posterior fundal attachments and also if needed one or two short gastrics, then anterior truncal vagotomy was performed and 1800 posterior fundoplication by two rows of sutures on both sides of the esophagus. For statistical comparison Mann-Whitney U test and Fisher’s exact test were used comparing both groups using visual analog scale for symptoms of GERD and dumping (defined for patients as flushing, palpitations or diarrhea following a meal)

RESULTS: Fifty patients of refractory GERD underwent antireflux surgery with mean follow up of 25 months, mean age of group A was 43+13 group B was 41+15, mean hospital stay for group A 2+1 for group B 2+2 days. Symptoms severity for: heartburn, regurgitation, dysphagia, abdominal pain, vomiting, chest pain, bloating, nausea, diarrhea, early satiety and dumping were considered with overall symptom severity improved by 88% for group A, by 92% for group B. There were no statistically significant difference between both groups as regards postoperative symptoms (even dumping), except in heartburn that was still present or recurrent in 7 cases group A that urged for medical treatment, while in group B in only one case (using Fisher’s exact test, the two tailed p= 0.048) with statistical significance. Perioperative complications were rare and self limited in both groups as: ileus (2 in group A, 5 group B), gastric distension (4 in group A, 7 in group B) and diarrhea (2 in group A, 6 in group B), no deaths and no need to redo for drainage procedure.

CONCLUSION: Adding anterior truncal vagotomy to partial posterior fundoplication enhanced postoperative symptom control in refractory GERD with no added co-morbidity. Possible benefits are lengthening the intra-abdominal esophagus, decreasing hyperacidity and mucosal hypersensitivity.


Session: Poster Presentation

Program Number: P204

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