Robotic Toupet Fundoplication

Abstract

Gastroesophageal reflux disease (GERD) is a widespread benign disorder of the distal oesophagus and gastroesophageal junction that severely affects a patient’s quality of life. GERD pathophysiology presents several causes, among them hiatal hernia with abnormal transdiaphragmatic pressure gradient and with an obtuse angle. Despite the extensive adoption of medical therapy with proton pump inhibitors, this treatment fails to resolve the GERD symptoms completely in almost 40% of all patients. Surgery was formerly considered only for severe cases. However, with the evolution of the minimally invasive approach, indications for anti-reflux surgery have broadened. Patients with failed medical management, with preference over life-long medication, Barrett’s oesophagus or extra-oesophageal manifestations, should be offered surgical management. A score calculated during a 24-hour oesophageal pH monitoring, the DeMeester score, higher than 14.7 is another indication for surgical treatment. The measure of impedance during the pH monitoring can detect also reflux with low acidity, which could also benefit from surgical correction. Oesophageal manometry completes the GERD work-up and allows diagnosis oesophageal motility abnormalities. Studies show that anti-reflux surgery in Barrett’s oesophagus patients effectively achieves relief of GERD symptoms, induction of histologic regression and prevention of progression of intestinal metaplasia to dysplasia or invasive carcinoma.