Abstract
Despite the absence of definitive explanations regarding either the physiologic or surgical factors which curtail gastro-esophageal reflux, effective antireflux operations exist. This article explores the theoretical factors relevant to the surgical control of reflux. These theoretical features include: (1) the pressure, length, and location of the manometrically defined lower esophageal sphincter (LES); (2) the gastro-esophageal valve as defined by the angle of His and a mucosal flap valve; and (3) the mechanical effects of a fundoplication which serve to increase the opening pressure of the cardia and optimize the physical relationships described by the law of La Place. Finally, the relation of these theoretical factors to actual operations is discussed.
Résumé
Malgré l'absence d'explications definitives concernant les facteurs physiologiques ou chirurgicaux susceptibles de contrôler le reflux gastro-oesophagion, il existe néammoins des interventions antireflux efficaces. Cet article examine les principes théoriques sur lesquels repose la chirurgie anti-reflux: Ces facteurs sont: (1) la pression, la longueur et la localisation du sphincter inférieur de l'oesophage défini par la manométrie; (2) la valve gastroesophagienne définie par l'angle de His et la valve muqueuse; (3) les effets mécaniques de la fundoplicature dont le but est d'augmenter la pression d'ouverture du cardia et d'optimiser les règles physiques décrites par le loi de La Place. Enfin, le rappor entre ces facteurs théoriques et les interventions pratiquées à l'heure actuelle est discuté.
Resumen
A pesar de carecer de un conocimiento claro que explique en forma definitiva el mecanismo de los factores fisiológicos y quirúrgicos que controlan el reflujo gastroesofágico, se acepta que existen eficaces operaciones anti-reflujo. El presente artículo analiza los factores pertinentes al control quirúrgico del reflujo. Las consideraciones teóricas incluyen: 1) la presión, longitud y ubicación del esfínter esofágico inferior según definición manométrica; 2) la válvula gastroesofágica, definida como la modificación del ángulo de His (ángulo entre el esófago y el fundus gástrico) y una válvula mucosa producida por la fijación de la unión gastroesofágica al ligamento arqueado o la construcción de una envoltura parcial del esófago; y 3) los efectos mecánicos de una fundoplicación cuyo propósito es aumentar la presión de apertura del cardias y optimizar las relaciones físicas según la Ley de La Place. Finalmente, se discute la relación de estos factores teóricos con operaciones reales en boga, especialemente la fundoplicación de Nissen, el procedimiento antirreflujo de Belsey Mark IV, la gastropexia de Hill y la prótesis de Angelchick.
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Little, A.G. Mechanisms of action of antireflux surgery: Theory and fact. World J. Surg. 16, 320–325 (1992). https://doi.org/10.1007/BF02071540
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DOI: https://doi.org/10.1007/BF02071540