Abstract
The prerequisites for a successful outcome after fundoplication are careful patient selection, good technique, and an understanding of the principles of antireflux surgery. The most important aspect of any such operation is the construction of a peri-esophageal ring around the gastro-esophageal junction buttressing the sphincter and, thus, neutralizing the gastric opening pressure. Accordingly, the operation has to comprise: 1) generous dissection around the gastric fundus to allow the formation of a “floppy” fundoplication; 2) construction of the cuff as short as possible (2 cm to 3 cm); and 3) proper fixation of the cuff at the correct site in the region of the lower esophageal sphincter. Adherence to these principles will avoid postoperative dysphagia or functional gastro-intestinal disorders and produce long-lasting reflux control in approximately 90% of patients at 10 years. Problems of hypercontinence may occasionally occur since gastro-esophageal reflux suppression is usually complete and any physiological reflux abolished. With the advent of modern drug treatment, the excellent results achieved by fundoplication need to be maintained despite fewer operations. Careful postoperative quality control including pH monitoring is therefore mandatory. The principle of periesophageal wrapping is likely to remain the cornerstone of antireflux surgery. Current techniques are, however, likely to evolve. One direction being investigated is laparoscopic fundoplication, rendering the procedure much less invasive.
Résumé
Les conditions nécessaires pour obtenir un bon résultat de la fundoplicature sont une sélection judicieuse des candidats à ce type de chirurgie, une technique irréprochable et une bonne compréhension des principes de la chirurgie du reflux. L'aspect principal est la construction d'un anneau périoesophagien autour de la jonction oesogastrique renforçant le sphincter et le rendant capable de vaincre la pression d'ouverture gastrique. Cela veut dir que l'intervention doit comporter une dissection poussée du fundus gastrique pour permettre la construction d'une valve adèquate et souple, courte (2 á 3 cm) et sa fixation correcte juste à l'endroit anatomique qui correspond au sphincter inférieur de l'oseophage. Si l'on observe ces principes, on évite la dysphagie postopératoire ou des désordres fonctionnels et on obtient en même temps un contrôle du reflux de longue durée chez approximativement 90% des patients à 10 ans. Les problèmes dus à un surserrage sont rares. Les résultats de ce type de chirurgie sont généralement excellents et doivent être confirmés par un contrôle par pHmétrie qui est presque obligatoire. Le principe de la fundoplicature reste la base de ce type de chirurgie. Les progrès actuels viennent de la chirurgie par coelioscopie qui permet une correction du reflux de manière moins invasive.
Resumen
Los prerrequisitos para obtener un resultado exitoso después de fundoplicación son: selección cuidadosa del paciente, depurada técnica operatoria y un buen conocimiento de los principios de la cirugía antirreflujo. El aspecto más importante de la operación es la construcción de un anillo (manguito) periesofágico alrededor de la unión gastroesofágica con lo cual se fija el esfínter y, por lo tanto, se neutraliza la presión de apertura gástrica. Por consiquiente, la operación debe incluir: 1) generosa disección alrededor del fundus gástrico que permita construir una fundoplicación “floja” (floppy); 2) construcción del manguito tan corto como sea posible (2–3 cm), y 3) fijación adecuada del manguito en el lugar correcto sobre la región del esfínter esofágico inferior. La cuidadosa observación de estos principios evita la disfagia postoperatoria o las alteraciones gastrointestinales funcionales y logra el control del reflujo a largo plazo. Los problemas de hipercontinencia pueden ocurrir ocasionalmente, puesto la supresión de reflujo gastroesofágico es usualmente total y queda abolido cualquier reflujo fisiológico. Con el advenimiento de la moderna terapia farmacológica es necesario mantener los excelentes resultados que se logran con la fundoplicación, a pesar de que actualmente se realizan menos operaciones; por lo tanto, aparece mandatario un meticuloso control de calidad postoperatorio, incluyendo la monitoría de pH. El principio de la envolutra periosofágica probablemente se mantendra como la piedra angular de la cirugía antirreflujo. Sin embargo, muy posiblemente las actuales técnicas quirúrgicas habrán de evolucionar. Una modalidad que es motivo de investigación es la fundoplicación laparoscópica, método que hace el procedimiento mucho menos invasivo.
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Siewert, J.R., Feussner, H. & Walker, S.J. Fundoplication: How to do it? Peri-esophageal wrapping as a therapeutic principal in gastro-esophageal reflux prevention. World J. Surg. 16, 326–334 (1992). https://doi.org/10.1007/BF02071541
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DOI: https://doi.org/10.1007/BF02071541