Aim of the treatment
The goal is to achieve a safe "closure" between the esophagus and the stomach. This is done on the one hand by restoring the normal anatomical conditions and on the other hand by means of additional formation of a kind of gastric sleeve, which is placed around the lowest section of the esophagus like a collar (so-called fundoplication). This prevents acid from entering the esophagus and causing inflammation here. For more than eight years, we have been performing an operation in which cuffing is no longer necessary. Only the normal anatomy is restored by returning the esophagus to its original position (stretched) and fixing it there without tension (esophagocruropexy). In addition, the angle (so-called His angle) between the esophagus and the uppermost part of the stomach is reduced and the widened diaphragmatic gap is reconstructed (hiatoplasty).
When should surgery be performed?
- Relapses or complications despite correct drug therapy
- Unsuccessful drug therapy or side effects thereof
- Patients who do not want to be dependent on medication for life
- Very large diaphragmatic hernias (mechanical problems, risk of entrapment)
- Long-term patients with concerns about drug side effects
Own surgical experience
We have been performing about 40-50 antireflux surgeries every year since 1996, so we now have a great deal of experience in this specialized surgery. We also perform so-called revision surgeries. These are operations in which a surgical intervention of some kind has already been performed due to reflux disease, but the success of the operation is insufficient or poor. These patients then either suffer from recurring reflux symptoms or can hardly eat or drink because the cuff was applied too tightly or incorrectly. In such cases, another operation (revision) is then necessary. In the last 25 years we have specialized in such reoperations, which can be technically very difficult and complex, which is why we now treat a large number of patients from abroad who have problems, recurrences or other complications after an anti-reflux operation.
The classic procedure is called "laparoscopic fundoplicatio". Different techniques exist. The position and the tightness of the cuff varies. In our latitudes, the most commonly performed are fundoplicatio according to Nissen (posterior 360-degree cuff) and that according to Toupet (posterior 270-degree cuff). The Toupet procedure has been our extremely reliable and proven standard procedure for 20 years. The mentioned procedures have their specific peculiarities. Both procedures involve the repositioning of any part of the stomach that may have slipped upwards (hernia contents). This is followed simultaneously by reconstruction (reduction) of the widened diaphragmatic gap (hiatoplasty) and formation of a sufficiently strong transition (similar to a valve mechanism) between the esophageal outlet and the gastric inlet by means of a gastric sleeve (so-called fundoplicatio). The side effects of a full-wall cuff are not insignificant, which is why we have not performed 360-degree cuffs at all for over 20 years. We also virtually abandoned 270-degree cuffs over eight years ago in favor of surgical treatment without a cuff.
Laparoscopic modified BICORN surgery.
Surgical therapy without cuffing consists of the so-called BICORN procedure (BIological COnservative ReconstructioN) according to Ablassmaier. We modified this procedure slightly in our center years ago. First of all, a diaphragmatic hernia is reduced and the esophagus is stretched again. This leads to an improved pumping function of the esophagus, not least because of the restoration of the muscular "stretch closure" in the area of the lowest part of the esophagus. The thus stretched esophagus is fixed tension-free to the two diaphragmatic crura (esophagocruropexy) to prevent recurrence as far as possible. The dilated diaphragmatic passage is reconstructed and the so-called His angle is corrected at the end of the procedure. Cuffing is not necessary! This modified BICORN procedure has been our standard procedure for more than eight years, not least because of the extremely low complication and side effect rate. In contrast to cuffed procedures, patients are able to regurgitate air (burp) after a modified BICORN operation and, if necessary, vomit. There is virtually never a so-called gas bloat syndrome, which is seen very often in cuffed surgeries.
Principle and mode of action
The BICORN operation, modified by us, results in restoring the normal anatomy and physiology in this region. This simple procedure reliably prevents pathological reflux of acid and gastric contents in the long term.
With all surgical procedures, there is a small risk that the hiatal hernia and/or acid reflux may recur (so-called recurrence). In that case, another operation may be indicated.
There are various other surgical procedures (e.g. implantation of a special magnetic ring, esophageal stimulation with electrodes, etc.), but we do not discuss them further, as we do not recommend them for various reasons and therefore do not perform them.
The main preliminary clarifications are as follows:
· Esophago-gastro-duodenoscopy incl. biopsy
· High-resolution esophageal manometry
· 24h impedance pH-metry or 48h capsule pH-metry
· Esophageal passage with contrast medium
The operation is performed under general anesthesia and usually lasts between 45-90 minutes. The hospital stay is 1-2 days.
Copyright Mischa Feigel, MD