Gastroesophageal reflux disease represents, in Western countries, one of the most common diseases of the upper digestive tract. In these cases, surgical therapy may offer a viable alternative for a final resolution of the disease. Bearing in mind the multifactorial nature of the disease, the ideal would be that the surgeon was able to repair “made to measure” of each individual patient. As is known, many surgical techniques have been proposed and implemented to treat GERD, but usually most of the surgeons who perform interventions according to their experience best suited for the treatment of GERD. The main purpose of surgery is to restore a normal anatomy at the level of GGE repositioning and anchoring the distal esophagus into the abdominal cavity and, if necessary, suture also diaphragmatic pillars. Experience has shown that to recreate a high-pressure zone, without weakening the capacity for clearance of esophageal and gastric emptying, is the prerequisite for effective action.
There is no doubt that surgery is indicated in cases of large symptomatic hiatal hernia. This pathological condition is associated with severe reflux, especially for the simultaneous combination of a SEI hypotonic. Many surgeons prefer to perform an antireflux intervention when patients do not respond to medical therapy, we know that the effectiveness of PPIs reduced the number of patients “non responders”. Medical treatment instead of maintenance can effectively control symptoms in most cases. Evaluation metanalitica of randomized studies in asymptomatic patients undergoing medical therapy for a long time has shown the persistence of a moderate esophagitis.
Radiology: Radiological study of patients with GERD is generally of little help, because in 25% of cases there are episodes of reflux disease in asymptomatic individuals. However, can be useful in the study of anatomical abnormalities such as stricture or hiatal hernia, in addition, failure to reduce the latter in an upright position, may suggest the presence of a brachiesofago typical contraindication to perform an intervention for abdominal surgery.
Endoscopy with biopsy: endoscopic evaluation is useful for measuring the position of the diaphragmatic pillars, the position of squamous-columnar junction, ie the crossing point between the two esophageal and gastric mucosa, and the presence of lesions at this level.. An esophageal stricture is demonstrated by the impossibility of advancing an instrument of 36 French.
Esophageal manometry: This method is the cornerstone for defining the indications for intervention. In fact, patients with normal pressure of SEI (baseline blood pressure limit of 20 mmHg) should not be candidates for intervention. Particular attention should be given to cases of abnormal esophageal motility.
pH-metry: the application of this method in all subjects with suspected GERD, does not seem necessary. The severity of symptoms in fact, is not related to the number of refluxes measured and even in asymptomatic patients can be demonstrated pathologic reflux, as normal values may instead be found in patients with epigastralgia due.
Intervention Nissen antireflux: The pneumoperitoneum is created as usual, either can be taken into account the use of devices for the suspension of the abdominal wall (Gasless Laparoscopy). 5 trocars are introduced sequentially of which 2 are used for retraction, 1 and 2 for the telcamera operational maneuvers, both located at 90 ° to the axis of the laparoscope and esophagus. The difficulties may be encountered are due to hypertrophy of the left lobe of the liver, obesity, adhesions, and due to a periesofagite.
Antireflux prosthesis of Angelchik (PAA) This technique is based on the use of a prosthetic silicone ring that is positioned and closed around the GGE. Esophageal rear window is practiced by the same technique already described, but the dissection can be even more modest than that done in previous techniques.