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Robotic Laparoscopic Gastroesophageal Valvuloplasty: An Alternative Anti-Reflux Procedure Which More Closely Replicates the Normal Anti-Reflux Barrier
Eric Strother, Mark Meyer, Marc Margolis, Barbara Tempesta, Farid Gharagozloo.
Washington Institute of Thoracic and Cardiovascular Surgery at The GW University Medical Center, Washington, DC, USA.
BACKGROUND: The Nissen fundoplication is the most common procedure performed for gastroesophageal reflux disease. The Nissen procedure wraps the fundus of the stomach around the distal esophagus and is associated with dysphagia and gas bloat in a subset of patients. The normal antireflux barrier consists of a valve which is formed by the intussusception of the esophagus into the stomach at the gastroesophageal (GE) junction. Creation of a gastroesophageal valve using the surgical robot may enable a more physiologic anti-reflux procedure associated with a lower incidence of dysphagia and gas bloat.
METHODS: From June 2005 until September 2011, 45 patients (15 men, 30 women, mean age 52 years) with gastroesophageal reflux disease underwent robot-assisted laparoscopic Belsey fundoplasty. Indications for surgery were intractability of symptoms and pulmonary complications. All patients underwent pre-operative manometry and 24 hour pH study. The procedure was performed through five laparoscopic ports. The hiatus was closed anteriorly and posteriorly. The esophagus was intussuscepted into the stomach by 2 cm for 270 degrees. Results were assessed by preoperative and postoperative endoscopy, manometry, 24 hour pH study, UGI study, subjective symptom questionnaire, and objective Viscik grading.
RESULTS: Mean operative time was 191 +/- 53 minutes. There were no complications and no mortality. Median hospitalization was 2 days. 23 patients (51%) had transient postoperative dysphagia which resolved by the third postoperative week. Median follow up was 20 months. On follow up, 78% patients had a Viscik I grading and the remaining patients had a Visick II grading. Additionally, there was no gas bloat or long term dysphagia and there was no recurrence of hiatal hernia.
CONCLUSION: Robotic laparoscopic gastroesophageal valvuloplasty recreates the normal anti-reflux barrier. This procedure is associated with a low incidence of gas bloat and dysphagia. The results appear to be sustained in a medium term follow up. Although greater experience is necessary, a robotic laparoscopic gastroesophageal valvuloplasty may represent a more physiologic alternative to the Nissen fundoplication.
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