Fundoplication/Gastroesophageal Reflux Surgery

The condition

Gastroesophageal reflux disease (GERD) occurs when the esophagus is exposed to prolonged periods of stomach acid. A defective lower esophageal sphincter is responsible for most cases of reflux. The lower esophageal sphincter (LES) is a high pressure zone near the junction of the stomach and esophagus. Normally the LES acts like a valve closing after swallowing. The LES fails to close adequately in patients suffering with GERD allowing the esophagus to be exposed to acid. Heartburn, esophagitis, esophageal stricture, and even cancer may result from GERD.

Symptoms

The symptoms associated with GERD are variable but generally include:

• Heartburn - 30 - 60 minutes after eating
• Regurgitation - worsened with lying flat
• Excessive belching
• Aspiration - stomach contents refluxed into the airway
• Asthma - chronic result of aspiration
• Chest pain - burning mid-chest pain
• Difficulty swallowing
• Pain with swallowing
• Bleeding

Surgical Management:

In the past, surgery was a last resort because of the prolonged recovery time and large painful incision involved with the procedure. With the new minimally invasive approach, surgery is now a viable option after early attempts of modifications and medical management fail to adequately resolve symptoms. The laparoscopic fundoplication is performed with five quarter-inch incisions through which a camera and four instruments are placed. A new lower esophageal valve is constructed by wrapping a 2-3 centimeter portion of the stomach around the lower most part of the esophagus. This collar is then anchored to the tough fibers of the diaphragm (the respiratory muscle separating the chest from the abdomen). The procedure typically lasts for forty-five minutes to one and a half hours. The patient is started on clear liquids the next morning and is discharged in the afternoon or the next day. The open surgical technique involves an 8-10 inch upper abdominal incision with a hospital stay of 3-6 days.

Risks

• Perforation of the stomach or the esophagus
• Pneumothorax (air into the chest)
• Bleeding
• Injury to the spleen
• Vagal nerve injury/transection
• Esophageal stricture
• Recurrent herniation
• Wrap slippage
• Mal-positioned wrap

Medical negligence

The above mentioned risks and complications are known to happen with fundoplication and such complications do not necessarily constitute deviation from the medical standard of care.  The following examples however may be considered as medical negligence.

• Surgeon’s inexperience.  This is a highly technical operation and good outcomes are dependent on experience.  Unlike amputative operations this operation is reconstructive in the sense that a valve like mechanism is created with the fundoplication.  If not done properly, by observing accepted guidelines, it can lead to chronic suffering and reoperations.
• Unrecognized perforation of the esophagus or the stomach can lead to high morbidity and mortality.