Surgical treatment of gastroesophageal reflux.

Most investigators agree that the most important goal in correcting gastroesophageal reflux is restoring or developing a competent lower esophageal sphincter. Although the sphincter can be incompetent in its normal intra-abdominal position and rarely a patient may have a competent sphincter in the thorax, generally the sphincter is much more effective in the positive pressure abdominal position. The choice of operative technique will depend upon the abnormal conditions present and the general condition of the patient. The thoracic approach is elected if there is associated intrathoracic disease warranting surgical correction, such as diffuse spasm of the esophagus, achalasia, epiphrenic diverticulum, or a pulmonary lesion requiring biopsy and possible resection. Very obese patients, patients with recurrent hernias, and patients with shortened esophagus are better managed by the thoracic approach. Patients with an essentially normal esophagus are treated with a Mark IV Belsey procedure. If shortening of the esophagus is present, a combination Collis-Nissen technique with fixation below the diaphragm is preferable. The abdominal approach is indicated when there is another intraabdominal disease known or suspected warranting surgical correction. This approach is also useful for the thin or poor risk patient. Usually, through an abdominal incision, we elect to use a modified Nissen fundoplication, with fixation of the fundoplication to the median arcuate ligament or the right crus of the diaphragm. The crural sling is returned to normal dimensions with interrupted sutures. Reflux in the absence of an hiatal hernia initially is treated medically. If symptoms are significant and intractable, a competent lower esophageal sphincter is restored, or developed by the modified Nissen procedure just described. Most reflux strictures at the esophagogastric junction are reversible by dilatation and restoration of a competent sphincter. Firm, fixed, fibrous strictures occasionally cannot be safely dilated. These may be managed by a Thal procedure to correct the stricture and a Nissen fundoplication to prevent recurrent reflux.