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Current Surgical Treatment of Gastro-oesophageal Reflux Disease
has raised the discussion of total versus partial fundoplication. Figure 3: Nissen (360º Wrap) and Diaphragmatic
Proponents of the Nissen acknowledge that the wrap needs to be
Repair with Biologic Mesh
‘floppy’ to minimise post-operative dysphagia. The floppy Nissen
fundoplication is safe and effective, even in patients suffering
from defective oesophageal peristalsis. Proponents of total
fundoplication importantly note the decreased effectiveness of a
partial fundoplication in controlling reflux.
18
Two partial fundoplications in practice are the 180º anterior Dor
fundoplication (see Figure 4) and the 270º posterior Toupet
fundoplication. Fibbe et al.
20
compared laparoscopic Nissen and
Toupet fundoplications in 200 patients with proven oesophageal
motility disorders and found no difference in post-operative
recurrence of reflux. Similarly, Laws et al.
21
found no clear advantage
of one wrap over the other in their prospective, randomised study
comparing the use of these two fundoplications in patients with
abnormal oesophageal motility. Moreover, in a meta-analysis of nine
prospective randomised trials including open and laparoscopic
Nissen versus Toupet fundoplications in 793 patients, no statistical
difference was found in new-onset dysphagia or recurrence of
Figure 4: Dor (180º Wrap) Anterior Fundoplication
reflux.
22
Currently, partial fundoplication is implemented in patients
with scleroderma and post-myotomy achalsia.
23
Endoluminal Therapy
Recent interest in the development of endoluminal therapy has led
to new alternatives in the treatment of GORD. These treatment
modalities are reserved for patients who suffer from a
dysfunctional LOS but with no hiatal hernia. Therapy is performed
transorally, via upper endoscopy. There are three principal types of
endoluminal treatment of GORD. First, radiofrequency energy
delivered to the LOS theoretically adds bulk to the LOS and changes
the sphincter’s compliance. Although the mechanism of action has
not been fully established, it is presumably due to neurolysis and
the abolishment of neuromodulated LOS relaxation. With the Stretta
catheter (Curon Medical, Sunnyvale, CA, USA), radiofrequency
energy is generated by a four-channel radiofrequency generator,
which delivers 465kHz/2–5W per channel/80V through four
nickel–titanium needle electrodes. Multiple prospective non- at six months.
26
Concerns remain about the durability and safety of
randomised studies with short-term results (up to two years) the implants, leaving the long-term utility of the procedure a
demonstrated promising results. Triadafilopoulos et al.
24
confirmed question for further study.
improved quality of life scores, decreased oesophageal acid
exposure, decreased median DeMeester scores (from 40.0 to 26.4; The third category of endoluminal procedures employs direct,
p<0.009) and 70% of patients off PPIs at 12 months. Additional data endoscopic tightening of the LOS via sewing or plication. This
on long-term follow-up, including the incidence and natural history appears to be the most promising of the endoluminal therapies.
of oesophagitis in these patients, are needed to establish the utility The endoscopic suturing devices currently available include the
of this procedure. EndoCinch (BARD Endoscopic Technologies, Billerica, MA), the ESD
(Wilson-Cook Medical, Winston-Salem, NC), the Esophyx
A second endoscopic therapy for GORD involves the creation of a (EndoGastric Solutions, Redmond, WA) and the Full-Thickness
mechanical barrier at the gastro-oesophageal junction (GOJ). Plicator (NDO Surgical Inc., Mansfield, MA. The major difference
Enteryx (Boston Scientific, Natick, MA) is an ethylene vinyl alcohol between the devices is the depth of suture. The Esophyx and the
co-polymer that was endoscopically injected within the submucosa NDO Plicator take full-thickness sutures of gastric fundus, whereas
or muscular layers of the oesophageal wall 1–2mm proximal to the the other endoscopic plicators utilise a partial mucosal/
Z-line. This technique was discontinued by the company due to submucosal stitch. Partial-thickness sutures have a greater
excessive complications.
25
The Gatekeeper Reflux Repair System potential to pull through the tissue or migrate over time. The
(Medtronic, Tolochenaz, Switzerland) entails the submucosal Esophyx and NDO Plicator system appear to have the technical
placement of a polyacrylonitrile-based hydrogel prosthesis advantages of a full-thickness stitch, with serosa-to-serosa
(1.5x18mm) above the GOJ. In a prospective, non-randomised study approximation. With the NDO Plicator system this provides direct
of 68 patients with a six-month follow-up, quality of life was tightening of the LOS, possible lengthening of the LOS and
improved, median LOS pressure was increased (from 8.8 to favourable altering of the angle of His. Pleskow et al.
27
showed in a
13.8mmHg; p<0.01) and 70.4% of the prostheses were still in place non-randomised, prospective study of 64 patients with follow-up of
EUROPEAN GASTROENTEROLOGY & HEPATOLOGY REVIEW 9
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