Overview
Definition:
Gastroesophageal reflux disease (GERD) is a chronic condition characterized by the abnormal reflux of gastric contents into the esophagus, leading to symptoms or complications
Fundoplication is a surgical procedure to create a valve-like mechanism around the lower esophagus to prevent reflux
The choice between Dor (anterior partial fundoplication) and Toupet (posterior partial fundoplication) can be influenced by esophageal manometry findings, particularly regarding lower esophageal sphincter (LES) pressure and esophageal peristalsis.
Epidemiology:
GERD affects approximately 20% of the adult population in Western countries
The prevalence in India is variable but increasing with lifestyle changes
Surgical intervention is typically reserved for patients with refractory symptoms, complications, or those who decline long-term medical management
Decision-making for partial fundoplication types is often guided by specific manometric parameters.
Clinical Significance:
Accurate selection of fundoplication type based on manometry can optimize surgical outcomes, reduce recurrence of reflux, and minimize postoperative complications such as dysphagia and gas bloat
Understanding manometric patterns is crucial for surgeons preparing for DNB and NEET SS examinations, as these are frequently tested concepts in surgical decision-making for GERD management.
Diagnostic Approach
History Taking:
Key history points include the nature, frequency, and duration of heartburn and regurgitation
Nocturnal symptoms, dysphagia, odynophagia, chest pain, and extraesophageal symptoms (cough, hoarseness, asthma) are also important
Assess previous treatments and patient adherence
Red flags include weight loss, anemia, early satiety, vomiting, and a family history of upper GI malignancy.
Physical Examination:
Physical examination is often unremarkable in uncomplicated GERD
Focus on abdominal palpation for tenderness, and listen for bowel sounds
Assess for signs of malnutrition or anemia
Barium swallow may reveal complications like strictures or Barrett's esophagus.
Investigations:
Upper endoscopy with biopsy is the gold standard for assessing esophageal mucosal damage, ruling out complications like Barrett's esophagus and malignancy, and confirming esophagitis
24-hour esophageal pH monitoring is crucial to objectively confirm the diagnosis of GERD and assess the extent of acid reflux
Esophageal manometry is essential for evaluating LES pressure, esophageal body motility, and identifying potential factors influencing fundoplication success, such as aperistalsis or low LES pressure.
Differential Diagnosis:
Differential diagnoses include peptic ulcer disease, functional dyspepsia, achalasia, diffuse esophageal spasm, eosinophilic esophagitis, cardiac ischemia, and anxiety disorders
Manometry findings help distinguish GERD from motility disorders like achalasia.
Esophageal Manometry Interpretation
Les Pressure:
Normal LES resting pressure is typically 15-25 mmHg
Hypotensive LES (<10 mmHg) is a common finding in GERD
Manometry helps quantify this pressure
Very low LES pressure may suggest a need for a more robust anti-reflux repair.
Esophageal Peristalsis:
Manometry assesses the contractility of the esophageal body
Absent or weak peristalsis (aperistalsis or hypoperistalsis) can be associated with GERD
This finding is critical for selecting the type of fundoplication.
Segmental Manometry:
Assessment of LES relaxation with swallows and esophageal body wave amplitude and duration provides a comprehensive picture of esophageal function
High-resolution manometry (HRM) offers more detailed analysis.
Implications For Fundoplication:
Aperistalsis or severe hypoperistalsis in the esophageal body often favors a partial fundoplication (Dor or Toupet) over a complete Nissen fundoplication to reduce the risk of severe postoperative dysphagia
The specific orientation (anterior vs
posterior) may be influenced by the degree of LES hypotensive and other manometric parameters, though evidence directly linking specific manometric patterns to Dor vs
Toupet preference is debated and often individualized.
Dor Vs Toupet Selection Criteria
Dor Fundoplication:
Anterior 180-degree partial fundoplication
Generally considered for patients with decent LES pressure and good esophageal peristalsis
It may be associated with a lower risk of dysphagia and gas bloat compared to full Nissen fundoplication, but potentially a higher recurrence rate.
Toupet Fundoplication:
Posterior 270-degree partial fundoplication
Often favored in patients with significant esophageal dysmotility or lower LES pressures
The posterior wrap may provide better coverage of the gastroesophageal junction while potentially sparing the anterior vagal nerve, theoretically reducing some complications.
Manometric Guidelines:
While no absolute manometric criteria dictate Dor versus Toupet, general principles apply: Patients with aperistalsis or significant hypoperistalsis might benefit from partial wraps to avoid aggravating dysphagia
Patients with extremely low LES pressures (<5 mmHg) might require a more complete wrap or adjunctive treatments
The decision is often multi-factorial, integrating manometry with symptom severity and surgeon preference.
Surgeon Preference And Experience:
Ultimately, the choice between Dor and Toupet can also be influenced by the surgeon's experience and preference, as both have demonstrated efficacy in managing GERD, particularly in specific patient subgroups identified by manometry.
Surgical Management
Indications:
Failure of medical management, disabling symptoms (heartburn, regurgitation), complications (esophagitis, stricture, Barrett's esophagus, aspiration pneumonia), patient preference for definitive treatment, or in the context of anti-reflux barrier failure post-bariatric surgery.
Preoperative Preparation:
Comprehensive evaluation including upper endoscopy and esophageal manometry is essential
Optimization of medical therapy
Patients should be counseled on potential risks and benefits of each fundoplication type
Smoking cessation is recommended.
Procedure Steps Dor:
A 180-degree wrap of the gastric fundus is passed anteriorly around the distal esophagus and secured with sutures
Care is taken to avoid excessive tension and preserve gastric and esophageal blood supply.
Procedure Steps Toupet:
A 270-degree wrap of the gastric fundus is passed posteriorly around the distal esophagus
The wrap is secured with sutures, ensuring adequate coverage of the GE junction while minimizing tension and preserving crucial structures.
Postoperative Care:
Dietary modification (soft diet progressing to normal) is crucial to allow healing and prevent dysphagia
Pain management
Early ambulation
Monitor for complications like dysphagia, odynophagia, gas bloat, and wound infection
A temporary nasogastric tube may be used in select cases.
Complications
Early Complications:
Bleeding, infection, injury to adjacent organs (spleen, esophagus, vagal nerves), anesthetic complications
Dysphagia and difficulty passing a nasogastric tube are common early issues.
Late Complications:
Recurrent GERD, dysphagia (persistent or worsening), gas bloat syndrome, dumping syndrome, incisional hernia, and rarely, esophageal perforation or stricture
Suture dehiscence of the wrap.
Prevention Strategies:
Meticulous surgical technique, intraoperative assessment of wrap integrity and tension, careful handling of gastric and esophageal structures, and judicious use of partial fundoplications in patients with known dysmotility are key
Postoperative dietary compliance and patient education are vital.
Key Points
Exam Focus:
DNB/NEET SS exams often test the indications for surgical management of GERD and the rationale behind choosing partial versus total fundoplication
Understanding how esophageal manometry findings (LES pressure, peristalsis) influence this decision is critical
Differentiating Dor from Toupet based on wrap orientation and potential implications for dysphagia and recurrence is important.
Clinical Pearls:
Always correlate manometric findings with symptoms and endoscopic findings for comprehensive GERD evaluation
In patients with significant esophageal aperistalsis, a partial fundoplication (Dor or Toupet) is generally preferred over a Nissen to mitigate dysphagia
Consider the anterior vagal nerve when performing posterior wraps (Toupet) and posterior vagal nerve with anterior wraps (Dor) if these are critically important to spare, though this is a less commonly emphasized distinction.
Common Mistakes:
Performing a full Nissen fundoplication in a patient with severe esophageal dysmotility
Inadequate assessment of LES pressure and peristalsis preoperatively
Incorrectly identifying the gastroesophageal junction during surgery
Not counseling patients adequately on dietary modifications post-fundoplication, leading to increased dysphagia complaints.