The Role of Laparoscopic Nissen Fundoplication In Gastroesophageal Reflux Disease

MedSurg Nursing, Dec, 1998 by Kathy J. Vaca, Carol J. Daake, Stephanie A. Marquez, Donna S. Lambrechts

Gastroesophageal reflux is a highly prevalent condition that usually requires long-term medical therapy. Although symptom management still remains satisfactory for the majority of patients, laparoscopic Nissen fundoplication is proving to be an effective alternative in treating complications of gastroesophageal reflux disease.

Gastroesophageal reflux disease (GERD) is a term used to include all the symptoms and the mucosal lesions that result from abnormal reflux of gastric contents (DeVault & Castell, 1994). Heartburn, the main symptom of GERD, is very common in the general population, accounting for approximately 75% of all esophageal pathologic conditions (DeMeester & Stein, 1989). The true incidence of this disease remains difficult to ascertain. Adequate population-based studies of GERD in the United States are not available, and the most widely cited study assessed symptoms in hospital employees, not the general population (Nebel, Fornes, & Castell, 1976). In fact, many people consider heartburn normal and do not seek medical attention.

An estimated 7% of adults in the United States experience heartburn daily, 21% weekly, and 36% report this symptom at least once per month (Nebel et al., 1976). However, the symptoms can be quite disabling. Further, chest pain, dysphagia, asthma, chronic bronchitis, hoarseness, dyspepsia, and Barrett's esophagus have all been reported to be associated with GERD (Locke, Talley, Weaver, & Zinsmeister, 1994). The effectiveness of specific antireflux therapy for many GERD-related conditions has yet to be established in well-designated placebo-controlled trials. In recent years, there has been an increasing interest in understanding the pathophysiology of reflux disease and in finding the optimal way to manage this disorder. Many questions remain about the cost effectiveness of both diagnostic tests and treatment for GERD.

Medical symptom management still proves satisfactory for the majority of patients with mild to moderate GERD. It is only those patients with symptoms refractory to medical therapy, or those demonstrating complications of chronic GERD such as anemia, stricture, and ulceration, who should be considered for surgery. There is controversy surrounding identifying the best operation for controlling severe GERD, whether open or laparoscopic Nissen fundoplication (LNF). By providing a minimally invasive method of treatment, LNF has the potential to influence the frequency of operative intervention. However, there are some limitations to this approach.

The focus of this article is to describe laparoscopic Nissen fundoplication in the management of reflux. Special patient problems specific to nursing and a case study are presented.

GERD: Pathogenesis and Symptoms

Numerous investigators have explored the causes and consequences of GERD (DeMeester & Stein, 1989; Nebel et al., 1976; Richter & Castell, 1982). The gastroesophageal junction, consisting of the lower esophageal sphincter (LES), the crural diaphragm, and the phrenoesophageal ligament is usually an effective barrier against reflux of harmful gastric contents such as hydrochloric acid, pepsin and, sometimes, bile (see Figure 1). However, retrograde movement of acid and other noxious substances from the stomach into the esophagus can occur when the LES is mechanically incompetent, when esophageal body motility is ineffective in clearing physiologic reflux episodes, or when abnormalities of the gastric reservoir are present (Bonavina et al., 1986; Joelsson et al., 1982; Zaninotto, DeMeester, Schwizer, Johansson, & Cheng, 1988).

[Figure 1 ILLUSTRATION OMITTED]

Initially, basal pressure at the LES and the stabilization of the gastroesophageal junction by phrenoesophageal ligaments help prevent reflux. When reflux occurs, a two-step defense mechanism helps to clear acid from the esophagus. First, one or two swallow-induced peristaltic contractions will strip the fluid bolus from the esophagus. However, a thin film of acid may still be present on the mucosa. The swallowing of bicarbonate-rich saliva rapidly neutralizes residual acid. During sleep, salivation and swallowing are markedly decreased and the supine position prevents gravity from helping to clear the refluxate. This accounts for the vulnerability of the esophagus and injury at night.

More than one factor can promote reflux. Abnormal function of the LES may predispose an individual to GERD. Other contributing factors include: (a) obesity, coughing, and straining, causing increased intra-abdominal pressure; (b) delayed gastric emptying, causing distention; (c) presence of a hiatal hernia, serving as a reservoir of gastric acid during periods of recumbency; (d) negative intrathoracic pressure; and (e) delayed esophageal acid clearance due to dysfunction of esophageal peristalsis. In addition, various dietary (fat, chocolate, and coffee), lifestyle (alcohol and smoking), and pharmacologic (theophylline and progesterone) factors can cause a transient decrease in LES pressure, resulting in reflux (Marshall, 1995). Table 1 lists recommended lifestyle modifications that can help control reflux symptoms and have additional health benefits for patients with GERD.