Laparoskopische Antirefluxchirurgie

Indikationen zur Antirefluxchirurgie

Der Mehrzahl an Refluxpatienten kann ohne Zweifel mit einer adäquaten medikamentösen Therapie geholfen werden und bedürfen keiner chirurgischen Behandlung.


Die Indikation zur Antirefluxchirurgie, unabhängig ob offen oder laparoskopisch durchgeführt, ist gegeben bei:  

  • Patienten mit einem mechanisch insuffizienten unteren Ösophagussphinkter (Druck < 6 mmHg)
  • Patienten, die nicht auf eine medikamentöse Therapie ansprechen
  • Patienten mit einem progressiven Erkrankungsverlauf unter dosissteigernder PPI-Therapie
  • Jungen Patienten, die eine lebenslange und kostenintensive medikamentöse Therapie benötigen
  • Patienten, die schwere Komplikationen (ösophageale Strikturen, Ulcera, Barrett Ösophagus, pulmonale Symptome) der Refluxerkrankung trotz adäquater Therapie entwickeln
  • Patienten mit respiratorischen Symptomen, wie Aspiration, Reflux assoziiertes Asthma (RAA), wiederkehrende Pneumonien und chronische Laryngitis
  • Patienten mit großen Hiatushernien

Funktionsdiagnostik & Abklärung

Kontraindikationen stellen dyspeptische Beschwerden ohne funktionellen Nachweis der Refluxkrankheit dar. Vorsicht ist ebenfalls geboten bei Patienten mit ausgeprägter Störung der Bodymotilität, wie bei der Sklerodermie oder auch Diabetes. Grundlage für jegliches chirurgische Vorgehen ist daher eine entsprechende Funktionsdiagnostik und Abklärung.

Englisch Version

Indications

The selection of patients for surgery is a subject of great interest to internists and surgeons. Although there are good results from medical therapy with PPI's, there are definite indications for surgery.

GERD is a chronic disease which requires lifelong medical treatment in about one-third of patients. Symptom and disease recurrence can be avoided by increasing the dosage or changing medication. Patients with a defect in LES pressure, overall length and intra-abdominal length (pressure < 6 mmHg, overall length < 2 cm and intra-abdominal length < 1 cm) develop more frequent recurrence of GERD after one year of medical treatment compared to patients with normal sphincter function. Another reason for treatment failure is noncompliance to medical therapy. Furthermore, young patients with severe reflux disease and failure of LES function are optimal candidates for antireflux surgery. Those patients will require long-term treatment and may develop complications. Because of the chronicity of the disease, the inconvenience and cost of medical therapy increases. It has been suggested that surgery has a cost advantage over medical therapy in patients less than 49 years of age (Veterans Administration Cooperative Trial) and that the cost of laparoscopic surgery is the same as medical treatment with omeprazole after about 3-5 years. Antireflux surgery is also indicated for patients suffering from severe reflux who have a preference for surgical therapy.

A structural defect of the LES is often found in patients with Barrett's esophagus. Those patients are at risk of progression of the mucosal abnormality up the esophagus, formation of strictures, hemorrhage from a Barrett's ulcer and the development of adenocarcinoma. For these reasons, Barrett's needs constant surveillance and suppression of reflux, which is not guaranteed by medical therapy. Barrett's patients are therefore also optimal candidates for surgical treatment. In addition, evidence is accumulating that an antireflux procedure provides better protection against progression to cancer, since there is elimination of bile reflux, an important risk factor for the development of Barrett's cancer.

Last, but not least, patients with atypical reflux symptoms such as chronic respiratory symptoms (cough, recurrent pneumonia, episodes of nocturnal chocking and aspiration) and noncardiac chest pain will benefit from antireflux surgery.