What procedures are unsuitable for laparoscopy?
F. Dubois (Paris)
This question is multifaceted and has no simple answer. Firstly, the following main principles must be applied:
- the indications for surgical treatment of reflux are governed by the same rules, whether the operation is to be carried out conventionally or by endoscopy; the fact that endoscopic surgery may be more readily accepted by the patient in no way extends the indications;
- clearly, endoscopic surgery should only be considered by those who are skilled in the procedures involved, and who possess all the necessary equipment;
- the type of surgical intervention carried out must be that which is considered to be the most effective, i.e., it is important not to make do with an incomplete or unsatisfactory surgical procedure, simply because it is easy or because it is the only surgical option available by the endoscopic route.
Beyond these essential rules it is much harder to make any firm recommendations, especially as the technique is a recent one which is still under development and its
approaches tend to change as experience is gained. For example, from 1989 to 1993 the transition has been made from simpler to more complicated interventions (i.e., Dor anterior valve, followed by Nissen and finally Toupet, which requires greater skill for the sutures).
It appears that all techniques for the surgical treatment of gastroesophageal reflux (GER) have been or could be carried out endoscopically, whether they involve formation of a valve, fixing of the cardia, or both of these procedures. Even if, due to lack of equipment, an operation such as Collis procedure for lengthening the esophagus is not feasible by endoscopy, it can be carried out by thoracoscopy.
Other contraindications, although still major at present, may become relative in the future and in some instances have already been removed:
- the dangers of pneumoperitoneum in patients with emphysematous bullae can be reduced by the suspension technique;
- reintervention for recurrence after surgical treatment of reflux: a few patients have been reoperated endoscopically with varying degrees of difficulty;
- reflux after gastric or esophageal resection: it is possible to imagine carrying out a duodenal diversion by endoscopy and this may well have already been done;
- undilatable esophageal constriction requiring esophageal resection: resections have already been carried out endoscopically and thoracoscopically;
- patients having undergone multiple operations at the supramesocolic level where dissection could be hazardous, or even patients with portal hypertension or severe periesophagitis;
- when there is a very large left liver lobe, it is very difficult to reach an underlying hiatus, and it is necessary to move the lobe in order to reach the hiatus from above. Perhaps one day that route may be used endoscopically.
In theory, therefore, there are no absolute contraindications for the endoscopic treatment of GER. It is only a matter of situations and procedures of varying and increasing difficulty, which the surgeon must take into account when considering the indications and the routes by which to tackle the problem.