Is a patient with LA (Los Angeles) grade C reflux esophagitis and a small sliding hiatus hernia indicated for a laparoscopic fundoplication with closure of the diaphragmatic hiatus?

Management of LA Grade C Reflux Esophagitis with Small Sliding Hiatus Hernia

Laparoscopic fundoplication with closure of the diaphragmatic hiatus is indicated for patients with LA grade C reflux esophagitis and a small sliding hiatus hernia (2cm), as this surgical approach provides effective control of reflux symptoms and prevents progression of complications. 1, 2

Indications for Surgical Intervention

• LA grade C reflux esophagitis represents severe disease with confluent erosions that extend along the mucosal folds, indicating significant acid exposure requiring definitive treatment 2
• Small sliding hiatal hernias (2cm) contribute to GERD pathophysiology by disrupting the anti-reflux barrier and should be addressed surgically when associated with severe esophagitis 1
• Surgery is recommended when there is evidence of pathologic GERD with severe esophagitis that is uncontrollable with medical therapy 2, 1
• The presence of a hiatal hernia with severe reflux esophagitis represents a more severe manifestation of GERD requiring surgical intervention 1

Preoperative Evaluation

• Complete endoscopic evaluation should include documentation of:
  • LA classification grade of erosive esophagitis (Grade C in this case)
  • Measurement of hiatal hernia length (2cm in this case)
  • Assessment of the diaphragmatic hiatus 2
• Barium swallow is necessary before surgical treatment to identify hiatus hernia, strictures, or short esophagus 2
• High-resolution manometry should be performed to assess esophageal peristaltic function and exclude achalasia 2
• 24-hour pH monitoring is recommended to confirm pathologic GERD if not already established by the presence of LA grade C esophagitis 2

Surgical Approach

• Laparoscopic approach is preferred over open surgery due to:
  • Excellent safety profile with reported overall in-hospital mortality rate of 0.14% 2
  • Lower morbidity (5-6%) compared to open approach (17-18%) 2, 1
  • Shorter hospital stay and faster recovery 3, 4
• Closure of the diaphragmatic hiatus is essential to repair the hernia defect using non-absorbable sutures 2, 1
• Fundoplication should be performed in conjunction with hiatal hernia repair to address the reflux component 2, 1

Type of Fundoplication

• Nissen fundoplication (360° wrap) is the most commonly performed technique and remains the gold standard for durable relief of GERD symptoms 2, 5
• Toupet fundoplication (270° posterior wrap) is an alternative with potentially:
  • Lower rate of postoperative dysphagia
  • Lower recurrence rate compared to Nissen according to some studies 2, 6
• The choice between total or partial fundoplication should consider:
  • Esophageal motility status (partial wrap may be preferred with hypomotility)
  • Severity of reflux (total wrap provides stronger barrier against severe reflux) 6, 5

Expected Outcomes

• Effective control of reflux symptoms without need for long-term PPI therapy 3, 4
• Resolution of esophagitis in most patients 6, 5
• Minimal morbidity with laparoscopic approach 2, 1
• Early hospital discharge (typically 3-5 days) 7, 4

Potential Complications

• Postoperative complications may include:
  • Dysphagia (more common with Nissen fundoplication)
  • Gas bloat syndrome
  • Recurrent reflux
  • Hernia recurrence 2, 4
• Factors associated with hernia recurrence include:
  • Use of absorbable sutures
  • Suture tension
  • Improper fixation technique
  • Increased intra-abdominal pressure 2

Follow-up Recommendations

• Endoscopic surveillance is recommended to monitor healing of esophagitis and detect potential complications 2
• Additional endoscopies are required in case of new or worsening symptoms 2
• Long-term follow-up is important to assess durability of the surgical repair 6