Laparoscopic fundoplication with or without pyloroplasty in patients with gastroesophageal reflux disease after lung transplantation: how I do it

Abstract

Introduction: Several studies have confirmed that gastroesophageal reflux disease (GERD) in lung transplant patients is a risk factor for the development and progression of bronchiolitis obliterans syndrome (BOS), a form of rejection after lung transplantation. Moreover, numerous reports indicate that surgical correction of GERD may control the decline in lung function characteristic of BOS. Although laparoscopic fundoplication is an accepted treatment option for these patients with GERD, the surgical technique, which often includes a laparoscopic pyloroplasty, has not been standardized.

Methods: The purpose of this article is to describe a step-by-step approach to the laparoscopic treatment of GERD in lung transplant patients. We also address specific technical concerns encountered in the surgical management of this high-risk patient population; we provide data on the safety of this operation; and we illustrate the evidence-based rationale for each technical step of the procedure.

Fig. 1

Position of operative ports in order of placement: (1) optical port, 14 cm below the xiphoid process; (2) left working port, below the left costal margin in the mid-clavicular line; (3) epigastric port for the Nathanson retractor; (4) right working port, below the right costal margin in the mid-clavicular line; (5) assisting port, on the left anterior axillary line at the level of the optical port.

Fig. 2

Position of operative ports for the pyloroplasty.

Fig. 3

Completed Nissen fundoplication with collar stitches, posterior gastropexy and pyloroplasty.