A novel concept on the origin of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a very common disease which results from anatomical and physiological alteration of a very sophisticated system that traverses the chest and abdominal cavities (1).

The lack of full understanding of the intricate relationship between these organs is reflected in various modalities of antireflux surgery with conflicting data. The two essential components of antireflux surgery are hiatal repair and fundoplication. The benefit of fundoplication is constantly being challenged for the simple reason of changing the shape and the geography of the gastroesophageal area (2). While fundoplication was studied extensively, the handling of the diaphragmatic crura received less attention (3). There is growing interest in the surgical community to understand the difference between hiatal closure and hiatal repair which have been used interchangeably for decades. Crural closure entails obscuring the diaphragmatic crural defect while crural repair focuses of restoration of the anatomy and producing a functional closure (4).

In this insightful case series, the patients did not have fundoplication and the antireflux surgery was tailored to reproduce the original anatomy. The main hypothesis is that the heart is the central engine for the cardio-oesophageal and diaphragm interaction system (CODIS). The author supports his theory with anatomical findings, logical physiological rationale, and excellent imaging. I find this hypothesis to be plausible and the conclusion to be compelling. However, this needs to be examined in the context of a prospective clinical trial with larger number of patients and with the inclusion of esophageal manometry and/or endoFLIP system to properly assess the esophageal motility and the dynamics of the esophagogastric junction.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Laparoscopic Surgery. The article did not undergo external peer review.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://ls.amegroups.com/article/view/10.21037/ls-22-32/coif). The author has no conflicts of interest to declare.

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References

1. El-Serag HB, Sweet S, Winchester CC, et al. Update on the epidemiology of gastro-oesophageal reflux disease: a systematic review. Gut 2014;63:871-80. [Crossref] [PubMed]
2. Müller-Stich BP, Köninger J, Müller-Stich BH, et al. Laparoscopic mesh-augmented hiatoplasty as a method to treat gastroesophageal reflux without fundoplication: single-center experience with 306 consecutive patients. Am J Surg 2009;198:17-24. [Crossref] [PubMed]
3. Broeders JA, Mauritz FA, Ahmed Ali U, et al. Systematic review and meta-analysis of laparoscopic Nissen (posterior total) versus Toupet (posterior partial) fundoplication for gastro-oesophageal reflux disease. Br J Surg 2010;97:1318-30. [Crossref] [PubMed]
4. Fanous M. Characterization of Crural Repair in Antireflux Surgery: Preliminary Experience with a Standardized Technique. Foregut 2022. [Epub ahead of print]. doi: .10.1177/26345161221101371