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

Indications for Surgical Intervention

The American Gastroenterological Association indicates that LA grade C reflux esophagitis represents severe disease with confluent erosions that extend along the mucosal folds, requiring definitive treatment 1
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, according to the American College of Gastroenterology 2
Surgery is recommended when there is evidence of pathologic GERD with severe esophagitis that is uncontrollable with medical therapy, as stated by the American Gastroenterological Association 3, 2

Complete endoscopic evaluation should include documentation of LA classification grade of erosive esophagitis (Grade C in this case), as recommended by the American Society for Gastrointestinal Endoscopy 1
Measurement of hiatal hernia length (2cm in this case) is necessary, according to the Society of American Gastrointestinal and Endoscopic Surgeons 4
Barium swallow is necessary before surgical treatment to identify hiatus hernia, strictures, or short esophagus, as suggested by the European Society of Gastrointestinal Endoscopy 5
High-resolution manometry should be performed to assess esophageal peristaltic function and exclude achalasia, according to the American Gastroenterological Association 3

Laparoscopic approach is preferred over open surgery due to its excellent safety profile with reported overall in-hospital mortality rate of 0.14%, as stated by the Society of American Gastrointestinal and Endoscopic Surgeons 4
Closure of the diaphragmatic hiatus is essential to repair the hernia defect using non-absorbable sutures, as recommended by the American College of Surgeons 4, 2
Fundoplication should be performed in conjunction with hiatal hernia repair to address the reflux component, according to the Society of American Gastrointestinal and Endoscopic Surgeons 6, 2

Nissen fundoplication (360° wrap) is the most commonly performed technique and remains the gold standard for durable relief of GERD symptoms, as stated by the American College of Surgeons 4
Toupet fundoplication (270° posterior wrap) is an alternative with potentially lower rate of postoperative dysphagia, according to the European Association for Endoscopic Surgery 4

Postoperative complications may include dysphagia (more common with Nissen fundoplication), as reported by the Society of American Gastrointestinal and Endoscopic Surgeons 4
Gas bloat syndrome is a potential complication, as noted by the European Society of Gastrointestinal Endoscopy 5
Recurrent reflux is a possible complication, according to the Society of American Gastrointestinal and Endoscopic Surgeons 4

Endoscopic surveillance is recommended to monitor healing of esophagitis and detect potential complications, as suggested by the European Society of Gastrointestinal Endoscopy 5

The American Gastroenterological Association recommends laparoscopic fundoplication as the treatment of choice for gastroesophageal reflux disease (GERD), as it is feasible, safe, and effective 7
The laparoscopic approach has been shown to be superior to the traditional open approach, with shorter hospital stays and fewer complications 7

The Society of American Gastrointestinal and Endoscopic Surgeons recommends mobilization of the gastric fundus by dividing the short gastric vessels 8
The American College of Surgeons recommends dissection of the phrenoesophageal ligament to isolate the esophagogastric junction 8
A complete mobilization of the esophagus is necessary, using a tape to allow for full mobilization and high dissection in the mediastinum 9

The American Society for Gastrointestinal Endoscopy recommends avoiding injury to the vagus nerve during esophageal dissection 8
The World Journal of Emergency Surgery recommends that the wrap should be tension-free to prevent postoperative complications 9
The use of external drainage of the subphrenic space is recommended 9

The American College of Cardiology is not relevant in this context, however, The American Gastroenterological Association recommends that the choice between total and partial fundoplication should be based on the quality of esophageal peristalsis documented by preoperative manometry 7
The Nature Reviews Gastroenterology and Hepatology recommends that total fundoplication (Nissen) may result in more dysphagia, nausea, and gas bloating, but has a lower failure rate 7
The Gastroenterology journal recommends that partial fundoplication is associated with fewer adverse effects but a higher rate of reflux recurrence 7