The "balanced" operation for life threatening complications of severe "non responding" form of gastroesophageal reflux disease. A case report.

The fate of patients developing life-threatening complications of the Barret's non-responding ulcer during an acute treatment is lacking in the literature. Medical therapy with proton pump inhibitors (PPI) for severe forms of gastroesophageal reflux disease fails in 15-20%. Emergency operation is indicated in failed cases. We present an operation which restores anatomical and functional deviations causing reflux disease. Two patients required early surgery due to bleeding and penetration of Barret's ulcer during PPI therapy. Both patients had reflux disease, a Savary Miller stage of IV, and/or the M3; U1; S0; E3 and M3; U3; S0; E3 stage of "MUSE" assessment respectively. The modified "balanced operation" was performed consisting of a truncal vagotomy, hiatus hernia reposition, posterior crura repair, fundoplication and extramucosal pyloroplasty. Both patients had excellent outcomes after surgery. Visick I and II, or M3; U0; S0; E1 and M3; U0; S0; E0 respectively and remained well over the year without any medication. The modified "balanced" operation seems to be the method of choice for treatment of severe, "non responding" form of GERD when complications occur. Various pathophysiological factors such as hyperacidity, the cardia valve and gastric emptying are affected simultaneously. The rationale for the performance of all steps of the "balanced" operation is based on the fact that we do not know before the operation, which steps will be necessary to produce a good result.