Partial fundoplication for gastroesophageal reflux

Surg Endosc (1997) 11: 445–448 Surgical Endoscopy © Springer-Verlag New York Inc. 1997 Partial fundoplication for gastroesophageal reflux M. G. Patti, M. De Bellis, M. De Pinto, S. Bhoyrul, J. Tong, M. Arcerito, S. J. Mulvihill, L. W. Way Department of Surgery, University of California, San Francisco, 533 Parnassus Avenue, U-122, San Francisco, CA 94143-0788, USA Received: 1 April 1996/Accepted: 1 July 1996 Abstract Background: About 20% of patients with gastroesophageal reflux disease (GERD) have severely impaired esophageal peristalsis in addition to an incompetent lower esophageal sphincter. In these patients a total fundoplication corrects the abnormal reflux, but it is often associated with postoperative dysphagia and gas bloat syndrome. We studied the efficacy of partial fundoplication in such patients. Methods: A partial fundoplication (240°–270°) was performed laparoscopically in 26 patients (11 men, 15 women; mean age 50.5 years) with GERD (mean DeMeester score: 92 ± 16) in whom manometry demonstrated severely abnormal esophageal peristalsis. Results: All operations were completed laparoscopically and the patients were dicharged an average of 39 h after surgery. The preoperative symptoms resolved or improved in all patients, and no patient developed dysphagia or gas bloat syndrome. Postoperative pH monitoring showed complete or nearly complete resolution of the abnormal reflux in every patient. Conclusions: Partial fundoplication is an excellent treatment for patients with GERD and weak peristalsis, for it corrects the abnormal reflux and avoids postoperative dysphagia. Key words: Gastroesophageal reflux disease — Esophageal manometry — Esophageal peristalsis — Esophageal clearance — Partial fundoplication erative dysphagia and gas bloat syndrome were almost inevitable following fundoplication [1, 14]. Nevertheless, the indications for an antireflux procedure in such patients are compelling, for in addition to heartburn they have a high incidence of esophageal stricture formation, Barrett’s esophagus, and respiratory symptoms [9, 15]. The goal of this study was to determine whether a partial fundoplication controls the symptoms and the reflux, while avoiding troublesome side effects in patients with GERD and a panesophageal motor disorder. Patients and methods Between June 1993 and August 1995, a laparoscopic partial fundoplication was performed in 26 patients (11 men, 15 women; mean age 50.5 years) for treatment of GERD. Peroperative evaluation Symptoms. Patients were questioned regarding the presence of symptoms suggestive of GERD. Figure 1 shows the severity of the presenting symptoms. Symptoms had been present preoperatively for an average of 133 months (range, 4–360). Upper gastrointestinal series. Twenty-two patients had a hiatal hernia. The study was normal in four patients. Some patients with gastroesophageal reflux disease (GERD) have severely impaired esophageal peristalsis in addition to an incompetent lower esophageal sphincter (LES) [5, 10, 11, 15]. They have often been considered to be poor candidates for surgery on the assumption that postopPresented at the 5th World Congress of Endoscopic Surgery of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Philadelphia, Pennsylvania, USA, 15 March 1996 Correspondence to: M. G. Patti Esophagogastroduodenoscopy. According to the SavaryMiller classification, 13 patients (50%) had grade I or II esophagitis, and 13 patients (50%) had grade III or IV esophagitis. Barrettt’s esophagus (verified by biopsy findings) was present in four patients (15%). Esophageal manometry. The patients were studied after an overnight fast. Medications which interfere with esophageal motor function (metoclopramide, cisapride, calcium- 446 chest roentgenogram was always taken to confirm the proper position of the probe in the esophagus. During the study, the patients consumed a normal diet and were taking no medications. A commercial software program was used for data analysis (Gastrosoft, Synectics Medical, Irving, TX). All patients had abnormal gastroesophageal reflux (mean preoperative DeMeester score, 92 ± 16; normal score <15) [4]. Radionuclide measurement of gastric emptying. The rate of gastric emptying of solids was selectively measured in six patients whose symptoms suggested delayed gastric emptying. Emptying was very slow in two of these six patients (85 ± 8% of the test meal remained in the stomach after 3 h [normal, 22 ± 10%]). The remaining four patients had normal emptying. Operative technique Fig. 1. Severity of symptoms among 26 patients ( , preop; ■, postop) with gastroesophageal reflux disease. Symptom score (0–4). *Statistically significant. **No patient developed postoperative dysphagia or gas bloat syndrome. channel blockers) were discontinued 24 h prior to the study. Manometry was performed using an 8-lumen catheter which was continuously perfused at a rate of 0.5 ml/min by a low-compliance pneumohydraulic pump (Arndorfer Medical Specialties, Greefiel, WI) and connected to a polygraph (Synectics Medical, Irving, TX). The length and pressure of the LES were measured using the station pull-through technique. Amplitude, duration, and velocity of the peristalitic waves were then assessed in response to 10 swallows of 5 ml of water given at 30-s intervals. Computerized data analysis was done using a commercial software program (Gastrosoft, Synectics Medical, Irving, TX). Twenty (76%) patients had an incompetent LES according to the DeMeester criteria [16]. All patients had severe abnormalities of peristaltic amplitude, duration, or velocity, and/or morphology of the peristaltic waves (i.e., amplitude in the distal esophagus <40 mmHg; >20% segmented waves; >30% double-peaked waves; and presence of triple-peaked and/or dropped waves). The operation was performed under general anesthesia. An orogastric tube was inserted at the beginning and was removed at the end of the procedure. The patient was placed supine on the operating table in steep reverse Trendelenburg position with the legs extended in stirrups. Five 10-mm trocars were used. The operation involved seven steps: (1) The gastrohepatic ligament was divided from mid lesser curve to the diaphragm, allowing the right side of the crus to come into view. (2) The right side of the crus was separated by blunt dissection from the abdominal esophagus posteriorly all the way to the point where it joined the left crus. (3) The peritoneum and phrenoesophageal membrane anterior to the esophagus were divided, and the left border of the crus was dissected away from the esophagus to the point where it met the right side of the crus. (4) A window was created behind the abdominal esophagus between the crus and the gastroesophageal junction. A Penrose drain passed around the abdominal esophagus was used for retraction. (5) The short gastric vessels were divided from a point midway along the greater curvature up to the angle of His using Laparosonic Coagulating Shears (LCS). (6) The diaphragmatic hiatus was narrowed with 2-0 silk sutures tied intracorporeally. (7) The gastric fundus was pulled behind the abdominal esophagus, and a 240°– 270° posterior wrap was created over a 56–60 F bougie. The total length of the fundoplication was 2 cm. Figure 2 shows the position of the stitches (2-0 silk) used for the reconstruction. Two or three stitches were used to close the hiatus (A); six stiches were used to suture the gastric fundus to the esophagus (B); two stiches were placed between the right side of the wrap and the closed crus to counteract lateral or cephalad traction on the wrap (C); and two stitches were placed apically (including the esophagus, the right or left crus, and the wrap) to counteract cephalad traction (D). The following concomitant laparoscopic procedures were performed in four (15%) patients: pyloromyotomy, two patients; cholecystectomy, one patient; and extensive lysis of adhesions, one patient. Statistical analysis Student’s t-test was used for statistical evaluation of the data. All results are expressed as mean ± standard error of the mean. Differences were considered significant at p < 0.05. Results Ambulatory 24-h pH monitoring. Acid-suppressing medications were discontinued 3–10 days before the test. Ambulatory pH monitoring was performed by using a pH probe with an antimony sensor which was positioned 5 cm above the upper border of the manometrically determined LES. A Hospital course All operations were completed laparoscopically, and there were no intraoperative complications. The average operat- 447 tients; their preoperative DeMeester score of 125 ± 40 decreased to 40 ± 9 postoperatively. Three of these four patients are asymptomatic. Discussion Fig. 2. Partial fundoplication: (A) stitches to approximate the crura; (B) stitches from the right side of the wrap to the closed crus; (C) stitches from the right and left side of the wrap to the esophagus; (D) apical stitches (incorporating the crus, the esophagus, and the wrap). ing time was 184 ± 10 min. The average blood loss was 30 ml. The patients were given oral liquids the evening of the procedure and were progressed to a regular diet the next morning (average 25 ± 2 h). They left the hospital an average of 1.7 days (39 ± 4 h) after surgery. No acidsuppressing drugs (e.g., H2-receptor blockers; omeprazole) were given after the operation. Postoperative complications developed in three patients (urinary retention, one patient; swollen labia due to patent canal of Nuck, one patient; angina pectoris, one patient). Postoperative follow-up The mean length of follow-up is 11 months. Patients were seen in the office one and two months postoperatively. Subsequently, they were interviewed by telephone at 2-months intervals by one of the authors. Heartburn and regurgitation resolved in 23 (88%) of the 26 patients and improved substantially in the remaining three patients. Respiratory symptoms, which were present preoperatively in five patients, disappeared in 4 patients and improved in one. Before surgery, nine patients experienced intermittent dysphagia for solids and liquids; postoperatively, the dysphagia resolved in six (66%) of these patients and improved in three patients. No patient developed de novo dysphagia or gas bloat syndrome postoperatively. Chest pain resolved in 13 (100%) out of 13 patients (Fig. 1). Twenty-four pH monitoring was repeated 2 months after the operation in 13 (50%) of the 26 patients. In nine patients, the abnormal reflux was completely corrected (the DeMeester score went from 76 ± 14 preoperatively to 6 ± 1 postoperatively). Residual reflux was identified in four pa- During the past decade it has become evident that the esophageal body plays a key role in the antireflux mechanism [5, 10, 15]. While the pressure and behavior of the LES regulate the amount of gastric contents that refluxes into the esophagus, esophageal peristalsis is the major determinant of esophageal volume clearance [6]. When peristalsis is weak, clearance is slow, and the time that gastric refluxate remains in contact with the mucosa lengthens, the upward extent of reflux increases, and the degree of mucosal injury worsens [5, 10, 15]. Severe concomitant abnormalities of the LES and esophageal peristalsis coexist in about 20% of patients with GERD [11], and the combination is especially common in patients with large hiatal hernias, in whom the LES is shorter and weaker, acid clearance is less effective, and the amount of refluxate is greater [13]. Furthermore, there is evidence that reflux of duodenal juices joins with acid reflux in producing the resulting disease [8]. Medical therapy in these patients is often ineffective. Patients such as these are most in need of a fundoplication, as stricutres and Barrett’s esophagus are more common [15], and respiratory symptoms are often present [9]. Some clinicians, however, have rejected surgery as an option, fearing that a fundoplication will cause dysphagia and gas bloat syndrome [1, 14]. Others have recommended a Nissen fundoplication for all patients with severe GERD regardless of their manometric findings, although postoperative dysphagia is common with this strategy [2, 3]. The question addressed in this report is whether a partial wrap is less likely to pose an obstacle to food passage while still preventing reflux [7, 11, 16]. If so, esophageal manometry and acid exposure should be measured preoperatively in all patients with GERD being considered for surgery, since there are no clinical findings that reliably identify patients whose peristalsis is especially weak. Then a partial wrap (240°–270°) should be chosen when amplitude of peristalsis in the distal esophagus is below 50 mmHg and esophageal clearance is slow [11, 12]. An upper gastrointestinal series and endoscopy found out the standard preoperative workup. The results of this study confirm the validity of this approach. After a mean follow-up of 11 months, the patients were either free of heartburn and regurgitation (88%) or much improved, respiratory symptoms had resolved in twothirds of patients, and chest pain had been relieved in all. No patient developed postoperative dysphagia or gas bloat syndrome, and, in fact, dysphagia improved whenever it had been present preoperatively. Postoperative pH monitoring showed a small amount of residual reflux in four patients; only one of these patients experiences mild heartburn during follow-up, which is adequately treated with PRN antacids. Longer follow-up will determine if these results are longlasting. These results show that a partial fundoplication is clinically effective in patients with GERD and severely impaired 448 esophageal peristalsis. This operation corrects the symptoms and the measurable reflux without incurring postoperative dysphagia or gas bloat syndrome. References 1. 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