Effects of fundoplication on the antireflux mechanism

Rumination syndrome: when the lower oesophageal sphincter rises

BACKGROUND

Rumination syndrome is an uncommon condition characterised by the self-induced regurgitation from the stomach to the mouth of recently ingested meal that is chewed and reswallowed. Rumination is caused by a voluntary rise in intra-abdominal and intra-gastric pressure leading to the reflux of the gastric content into the oesophagus. However, the precise mechanisms preventing reflux at the gastro-oesophageal junction during the rise in intra-gastric pressure remains unknown.

METHODS

In 5 patients, rumination episodes were monitored using combined multiple intra-luminal impedance monitoring, high resolution manometry, and video-fluoroscopic recording.

RESULTS

We showed that the gastro-oesophageal junction moved from the abdominal cavity into the thorax creating a "pseudo-hernia". This occurred at a range of 1.4 ± 0.3 s before the rise in intra-oesophageal pressure and the gastro-oesophageal reflux.

CONCLUSION

This displacement of the gastro-oesophageal junction into thorax, rather than a lower oesophageal sphincter opening, explains the mechanism of voluntary regurgitations occurring during rumination syndrome.

Altered esophageal sensory-motor function in patients with persistent symptoms after Nissen fundoplication

BACKGROUND

The pathophysiology of persistent gastroesophageal reflux disease (GERD) symptoms after antireflux surgery is unclear. We assessed esophageal sensorimotor function in patients with GERD before and after Nissen fundoplication (NF).

METHODS

Sensory and biomechanical properties were evaluated before surgery using impedance planimetry in 17 GERD patients and 16 healthy volunteers. All patients underwent standard laparoscopic NF. Eight GERD patients with persistent symptoms after surgery underwent repeat evaluations at least 12 months after surgery.

RESULTS

At baseline, GERD patients had lower thresholds for first perception (P < .001), discomfort (P < .001), and pain (P < .001) compared with controls. The esophagus was more reactive (P = .001) and less distensible (P = .04) in patients than controls. After NF, in patients with persistent symptoms, the sensory thresholds were unchanged (P > .05) but esophageal wall reactivity decreased (P = .001), and distensibility improved (P = .025).

CONCLUSIONS

NF improves esophageal biomechanical dysfunction but not the underlying hypersensitivity. Visceral hypersensitivity of the esophagus may explain persistent symptoms after NF.

Nonobstructive dysphagia and recovery of motor disorder after antireflux surgery

BACKGROUND

Changes in motor disorder after Nissen 360 degrees surgery were studied based on clinical signs of preoperative nonobstructive dysphagia.

MATERIALS AND METHODS

Forty-seven patients undergoing Nissen 360 degrees fundoplication for gastroesophageal reflux were studied with pH recording and esophageal manometry before and 1 year after fundoplication. Amplitude of contraction of the distal third of the esophagus (ACDTE) and the presence of primary propulsive waves were studied.

RESULTS

Fourteen patients had clinical signs of preoperative dysphagia. Of these, 50% had an ACDTE lower than 30 mm Hg, and 71.4% nonpropulsive waves (P <0.05). Forty-three percent and 30%, respectively, of patients with dysphagia recovered ACDTE and the presence of primary propulsive waves 1 year after the procedure, as compared with 66.6% (P <0.05) and 81.8% (P <0.01%) of patients without dysphagia.

CONCLUSIONS

A correlation was found between preoperative dysphagia and esophageal motility disorders (P <0.05). One year after fundoplication, recovery was significantly higher in patients without preoperative dysphagia.

Effect of laparoscopic partial fundoplication on reflux mechanisms

OBJECTIVES

Transient lower esophageal sphincter relaxations (TLESRs) are the main mechanism causing gastroesophageal reflux. Since 1994 we have performed laparoscopic partial instead of complete fundoplication as standard surgical treatment for therapy resistant reflux disease to minimize postoperative dysphagia. To better understand the management of gastroesophageal reflux, we conducted a prospective study of the effects of laparoscopic partial fundoplication on TLESRs and other reflux mechanisms.

METHODS

From 1994 to 1999, 65 patients underwent laparoscopic partial fundoplication (180-200 degrees) and 28 of these patients (16 female, 12 male, mean age 43 +/- 2 yr [range, 26-66 yr]) agreed to participate in this prospective study on reflux mechanisms. Before and 6 months after surgery, all patients were evaluated by simultaneous recording of pH and lower esophageal sphincter characteristics, using sleeve manometry.

RESULTS

After partial fundoplication basal LES pressure increased significantly (p < 0.05), from 14.3 +/- 1.2 mm Hg to 17.8 +/- 1 mm Hg. Partial fundoplication significantly (p < 0.05) decreased the number of TLESRs, from 3.4 +/- 0.8 to 1.6 +/- 0.3 per hour in the fasting period, and from 4.7 +/- 0.5 to 1.9 +/- 0.3 per hour postprandially. The percentage of TLESRs associated with reflux also decreased significantly (p < 0.05), from 45 +/- 7% to 27 +/- 6% after operation. The number of reflux episodes decreased significantly (p < 0.05), from 4.1 +/- 0.7 to 1.3 +/- 0.3 per hour postoperatively. The majority of these episodes were associated with TLESRs: 57% and 46%, pre- and postoperatively, respectively.

CONCLUSIONS

Laparoscopic partial fundoplication significantly increased fasting and postprandial LES pressure and significantly decreased TLESR frequency. This resulted in a significant reduction in esophageal acid exposure, with preservation of postprandial LES characteristics.

Patients' experiences of illness, operation and outcome with reference to gastro-oesophageal reflux disease

BACKGROUND

Describing the illness-story from a patient perspective could increase understanding of living with a chronic disease for health professionals and others, facilitate decision-making about treatment and enhance information about the outcome from a patient perspective.

AIM

To illuminate patients' illness experiences of having a gastro-oesophageal reflux disease (GORD), going through surgery and the outcome.

METHODS

Twelve patients were interviewed 5 years after having had the operation; six patients had had fundoplication via laparoscopy and six via open surgery. Each patient was asked to talk openly about their experiences, thoughts, feelings and consequences of living with the illness, going through surgery and the period from surgery to the day of interview. A qualitative content analysis was performed concerning the context of the data and its meaning.

FINDINGS

Three central categories were identified and nine subcategories: living with GORD- symptoms of the disease affecting daily living, taking medicines, work, family and social life; concerns related to surgery- decision-making about the operation, influence by physicians; life after the operation- outcomes and consequences, side-effects and complications of the operation, sick leave, information and sharing experiences with future patients. All patients were free from symptoms of the illness after surgery independent of type of surgery, but side-effects from surgical treatment varied individually. Interviewees would have liked information concerning side-effects after surgery from previous patients.

CONCLUSIONS

This study contributes to knowledge about patients' long-term suffering, their control of symptoms and how they have tried to cure themselves, but also about their concerns about surgery and the importance of surgical treatment to their quality of life. They wanted information about treatment, outcome and consequences, not only from a health care perspective but also from previous patients having had the same treatment.

Laparoscopic fundoplication for symptomatic but physiologic gastroesophageal reflux

Esophageal pH monitoring identifies some patients who have physiologic amounts of esophageal acid exposure but have a strong correlation between symptoms of esophageal reflux events. These patients with symptomatic physiologic reflux probably have enhanced sensory perception of reflux events and may be difficult to control with acid-suppressive therapy. Little is known about the role of fundoplication in such patients. Patients with no endoscopic evidence of gastroesophageal reflux disease and a normal 24-hour pH composite score (<22.4 in our laboratory), but a symptom index (SI = number of symptoms with pH <4/total number of symptoms) greater than 50% were offered laparoscopic fundoplication if acid-suppressive therapy was unsatisfactory. This group comprised 18 (4%) of 459 patients undergoing fundoplication at our institution. Heartburn, dysphagia, and reflux symptoms were scored on a scale of 0 to 10 with patients on and off medicine preoperatively, and at a mean of 7.2 months (range 1 to 32 months) postoperatively. The 18 patients with symptomatic physiologic reflux (6 males and 12 females) had heartburn as a major complaint. Preoperative response to proton pump inhibitors for heartburn was 72% and for all symptoms was 60%. The group had a mean pH composite score of 14 (range 4 to 22). The symptom used to calculate the symptom index was heartburn in 12 patients, regurgitation in three, chest pain in two, and cough in one. An average of 18 symptoms (range 2 to 56) were recorded. The mean symptom index was 82% (range 50% to 100%). A Nissen fundoplication was performed in nine patients and a Toupet fundoplication in nine. Surgery was successful (>90%) in alleviating reflux symptoms in 14 patients and partially successful (>75%) in three of the remaining four patients. Gas bloat and dysphagia were seen in one patient each. Fundoplication is effective at relieving reflux symptoms in carefully selected patients with symptomatic physiologic reflux, with minimal side effects.

Prognostic value of the lower esophageal sphincter gradient and acid exposure in the follow-up of antireflux operations

Eighty-eight consecutive patients with antireflux fundoplication had manometry and pH recording pre- and post-operatively at 6 months and 1, 3 and 5 years for a mean follow-up of 30.6 months. Failure occurred in nine patients (11.4%). For the whole group of patients, surgery produced a significant increase in the lower esophageal sphincter (LES) pressure gradient from 9.5 +/- 6.3 to 14.6 +/- 6.7 mmHg and a significant decrease in acid exposure from 20.6% +/- 17.6% to 5.5% +/- 8.8% at 6 months. There was a similar change in pressure (p < 0.0005) and pH (p < 0.002) in the successful but not in the failure group. Over time, the values remained stable in both groups. Post-operative LES pressure was significantly correlated with the outcome at 6 months (p < 0.02), and the pH was inversely correlated at 5 years (p < 0.039). This study confirms the early predictive value of the post-operative LES pressure. Esophageal acid exposure remains a reliable marker of the outcome. However, recurrences remain unexplained by LES pressure measurement and long-term follow-up using manometry and pH recording does not bring additional valuable data.

Randomized clinical trial of laparoscopic versus open fundoplication: blind evaluation of recovery and discharge period

BACKGROUND

There is a widespread belief that introduction of the laparoscopic technique in antireflux surgery has led to easier postoperative recovery. To test this hypothesis a prospective randomized clinical trial with blind evaluation was conducted between laparoscopic and open fundoplication.

METHODS

Sixty patients with gastro-oesophageal reflux disease were randomized to open or laparoscopic 360 degrees fundoplication. The type of operation was unknown to the patient and the evaluating nurses after operation.

RESULTS

The operating time was longer in the laparoscopy group, median 148 versus 109 min (P < 0.0001). The need for analgesics was less in the laparoscopically operated patients, 33.9 versus 67.5 mg morphine per total hospital stay (P < 0.001). There was no significant difference in postoperative nausea and vomiting. On the first day after operation patients in the laparoscopy group had better respiratory function: forced vital capacity 3.2 versus 2. 2 litres (P = 0.004) and forced expiratory volume 2.6 versus 2.0 litres (P = 0.008). Postoperative hospital stay was shorter in the laparoscopic group, median (range) 3 (2-6) versus 3 (2-10) days (P = 0.021). No difference was found in the duration of sick leave.

CONCLUSION

Laparoscopic fundoplication was associated with a longer operating time, better respiratory function, less need for analgesics and a shorter hospital stay, while no reduction in the duration of postoperative sick leave was found compared with open surgery.

The effect of fundoplication on the motility of the canine lower oesophageal sphincter

BACKGROUND

A canine model was used to define whether Nissen fundoplication inhibits gastro-oesophageal reflux by inhibiting transient lower oesophageal sphincter relaxations (TLOSR) or by creating a pressure barrier at the gastro-oesophageal junction.

METHODS

Four surgical models were studied pre-operatively and postoperatively. These were: (i) the surgical mobilization required for fundoplication (sham fundoplication, n = 5); (ii) a standard fundoplication (n = 4); (iii) anterior and posterior myotomy of the lower oesophageal sphincter (LOS; cardiomyotomy, n = 4); and (iv) combined cardiomyotomy and fundoplication (n = 4). Each operative procedure was assessed for its effect on the incidence of TLOSR and gas reflux events, the mean LOS pressure and the LOS pressure profile during swallow events.

RESULTS

Sham fundoplication reduced the rate of evoked TLOSR in response to gaseous gastric insufflation from 9.8+/-1.6/h (mean +/- SEM) to 5.4 +/-1.5/h. The mean LOS pressure was reduced from 25.1+/-2.6 to 18.5+/-2.1 mm Hg but nadir LOS pressure during swallowing was not altered. Nissen fundoplication virtually abolished evoked TLOSR from 10.4+/-1.2/h to 0.4+/-0.4/h, increased mean basal LOS pressure from 19.8+/-2.1 to 27.0+/-1.1 mm Hg and increased the nadir pressure on swallowing from 3.4+/-1.0 mm Hg to 14.4+/-1.0 mm Hg. Cardiomyotomy was associated with a near continuous leakage of gas across a chronically hypotensive LOS. Cardiomyotomy reduced the resting LOS pressure from 14.7+/-1.2 mm Hg to 2.3+/-1.0 mm Hg. Cardiomyotomy with fundoplication was associated with no loss of LOS competence. No gas venting episodes occurred either by passive leakage or by TLOSR. Cardiomyotomy with fundoplication was associated with a fall in mean LOS pressure from 14.3+/-1.5 mm Hg to 7.1+/-1.8 mm Hg but no LOS relaxation occurred during swallowing.

CONCLUSION

Nissen fundoplication is highly effective in preventing reflux across a normal or chronically hypotensive LOS. Fundoplication results in a constant, measurable pressure barrier at the lower end of the oesophagus that is not due to a change in intrinsic LOS tone. Following fundoplication TLOSR are prevented by the constant low-pressure barrier.

Evaluation of the antireflux mechanism following laparoscopic fundoplication

BACKGROUND

Laparoscopic Nissen fundoplication is an effective procedure for the treatment of gastro-oesophageal reflux disease (GORD), but the underlying motility mechanisms that explain the success of this operation remain unclear.

METHODS

Twenty patients with a history of GORD underwent stationary oesophageal manometry and prolonged ambulatory pH monitoring, both before and 3 months after fundoplication.

RESULTS

Eighteen patients were completely cured of reflux symptoms and stopped all antireflux medication after operation. After fundoplication there was a significant increase (P < 0.01) in median resting lower oesophageal sphincter (LOS) pressure and length. Median residual LOS pressure during swallow-induced LOS relaxation also increased significantly after operation (P < 0.01). The number of reflux episodes decreased from a median of 48 to 3 after fundoplication (P < 0.01). The time at pH less than 4 decreased from 5.7 to 0 per cent in the supine position (P < 0.01), and from 9.8 to 0.2 per cent while upright (P < 0.001).

CONCLUSION

Early subjective results at 3 months following laparoscopic antireflux surgery show improved symptoms. One of the mechanisms underlying the antireflux action of fundoplication is an increase in median residual LOS pressure at the gastro-oesophageal junction. This may be a purely mechanical effect of the fundic wrap extrinsic to the LOS.

Cost effectiveness of medical versus surgical treatment in patients with severe or refractory gastroesophageal reflux disease in the Netherlands

BACKGROUND

For a significant number of patients with severe or refractory gastroesophageal reflux disease, maintenance treatment with omeprazole and reflux surgery (Nissen fundoplication) are alternative treatment options. In this study maintenance treatment with omeprazole is compared with open and laparoscopic Nissen fundoplication from a health-economic perspective.

METHODS

Meta-analysis of published articles to assess effectiveness and simple decision-analytic techniques to combine costs and effects are used. Findings and assumptions are submitted to sensitivity analysis.

RESULTS

It is estimated that it costs approximately 1880 Dutch guilders to initially heal a patient with severe or refractory esophagitis with 40 mg omeprazole daily. When medical maintenance therapy was compared with surgery, it appeared that medical maintenance therapy with omeprazole (20-40 mg daily) for a prolonged period of time (more than 4 years) is less cost effective than a Nissen procedure. It is estimated that a laparoscopic Nissen will shift this so-called break-even point towards 1.4 years, mainly due to a shorter hospital stay.

CONCLUSIONS

Although caution is required in drawing conclusions, it appears that replacing treatment with (laparoscopic) Nissen fundoplications in these patients might lead to substantial savings.

A prospective study on the effect of the Belsey Mark IV 270-degree fundoplication on lower esophageal sphincter characteristics and esophageal body motility

The effect of the Belsey Mark IV operation on lower esophageal sphincter characteristics and esophageal body motor function was prospectively studied in 38 patients who underwent successful operation (relief of symptoms, healing of esophagitis; group I) and 8 who had surgical failure (group II). Mean follow-up was 3 years (0.5 to 8 years). Only in group I a rise in basal lower esophageal sphincter pressure (from 8.3 +/- 0.8 mm Hg to 14.5 +/- 0.5 mm Hg, p < 0.001), total sphincter length (from 2.7 +/- 0.1 cm to 3.4 +/- 0.1 cm, p < 0.001), and the intraabdominal sphincter segment (1.3 +/- 0.1 cm to 2.3 +/- 0.1 cm, p < 0.001) with a reduction of the intrathoracic segment (from 1.5 +/- 0.1 cm to 1.1 +/- 0.1 cm, p < 0.05) was recorded. Preoperative and postoperative lower esophageal sphincter pressure and length values showed a large overlap. Antireflux operation had no effect on peristaltic amplitude, velocity, and duration, irrespective of the outcome of operation. One of five patients with incomplete swallow-induced lower esophageal sphincter relaxation had moderate dysphagia. Successful operation by 270-degree fundoplication is accompanied by a significant increase in lower esophageal sphincter pressure and length and does not affect esophageal body motor function.

Laparoscopic Nissen-Rossetti fundoplication

Although antireflux surgery offers very good results and patient's satisfaction, the referral rate to the surgeon remains very low. We present our experience with a less-invasive procedure that would result in minimal pain and very rapid return to normal activities and thus might lead to earlier referral. Fifty-nine patients with documented reflux esophagitis were treated. There were 31 females and 28 males whose age ranged from 27 to 69 years and whose weight varied between 140 and 280 lbs. Pre-op work-up included endoscopy, barium swallow, manometry, and 24-h pH studies. There was no mortality and morbidity was minimal; hospital stay was 2-3 days. Ten patients were lost to follow-up; all the remaining patients are completely asymptomatic, and the patients who had their pre-op work-up repeated showed normal results. Laparoscopic fundoplication seems to be as efficient and safe as the open procedure.

Laparoscopic Nissen fundoplication: technique and preliminary results

Between May 1991 and November 1992, 80 consecutive patients with gastro-oesophageal reflux disease underwent laparoscopic Nissen fundoplication. The technique used was exactly the same as for the conventional open approach. There were no deaths but there were four peroperative complications: one gastric perforation, two pleural perforations and one hepatic laceration. Three conversions to laparotomy were necessary, one because of a defective needle holder and two as a result of left hepatic lobe hypertrophy. The duration of operation ranged from 40 to 300 (median 150) min. The median postoperative stay was 3 days, but increased to 10 days in two patients who developed pulmonary infection. One major postoperative complication (necrosis of the wrap) required a laparotomy on day 8 after operation. No recurrence of heartburn has been observed and there were no instances of long-term dysphagia after surgery. These findings indicate that laparoscopic Nissen fundoplication can be performed safely if the team is well trained.

Nissen fundoplication for reflux esophagitis. Long-term clinical and endoscopic results in 109 of 127 consecutive patients

OBJECTIVE

This study evaluates the clinical and endoscopic long-term results of Nissen fundoplication in reflux esophagitis.

SUMMARY BACKGROUND DATA

Nissen fundoplication has been reported to give good results in the treatment of gastroesophageal reflux with success rates up to 78-97%. Most of the previous studies on long-term results of fundoplication have, however, been based on interviews with only sporadic endoscopic examinations.

METHODS

Of 127 patients consecutively treated with Nissen fundoplication for reflux esophagitis, 109 were available for follow-up after a median of 77 months. Upper gastrointestinal endoscopy was done in 105 cases, and all the patients with reflux symptoms or abnormal endoscopic observations were referred to esophageal 24-hour pH monitoring and manometry.

RESULTS

No symptoms of gastroesophageal reflux were reported by 73 of the 109 patients, but dysphagia was present in 47. Endoscopy showed defective fundic wrap in 24 patients. Objective evidence of reflux was found in 24 patients (endoscopic esophagitis in 18 and pathologic 24-hour pH score without esophagitis in 6). Esophagitis was found in 14 of the 24 patients with defective wrap, but in only 4 of the 81 with infact wrap.

CONCLUSIONS

Nissen fundoplication alleviated symptoms of gastroesophageal reflux and cured esophagitis in great majority of cases. The main determinant of outcome was the state of the fundic wrap.

Outcome 5 years after 360 degree fundoplication for gastro-oesophageal reflux disease

Forty patients with a mean age of 45 (range 22-65) years were operated on between 1982 and 1985 for gastro-oesophageal reflux disease with a short floppy 360 degree fundoplication. The results of the operation were determined by endoscopy, oesophageal manometry, ambulatory 24-h pH recording and symptom evaluation 6 months and 5 years after operation. These results were compared with findings in healthy controls. The median pressure in the lower oesophageal high-pressure zone was 13.3 (interquartile range (i.q.r.) 11.3-21.3) mmHg after 5 years, which did not differ significantly from the value at 6 months' follow-up or from that in controls. It was, however, significantly higher than the preoperative pressure. The median intra-abdominal length of the high-pressure zone was 1.7 (i.q.r. 1.3-2.3) cm after 5 years, significantly less than at 6 months but equal to control length. Measurement of the proportion of total time at pH < 4 at 5 years (median 0.2 (i.q.r. 0.0-0.6) per cent) and 6 months after operation revealed a significant reduction in acid reflux compared with preoperative values and normal controls. There was no significant difference in acid exposure between the two postoperative investigations. Endoscopy showed that 27 patients had no oesophagitis, three had erythema and three persistent Barrett's oesophagus 5 years after operation. Normal belching was possible in 22 patients and 18 experienced increased flatulence 5 years after fundoplication. An independent gastroenterologist found that the result was excellent in 16 patients, good in 16 and fair in four; two patients had a poor overall outcome of the operation. It is concluded that a 360 degree fundoplication provides good long-term control of reflux and that slight symptoms of overcompetence are common among patients operated on without affecting the overall result.

Identification of an abnormal esophageal clearance response to intraluminal distention in patients with esophagitis

Esophageal clearance responses were studied by a new technique comprising a miniature electronic strain gauge attached to an inflatable balloon in 30 normal volunteers and 48 patients with gastroesophageal reflux disease. The pressure changes around the balloon and traction forces acting on the balloon were measured during graded balloon distention (0-12 mL of air for 30 seconds each inflation) in the lower and midesophagus. All normal volunteers responded to distention with development of swallow independent contractions above the balloon [65 mm Hg/30 s (range, 45-100 mm Hg/30 s)] together with generation of an aboral traction force [15 g (range, 9-20 g)]. Patients with reflux esophagitis showed a higher distention threshold for initiation of these responses, induced fewer proximal contractions [24 mm Hg/30 s (range, 0-38 mm Hg/30 s); P less than 0.01 vs. normal], and generated weaker traction forces [4 g (range, 0-6 g) at 10 mL P less than 0.01 vs. normal]. Patients with the most severe esophagitis showed greatest impairment of the clearance response (correlation = 0.7, P less than 0.01) and the greatest esophageal residence of refluxed acid (correlation = 0.5, P less than 0.01). These abnormalities appear to be of relevance to the pathophysiology of esophageal reflux disease although it remains to be determined whether they are the cause, or the result, of the esophagitis.

Maintenance therapy: Is there still a place for antireflux surgery?

Effective and safe maintenance medical therapy for uncomplicated reflux esophagitis is now feasible with omeprazole and it is likely that other H+K+ATPase blockers, and possibly very high dose H2 receptor antagonist regimens, will also be acceptable. In addition, many patients with ulceration, strictures, and Barrett's esophagus will respond to conservative medical therapy and a proportion of patients with erosive esophagitis may remain in remission with cisapride or with low dose H2 receptor antagonists, if disease is less severe. Thus, there is now a medical "gold standard" against which surgical therapy for uncomplicated esophagitis must be judged and it is essential that all future studies be conducted with clearly defined criteria for the assessment of the symptoms and endoscopic signs of esophagitis and its complications. As ever, the patient's wishes are paramount, but he or she must be allowed to select his or her therapy on the basis of a balanced and fully informed assessment of the long-term and short-term risks of all therapeutic modalities. The burdensome prospect of lifelong tablet ingestion and its potential dangers must be weighed against the alternative, in up to 30% of cases, that surgery may produce dysphagia, gas bloat, or dumping with no guarantee of a long-term cure.

Fundoplication: how to do it? Peri-esophageal wrapping as a therapeutic principal in gastro-esophageal reflux prevention

The prerequisites for a successful outcome after fundoplication are careful patient selection, good technique, and an understanding of the principles of antireflux surgery. The most important aspect of any such operation is the construction of a peri-esophageal ring around the gastro-esophageal junction buttressing the sphincter and, thus, neutralizing the gastric opening pressure. Accordingly, the operation has to comprise: 1) generous dissection around the gastric fundus to allow the formation of a "floppy" fundoplication; 2) construction of the cuff as short as possible (2 cm to 3 cm); and 3) proper fixation of the cuff at the correct site in the region of the lower esophageal sphincter. Adherence to these principles will avoid postoperative dysphagia or functional gastro-intestinal disorders and produce long-lasting reflux control in approximately 90% of patients at 10 years. Problems of hypercontinence may occasionally occur since gastro-esophageal reflux suppression is usually complete and any physiological reflux abolished. With the advent of modern drug treatment, the excellent results achieved by fundoplication need to be maintained despite fewer operations. Careful postoperative quality control including pH monitoring is therefore mandatory. The principle of periesophageal wrapping is likely to remain the cornerstone of antireflux surgery. Current techniques are, however, likely to evolve. One direction being investigated is laparoscopic fundoplication, rendering the procedure much less invasive.

The otolaryngologic manifestations of gastroesophageal reflux disease (GERD): a clinical investigation of 225 patients using ambulatory 24-hour pH monitoring and an experimental investigation of the role of acid and pepsin in the development of laryngeal injury

Occult (silent) gastroesophageal reflux disease (GER, GERD) is believed to be an important etiologic factor in the development of many inflammatory and neoplastic disorders of the upper aerodigestive tract. In order ot test this hypothesis, a human study and an animal study were performed. The human study consisted primarily of applying a new diagnostic technique (double-probe pH monitoring) to a population of otolaryngology patients with GERD to determine the incidence of overt and occult GERD. The animal study consisted of experiments to evaluate the potential damaging effects of intermittent GER on the larynx. Two hundred twenty-five consecutive patients with otolaryngologic disorders having suspected GERD evaluated from 1985 through 1988 are reported. Ambulatory 24-hour intraesophageal pH monitoring was performed in 197; of those, 81% underwent double-probe pH monitoring, with the second pH probe being placed in the hypopharynx at the laryngeal inlet. Seventy percent of the patients also underwent barium esophagography with videofluoroscopy. The patient population was divided into seven diagnostic subgroups: carcinoma of the larynx (n = 31), laryngeal and tracheal stenosis (n = 33), reflux laryngitis (n = 61), globus pharyngeus (n = 27), dysphagia (n = 25), chronic cough (n = 30), and a group with miscellaneous disorders (n = 18). The most common symptoms were hoarseness (71%), cough (51%), globus (47%), and throat clearing (42%). Only 43% of the patients had gastrointestinal symptoms (heartburn or acid regurgitation). Thus, by traditional symptomatology, GER was occult or silent in the majority of the study population. Twenty-eight patients (12%) refused or could not tolerate pH monitoring. Of the patients undergoing diagnostic pH monitoring, 62% had abnormal esophageal pH studies, and 30% demonstrated reflux into the pharynx. The results of diagnostic pH monitoring for each of the subgroups were as follows (percentage with abnormal studies): carcinoma (71%), stenosis (78%), reflux laryngitis (60%), globus (58%), dysphagia (45%), chronic cough (52%), and miscellaneous (13%). The highest yield of abnormal pharyngeal reflux was in the carcinoma group and the stenosis group (58% and 56%, respectively). By comparison, the diagnostic barium esophagogram with videofluoroscopy was frequently negative. The results were as follows: esophagitis (18%), reflux (9%), esophageal dysmotility (12%), and stricture (3%). All of the study patients were treated with antireflux therapy. Follow-up was available on 68% of the patients and the mean follow-up period was 11.6 +/- 12.7 months.(ABSTRACT TRUNCATED AT 400 WORDS)

Lower esophageal sphincter characteristics and esophageal acid exposure following partial or 360 degrees fundoplication: results of a prospective, randomized, clinical study

In a prospective, randomized, clinical trial, we compared a partial (180-200 degrees, Toupet) with a total fundoplication (360 degrees, Rossetti) in the surgical treatment of gastroesophageal reflux disease. Seventy-one patients entered the trial; 33 were allocated to a partial fundoplication and 38 to a 360 degrees fundic wrap. Each patient was investigated prior to as well as 3 and/or 6 months after the operation, including an endoscopic and clinical assessment. Manometry was carried out via a triple lumen catheter and the pressure in the high pressure zone (HPZ) in the distal esophagus was measured as well as the length of the intraabdominal segment by a "station pull-through" technique. Acid exposure of the esophageal mucosa was evaluated by ambulatory 24-hour pH measurements. Acid exposure of the esophageal mucosa was "normalized" by the 2 operations. In addition, the length of the HPZ was increased to a "normal" level by both operations. The pressure of the HPZ was, however, "normalized" only in patients allocated to a Rossetti fundoplication, whereas patients operated on with a partial fundoplication had a significantly lower HPZ pressure (p less than 0.01). The clinical assessment revealed excellent results in both groups with no significant differences between the 2 operations except for a higher incidence of dysphagia at 3 months after a Rossetti fundoplication (p less than 0.01), which disappeared during the subsequent 3 months.

Twelve hour overnight oesophageal pH monitoring in patients with reflux symptoms

Results of continuous 12 hour overnight pH monitoring (duration of pH less than 4) were reviewed in 112 patients with heartburn or regurgitation, or both, and in 56 normal subjects. Patients had more reflux than normal subjects. Medically controlled patients (n = 51) had less acid reflux than patients who subsequently underwent reflux surgery (n = 61), but there was a considerable overlap between those two groups. Surgery was followed by a reduction in acid reflux to a value similar to that in normal subjects. Patients in whom surgery was deemed to have failed had more reflux after the operation than those in whom it was successful, but no difference could be found in the preoperative reflux values of these two subgroups. Monitoring pH is not of value in selecting candidates for surgery since the results are not a good predictor of outcome, but it is useful in the objective evaluation of surgical results.

Healing, relapse rates and prophylaxis of reflux esophagitis

Gastroesophageal reflux is a daily occurrence in the general population. Reflux esophagitis is less common but still a considerable clinical problem. The results of medical therapy are generally clearly inferior to those seen in peptic ulcer disease. After healing relapse is rapid and maintenance has not been proved superior to placebo. The promising results with omeprazole (inducing pronounced acid inhibition) and surgery (strengthening anti-reflux mechanisms) indicate that a more aggressive approach may be needed in future treatment. Additional studies also using combinations of drugs both in the healing stage and during maintenance is needed. These should be compared to the long-term results of surgery.