Acid normalization and improved esophageal motility after Nissen fundoplication: equivalent outcomes in patients with normal and ineffective esophageal motility (original) (raw)
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Ain Shams Journal of Surgery, 2011
Review: Gastro-esophageal reflux disease is one of the most widely spread diseases allover the world. The principle underlying its surgical management is the creation of a mechanical antireflux barrier between the esophagus and the stomach through the creation of either a total (360 degree), or partial anterior or posterior fundal wraps around the lower esophageal end. The ability of surgery to mechanically control the reflux has been documented. The pathogenesis of gastro-esophageal reflux disease is essentially a motility-related problem with varying contributory elements. The role of different techniques in correcting the underlying motility disorder has been little studied in the randomised literature. Aim: The aim of this study was to compare the ability of the laparoscopic partial posterior and the laparoscopic total fundoplication techniques in objectively controlling the reflux and correcting the underlying esophageal motility disorder in gastro-esophageal reflux patients on the mid-term. Patients and methods: In the period between June 1998 and July 2007, 40 patients considered for antireflux surgery in the department of surgery, Tanta University Hospital, were prospectively recruited and randomised to undergo either laparoscopic total (Nissen) or laparoscopic partial posterior (Toupet) fundoplication. In addition to the clinical follow-up, objective follow up through esophageal manometry, 24-h pH monitoring and upper gastrointestinal endoscopy were performed 24 months after operation and compared to the same data recorded preoperatively. Results: Both the total and the partial posterior fundoplication techniques showed excellent control of heartburn and regurgitation postoperatively. This correlated well with the postoperative endoscopic findings, where both techniques were equally effective in correcting hiatus hernias and healing reflux esophagitis. In the Nissen group, the lower esophageal resting pressure significantly increased postoperatively from a median of 23, to 33 mmHg (p<0.01) and the nadir pressure from a median of 0 to 9 mmHg (p<0.01). Similar significant improvements were observed in the Toupet group as well (24 to 31mmHg, 2 to 8 mmHg respectively, p<0.01), no significant difference was found in-between the studied groups (P>0.05). Length of the abdominal component was significantly increased postoperatively from a median of 3 to 4 cm and from a median of 2 to 4 cm in the Nissen and Toupet groups respectively (p<0.01), with no significant difference in-between the studied groups (P>0.05). No significant changes were found in the esophageal body contraction amplitude on comparing the pre and postoperative values in both groups (p>0.05). The median total acid exposure time in the Nissen and Toupet groups was significantly reduced from a preoperative 13% to 1% and from 17 % to 0% respectively, with similar reduction in the number of pH proven reflux episodes from a median of 24 to 2 and from 30 to 2 respectively (p<0.01). The small number of cases with Barrett's metaplasia in our study made it difficult to draw hard conclusions on the difference between the two surgical techniques in this particular type of patients. Conclusion: The partial posterior and total fundoplication techniques are equally effective in restoring the lower esophageal pressure profile and in objectively controlling the reflux on the mid-term. No changes in the esophageal body contraction amplitude could be found with either technique. No objective advantages could be demonstrated for either technique to support a tailored approach.
Journal of Gastrointestinal Surgery, 2008
In Barrett's esophagus, total abolition of reflux may give maximum protection against the development of malignancy. To determine whether laparoscopic anterior fundoplication gives the same degree of antireflux control as a total fundoplication, we analyzed a prospectively followed cohort of patients from randomized controlled trials of laparoscopic antireflux surgery. There were 167 patients who returned for routine esophageal pH studies within 6 months of surgery (123 laparoscopic total fundoplications and 44 anterior fundoplications). There was no difference in percentage time pH <4 between fundoplication groups, but the total number of reflux episodes was significantly different (total fundoplication, four reflux events vs. partial fundoplication, six reflux events; p=0.03). It is difficult to believe that this difference is either biologically or clinically important. In patients with a second esophageal pH study more than 5 years later, both the percentage time pH <4 (0.1% total fundoplication vs. 2.7% partial fundoplication; p=0.004) and total number of reflux episodes (three total fundoplication vs. 24 partial fundoplication; p=0.002) were significantly different. However, the postoperative esophageal acid exposure was within the normal range for both total and partial fundoplication, so whether the statistical difference is clinically important, remains a moot point.
Impact of Total Fundoplication on Esophageal Transit
Journal of Clinical Gastroenterology, 2012
Background: Laparoscopic total fundoplication is considered the most effective surgical option for gastroesophageal reflux (GER) disease. Some authors assume that total fundoplication may expose the patient to delayed transit of the swallowed bolus and increased risk of dysphagia, particularly when peristaltic dysfunction is present. We undertook this study to evaluate by means of combined multichannel intraluminal impedance and esophageal manometry (MII-EM) the impact of fundoplication on esophageal physiology. An objective measurement of the influence of the total wrap on bolus transit may be helpful in refining the optimal antireflux wrap (ie, partial vs. total).
Surgical Endoscopy, 2008
Objective To determine the influence of preoperative esophageal motility on clinical and objective outcome of the Toupet or Nissen fundoplication and to evaluate the success rate of these procedures. Summary background data Nissen fundoplication (360°) is the standard operation in the surgical management of gastroesophageal reflux disease (GERD). In order to avoid postoperative dysphagia it has been proposed to tailor antireflux surgery according to pre-existing esophageal motility. Postoperative dysphagia is thought to occur more commonly in patients with esophageal dysmotility and it has been recommended to use the Toupet procedure (270°) in these patients. We performed a randomized trial to evaluate this tailored concept and to compare the two operative techniques concerning reflux control and complication rate (dysphagia). Methods 200 patients with GERD were included in a prospective, randomized study. After preoperative examinations (clinical interview, endoscopy, 24-hour pH-metry and esophageal manometry) 100 patients underwent either a laparoscopic Nissen procedure (50 with and 50 without motility disorders), or Toupet (50 with and 50 without motility disorders). Postoperative follow-up after two years included clinical interview, endoscopy, 24-hour pH-metry, and esophageal manometry.
Effects of laparoscopic Nissen fundoplication on esophageal motility
Surgical Endoscopy, 2006
Background: This study aimed to evaluate the long-term impact of laparoscopic Nissen fundoplication on esophageal motility in patients with preoperative esophageal dysmotility. Methods: This study prospectively followed 580 patients who underwent laparoscopic Nissen fundoplication between 1992 and 1999. Esophageal manometry, 24-h pH monitoring, and symptom score assessment were performed before surgery, then 6 months, 2 years, and 5 years after surgery. Preoperatively, 533 of the patients (93.5%) had normal esophageal contractile pressure (group 1), whereas 38 of the patients (6.5%) had reduced contractile pressure (<30 mmHg) (group 2). Results: Esophageal contractile pressures increased significantly in the patients with low preoperative values, whereas it remained unchanged in the patients with normal preoperative contractile pressures. Both groups reported a significant reduction in the dysphagia symptom score after surgery. Conclusion: Nissen fundoplication produces a significant long-lasting increase in esophageal contractile pressures in patients with preoperative esophageal dysmotility (i.e., contractile pressure lower than 30 mmHg). Preoperative esophageal dysmotility is therefore not a contraindication to laparoscopic Nissen fundoplication.
Journal of Gastrointestinal Surgery, 2014
Background Ineffective esophageal motility (IEM) in patients with gastroesophageal reflux disease includes three different subsets that may affect symptom profiles. Our aim was to assess symptoms and functional outcome in patients with erosive esophagitis according to different subsets of IEM, before and after Nissen fundoplication (NF). Methodology A retrospective study with prospective follow-up of 72 patients with reflux esophagitis and IEM in whom open NF was performed. Based on principal manometric esophageal body motility disorder, patients were divided in three groups: predominantly low-amplitude (LAC, N=38), non-propulsive (NPC, N=18), and simultaneous low-amplitude esophageal contractions (SC, N=16). Patients underwent symptomatic questionnaire and stationary esophageal manometry before and 6 months, 1 year, and 3 years after surgery. Results Preoperatively, patients in NPC and SC groups had higher mean scores of dysphagia, without statistical significance as opposed to the LAC group (p=0.239). Postoperative dysphagia occurred in 36 patients, without statistical significance between groups regarding dysphagia grades (p=0.390). A longer duration of postoperative dysphagia was noted in the SC group (p<0.05). Improvement of nadir values of contraction amplitudes in distal esophagus occurred postoperatively in all groups, significantly higher in LAC (p<0.001). Conclusion Three years after NF, successful symptomatic and functional outcome was achieved in analyzed groups of patients with erosive esophagitis regardless of IEM subtype.
Gastroenterology, 2001
Recent studies have shown that many patients use acid suppression medications after antireflux surgery. The aim of this study was to determine the frequency of gastroesophageal reflux disease in a cohort of surgically treated patients with postoperative symptoms and a high prevalence of acid suppression medication use. The study group consisted of 86 patients who had symptoms following Nissen fundoplication that were sufficient to merit evaluation with 24-hour distal esophageal pH monitoring. All completed a detailed symptom questionnaire. The mean postoperative follow-up period was 28 months (median 18 months). Thirty-seven patients (43%) were taking acid suppression medications after fundoplication. Only 23% (20 of 86) of all the patients and only 24% (9 of 37) of those taking acid suppression medications had abnormal esophageal acid exposure on the 24-hour pH study. Heartburn and regurgitation were the only symptoms that were significantly associated with an abnormal pH study. Endoscopic assessment of the fundoplication was the most significant factor associated with an abnormal pH study. Multivariable logistic regression analysis showed that patients with a disrupted, abnormally positioned fundoplication had a 52.6 times increased risk of abnormal esophageal acid exposure. Most patients who use acid suppression medications after antireflux surgery do not have abnormal esophageal acid exposure, and the use of these medications is thus often inappropriate. Because of the limited predictive power of symptoms, objective evidence of reflux disease should be obtained before prescribing acid suppression medication for patients who have undergone antireflux surgery. ( J G ASTROINTEST S URG 2002;6:3-10.)