Annals of the Royal College of Surgeons of England
(I979) vol 6I
ASPECTS OF TREATMENT*
A new approach to the surgical treatment of reflux oesophagitis N A G Jones FRCS Surgical Registrar, St Thomas's Hospital, London
C J Anders FRCS Consultant Surgeon, NW Surrey Hospital Group; Honorary Clinical Tutor, St Thomas's Hospital, London
Summary The rationale of combining proximal gastric vagotomy with Nissen fundoplication in the treatment of reflux oesophagitis due to hiatus hernia is discussed. The application of this procedure in 12 cases over a period of 4 years is described and the results, with a follow-up of I3-48 months, are reported. Ten of the 12 patients have been completely relieved of their symptoms and one has been significantly improved. Introduction Proximal gastric vagotomy results in a complete clearance of the lesser curve of the stomach from the terminal 'crow's foot' branches of the anterior nerve of Latarjet up to the oesophagus. Since clearance of the upper part of the lesser curve of the stomach is a necessary part of the preparation for a Nissen fundoplication, a proximal gastric vagotomy provides ideal conditions for a Nissen fundoplication. It has been the practice of many surgeons to carry out a truncal vagotomy and pyloroplasty with a Nissen fundoplication when treating reflux oesophagitis due to hiatus hernia. The aim of this procedure was to reduce the production of gastric acid as well as to prevent reflux. This practice has fallen into disrepute because of the complications which follow truncal vagotomy and pyloroplasty. Such complications are not encountered with proximal gastric vagotomy. Twelve patients suffering from reflux oesophagitis due to a sliding hiatus hernia have been treated over the past 4 years by combining proximal gastric vagotomy and Nissen
fundoplication.
Patients and methods There were 6 male and 6 female patients ranging in age from 8 to 74 years. All had clear symptoms of reflux oesophagitis and surgery was advised only after medical treatment had been conscientiously applied but had failed to produce relief. Medical treatment consisted of advice on how to reduce reflux by avoiding stooping and by raising the head end of the bed. Also antacids such as aluminium hydroxide were given. Metoclopramide (Maxalon) was often used as it helps symptoms by increasing the tone of the lower oesophageal sphincter. Weight reduction was encouraged and dietetic advice given. The patients were also advised to give up smoking. Ten of the patients complained of symptoms of oesophageal reflux. This was characteristically substernal pain described as heartburn. The pain was brought on by recumbency and stooping. In addition the pain often caused frequent swallowing, of which the patient was unaware, and this led to flatulence. Three patients complained of dysphagia, one of whom also had oesophageal reflux. Table I shows the patients' preoperative symptoms and their duration. All the patients were investigated by bariumswallow X-ray and endoscopy before operation. The presence of a sliding hiatus hernia was confirmed radiologically in all cases. Endoscopy confirmed oesophagitis in most of the cases. In 3 patients the presence of previous duodenal ulceration was seen and a fourth was found to have an active duodenal ulcer. Of the 3 patients who complained of dysphagia, only one was found to have a fibrous stricture at endoscopy and this was later confirmed at
*Fellows and Members interested in submitting articles for consideration publication in this series should first write to the Editor.
with
a view to
A new approach to the surgical treatment of reflux oesophagitis
TABLE I Preoperative symptoms and duration Patient
I 2
3 4 5 6 7 8
Age (years) and sex 67F 7o F 64 M 35 M
54F
36M 40M 74F
Symptoms of acid Dysphagia reflux (years) (years) 2 IO
I
20
-
3 3
-
9
2 -
I
49
tient himself felt as if something had given way. His description leads us to postulate that the sutures of the fundoplication had disrupted. The only other complication in the series was that the patient with a fibrous stricture complained of dysphagia i i months after her operation. This required oesophageal dilatation, but she has had no further dysphagia during the last I9 months.
Discussion It is accepted that surgery for reflux oesophaII 8M 6 is only indicated in the minority of patients gitis 12 53 F 5 in whom medical treatment has failed. Foroperations aimed to achieve as precise operation. Gallstones were found at operation merly an anatomical repair of the hiatus and oesoin 3 patients on whom cholecystectomy was phagogastric junction as possible. However, carried out at the same time. such repairs are not always successful in reThe operation is performed through an up- lieving symptoms, nor are they anatomically per midline abdominal incision. A Goligher permanent. sternal lifting retractor is used to aid exposure. In recent years there has been a change in The proximal gastric vagotomy is carried out practice based on a better understanding of first in the manner described by Goligher1. the pressure patterns at the lower end of the The bared lesser curve of the stomach is easily oesophagus. The main object of surgery is to plicated with interrupted linen sutures as the secure a continuous subdiaphragmatic location Nissen fundoplication is next performed2. for the lower oesophageal sphincter so that an increased pressure is maintained in this zone. Results The symptoms of reflux oesophagitis can be Symptomatically i I of the i 2 patients were reproduced in the acid perfusion test. Infubenefited by their operation. The results of sions of physiological saline, N/io hydrochloric operation and duration of follow-up are shown acid, and N/io sodium bicarbonate in turn in Table II. Ten of the i I patients were entire- into the lower oesophagus are used to reproly relieved of their symptoms and the other duce the patient's symptoms. The test is conpatient had slight reflux which was easily con- sidered positive if the pain is produced by hydtrolled by antacids. rochloric acid alone and is then relieved by The single failure in the series was in a 36- sodium bicarbonate. The pain must be idenyear-old man. He was symptomatically cured tical with spontaneously occurring pain. for 9 months, when his preoperative symptoms Because of the association of the pain of recurred suddenly and dramatically. The pa- gastro-oesophageal reflux with gastric juice containing hydrochloric acid and pepsin many TABLE II Results of operation surgeons carried out a combination of truncal vagotomy and pyloroplasty with the Nissen Patient Follow-up (months) Results fundoplication in order to reduce gastric acidI 48 Slight reflux ity and hence minimise symptoms due to any 2 No symptoms 30 residual reflux of gastric juice. 3 25 No symptoms 4 25 No symptoms Several large series of hiatus hernia repair 5 24 No symptoms combined with truncal vagotomy and pyloro6 24 Original symptoms plasty have been reported in the literature, 7 23 No symptoms particularly from the United States. Vansant 8 I7 No symptoms i6 and Baker3 reported I59 patients treated with 9 No symptoms IO 15 No symptoms hiatus hernia repair and truncal vagotomy I I15 No symptoms with pyloroplasty compared with I52 patients 12 13 No symptoms who had hiatus hernia repair alone. In the 9
IO
42 F 5I M
I
I5 -
r)o
N A G Jones a(nd C J Anders
long term disabling symptoms were significantly increased in the group who had undergone vagotomy. These symptoms were diarrhoea and dumping. In a recent leading article in the British Medical Journal4 it was stated that 'neither is there good evidence that any form of vagotomy with or without gastric drainage procedures benefits sliding hiatus hernia'; Vansant and Baker were cited in justification of this view. It is our belief that the objections raised are to the well-known complications of truncal vagotomy and pyloroplasty-namely, diarrhoea, dumping, and biliary reflux. A logical approach to the symptoms of reflux oesophagitis has led to the standard medical treatment with antacids. At the present time cimetidine is being widely used to treat reflux oesophagitis with success5. Such measures achieve a reduction in gastric acidity. Many surgeons have used an acid-reducing procedure with their hiatus hernia repair based on the sarne logical approach. XVe suggest that this view can be upheld by using a proximal gastric vagotomy with a
Nissen fundoplication. Such a combination is particularly useful when there is associated duodenal ulceration, as in 4 cases in our series. WVe have found this procedure to be easily accomplished and to give an opportunity for improving the success rate of surgery for reflux oesophagitis due to sliding hiatus hernia. We thank Mr K W Wilkinisoni for permission to report two of his patients. This paper was originally given at a meeting of the Thames Valley Surgical Society at Windsor in October '977 when the President and Council of the Royal College of Surgeons were present.
References Goligher, J C (I974) British Journal of Surgery, 6r, 337. 2 Nissen, R (I96i) American Journal of Digestive Diseases, 6, 954. 3 Vansant, J H, and Baker, J W (1976) Annals of I
Surgery, I83, 629.
4 British Medical Journal (i977), 2, 1436. 5 McCluskie, R A, Bardhan, K D, Saul, D M, Duthie, H I, Greaney, M G, and Irvin, T P (I977) Proceedings of the Second International Symposium on Histamine H2-receptor Antagonists, p 297. Amsterdam, Excerpta Medica.
(I979) vol 6I
ASPECTS OF TREATMENT*
A new approach to the surgical treatment of reflux oesophagitis N A G Jones FRCS Surgical Registrar, St Thomas's Hospital, London
C J Anders FRCS Consultant Surgeon, NW Surrey Hospital Group; Honorary Clinical Tutor, St Thomas's Hospital, London
Summary The rationale of combining proximal gastric vagotomy with Nissen fundoplication in the treatment of reflux oesophagitis due to hiatus hernia is discussed. The application of this procedure in 12 cases over a period of 4 years is described and the results, with a follow-up of I3-48 months, are reported. Ten of the 12 patients have been completely relieved of their symptoms and one has been significantly improved. Introduction Proximal gastric vagotomy results in a complete clearance of the lesser curve of the stomach from the terminal 'crow's foot' branches of the anterior nerve of Latarjet up to the oesophagus. Since clearance of the upper part of the lesser curve of the stomach is a necessary part of the preparation for a Nissen fundoplication, a proximal gastric vagotomy provides ideal conditions for a Nissen fundoplication. It has been the practice of many surgeons to carry out a truncal vagotomy and pyloroplasty with a Nissen fundoplication when treating reflux oesophagitis due to hiatus hernia. The aim of this procedure was to reduce the production of gastric acid as well as to prevent reflux. This practice has fallen into disrepute because of the complications which follow truncal vagotomy and pyloroplasty. Such complications are not encountered with proximal gastric vagotomy. Twelve patients suffering from reflux oesophagitis due to a sliding hiatus hernia have been treated over the past 4 years by combining proximal gastric vagotomy and Nissen
fundoplication.
Patients and methods There were 6 male and 6 female patients ranging in age from 8 to 74 years. All had clear symptoms of reflux oesophagitis and surgery was advised only after medical treatment had been conscientiously applied but had failed to produce relief. Medical treatment consisted of advice on how to reduce reflux by avoiding stooping and by raising the head end of the bed. Also antacids such as aluminium hydroxide were given. Metoclopramide (Maxalon) was often used as it helps symptoms by increasing the tone of the lower oesophageal sphincter. Weight reduction was encouraged and dietetic advice given. The patients were also advised to give up smoking. Ten of the patients complained of symptoms of oesophageal reflux. This was characteristically substernal pain described as heartburn. The pain was brought on by recumbency and stooping. In addition the pain often caused frequent swallowing, of which the patient was unaware, and this led to flatulence. Three patients complained of dysphagia, one of whom also had oesophageal reflux. Table I shows the patients' preoperative symptoms and their duration. All the patients were investigated by bariumswallow X-ray and endoscopy before operation. The presence of a sliding hiatus hernia was confirmed radiologically in all cases. Endoscopy confirmed oesophagitis in most of the cases. In 3 patients the presence of previous duodenal ulceration was seen and a fourth was found to have an active duodenal ulcer. Of the 3 patients who complained of dysphagia, only one was found to have a fibrous stricture at endoscopy and this was later confirmed at
*Fellows and Members interested in submitting articles for consideration publication in this series should first write to the Editor.
with
a view to
A new approach to the surgical treatment of reflux oesophagitis
TABLE I Preoperative symptoms and duration Patient
I 2
3 4 5 6 7 8
Age (years) and sex 67F 7o F 64 M 35 M
54F
36M 40M 74F
Symptoms of acid Dysphagia reflux (years) (years) 2 IO
I
20
-
3 3
-
9
2 -
I
49
tient himself felt as if something had given way. His description leads us to postulate that the sutures of the fundoplication had disrupted. The only other complication in the series was that the patient with a fibrous stricture complained of dysphagia i i months after her operation. This required oesophageal dilatation, but she has had no further dysphagia during the last I9 months.
Discussion It is accepted that surgery for reflux oesophaII 8M 6 is only indicated in the minority of patients gitis 12 53 F 5 in whom medical treatment has failed. Foroperations aimed to achieve as precise operation. Gallstones were found at operation merly an anatomical repair of the hiatus and oesoin 3 patients on whom cholecystectomy was phagogastric junction as possible. However, carried out at the same time. such repairs are not always successful in reThe operation is performed through an up- lieving symptoms, nor are they anatomically per midline abdominal incision. A Goligher permanent. sternal lifting retractor is used to aid exposure. In recent years there has been a change in The proximal gastric vagotomy is carried out practice based on a better understanding of first in the manner described by Goligher1. the pressure patterns at the lower end of the The bared lesser curve of the stomach is easily oesophagus. The main object of surgery is to plicated with interrupted linen sutures as the secure a continuous subdiaphragmatic location Nissen fundoplication is next performed2. for the lower oesophageal sphincter so that an increased pressure is maintained in this zone. Results The symptoms of reflux oesophagitis can be Symptomatically i I of the i 2 patients were reproduced in the acid perfusion test. Infubenefited by their operation. The results of sions of physiological saline, N/io hydrochloric operation and duration of follow-up are shown acid, and N/io sodium bicarbonate in turn in Table II. Ten of the i I patients were entire- into the lower oesophagus are used to reproly relieved of their symptoms and the other duce the patient's symptoms. The test is conpatient had slight reflux which was easily con- sidered positive if the pain is produced by hydtrolled by antacids. rochloric acid alone and is then relieved by The single failure in the series was in a 36- sodium bicarbonate. The pain must be idenyear-old man. He was symptomatically cured tical with spontaneously occurring pain. for 9 months, when his preoperative symptoms Because of the association of the pain of recurred suddenly and dramatically. The pa- gastro-oesophageal reflux with gastric juice containing hydrochloric acid and pepsin many TABLE II Results of operation surgeons carried out a combination of truncal vagotomy and pyloroplasty with the Nissen Patient Follow-up (months) Results fundoplication in order to reduce gastric acidI 48 Slight reflux ity and hence minimise symptoms due to any 2 No symptoms 30 residual reflux of gastric juice. 3 25 No symptoms 4 25 No symptoms Several large series of hiatus hernia repair 5 24 No symptoms combined with truncal vagotomy and pyloro6 24 Original symptoms plasty have been reported in the literature, 7 23 No symptoms particularly from the United States. Vansant 8 I7 No symptoms i6 and Baker3 reported I59 patients treated with 9 No symptoms IO 15 No symptoms hiatus hernia repair and truncal vagotomy I I15 No symptoms with pyloroplasty compared with I52 patients 12 13 No symptoms who had hiatus hernia repair alone. In the 9
IO
42 F 5I M
I
I5 -
r)o
N A G Jones a(nd C J Anders
long term disabling symptoms were significantly increased in the group who had undergone vagotomy. These symptoms were diarrhoea and dumping. In a recent leading article in the British Medical Journal4 it was stated that 'neither is there good evidence that any form of vagotomy with or without gastric drainage procedures benefits sliding hiatus hernia'; Vansant and Baker were cited in justification of this view. It is our belief that the objections raised are to the well-known complications of truncal vagotomy and pyloroplasty-namely, diarrhoea, dumping, and biliary reflux. A logical approach to the symptoms of reflux oesophagitis has led to the standard medical treatment with antacids. At the present time cimetidine is being widely used to treat reflux oesophagitis with success5. Such measures achieve a reduction in gastric acidity. Many surgeons have used an acid-reducing procedure with their hiatus hernia repair based on the sarne logical approach. XVe suggest that this view can be upheld by using a proximal gastric vagotomy with a
Nissen fundoplication. Such a combination is particularly useful when there is associated duodenal ulceration, as in 4 cases in our series. WVe have found this procedure to be easily accomplished and to give an opportunity for improving the success rate of surgery for reflux oesophagitis due to sliding hiatus hernia. We thank Mr K W Wilkinisoni for permission to report two of his patients. This paper was originally given at a meeting of the Thames Valley Surgical Society at Windsor in October '977 when the President and Council of the Royal College of Surgeons were present.
References Goligher, J C (I974) British Journal of Surgery, 6r, 337. 2 Nissen, R (I96i) American Journal of Digestive Diseases, 6, 954. 3 Vansant, J H, and Baker, J W (1976) Annals of I
Surgery, I83, 629.
4 British Medical Journal (i977), 2, 1436. 5 McCluskie, R A, Bardhan, K D, Saul, D M, Duthie, H I, Greaney, M G, and Irvin, T P (I977) Proceedings of the Second International Symposium on Histamine H2-receptor Antagonists, p 297. Amsterdam, Excerpta Medica.
