World J. Surg. 1,439-444, 1977
9 1977 by the Soci6t~ lmernationale de Chirurgie
Fundoplication for the Treatment of Gastroesophageal Reflux in Hiatai Hernia M. ROSSETTI, M.D. and K. HELL, M.D. Department of Surgery, (University of Basel), Kantonsspital, Liestal, Switzerland Fundoplication, using an abdominal approach, is advocated to create an adequate substitute for the insufficient sphincter in gastroesophageal reflux associated with hiatus hernia. To achieve success, correct indications for surgical treatment are important. Based on experience with approximately 1,400 patients over the past 20 years, these include: (a) a retrosternal burning sensation (in 90% of our cases); (b) objective confirmation of reflux by means of x-ray and endoscopic examination, together with biopsy examination of the esophageal mucosa and gastric acid evaluation; and (c) evidence of organic complications such as endobrachyesophagus with ulcerostenotic changes at the junction between the esophageal and gastric mucosa. Long-term follow-up of 590 patients with simple reflux esophagitis who underwent fundoplication showed that 87.5% were symptom free. In 44 patients with complicated gastroesophageal reflux disease, fundoplication produced clinical healing in 84.1%.
gravity favors reflux and its sequelae in cases with sphincteric insufficiency; here fundoplication counteracts reflux by hindering funnel formation, a condition well known to facilitate reflux. At the present time we favor fundoplication in order to create an adequate substitute for the insui~icient sphincter. The fundoplication remains influenced by neurohormones and, therefore, behaves normally. This has been demonstrated by the experiments of Siewert [2], which showed that the gastric muscle layers close to the cardia react to natural stimuli and blood gastrin levels in the same way as the sphincter. These properties are highly specific for the gastric wall in the vicinity of the cardia and cannot be reproduced in the remaining gastric musculature. Furthermore, the studies of Liebermann [3] showed the anatomical position of the muscle fibers in the fundusicuff, thus explaining the function of the newly created muscle sling.
Since 1956, when Nissen [1] described "a simple operation to influence reflux esophagitis" and reported for the first time the procedure called "fundoplication," our understanding of how this operation prevents reflux has increased greatly. The original concept was that of a mechanical valve formation which prevented reflux by purely mechanical forces. The stability of the cardia and especially of the angle of His is considered essential for such valve function; increases of pressure and volume in the upper part of the stomach result in reflux if the cardia is unstable and slides into the thoracic cavity. If the cardia is stable, these same mechanisms tend to occlude the orifice of the esophagus, thus eliminating the potentially hazardous reflux of gastric contents. This is even more pronounced in the prone position where
Operative Technique
There are two available techniques for creating a fundoplication, both of which function in the manner described above when performed correctly. In the original method [1, 4] portions of the anterior and posterior walls of the fundus are united in front of the esophagus, usually incorporating layers of the esophageal wall into the suture line in order to prevent sliding back of the periesophageal cuff and recurrence of reflux due to funnel formation above the plication. This method requires extensive preparation of the area surrounding the cardia. The upper part of the gastrohepatic ligament has to be divided in order to provide access to the omental bursa and permit formation of the posterior fold of gastric fundus. As a result, most of the vagal innervation to the liver, antrum, and duodenum are traumatized. Furthermore, the stitches through the esophageal wall may damage
Reprint requests: M. Rossetti, M.D., Kantonsspital, CH-4410 Liestal, Switzerland. 439
440
World J. Surg. Vol. 1, No. 4, July, 1977
the cuff and the esophagus. Muscular contraction will lead to the valvelike action whenever needed and will counteract any tendency to funnel formation. This precaution is essential to avoid the postfundoplication syndrome, with overdistension of the stomach due to inability to belch or vomit. In experienced hands, this complication is rarely encountered because the loose plication functions only in response to neurohumoral impulses. Technical Details
Fig. 1. Technique of fundoplication. The peritoneum over-
lying the cardia is incised, the phrenoesophageal membrane is stripped offand a 4 to 5 cm segment of distal esophagus is isolated and surrounded with a rubber tube for downward traction. A large bare esophageal probe, inserted by the anesthetist, facilitates identification of the cardia and prevents creating too tight a fundoplication. branches of the anterior vagus nerve, either directly or indirectly by scar tissue formation from periesophagitis, To correct these shortcomings of the original method, and particularly to preserve the vagal nerves, the technique was modified to one in which the plication is confined to the anterior wall of the fundus [5-8], To facilitate identification of the esophagus the anesthetist inserts a thick esophageal probe, 8-10 mm in diameter, After detachment of the phrenoesophageal membrane, the distal esophagus is freed by finger dissection creating a plane between esophagus and aorta without disturbing important anatomical structures. Interference with the various branches of the vagus nerve is avoided. Through the "window" created in this manner a mobile anterior fold of fundus is brought around posterior to the esophagus (to encircle ~he esophagus anteriorly) and is reattached to the anterior aspect of the fundus by a few seromuscular sutures. The esophageal wall is not included in this suture. We stress the point that the fundoplication has to be loose and without tension; there should be no attempt to form a permanent one-way valve. A clamp with a small swab should pass easily between
Preoperative investigation includes full assessment of gastroduodenal function by radiological and endoscopic examinations. The patient is placed in the supine position with slight elevation of the left side. After intubation, the anesthetist inserts a thick esophageal probe which serves the purposes of facilitating identification of the subdiaphragmatic esophagus, and of splinting the esophagus to prevent undue narrowing by the fundoplication. Usually an upper midline abdominal incision is used to permit simultaneous treatment of accompanying conditions such as gallstones or gastroduodenal ulcers. Self-retaining Rochard retractors facilitate exposure of the cardia. After routine exploration of the abdominal organs the cardia and esophageal hiatus are palpated. The width of the hiatus, the presence of a hernia sac, and the mobility of the cardia are determined. Evaluation of the gastroesophageal junction may be complicated by periesophagitis. The stomach is drawn down to expose the peritoneal reflection near the hiatus, and the reflection is incised (Fig. 1). The extraperitoneal fat pad and the yellowish phrenoesophageal membrane are gently removed with a soft swab until the longitudinal muscle fibers of the esophagus are exposed. In cases of endobrachyesophagus or Barrett's esopha-
Fig. 2. Technique of fundoplication. The anterior fundic wall is gently brought around the esophagus and grasped with an atraumatic clamp.
M. Rossetti: Fundoplication as Treatment of Gastroesophageal Reflux
441
addition to performing the fundoplication. The operation requires about 30 minutes. Peroral alimentation is started on the first postoperative day. Following an uncomplicated fundoplication the average period of hospitalization is one week. Technical Errors
Fig. 3. Technique of fundoplication. Seromuscular non-
absorbable interrupted sutures are placed across the esophagus from fundic wall to fundic wall. The wall of the esophagus is not included in the sutures. gus, in contrast to the acquired secondary esophageal shortening, these muscle fibers continue into the wall of the stomach and the angle of His is readily recognizable; furthermore, the fundus is quite normal so that no difficulty is encountered in performing a fundoplication. The subdiaphragmatic esophagus is gently freed by passing a finger around the esophagus, creating a window that will admit 2 or 3 fingers easily. The cardia is encircled with a soft rubber tube and retracted forward. A fold of the anterior fundal wall is brought around posteriorly until the serosa emerges on the right side of the esophagus where it is kept in place with a long Allis or Babcock clamp (Fig. 2). The fundal fold is sutured to the remainder of the fundus by 3 or 4 seromuscular sutures of nonabsorbable 3-0 suture material (Fig. 3). The esophagus is not included in these sutures. The fundic cuff loosely surrounds the esophagus and its indwelling probe. The rubber tube is removed and the thick esophageal probe is replaced by a conventional gastric tube which is left indwelling for 24 hours. A few interrupted sero-serous sutures at the inferior border of the fundoplication provide adequate stability and prevent upward migration of the fundal fold and periesophageal cuff (Fig. 4). Manipulation" of the hiatus itself is not a part of this procedure. Only in the case of a mixed hernia with a paraesophageal component and considerable dilatation of the hiatus do we narrow the hiatal gap in
Traumatizing the distal esophagus may lead to bleeding and perforation. This complication may be fatal, if it is not recognized immediately. The perforation is dealt with by oversewing and incorporation into the fundoplication, together with adequate drainage. Laceration of the spleen is not infrequent and may call for splenectomy. In spite of careful handling and gentle manipulation we have encountered this complication about 10 times. We strongly advise against intentional splenectomy in order to free the greater curve, because it is usually unnecessary and, furthermore, may increase the risk to the patient. The most frequent surgical error is creating a tight fundoplication which interfers with the essential active muscular function of the gastric fundus and may lead to permanent postoperative dysphagia. Dilatation may not be helpful in this situation and
/ ,/// r
Fig. 4. Technique of fundoplication. The sutures are tied to unite the gastric wall in front of the esophagus. The cuff of stomach should be loose, easily admitting one finger.
442
reoperation may prove necessary. Finally, an uneven cuff may cause pseudodiverticula formation and give rise to complaints similar to those seen in paraesophageal hernias. The surgical correction of this complication may prove technically difficult.
Reasons for the Abdominal Approach The abdominal approach is less traumatic for the patient and less time-consuming. About one-third of our patients are over 60 years of age and are not suited to the thoracic approach. In our view, thoracic and thoracoabdominal procedures are not justified by the clinical implications of the disease. The fundoplication can be performed more correctly from below even if access and visibility are more limited in obese patients. Furthermore, the abdominal approach facilitates evaluation of the entire morphological and functional unit (distal esophagus, cardia, stomach, duodenum) and allows correction of concomitant abdominal lesions. For example, surgical disorders of the biliary tract have been encountered in 25% of our patients suffering from gastroesophageal reflux.
Addition of Measures to Reduce Gastric A cid Secretion Fundoplication should be combined with proximal selectiv~e vagotomy under 3 circumstances: (1) presence of duodenal ulcer; (2) proven hyperacidity (PAO > 30 mEq/1 per hour); and (3) presence of an endobrachyesophagus with ulcerostenotic complications. In obese or high risk patients we use a truncal vagatomy with mini-pyloroplasty (anterior elliptoid partial hemipylorectomy) instead of the time-consuming proximal selective vagotomy. In cases of intrathoracic esophageal stenosis, usually associated with endobrachyesophagus, the antireflux and antipeptic procedures are combined with perioperative dilatation. We believe that pyloroplasty alone without vagotomy, in addition to the antireflux procedure, is potentially dangerous. The sequelae of the biliarypancreatic duodenogastric reflux have not yet been fully assessed but are not without hazards. Experimental data show that bile may sensitize the gastric mucous membrane to acid and peptic secretion. In certain instances it may be necessary to divert the bile and pancreatic secretion by means of a long Roux-enY intestinal loop, usually combined with adequate gastric resection. This procedure may also have to be considered if mobilization of the cardia is judged to be too hazardous as a result of excessive inflammatory adhesions and periesophagitis in the region of the cardia.
World J. Surg. Vol. 1, No. 4, July, 1977 Results and Indications
During the past 20 years, we have operated on about 1,400 patients. In 1972, 590 patients with fundoplication were evaluated in our follow-up clinic. An x-ray examination was performed if the patient was not satisfied with the results or if the operation had not completely relieved symptoms. The results are shown in Table l. In the early stages of our attempts to understand gastroesophageal reflux we encountered many errors in patient selection and surgical technique, which later proved to be avoidable. In this respect our experience was similar to that of other surgeons working in this field. New insight into the disease followed the adoption of routine endoscopic examinations and histological verification of esophagitis. Endomanometric measurements, not routinely employed, also proved helpful in providing an understanding of the abnormal pathology and physiology of gastroesophageal reflux. In achieving success in this field a mature appreciation of the correct indications for surgical treatment is as important as the development of a satisfactory surgical technique. Originally many unnecessary operations were performed for the relief of reflux. As a consequence, many patients were dissatisfied with the results. Some physicians became disenchanted with the results of surgical therapy and advised against operation even when surgical treatment was mandatory. Today the majority of patients are satisfied with the operative results after many years of suffering under ineffectual conservative treatment, and a satisfactory understanding between patient, gastroenterologist, and surgeon has been established. Our indications for surgical treatment are based on the following: 1. Typical symptoms of retrosternal burning sensation (90% of our patients) or reflux with tracheal irritation due to recurrent aspiration (10% of our patients). 2. Objective comfirmation of reflux by means of xray and endoscopic examinations together with biopsy of the esophageal mucosa and measurement of gastric acid secretion. We do not routinely perform endomanometry, esophageal pH determinations, or the Bernstein test. 3. Evidence of organic complications such as enTable 1. Long-term results Of fundoplication in 590 pa-
tients with simple reflux esophagitis. Patients Postfundoplication syndrome Reoperation for gastric or duodenal ulcer Reoperation for recurrence Symptom-free
Percent
62
10.5
7 5 516
1.2 0.8 87.5
M. Rossetti: Fundoplication as Treatment of Gastroesophageal Reflux Table 2. Results of fundoplication in 44 patients with com-
plicated gastroesophageal reflux disease. Clinical healing Early postoperative deaths Late deaths (within 3 years)
Patients*
Percent
37 4 3
84. l 9.1 6.8
*Observation period: 5 years--5 patients; 4 years--8 patients; 1-3 years--25 patients. dobrachyesophagus with ulcerostenotic changes at the mucosal junction between the esophagus and stomach. Secondary brachyesophagus is rarely seen. It is highly significant that we have encountered 20 instances of adenocarcinoma in patients with endobrachyesophagus during the past 10 years. Of our surgical patients, 75% have had gastroesophageal reflux secondary to a hiatal hernia, and in 25% the reflux was due to functional incompetence of the lower esophageal sphincter without hernia formation. Persistence of typical symptoms with radiological evidence of recurrent and easily stimulated reflux are an indication for operation even if on endoscopic examination no pathological changes are seen in the lower esophagus. Endobrachyesophagus must be regarded as a potential cause of serious complications and an indication for surgical treatment even in the absence of alarming clinical symptoms. The results of fundoplication in 44 patients with complicated gastroesophageal reflux disease are shown in Table 2.
443
ation for recurrence is hazardous and should be considered only when a long course of medical treatment has failed to relieve the patient's symptoms. The only definite indications for further surgical treatment are mechanical stenosis due to chronic ulcerative esophagitis, hemorrhage, persisting severe and uncontrollable symptoms, and the suspicion of malignant degeneration. R6sum6
La fundoplicature par voie abdominale est conseill6e en cas de reflux gastro-oesophagien associ6/~ une hernie hiatale, car cette op6ration pallie la fonction du sphincter d6ficient. Le succ6s d6pend des indications op6ratoires. En nous basant sur pr6s de 1,400 cas vus au cours de 20 derni6res ann6es, nous pouvons pr6ciser les 616ments importants de ces indications: (a) sensation de brfilure r6trosternale (80% des cas); (b) confirmation objective du reflux par examen radiologique et endoscopique, biopsie de la muqueuse oesophagienne et 6tude de la s6cr6tion gastrique; (c) complications organiques telles que endobrachyoesophage avec st6nose et ulc6rations fi la jonction gastro-oesophagienne. Un follow-up de longue dur6e de 590 malades avec simple oesophagite de reflux, trait6s par fundoplicature, a montr6 que 87.5% sont sans symptomes. Sur 44 malades avec reflux gastro-oesophagien compliqu6, la fundoplicature a gu6ri cliniquement 84.1% d'entre eux.
Management of Recurrence
Most patients with recurrent reflux seek help at another clinic or consult surgeons other than those who performed the original operation. If the original operation was performed on the basis of inadequate indications and improper surgical technique, then persisting signs and symptoms are classified as due to a "false" recurrence. Genuine recurrences may be due to technical errors or, in late recurrences, to physiological degenerative changes. Treatment of recurrences requires experience and technical skill together with the necessary facilities for the performance of thoracoabdominal operations. Reoperation commences with a laparotomy, with the patient in the supine position and the left side elevated to an angle of 45 ~ The first step involves mobilization of the cardia and an attempt to achieve correct fundoplication. Occasionally this is impossible to achieve by the abdominal route and a thoracotomy may be needed to provide access to the esophagus and cardia. Any oper-
References
1. Nissen, R.: Eine einfache Operation zur Beeinflussung der Refluxoesophagitis. Schweiz. reed. Wochenschr. 86: 590, 1956 2. Siewert, R., Jennewein, H.M., Waldeck, F , Peiper, H.J.: Experimentelle und klinische Unterschungen zum Wirkungsmeehanismus der Fundoplicatio. Arch. Kiln. Chir. 333:5, 1973a 3. Liebermann-Meffert, D.: Architecture of the musculature at the gastroesophageal junction and in the fundus. Chir. Gastroenterol. 9:425, 1975. 4. Nissen, R., Rossetti, M.: Die B'ehandlung der Hiatushernien und Refluxoesophagitis mit Gastropexie und Fundoplicatio. Stuttgart, Thieme, 1959 5. Rossetti, M.: Die Refluxkrankheit des Oesophagus. Stuttgart, Hippokrates-Verlag, 1966 6. Rossetti, M.: Zur Technik der Fundoplicatio. Actuelle Chit. 3:229, 1968 7. Rossetti, M., Hell, K., Allg~Swer, M.: Surgical therapy of reflux oesophagitis. Chir. Gastroenterol. 5:5, 1971 8. Rossetti, M., Allg6wer, M.: Fundoplication for treatment of hiatal hernia. Prog. Surg. 12:1, 1973
9 1977 by the Soci6t~ lmernationale de Chirurgie
Fundoplication for the Treatment of Gastroesophageal Reflux in Hiatai Hernia M. ROSSETTI, M.D. and K. HELL, M.D. Department of Surgery, (University of Basel), Kantonsspital, Liestal, Switzerland Fundoplication, using an abdominal approach, is advocated to create an adequate substitute for the insufficient sphincter in gastroesophageal reflux associated with hiatus hernia. To achieve success, correct indications for surgical treatment are important. Based on experience with approximately 1,400 patients over the past 20 years, these include: (a) a retrosternal burning sensation (in 90% of our cases); (b) objective confirmation of reflux by means of x-ray and endoscopic examination, together with biopsy examination of the esophageal mucosa and gastric acid evaluation; and (c) evidence of organic complications such as endobrachyesophagus with ulcerostenotic changes at the junction between the esophageal and gastric mucosa. Long-term follow-up of 590 patients with simple reflux esophagitis who underwent fundoplication showed that 87.5% were symptom free. In 44 patients with complicated gastroesophageal reflux disease, fundoplication produced clinical healing in 84.1%.
gravity favors reflux and its sequelae in cases with sphincteric insufficiency; here fundoplication counteracts reflux by hindering funnel formation, a condition well known to facilitate reflux. At the present time we favor fundoplication in order to create an adequate substitute for the insui~icient sphincter. The fundoplication remains influenced by neurohormones and, therefore, behaves normally. This has been demonstrated by the experiments of Siewert [2], which showed that the gastric muscle layers close to the cardia react to natural stimuli and blood gastrin levels in the same way as the sphincter. These properties are highly specific for the gastric wall in the vicinity of the cardia and cannot be reproduced in the remaining gastric musculature. Furthermore, the studies of Liebermann [3] showed the anatomical position of the muscle fibers in the fundusicuff, thus explaining the function of the newly created muscle sling.
Since 1956, when Nissen [1] described "a simple operation to influence reflux esophagitis" and reported for the first time the procedure called "fundoplication," our understanding of how this operation prevents reflux has increased greatly. The original concept was that of a mechanical valve formation which prevented reflux by purely mechanical forces. The stability of the cardia and especially of the angle of His is considered essential for such valve function; increases of pressure and volume in the upper part of the stomach result in reflux if the cardia is unstable and slides into the thoracic cavity. If the cardia is stable, these same mechanisms tend to occlude the orifice of the esophagus, thus eliminating the potentially hazardous reflux of gastric contents. This is even more pronounced in the prone position where
Operative Technique
There are two available techniques for creating a fundoplication, both of which function in the manner described above when performed correctly. In the original method [1, 4] portions of the anterior and posterior walls of the fundus are united in front of the esophagus, usually incorporating layers of the esophageal wall into the suture line in order to prevent sliding back of the periesophageal cuff and recurrence of reflux due to funnel formation above the plication. This method requires extensive preparation of the area surrounding the cardia. The upper part of the gastrohepatic ligament has to be divided in order to provide access to the omental bursa and permit formation of the posterior fold of gastric fundus. As a result, most of the vagal innervation to the liver, antrum, and duodenum are traumatized. Furthermore, the stitches through the esophageal wall may damage
Reprint requests: M. Rossetti, M.D., Kantonsspital, CH-4410 Liestal, Switzerland. 439
440
World J. Surg. Vol. 1, No. 4, July, 1977
the cuff and the esophagus. Muscular contraction will lead to the valvelike action whenever needed and will counteract any tendency to funnel formation. This precaution is essential to avoid the postfundoplication syndrome, with overdistension of the stomach due to inability to belch or vomit. In experienced hands, this complication is rarely encountered because the loose plication functions only in response to neurohumoral impulses. Technical Details
Fig. 1. Technique of fundoplication. The peritoneum over-
lying the cardia is incised, the phrenoesophageal membrane is stripped offand a 4 to 5 cm segment of distal esophagus is isolated and surrounded with a rubber tube for downward traction. A large bare esophageal probe, inserted by the anesthetist, facilitates identification of the cardia and prevents creating too tight a fundoplication. branches of the anterior vagus nerve, either directly or indirectly by scar tissue formation from periesophagitis, To correct these shortcomings of the original method, and particularly to preserve the vagal nerves, the technique was modified to one in which the plication is confined to the anterior wall of the fundus [5-8], To facilitate identification of the esophagus the anesthetist inserts a thick esophageal probe, 8-10 mm in diameter, After detachment of the phrenoesophageal membrane, the distal esophagus is freed by finger dissection creating a plane between esophagus and aorta without disturbing important anatomical structures. Interference with the various branches of the vagus nerve is avoided. Through the "window" created in this manner a mobile anterior fold of fundus is brought around posterior to the esophagus (to encircle ~he esophagus anteriorly) and is reattached to the anterior aspect of the fundus by a few seromuscular sutures. The esophageal wall is not included in this suture. We stress the point that the fundoplication has to be loose and without tension; there should be no attempt to form a permanent one-way valve. A clamp with a small swab should pass easily between
Preoperative investigation includes full assessment of gastroduodenal function by radiological and endoscopic examinations. The patient is placed in the supine position with slight elevation of the left side. After intubation, the anesthetist inserts a thick esophageal probe which serves the purposes of facilitating identification of the subdiaphragmatic esophagus, and of splinting the esophagus to prevent undue narrowing by the fundoplication. Usually an upper midline abdominal incision is used to permit simultaneous treatment of accompanying conditions such as gallstones or gastroduodenal ulcers. Self-retaining Rochard retractors facilitate exposure of the cardia. After routine exploration of the abdominal organs the cardia and esophageal hiatus are palpated. The width of the hiatus, the presence of a hernia sac, and the mobility of the cardia are determined. Evaluation of the gastroesophageal junction may be complicated by periesophagitis. The stomach is drawn down to expose the peritoneal reflection near the hiatus, and the reflection is incised (Fig. 1). The extraperitoneal fat pad and the yellowish phrenoesophageal membrane are gently removed with a soft swab until the longitudinal muscle fibers of the esophagus are exposed. In cases of endobrachyesophagus or Barrett's esopha-
Fig. 2. Technique of fundoplication. The anterior fundic wall is gently brought around the esophagus and grasped with an atraumatic clamp.
M. Rossetti: Fundoplication as Treatment of Gastroesophageal Reflux
441
addition to performing the fundoplication. The operation requires about 30 minutes. Peroral alimentation is started on the first postoperative day. Following an uncomplicated fundoplication the average period of hospitalization is one week. Technical Errors
Fig. 3. Technique of fundoplication. Seromuscular non-
absorbable interrupted sutures are placed across the esophagus from fundic wall to fundic wall. The wall of the esophagus is not included in the sutures. gus, in contrast to the acquired secondary esophageal shortening, these muscle fibers continue into the wall of the stomach and the angle of His is readily recognizable; furthermore, the fundus is quite normal so that no difficulty is encountered in performing a fundoplication. The subdiaphragmatic esophagus is gently freed by passing a finger around the esophagus, creating a window that will admit 2 or 3 fingers easily. The cardia is encircled with a soft rubber tube and retracted forward. A fold of the anterior fundal wall is brought around posteriorly until the serosa emerges on the right side of the esophagus where it is kept in place with a long Allis or Babcock clamp (Fig. 2). The fundal fold is sutured to the remainder of the fundus by 3 or 4 seromuscular sutures of nonabsorbable 3-0 suture material (Fig. 3). The esophagus is not included in these sutures. The fundic cuff loosely surrounds the esophagus and its indwelling probe. The rubber tube is removed and the thick esophageal probe is replaced by a conventional gastric tube which is left indwelling for 24 hours. A few interrupted sero-serous sutures at the inferior border of the fundoplication provide adequate stability and prevent upward migration of the fundal fold and periesophageal cuff (Fig. 4). Manipulation" of the hiatus itself is not a part of this procedure. Only in the case of a mixed hernia with a paraesophageal component and considerable dilatation of the hiatus do we narrow the hiatal gap in
Traumatizing the distal esophagus may lead to bleeding and perforation. This complication may be fatal, if it is not recognized immediately. The perforation is dealt with by oversewing and incorporation into the fundoplication, together with adequate drainage. Laceration of the spleen is not infrequent and may call for splenectomy. In spite of careful handling and gentle manipulation we have encountered this complication about 10 times. We strongly advise against intentional splenectomy in order to free the greater curve, because it is usually unnecessary and, furthermore, may increase the risk to the patient. The most frequent surgical error is creating a tight fundoplication which interfers with the essential active muscular function of the gastric fundus and may lead to permanent postoperative dysphagia. Dilatation may not be helpful in this situation and
/ ,/// r
Fig. 4. Technique of fundoplication. The sutures are tied to unite the gastric wall in front of the esophagus. The cuff of stomach should be loose, easily admitting one finger.
442
reoperation may prove necessary. Finally, an uneven cuff may cause pseudodiverticula formation and give rise to complaints similar to those seen in paraesophageal hernias. The surgical correction of this complication may prove technically difficult.
Reasons for the Abdominal Approach The abdominal approach is less traumatic for the patient and less time-consuming. About one-third of our patients are over 60 years of age and are not suited to the thoracic approach. In our view, thoracic and thoracoabdominal procedures are not justified by the clinical implications of the disease. The fundoplication can be performed more correctly from below even if access and visibility are more limited in obese patients. Furthermore, the abdominal approach facilitates evaluation of the entire morphological and functional unit (distal esophagus, cardia, stomach, duodenum) and allows correction of concomitant abdominal lesions. For example, surgical disorders of the biliary tract have been encountered in 25% of our patients suffering from gastroesophageal reflux.
Addition of Measures to Reduce Gastric A cid Secretion Fundoplication should be combined with proximal selectiv~e vagotomy under 3 circumstances: (1) presence of duodenal ulcer; (2) proven hyperacidity (PAO > 30 mEq/1 per hour); and (3) presence of an endobrachyesophagus with ulcerostenotic complications. In obese or high risk patients we use a truncal vagatomy with mini-pyloroplasty (anterior elliptoid partial hemipylorectomy) instead of the time-consuming proximal selective vagotomy. In cases of intrathoracic esophageal stenosis, usually associated with endobrachyesophagus, the antireflux and antipeptic procedures are combined with perioperative dilatation. We believe that pyloroplasty alone without vagotomy, in addition to the antireflux procedure, is potentially dangerous. The sequelae of the biliarypancreatic duodenogastric reflux have not yet been fully assessed but are not without hazards. Experimental data show that bile may sensitize the gastric mucous membrane to acid and peptic secretion. In certain instances it may be necessary to divert the bile and pancreatic secretion by means of a long Roux-enY intestinal loop, usually combined with adequate gastric resection. This procedure may also have to be considered if mobilization of the cardia is judged to be too hazardous as a result of excessive inflammatory adhesions and periesophagitis in the region of the cardia.
World J. Surg. Vol. 1, No. 4, July, 1977 Results and Indications
During the past 20 years, we have operated on about 1,400 patients. In 1972, 590 patients with fundoplication were evaluated in our follow-up clinic. An x-ray examination was performed if the patient was not satisfied with the results or if the operation had not completely relieved symptoms. The results are shown in Table l. In the early stages of our attempts to understand gastroesophageal reflux we encountered many errors in patient selection and surgical technique, which later proved to be avoidable. In this respect our experience was similar to that of other surgeons working in this field. New insight into the disease followed the adoption of routine endoscopic examinations and histological verification of esophagitis. Endomanometric measurements, not routinely employed, also proved helpful in providing an understanding of the abnormal pathology and physiology of gastroesophageal reflux. In achieving success in this field a mature appreciation of the correct indications for surgical treatment is as important as the development of a satisfactory surgical technique. Originally many unnecessary operations were performed for the relief of reflux. As a consequence, many patients were dissatisfied with the results. Some physicians became disenchanted with the results of surgical therapy and advised against operation even when surgical treatment was mandatory. Today the majority of patients are satisfied with the operative results after many years of suffering under ineffectual conservative treatment, and a satisfactory understanding between patient, gastroenterologist, and surgeon has been established. Our indications for surgical treatment are based on the following: 1. Typical symptoms of retrosternal burning sensation (90% of our patients) or reflux with tracheal irritation due to recurrent aspiration (10% of our patients). 2. Objective comfirmation of reflux by means of xray and endoscopic examinations together with biopsy of the esophageal mucosa and measurement of gastric acid secretion. We do not routinely perform endomanometry, esophageal pH determinations, or the Bernstein test. 3. Evidence of organic complications such as enTable 1. Long-term results Of fundoplication in 590 pa-
tients with simple reflux esophagitis. Patients Postfundoplication syndrome Reoperation for gastric or duodenal ulcer Reoperation for recurrence Symptom-free
Percent
62
10.5
7 5 516
1.2 0.8 87.5
M. Rossetti: Fundoplication as Treatment of Gastroesophageal Reflux Table 2. Results of fundoplication in 44 patients with com-
plicated gastroesophageal reflux disease. Clinical healing Early postoperative deaths Late deaths (within 3 years)
Patients*
Percent
37 4 3
84. l 9.1 6.8
*Observation period: 5 years--5 patients; 4 years--8 patients; 1-3 years--25 patients. dobrachyesophagus with ulcerostenotic changes at the mucosal junction between the esophagus and stomach. Secondary brachyesophagus is rarely seen. It is highly significant that we have encountered 20 instances of adenocarcinoma in patients with endobrachyesophagus during the past 10 years. Of our surgical patients, 75% have had gastroesophageal reflux secondary to a hiatal hernia, and in 25% the reflux was due to functional incompetence of the lower esophageal sphincter without hernia formation. Persistence of typical symptoms with radiological evidence of recurrent and easily stimulated reflux are an indication for operation even if on endoscopic examination no pathological changes are seen in the lower esophagus. Endobrachyesophagus must be regarded as a potential cause of serious complications and an indication for surgical treatment even in the absence of alarming clinical symptoms. The results of fundoplication in 44 patients with complicated gastroesophageal reflux disease are shown in Table 2.
443
ation for recurrence is hazardous and should be considered only when a long course of medical treatment has failed to relieve the patient's symptoms. The only definite indications for further surgical treatment are mechanical stenosis due to chronic ulcerative esophagitis, hemorrhage, persisting severe and uncontrollable symptoms, and the suspicion of malignant degeneration. R6sum6
La fundoplicature par voie abdominale est conseill6e en cas de reflux gastro-oesophagien associ6/~ une hernie hiatale, car cette op6ration pallie la fonction du sphincter d6ficient. Le succ6s d6pend des indications op6ratoires. En nous basant sur pr6s de 1,400 cas vus au cours de 20 derni6res ann6es, nous pouvons pr6ciser les 616ments importants de ces indications: (a) sensation de brfilure r6trosternale (80% des cas); (b) confirmation objective du reflux par examen radiologique et endoscopique, biopsie de la muqueuse oesophagienne et 6tude de la s6cr6tion gastrique; (c) complications organiques telles que endobrachyoesophage avec st6nose et ulc6rations fi la jonction gastro-oesophagienne. Un follow-up de longue dur6e de 590 malades avec simple oesophagite de reflux, trait6s par fundoplicature, a montr6 que 87.5% sont sans symptomes. Sur 44 malades avec reflux gastro-oesophagien compliqu6, la fundoplicature a gu6ri cliniquement 84.1% d'entre eux.
Management of Recurrence
Most patients with recurrent reflux seek help at another clinic or consult surgeons other than those who performed the original operation. If the original operation was performed on the basis of inadequate indications and improper surgical technique, then persisting signs and symptoms are classified as due to a "false" recurrence. Genuine recurrences may be due to technical errors or, in late recurrences, to physiological degenerative changes. Treatment of recurrences requires experience and technical skill together with the necessary facilities for the performance of thoracoabdominal operations. Reoperation commences with a laparotomy, with the patient in the supine position and the left side elevated to an angle of 45 ~ The first step involves mobilization of the cardia and an attempt to achieve correct fundoplication. Occasionally this is impossible to achieve by the abdominal route and a thoracotomy may be needed to provide access to the esophagus and cardia. Any oper-
References
1. Nissen, R.: Eine einfache Operation zur Beeinflussung der Refluxoesophagitis. Schweiz. reed. Wochenschr. 86: 590, 1956 2. Siewert, R., Jennewein, H.M., Waldeck, F , Peiper, H.J.: Experimentelle und klinische Unterschungen zum Wirkungsmeehanismus der Fundoplicatio. Arch. Kiln. Chir. 333:5, 1973a 3. Liebermann-Meffert, D.: Architecture of the musculature at the gastroesophageal junction and in the fundus. Chir. Gastroenterol. 9:425, 1975. 4. Nissen, R., Rossetti, M.: Die B'ehandlung der Hiatushernien und Refluxoesophagitis mit Gastropexie und Fundoplicatio. Stuttgart, Thieme, 1959 5. Rossetti, M.: Die Refluxkrankheit des Oesophagus. Stuttgart, Hippokrates-Verlag, 1966 6. Rossetti, M.: Zur Technik der Fundoplicatio. Actuelle Chit. 3:229, 1968 7. Rossetti, M., Hell, K., Allg~Swer, M.: Surgical therapy of reflux oesophagitis. Chir. Gastroenterol. 5:5, 1971 8. Rossetti, M., Allg6wer, M.: Fundoplication for treatment of hiatal hernia. Prog. Surg. 12:1, 1973
